I have a couple of follow-up questions, one or two that came from the audience, and then I have a few. First one, starting off with telehealth, which has been the most current and urgent question. Have you found any particular platform to be more reliable than the other, having looked at this from a more broader perspective? So the telehealth platform that we use here at our hospital is Epic. I don't have a lot of experience with the other telehealth platforms. I think the one that I use on a regular basis actually had a telehealth consultation before this meeting today. I think it's, for the most part, pretty user-friendly for the patients and for the physicians, but I know there's a whole host of platforms. I don't know if there's... I think we lost you there. From Epic, I think the biggest challenge with telehealth now is that as the pandemic is receding a bit, it's difficult to get reimbursement or reimbursement has stopped going across state lines. I know we have that difficulty here in New York about doing a telehealth with a patient now in Connecticut or Pennsylvania, et cetera, because the insurers are cutting back on the reimbursement. I agree about that. And we in the Northeast have snowbirds and it's extremely difficult to maintain the continuity of care. And that's something that at the policy level we have been talking about. And still, what I have come across are the platforms that I have used are DocSeeMe initially. I still, at times when patients didn't have good connectivity or didn't know how to click on a link, also used Doximity direct calling, because that is private and it's TIPA compliant, and currently use the Epic Zoom links, which seem to work okay, just like you do. So at least those are the three platforms that I've come across. And I found the Epic Zoom links and Doximity to be much more reliable, just because they use your network and they seem to be much more ease of use for patients in terms of that. Remaining on telehealth, I have a couple of questions which are, again, broader in terms of long-term application of this. Do you, I mean, not keeping the PHE or the public health emergency restrictions in place, but just kind of ignoring that at this moment and looking at it as a broader use. Do you anticipate this will remain in place? And the second corollary question to that is, how do you see this impacting our harder-to-reach population or those folks that don't tend to typically come into the offices or not well-served medical communities? Yeah, I think those are both two very important questions. For the first one, I think not just the gastroenterology societies, but I think all of medicine saw the true value of telehealth beyond this pandemic. And I know that people are working with their legislatures to continue telehealth services. I really do think it's a game changer in terms of patient access and physician access to their patients. And as far as those under-resourced areas, again, I think this is a great first step for those patients or those individuals that don't have easy access to health care or they just can't come in. This is a great way to initially evaluate someone and give them the recommendations that they need for managing their health. So I'm very hopeful that this will remain in our daily clinical practice. Completely agree with you. And overseeing one of the Yale GI clinics, I found that there were patients, when they were called with the telemedicine during the pandemic, were extremely surprised that a doctor was calling them and that they didn't have to take three different modes of transportation to get to the clinic to be seen by the doctor to maintain their IBD medications and to make sure that they had a touchpoint in follow-up. I completely agree with that. And I really hope that we can lobby for that to be in place, especially for those underserved communities. But I think the technical issue with that will be making sure that everyone has the connectivity. And I think that brings us to somewhat of a question that we can answer at this point. Do you agree? Right. So I think that the ability to get onto a network or at least have a smartphone, I think the good news is that so many people have smartphones. But yes, the infrastructure from a connectivity point of view is going to be very important for the continued success of telehealth. Thank you. I have a couple of questions in terms of the various different aspects the technology affects us in GI. And I couldn't agree with you more in that GI is that gastroenterology is that subspecialty that interacts with technology. It's embedded in our practice every single day and every part of our practice. In terms of the EHR, do you see improvements with the AI where a algorithm can help us take care of a specific patient based on their response to medications? Do you feel like that may become a norm in future? Because that would make it much easier. For example, if somebody has tried a PPI that they were resistant to, it will allow you to choose the right one for them in future. That's just a simple question, but that hopefully gives you a gist of what I'm asking. I think so. I think that the algorithms and the one I mentioned a few moments ago, there was a really nice study about GI bleeding, which sort of goes hand in hand in what you're talking about, which is sort of personalized management for patients. But the article that was actually put out, I believe by Lauren Lane's group, looked at risk stratifying patients for gastrointestinal bleeding, and the AI algorithm really outperformed some of the bleeding scores that we learned about in fellowship that I think I don't even see my own fellows put that in their note. But certainly for conditions like inflammatory bowel disease or IBS, looking at symptoms and giving recommendations for different medications to try if patients are failing, I think that's something we're going to start to see. I think those types of algorithms are being worked on. It's not going to happen overnight, but I would say in the next couple of years, I think we're going to start to see exactly what you're talking about. And I know that the big electronic health record companies are really looking to pull AI into daily clinical practice to help patients and also help physicians. Thank you. I won't hold you to the answer for this question, but do you see in future us using genetics, big data, AI to actually help develop treatment algorithms? Do you actually feel like that may be the norm in future and not necessarily the double blind randomized studies? So I do think that as the algorithms are developed, I think we are going to start to see the value of personalized care. I'm not sure if it's going to fully eliminate randomized control trials. I think clinical research is going to be a key element. And I think the results of those types of trials, which I think will work in parallel to the development of really robust AI systems will take time, but it's certainly a future state that we could think about. I'm not sure where that's going to happen in our careers, but I suspect it's something that we'll hear more about. Thank you. Going on to the next, which is the EHR data entry aspect of it. I couldn't agree with you more about the burnout aspect of it, the data entry burden that all of us carry. Are you anticipating any changes in terms of a real life bot helping us enter the orders, enter our thoughts into the notes? As I've said to my staff before, I would love to have a Siri follow me everywhere I go and enters my notes and also enters my orders. Do you see that coming into fruition? I think so. I know that there are practices out there that use real time scribes to decrease the burden for physicians for doing the routine tasks. So I don't see why an AI system or a Siri like system can not only help put our notes together, but also put in orders in the EHR. I think that type of progress and software development would be a big game changing moment for all of us that are very busy in clinical practice. So I think that's something that we should see in the future. I really hope that there is interest. As I mean, often it surprises me how much interest there is to visit outer space and not the same amount of interest in putting technology into our medical field. I hope that equal, if not a higher amount of interest is shown in this. I just want to switch gears a bit into the data aspect of it. Big data or collecting data and analyzing data takes time. And often we know similar to the double blind control studies that you could be onto something and you may not be able to prove it or it is completely wrong. And our data right now is not complete, meaning some of it is very rudimentary way of entering and it cannot be tracked or mined. How do you see the current data being utilized for any specific use for medical purposes? And do you think that the entry should be different in terms of how we can use it in future? Well, so I think that to your point that the data is there, right? It's really just having the machine based learning algorithm to analyze that information. And I think we're going to see that just from the ability to for an AI algorithm to scan through a patient's chart or thousands of patients charts, not only to give clinical recommendations, but I think another area would be to identify patients that could be part of a clinical trial, meeting various criteria. And I think we're going to see that. So the data is there. Now we just need to have the algorithms to sort of run that data and pull that data. And I think that's where a tremendous effort is happening in healthcare today. I think the insurance companies are very interested in something like this. I think it has tremendous benefit to improve outcomes, improve the quality of what we do, even potentially reduce medical errors. Thank you so much for that. And I have a couple of other questions that I'm going to reserve. And one question that came in the Q&A box, our providers do stricturotomy for IBD. I have not had much success in obtaining prior authorization. Any suggestions? Yeah, so I think for these unlisted procedures, it's one, making sure you have good documentation for what you've done to that point. And then it's really just negotiating at this point with the local payers. Other avenues that you could explore is even the ASGE. You could reach out to the reimbursement folks there. They could give you some guidance since they get requests from across the country. And they have good suggestions. I hope in the future we'll have a code for something like this. But again, I think it just relates to the fact that there are not that many people that offer this procedure. But in that situation where it's relatively novel and there's not a high utilization number, it's really just trying to negotiate with the local payers to get coverage. I think we've had some good success with ESD and POEM. And I suspect this procedure also could have that success. But I think it's more working locally right now. Yeah, so it does make it difficult. But each one of us has to sort of tackle it at our local market. I want to switch gears to the equipment aspect. And as you know, I'm passionate about the ergonomics aspect and how the equipments are developed. Are you working on anything that the equipments will change drastically in the near future? What do you foresee with our DI equipment and how we use them in the next few years? Yeah, it's a really good question. Because the manufacturers that produce the scope equipment, they start thinking about something today for a platform that won't be available for 5 to 10 years. I think that the ergonomics of endoscopy has really gained a lot of steam in recent years, a lot of momentum. And I think the scope manufacturers are really looking at that to try to improve the ergonomics, whether it's the dials or the drive of the scope. I think that we're going to head into an era of robotics in endoscopy. There was a little glimpse of that a couple of years ago. But I know that there are a bunch of companies working in that way. And it could be how we advance the scope changes versus the traditional way we've been doing it for decades. But I do suspect there'll be some adjustments in the future. I'm not sure exactly what that's going to look like. Because again, you need to make sure that the new version of a scope or a processor performs just as well as what we're used to today. Yeah, I really hope that is the case. And I hope that at least I will get to see it before I stop doing endoscopies. I have a two-part question to something that you already addressed, which is, do we know enough about the technology and the malpractice aspect of it? So just keeping in mind the duodenoscope dilemma that we kind of uncovered and dealt with a few years ago, when we use new technology, do you feel as providers we have adequate amount of information to explain to patients what to anticipate? And to that end, how do you think we can protect ourselves with the malpractice issues that arise from new technology? Yeah, so I think that's a really important question. When we think about the duodenoscope, for instance, I think the FDA recognizes it's a very valuable procedure, and it's really beneficial to patients. And I think the recommendations that they had given were to, one, redesign the scope itself and address different ways to clean the scope. And both of those things are being worked on. In terms of the impact of new technology for malpractice, I think the patients just really need to be informed if they're really getting something that is completely new, not been done very, very often, or something that's really growing in the space. And you could look at what happened in surgery and the introduction to robotics back in 2000 and look at where robotics is today. And I think we're starting to see some of that type of progress in endoscopy. When you think of third space endoscopy, where we have some really talented colleagues that are doing things that 10 years ago we would not think is possible, but I think the patients just need to be informed of what they could do the traditional way, or if they really want to do something less invasive, like some of our colleagues are offering. I think as long as that is well-documented and the patient's truly informed, I think that's probably the best form of protection. Thank you. I have one more question that came from the audience, and then I'll let Colleen join in because she has a question she would like to ask you as well. Dr. Seth, are you using AI for polyp detection? What is the cost? Any suggestions for an app for bowel prep? OK, so good questions. I'm doing more clinical research in the area of AI, so we haven't committed to the commercially available system. I do suspect that over the next probably 12 months or so, we're going to see other AI systems get approved and be available to make the market a bit more competitive. I think the current AI system that is commercially available, GI Genius, they do have different options in terms of, or plans rather, to bring that into your endoscopy unit. I think the best thing to do would be to speak with them directly, and they'd be the best person to figure out what's best for your practice if you think that's a technology you want to bring in. In terms of a bowel prep app, there's no specific bowel prep app that we're currently using here, but if anybody who's listening today wants to type in to the chat box a bowel prep app that may be helpful, I'd love to learn something new as well. I think that's a perfect point in terms of the bowel prep app. There doesn't seem to be one that fits everybody's needs, and it's still a work in progress for many, many practices. But in terms of the AI, we are about to use AI just as a trial basis in our own practice. It'll be interesting for me, at least, intriguing to see what it does to our practice and procedure length. So what have you found? Does that take longer? And have you found it to be particularly useful or distracting? So I think it's important for when you trial something like this, one, to get a baseline of where you are in terms of your quality metrics for colonoscopy. And in this case, it would be adenoma detection rate. When you think about incorporating artificial intelligence, you're still going to just do colonoscopy, right? You're going to get to the cecum like you normally do. And then it's really just getting used to being alerted that there could be a polyp. And fortunately, the systems are pretty sensitive that once you insufflate enough CO2, then you're going to get a lot less false positives where a bunch of boxes are coming up. I think after a couple of cases, you sort of just get used to having that box pop up if there's a polyp there. And I think you'll sort of wrestle in your mind, did I see it or did the AI system see it? Did we both see it at the same time? I think the key for the AI system to be successful when you do demo it is how much surface area exposure you could show it because that's really what it's dependent on. It's not going to help us see more surface area. So if there's blind spots, it's not going to help you with a blind spot per se. But anything in front of you could potentially pick up those very subtle, say, SSAs that we really work hard to define. So it's a true step forward in innovation in endoscopy. So I think you'll definitely enjoy your trial. Yeah. Having been, I know you worked on this. That's, I think, the last time we worked together on something is the colon capsule. And with the fluid in the lumen and the partial not being fully inflated made a significant difference in how you could identify the SSPs much better. So in terms of using AI or in your general practice, do you tend to have your colon fully inflated, partially inflated for pickup of these polyps? And do you use any specific settings while using GIG News? No, you know, no, no, no specific settings. You know, I, I think the key for SESL serrated lesions is that, you know, many times they give you a little clue, right, where there's like that little mucus rim. And I think that when you have a patient that has overall a very good to excellent prep, and then you're just seeing a couple of areas where you're surprised that there's some residual mucus or stool, you know, that's when I really start to pay attention. Because usually, you know, that's where we're going to, you know, potentially find them, you know, to your point of over insufflating the colon. You know, I'll agree with you that, you know, the PILCAM colon polyps tend to be a bit more pronounced because it's in the normal physiologic state of the, of the colon. So I think you just have to have that balance of just the right amount of insufflation so they're, so they're not, you know, too, too flat. But that's what I tend to, you know, tend to do. And it seems to work out pretty well. But I'm always still trying to learn and even improve my technique to find these SSAs. Yep, I mean, they are tricky. Sometimes I go back and forth on a mucosal edema and have to use the PIT pattern to finally tell me that, okay, it's not an SSP. And I think the more cognizant you become, the more anxious you become about missing polyps. Yeah. In terms of technology, anything else that you'd like to share with us as closing points? No, I, you know, I think that it's, you know, going forward, we all need to have a strategy of how we're going to, you know, determine what technology is going to be most beneficial to our practice. And, you know, from the, from the society level, we have to continue to work with industry. And we, for many new technologies, have to come up with a pathway, you know, to at least sort of offset that practice expense, which I think is the biggest barrier sometimes for implementing new technology. Thank you. And I posted a couple of pictures that I took in Egypt Museum into the chat box based on your initial history aspect of the technology. I was very surprised to see that there was a birthing chair and that there were forceps and knives used in ancient Egypt medical practice. And of course, their mummification used various different, and I think our technology has been evolving since. I just feel like we are at a crucial phase in that technology aspect where it's taking off into a completely new direction. And it couldn't be more exciting. And I really hope that we can help improve care for our patients. But not only that, as you and I spoke, reach more patients that are not being currently reached for various different reasons. I thank you so much, Seth. This was just extremely informative. And as I said before, broad. And you touched on so many different aspects. And I'm sure we'll have follow-up questions. And nice to see you here. And thanks again. No, thank you. And enjoy the rest of the meeting. And congratulations to you, Colleen and Bruce. Thank you.

telehealth

artificial intelligence

endoscopy technology

Epic

underserved populations

polyp detection