We'll kick the program off, the live part of it, with none other than Dr. Gross, who I crossed paths with when he was in Connecticut. Hey, Seth, good to see you. He's currently the clinical chief of GI and hepatology at NYU Langone Health and a professor of medicine at NYU Grossman School of Medicine. He's also very active with ASGE, a member of ASGE reimbursement committee and on the RUC advisory. He is the associate editor for GIE and he's relevant to today's talk. He's ASGE's AI task force member. And so he will get this program started with the talk on technology's impact on GI practice. Take it away, Seth. So my topic today is technology's impact on GI practices. And we are continuously being introduced to new technology in the field of gastroenterology. And it's quite amazing over the last number of years, especially since I've gone into practice, the transformation in the gastroenterology space, especially in the area of endoscopy. So my objectives this morning are to go over some background and also talk about adoption challenges. Because technology is very exciting and when we're first introduced to it, many of us want to figure out a way to implement it into our practices. But there are certain hurdles and barriers that we face. And sometimes even for a technology that seems to really be beneficial to patients, sometimes it doesn't have that longevity because it cannot overcome some of the challenges that we face. And I really fully didn't appreciate this until I became a reimbursement advisor for the ASGE. It opened up a whole new world to me in terms of what is required to take something that gets FDA approval to where it's used in clinical practice on a daily basis. And whether it's a technology or a new procedure or skill that the endoscopist could offer, it's certainly sometimes a long and tedious road. But when we think about technology itself, technology has been around forever. And whether you are someone that's embracing technology or a little bit more restrained and you're waiting for more evidence or a practice guideline, technology really does go hand in hand in medicine. And sometimes one would think that technology even came before medicine. And if we look back to the Egyptian times, the technology of the splint was used and they saw this in mummies. So people even back then were thinking about medical technology. And sometimes it's even older than the science itself. When I just look back at the field of gastroenterology and endoscopy, you could see just the timeline of how things have really evolved in 1805, Bozzini evaluated the rectum using a lighted instrument. And then in 1853, the first endoscope was used for urinary work. And in 1868 was the first time someone looked inside the stomach. And it wasn't until 1932 that the first flexible gastroscope was invented by Schindler. And in 1964, we had the first gastroscope that was able to take pictures. And you can just see from this slide, the evolution of technology and how medicine and procedural based specialties like ours have truly advanced. And then even beyond that, from 1968 to 1990, we have introduction to ERCP and things that we take for granted today in 1969, colonoscopy with polypectomy, and then putting in a gastrostomy tube in 1979. And then endoscopic ultrasound came on the scene in 1980. And I think even back then there was this question of, would this procedure have longevity? Will the clinical applications be there? And if you look at what's happening with endoscopic ultrasound today, it even seems crazy that that was even a question. In 1985, we started to do more interventional work, controlling bleeding, which we do on a regular basis. And then in 1990, we have banned ligation. When you think about where we are in 2021, third space endoscopy has really taken off. Physicians are doing endoscopic submucosal dissection and the POM procedure and other interventional things within endoscopy. And I think one of the challenges with new technology, whether it's a device or just a new approach to a procedure, is how do we have more physicians be able to do that? And one of the biggest challenges, which I'll talk about, is the issue of reimbursement. I think that that's probably the biggest barrier sometimes for physicians and practices and hospitals to offer new technologies to patients. And I'm really looking forward to the question and answer section after this talk. So really think about the questions you might have in the area of technology, and I'll certainly do my best to try to answer those for you. So when I think about the current impact of technology, there are a couple of things that immediately come to mind for me. So in the office, especially as we're getting through this pandemic, telemedicine. And in endoscopy, as I mentioned, there's the therapeutic aspect from a procedural side, such as third space or endoluminal surgery. But when we think about the diagnostic side, the thing that really pops into my mind is artificial intelligence. And I will talk a little bit about that from a reimbursement side of things in terms of how you bring technology into your practice. But artificial intelligence is probably the most exciting thing in medicine today, especially in gastroenterology. And I do believe that we're scratching the surface in terms of what the current AI system offers, which is really meant to improve polyp detection. But I think that's really just the tip of the iceberg. So when we think of a technology success story, I certainly think of telehealth. And telehealth was an amazing way for physicians to continue to interact with their patients and take care of them at a time where we couldn't see our patients face-to-face in the office. And procedures were certainly pushed off due to what was happening with the COVID pandemic. But it gave us that face-to-face experience. But the keys to telehealth success is just how quickly it was put into action, whether it's a practice or a hospital needing to implement the software, where insurance companies offered reimbursement and industry continued to help evolve the technology in a very short period of time. If we were in regular times, telehealth itself would probably have a much slower launch specifically because of the issue of reimbursement. But it's amazing when everything comes together, how you could see technology really be successful and adapted into clinical practice really almost overnight. That's the way I look at telehealth. And here's just a graph to just show you how quickly telehealth really took off over the last almost two years now. When you look back to March of 2020, in April, it was really at its peak. And even though it did level off as the first wave of COVID started to wind down in June of 2020, it does have staying power. And I think we all continue to use telemedicine and telehealth today. And I think our patients appreciate it. It's an easy way to connect with someone where they don't necessarily need to come to the office. But this is just such a great example of how practices were able to incorporate telehealth really based on, again, the key here, which was the ability to have reimbursement and the ability to implement the software for respective practices. I wouldn't say easily, because I'm sure everybody has a different experience. I could tell you where I work, it was pretty seamless. A couple of kinks in the first couple of weeks, but then once we figured out what we were doing in terms of how to maximize telehealth, it was very helpful to our patients and quite a success. And you could see that the role of telehealth really went across specialties. Everybody from psychiatry, and you could see here, gastroenterology, all the different subspecialties incorporated telehealth into their practices. And again, I can't stress how beneficial it was. But that is technology. And when we think of the endoscopy space, the area that I alluded to before is artificial intelligence. And artificial intelligence currently is being worked on in the colonoscopy space. But I would say over the last 12 months, we're seeing all areas of medicine have artificial intelligence, especially in endoscopy. But here, just to give you a sense of what we're talking about, and this is really an AI system for colonoscopy that offers everything. You see that green box that identifies the polyp on the left side. This is to gauge the bowel preparation if you're using the Boston bowel prep score. It's a level three here because it's a pristine prep. And it's also telling us the size of the polyp and the type of polyp, 12 millimeters, 1S, with pretty high confidence in terms of what the AI system is looking at. And this is a type of technology that I think over time, more and more physicians and endoscopist practices are going to figure out a way to embrace it and bring it on. And I think that especially in a procedure-based specialty, we can't run away from technology. We just have to figure out the smartest way to bring technology into our practices and really picking the ones that we think are going to be most valuable to our patients because not all of them are going to have the same clinical impact. But even when we think of artificial intelligence, again, just like technology itself is not a new concept. Artificial intelligence has been worked on dating back to 1950 with the Turing test. And then you take it all the way to present day. There was a gap between, I would say, 1986 and 2000. But then when you look at where we are over the last, I would say, three years or so, there's been a tremendous amount of work in the area of artificial intelligence. And I think this is going to expand way beyond just endoscopy. I think it's going to improve the whole procedure experience, not just for the patient in terms of quality outcomes, but also for the physician. But there's tremendous resistance to technology. I think advances in medicine, even in our space, there's hesitancy. You're doing something differently. What does it mean? How is it going to impact my daily workflow? Once you get past the fact that there's good evidence to suggest that it's going to be very helpful to your patients, how is it going to impact my practice and something that I really built and cultivated over all these years? And how am I going to be able to bring this technology into regular use on a daily clinical basis? And you have to think about that the medical team itself is going to be changing. We have our physicians, nurses, and other members of the team. Of course, we have our patients. One thing that's certainly going to be introduced is going to be machines and artificial intelligence. You're going to see that it's going to continue to get more involved in our daily clinical lives. We use a fair amount of artificial intelligence in our life outside of medicine. When I think about it, where I work in Manhattan, there's an Amazon Go store, and it truly is you're on the go. You just scan your phone to enter, and then you just pick up your items, and then you walk out, and there's no checkout. Everything is all automated, and then you just get a little notification on your phone of what you purchased. And it's pretty amazing how seamless it is for us to incorporate machines and artificial intelligence to make our daily lives maybe a bit better, a bit easier, a bit more efficient. I think we're going to see those applications happen in gastroenterology, and we're starting to see that already. What are some of the benefits when we think about technology, especially this type of technology, which is artificial intelligence? Automate mundane tasks. The pain points in our lives, like documentation, coding, billing, scheduling, potentially could get easier, even though I'm sure many of you have good systems in place, but imagine the ability of making it better. Consolidate and analyze data from multiple sources. Give some guidance with decision making. And all of this will make, potentially, a physician's life easier, and also get them back to the basics of why we went into medicine, which is to interact with patients, and spend more time with them, and really personalize their care, and putting them in the best position for the best outcome. So what are some of the areas that we're seeing technology slowly creep into the gastroenterologist's practice? We'll talk a little bit about digital health and wearable technology. I'm not sure how many of you, during this talk, already looked at your Apple Watch. The electronic medical record, I think, continues to evolve and is becoming a staple. It's just really a question of how many features a given practice could activate when they introduce the electronic health record. And we'll touch a little bit more about artificial intelligence. I know there's a talk later today, more probably around the clinical aspects of it. I'm going to strictly limit myself to just some of the reimbursement that concerns. So when we think about digital wearable technology, this whole idea of a continuous health monitoring, the areas that have been worked on in gastroenterology include IBD and IBS, which I think being able to better monitor patients' symptoms remotely will potentially make it easier for us to give advice and change management for these patients that are struggling with persistent symptoms. And when we think about the different devices that are available, everything again from a Fitbit to an Apple Watch, Apple Watches are somewhat sensitive to the effect that even my father, who's got atrial fibrillation, will text me and just say he got a notification and he'll send me a tracing of his EKG showing that he's in a rate-controlled atrial fibrillation. When you think about some of the things specific to gastroenterology, you have this UCLA IBD patient app, which is again a disease activity marker. There's Health Promise that sort of monitors the quality of life based on symptoms. There's even Poop MD, which records your bowel movements for patients, and some of them are very focused on that. And then IMBED, gastrointestinal bleeding and management. So you could see that these devices potentially could help us as we manage our patients and it's just figuring out, you know, how we implement these technologies into practice, you know, some of these are not going to have a significant overhead for one's practice, whereas when you look further down this list and you think of, you know, colon capsule, you know, colon capsule is certainly an interesting technology. It's been around for a number of years and it was only until recently that we were able to successfully get an RVU value for this technology, and I think that's the key, right? Once we have reimbursement aside for the physician work, but it's also the practice expense because I think that's the hardest thing that practices and hospitals have to overcome, which is to at least get the equipment and devices covered, and so we've sort of made some headway here, you know, with, you know, capsule colon, pill cam colon for patients. And when we think of the, you know, the benefits of these remote monitoring devices, you know, the benefits will be to help with diagnosis and management of our patients, and this could potentially even reduce healthcare costs since you could address things a bit more real-time and also, you know, develops an even better partnership between the physician and patient, and the medicine can be a bit more personalized for patients, which I think they're really looking for today. You know, what are some of the challenges? Anything that's related to artificial intelligence or remote monitoring is privacy, and, you know, what about inaccuracies with the data that's being collected? And of course, you know, we'll certainly need, you know, additional research in this area to make sure that the software algorithms are maximized and there are a few false positives or false negatives when these things are reporting clinical symptoms for patients. And you must ask yourself, why should we consider embracing technology? And I think that there are a couple of things that we have to think about, which is improving practice efficiency, increasing your scope of practice, offering more to your patients, and of course, improving the quality of care. And I think these are foundation principles that, from a practice point of view, we have to think about when we're taking care of patients, because these days, you know, everybody wants to offer the best medical care for their patients, but, you know, oftentimes these things come at a price, and we have to be strategic of trying to figure out, you know, what should be, you know, brought into one's practice. So, now I'm going to talk about, you know, probably the most important part, you know, of this talk is the adoption hurdles. And when I think of the adoption hurdles, I think of coverage, coding, and reimbursement, and they all go hand in hand. And you need to have all of these, I think, from a technology point of view, to be successful for implementation into one's practice. And so, what are some of the concerns? When I think of the concerns, there are concerns about technology for patients, but there's also concerns for physicians and hospitals. From a patient point of view, they're going to ask, you know, what are the risks? And then the next big question for them, you know, does insurance cover it? And if it doesn't, what's going to be the cost? And are there alternatives beyond what, you know, what we're talking about for respective technology? The physicians and hospitals, you know, have different concerns. Will they get paid? You know, is it very difficult to do? You know, I think after someone's mastered something and has done something for a number of years, the idea of bringing something new in, you know, how is that going to impact my procedure? Will it add time? Do I have the resources to incorporate this technology? And what's the impact on my malpractice? And I think any one of these, if we can't overcome them, will impact the ability for technology to make progress and, you know, penetrate the market. So what about coverage? You know, payers will determine if a technology will be covered. And I think many times there's this misconception that FDA clearance means coverage or that something's going to be imminently covered. And that's really not the case. You know, from my experience, all it tells us is that this device is safe, which is great. But, you know, there's still a big gap between something being FDA approved to, again, being used all the time if there's no coverage. And I've seen some technologies over the years that had some great promise, but sort of ran out of steam or the respective companies that were developing this technology ran out of funding just because they did not get to where they needed to be, which is ultimately coverage. And payers are very picky in deciding if something should get covered. And what they'll do is, as many of you know, they're going to look at what they currently cover, you know, and how is this new technology different? How does it impact patients? You know, is it better than what's currently being offered by a respective plan? And this is a very, you know, challenging concept that I think we as physicians need to be aware about. Because I, you know, talk to physicians all the time in our field, and they always ask me, you know, why isn't this covered? Or why did, you know, our reimbursement change? You know, when is this going to be covered? How come no one's working on it? And so the another aspect of this is coding. And coding is just that universal language for diagnoses, procedures, and products. And there are different level codes that one could get. Level one code is, you know, the by far the best one, which is FDA approved, a distinct service that many physicians perform. And that's often could be a challenge, because when you're dealing with new technology, due to the constraints of who's going to pay for this could limit, you know, physician use, and is it supported by the medical literature. And there's a nice table in terms of the types of studies that are required both here in the U.S. and abroad, that could really justify a technology that it meets the clinical standard that should get reimbursement. Level two codes are more of those pass-through codes. So for instance, you know, the disposable duodenoscope, one of them has a, you know, has a pass-through code, you know, to get reimbursement for the device itself, which is going to be very helpful, you know, if hospitals are interested to go down a disposable scope model. And level three, which is probably the worst case scenario, I think, for an emerging technology, which is where it's very promising. The level of evidence is preliminary, suggesting that it works, but it's deemed investigational. And once you have that investigational label, it takes a tremendous amount of work to move it from a level three to a level one, mainly on the research side of things, of doing the right trials, you know, to show that this is not just investigational, but should be used routinely in clinical practice. So what about reimbursement? Reimbursement is that combination of coding plus coverage. And I think there are really other important factors that we have to think about. And I think the professional societies and the ASHE does a really fantastic job about helping technology reach the hands of physicians by really putting a tremendous amount of effort to get things reimbursed, get value for things. And the professional societies, when they look at a new technology, I know they look at, you know, how does it impact cost? You know, is the quality and safety there? And is there enough evidence-based medicine, you know, for the society to support it and to try to help move that technology forward? And if all these boxes are where the bottom two boxes are checked, where the quality and safety is there and the evidence-based is there, you know, sometimes new technology often is associated with increased cost, you know, and that's why you need a robust plan to get, you know, reimbursement for these technologies. So when we think about, you know, artificial intelligence, I alluded to it before, you know, this quote-unquote AI doctor is really going to just be, you know, another member of the clinical team to help make us do better decision-making. It's sort of similar to when you're doing a colonoscopy and you're working with your nurse or tech and they point out a polyp for you. Now, of course, you saw that polyp too, but just think of it as another set of eyes, you know, to help us, whether it's in the procedure room or crunching big data or analyzing an electronic medical record to sort of risk stratify a patient that may need to get admitted to the hospital for presenting with a GI bleed or the data suggests that the patient can get safely discharged. So currently being used in colonoscopy, one of the big limiting factors today is there's only one AI approved FDA device. And again, AI systems currently don't have additional reimbursement and I think that's going to be a limiting factor. The applications, I think, are going to tremendously expand. And what could technology do in this situation? Improve our lesion detection, reduce blind spots, assess bowel cleanse, target biopsy. So the first three are around colonoscopy, the other is in upper endoscopy. But I think of AI even bigger and machine learning to improve healthcare overall. Ease the paperwork burden, reduce medical errors, improve access to care, and decrease physician burnout. You know, I think these are things that we deal with on a daily basis. And when psychologists look at humans and what we could handle, we're very good at four independent variables, but if we get to a fifth one, we've run into trouble. And that's why machine learning and technology could be very helpful with the tremendous data overload that we face on a daily basis. But how do you incorporate, you know, AI into your practice? And that's the crux of what we're talking about today. And you have to look at patient benefit, clinical evidence, value-based care, offsetting the cost, and how this will complement the care team and not replace them. What are some of the barriers to a technology like this? The algorithms need to continue to be validated, regulatory approval. And again, how do we overcome the cost? I think the biggest barrier with technology and the lack of reimbursement. What is needed to get a technology to the provider? There's this, I think, this ecosystem within gastroenterology involving regulatory bodies, research, GI society support, academia, and commitment from industry. And I think we have that and we've had this for years. I just think that we've had such a tremendous advancement over the last 10 years in new technology that we're going to need all these parts working together to get us where we need to be, which is to get technology reimbursed and valued so we could offer that to our patients. I mentioned this earlier, you know, the most attractive things about machine-based learning is that we could get closer to our patients. It eliminates these mundane tasks related to electronic medical record, where imagine living at a time where after you're done with the office or the hospital and you went home, you had nothing else to do. But I know many of us spend hours upon hours in their electronic medical records, closing notes, writing notes, putting orders in. I imagine if this made it a bit easier. And potentially this could also help us in the endoscopy space where we can improve the quality and performance of physicians leveling the playing field. So how do you strategize to bring technology into a practice, an ambulatory center, a hospital? I think the first thing you need to do is you need to identify the key stakeholders for that. And you really need a champion to move a technology forward and you have to strategize. You need to determine for a specific practice or hospital, you know, what is really needed versus what is a wishlist item. And, you know, that's the challenge, especially with technology, especially with the advancements and the new things that we're seeing, you know, almost on a daily basis, you know, what is critical and what is not, and how does that fit into the budget that was planned for that practice and what's going to be the return on investment if we bring that in. And these are hard conversations and hard decisions because ideally we would love to have everything, but the reality is not everything needs to be brought onto a practice or into a procedural-based space. One of the things that I deal with from a hospital level is a value analysis committee. And the value analysis committee is made up of a bunch of different individuals from the hospital, whether it's physicians, nursing, people from finance, and they look at a couple of key things. They look at the cost, will the device have a negative financial impact, the quality, is it durable and reliable, how effective is it, and what's the outcome for what it's being performed for, is it available, you know, is it difficult to store, because that's the other thing, space is tight in most places, and the packaging, you know, the carbon footprint is very important today, you know, not just globally, but especially, you know, in endoscopy, we go through a lot of devices, single use, and, you know, how will that be looked at. Now, if you're the one going to the value analysis committee, you have to be prepared, you know, to address some of the concerns from the prior slide. If you're going to value analysis committee, the product has really already been deemed safe and effective. Is it more cost effective than the device it's replacing? So sometimes when we deal with technology, it's going to replace something that's already on the shelf. But I think many times it's going to just be something in addition to, and you really need to justify that and understand the clinical value of what it's trying to complement in a specific procedure. Will it improve clinical outcomes for patients? In endoscopy, I think what we're doing today is we're doing many procedures, and in the past, you know, a patient would need to go for surgery. And so I think that, you know, when you think about it that way, you know, there's certainly value. Will it improve the efficiency of a physician? So when I think of devices we look at here at our medical center, especially in third space endoscopy, you know, could we shorten the time of an ESD? Could a POM procedure also, you know, end a little faster in a shorter time period? You know, then those are certainly going to be value-added, you know, devices. Are there any negatives about bringing this on? The other important thing is the training. You know, what's the training and education needed for the physician that's going to use this, but also the staff, because oftentimes with technology, there's a lot of back-end work, and you really want to have something that's not going to overload the staff that's already busy, you know, doing the routine stuff in an endoscopy space. So just to conclude, I think the future of healthcare lies working hand-in-hand with technology, and we really need to figure out a way to embrace it. Since it's not going away, I think it's just going to get more immersed in our daily clinical life, and we have to balance the clinical and quality merits of a technology versus the cost, and I think that really is the biggest challenge that I see from the work I do with reimbursement nationally and the daily stuff I face here at the hospital I work out of how do we balance the clinical and quality and the cost of some of these new exciting technologies. So I'm happy to take any questions.

technology

endoscopy

digital health

artificial intelligence

validation of AI algorithms

strategic implementation

quality of care