Dr. Gutta, Dr. Anderson, thank you for the kind invitation to come and speak today. Let's see if I can get this to work. What am I doing wrong? They probably have to start your slides. Probably have to start the slides. Okay. I did YouTube video TED Talks and I just wanted to say I was going to dress up in like a black turtleneck and put on like a cool microphone and stroll around, but the setup is not that way. So that's okay. The cool part about giving a talk like this is there's no right answer. And so there's not going to be a major challenge to any data. And my intention is to talk you through the introduction of new technology. I'm just going to wait for the slides. Yeah, they do include slides, apparently. We can do jokes. I mean, you know, we can... We can... Thank you. That's right, interpretive dance is next. We could do, yes, we could do it all. Here we go, okay. Very good. Thank you. Let's see if I can make this work. Okay. So here are my disclosures. So we heard this morning, and if you walk downstairs onto one floor beneath us, you will see a room filled with our vendor colleagues. And we heard this morning about a ton of new technologies. And I feel like every day in the endoscopy lab, somebody is coming and saying, try this. Here's a new box. Here's a new scope. Here's a new probe. Here's a new procedure. Here's a new technique. You should introduce it into your clinical practice, and we should expect this, right? We should expect technology to change because that's our field. Gone are the days, however, of here's a new technology. I want it. Therefore, let's get it. Therefore, it's going to happen. Therefore, we're going to make it work. Those days have ended, and those days have ended for a variety of reasons. One, healthcare has changed. Two, the way that we approach healthcare has changed. Three, the way that we work within healthcare has changed. And so if you leave here today with anything, it's to reinforce the idea that in introducing new technology or new anything into your endoscopy unit, you need to have a technique. You need to have an approach. However, even if you don't have a formal leadership title, you are a leader in your endoscopy space, and that's because as a practicing physician or as an endoscopist, you are in many respects the captain of the room. And so when you come to bring a new technology in, I really like Kotter's eight-step model as it pertains to change because what you really are doing is changing the routine that everybody goes through on a daily basis. So it's really eight steps. You don't have to memorize them all, but it provides you with a framework and an approach to actually implementing change within the endoscopy unit can be applied to any new technology. So one, create. This is the why. Create the burning platform. Why are we bringing in this new technology? Two, build. Form a guiding team or a coalition. So who are going to be the early adopters of this new technology? Who's going to help you to implement it in your everyday endoscopy practice? Bring that group together. So you've built, you've formed. Now number three is forming a strategy. You need to have an approach to bringing in the new technology. Like I said before, I want it, so therefore it comes, doesn't really work anymore. And so you really need to have a strategy as to how you're going to implement and bring these new technologies in. You're going to start to then enlist colleagues to help communicate and put forth your vision and able, so it's not just you. We know that with any new technology, you may have techs, nurses, anesthesiologists, people who run your clinic, administrators. Bring people together, empower them, and make them part of the process. You're going to formulate short-term goals, so you want to understand what are the early wins. I'm a big baseball fan, and the best baseball is probably small ball, where you can score many runs by just hitting singles. You don't have to swing for the fences. Most heavy-hitting home run teams never, ever win the World Series. Sustain, and so really you need to understand the wins. You need to celebrate the early wins, so when you introduce the new technology and you've brought your team together and you've established the why we're doing this, once you successfully implement the new technology and you help the first few patients, you want to celebrate those wins, and then you rinse and repeat this cycle over and over again. So again, new technology innovation is really just an exercise in change management, and in change management, you need to have an approach. So you want to bring in a new, and I said here, fill in the blank. There are a number of things that you really need to think about beyond just having a method for implementing the new technology. So technical readiness. Do you know how the new technology works? If it's a new box, do you just know how to turn it on, or do you know how the probe fits in? How does it function? How to troubleshoot the issue? So do you know how it works? A lot of the technologies are new skills. So think about this. Our field of endoscopy has seen incredible innovation in the things that we're doing today. When I trained in the days of the giants, we thought the muscularis propria should not be violated. And if you did violate the muscularis propria, the patient went to the operating room. But now we actually do that on purpose. And so this is a huge set of new skills that need to be acquired, and so that's where I fit under the guise of technical readiness. Operational readiness. So do you need capital equipment? Do you need the capital to buy the capital equipment? How about IT? How does this fit in with the IT platform? Do you need disposables? Have you figured out how you're going to bill for this procedure? What have you told your GI clinic? How about scheduling considerations? And what do you tell the patients before and after the procedure? And finally, operational readiness. How will this work in the endoscopy unit? Are there safety concerns? Do you need an operating room for some of these procedures? What have you told your nursing colleagues? And if your anesthesiologists are like mine, mine like to have protocols, and they have protocols for different procedures. It's good clinical practice, but you need to make sure that you engage other colleagues in the work that you're doing. And so I talk to some of my colleagues all the time, and I say, you know, we're going to bring in a new technology. You might say you want this technology. Some people in your endoscopy unit will just show up, and the technology will be there, and they will be users. But if you are leading the change, and you are leading the implementation of the new technology, these are all of the considerations that need to go through your head in order to properly implement it in your new endoscopy unit. So let's talk a little bit about new skill acquisition. And so the answer is, yes, you can teach an old dog new tricks. And so think about how we are trained as physicians. We have a very prescribed training period. So we go through medical school, then we go to residency, then maybe we do a fellowship, and then we enter into clinical, and then maybe we do another fellowship, and then we enter into clinical practice. Those are very, very heavily concentrated and very prescribed years of training and steps. And at the completion of those steps, you're supposed to enter into a clinical practice where you will then stay for the next 40 years. The period between the ending of your training and the ending of your career is the longest time you're going to be in medicine. And in fact, it's the least prescribed time relative to what you are going to do. And we have to anticipate that technology is going to change, and new skills are going to become available. And so we need to really think about how we are able to acquire these skills after our formal training period has ended. And so the days of kind of like see one, do one, teach one. I saw a poem, and then I did a poem, and then I taught a poem. Probably not the right thing to do, especially with some of these highly technical skill sets that have very, very steep learning curves. So steps have changed in endoscopic innovation, and I'm going to continue to go back to poem multiple times, not because it's the only technology that we reintroduce or the only new procedure that we introduce. But you'll see at the end that it's kind of an example that I'll use as to how we applied all of these steps in our own endoscopy unit to bring the program. But for many of the things that we do, the risk profile is higher. When we introduced poem, you know, in the third case, we were looking at the pericardium. My endoscopy nurse turned green and almost fainted because we're not supposed to be looking at the pericardium. We're not trained to look at the pericardium. And so, again, the times have changed, and the learning of new skills has to be done. And so there are a number of opportunities that you can take advantage of to learn. There are hands-on programs that own ASGE, is heavily invested in this space. There are mentors that you can have. And you need to bring your team. So, again, at the end of the day, this is not just about you. Endoscopy these days is, in many respects, a team sport. And I think you're much more likely to be successful if you bring your team members along with you so that everybody is moving in the same unified direction. Newsflash, healthcare has changed. And this really impacts our ability to implement new technology. Because I want it is really no longer going to make a lot of sense to the people who are helping you to make decisions about bringing in new technologies that may cost money. So most physicians in the United States are now employed by some entity. Huge consolidative forces in our industry have led to expansion of what I would call a corporate infrastructure in healthcare settings. So like it, love it, hate it, understand it, and embrace it, and really comprehend it because it has a huge impact relative to our ability to function. And so you will likely know that in your hospital where you perform your endoscopy, that there's a value analysis team or equivalent. There's some entity looking at the cost, the charges, the reimbursement, et cetera, to help make decisions about new technology. So understand that process. And also know that administrators are not part of a sinister agenda that is out to get you and to say no. But realize that every year, our patients want procedures with robots and the newest, latest, greatest technology with the medications that cost the most. And the largest payer of health care services in the United States, the federal government, tries to either decrease reimbursement or at best, it takes an act of Congress to keep it flat or maybe mildly increase. And so those are in the faces of major labor force issues and rising health care costs. That's really what your administrative colleagues are up against. So realize that and recognize that and know that beyond your ask for capital and capital equipment and new technology, they've got a list of 100 or 200 other things if they're part of a very large hospital setting. So understand the process, understand the people, and use the methodology and the change management methodology to bring people along to help you get what you need. So my colleague Dr. Oppmann at Baylor in Houston, I saw a talk that he gave at DDW this year and he was generous enough to provide me with a couple of slides on how to work with hospital administrators. So on the left side, you can see that hospitals are interested in certain things. Things that save money, good. Shorter procedure time so that you can have increased throughput, also probably a good thing. Decreased length of stay. Right? Remember, we get paid for a single episode of care, especially for inpatients. So the shorter the patients stay in the hospital, the better off it is financially. Things that decrease morbidity and mortality and novel devices or procedures which will set them apart from the competitor. I think these are all very, very compelling reasons when you start to discuss new technology with administrators. Hospitals are not interested in the items on the right. Your personal preference with some exceptions. Right? I only use this one single fill in the blank. Most consolidated health systems have large contracts and it's really hard to go upstream against those contracts. Very expensive products with minimal use, so really pricey things that are going to sit in the endoscopy unit and are going to expire. We have to have it because the fill in the blank has it next door. Probably not a compelling reason. Me too products, so having two of anything probably not the best. The issue of downstream revenue, and this is coming from somebody who wrote a paper on this that has been widely quoted over and over and over again in the setting of new technologies. Downstream revenue arguments could be made for almost every single specialty in medicine. You can make some degree of a downstream revenue argument. So while it's important to be able to delineate what the downstream revenue is going to be, that is a very, very common rationale that is given and we look at that all the time, but it's not the only factor. And then finally, unreimbursed procedures are a major issue as it comes to getting your equipment approved. So how do you work together with administrators? Write it up. Sit down with the administrators overseeing your endoscopy unit. You deal with really complex problems every single day. Writing a very brief and simple business plan that is a set of agreements relative to what you're going to implement, what you expect to get from it, and how you're going to look at that moving forward is really, really straightforward. You don't need an MBA to sit down and write a business plan. And this is the method by which, again, going back to the first slide that I showed you, this is the method by which you are going to bring your teams together around the goal of implementing new technology. And so a really simplified version, what's the current state, what's your future state, and ultimately, what are the barriers to implementation of the technology? Be prepared to come back and revisit this. So it's not good enough just to say, this is what we're anticipating. Come back, revisit it, see where you are, and commit to doing that, and you're much more likely to be successful. How about the clinic? I think there are a number of things that need to be considered here. How will the new technology impact scheduling? So if you're starting out with a new procedure, and at the beginning, it's going to take you a really long time, don't put a three-hour procedure in a 40-minute time slot, because you'll just make everybody else late. What about pre-procedure preparation? So what are you going to tell the patients? Is there any special prep? Do they need to be NPO? Is there a special diet? Consider written information for patients. Post-procedure follow-up, also the same. Any dietary changes, anticoagulation. Understand that some of our procedures now, just like surgical procedures, have a global fee period, meaning we get paid once for the procedure and the follow-up care that occurs in 90 days. And that may impact who you have seeing the patient for the follow-up care relative to how it's being reimbursed. And then everybody's favorite topic, prior authorization. And this one, I want to give a disclaimer. And it's the last point that I'm going to make first. Be prepared for frustration. So be prepared to be really frustrated. Be prepared to talk to people on the other end of the line who have no idea what you're trying to get approved, but really don't take it personally. The people on the other end of the line are just responding to a medical policy that may not be rooted in Level 1 evidence. So you really need to understand coding, CMS, and commercial carrier medical policies. Because the worst thing that you can do for a patient who requires prior authorization for a procedure is not get it. Because if you don't get it, you do the procedure. Then they're on the hook for the charges. And then you're at the mercy of your hospital to try to write those things off, which has financial implications. So you really need to be prepared around the need for prior authorization and understanding what the approval, what's the appeals process. So finally, what about preparing the team in the endoscopy unit? And I think we've all done this in multiple different iterations in our own endoscopy units. Remember that we have to think about supplies. Do not forget your anesthesiologist. So again, going back to the issue of POEM, it turns out that when you violate the muscular spherospropia and you insufflate CO2 across the chest or abdomen, you could get pneumoperitoneum. You could get pneumothoraces. And so it's important that the anesthesiologist actually understands what you're doing so that you can respond appropriately. And they don't start saying, hey, the airway pressures are 60. Do you know why that is? They are prepared for that so they can actually tell you, the airway pressures are 60. You may want to consider decompressing the pneumoperitoneum or the capnoperitoneum. Your nursing team and techs, do not forget about your nursing team and techs. Build a coalition. Build the team. Help them to understand why you are bringing in whatever technology and bring them along in the training so that they can be part of the process and they can be the experts just like you are. How about the room setup? Are you going to start the new technology in your endoscopy suite? Should it be done in the operating room? Are you going to start in the operating room, then move it to endoscopy? It kind of depends on what you're doing, but you want to know this ahead of time and have everybody set up. IT. So we talked a lot about AI this morning. How is that going to interface with your endoscopy reporting system and or electronic health record? And if you are bringing in a new technology that plugs into something, because a lot of these do, how is that going to interface with your IT systems? And that is not an inconsequential consideration. Credentialing. So again, as we get into higher risk procedures, your credentials committee is going to want to know what is required in order to do this. Not just for you, but for the next 5, 10, 20 people who are coming wanting to get credentials to do whatever procedure it is. And then finally, multidisciplinary care. So always remembering that for some of the procedures that we do, they may be best introduced with our surgical colleagues or radiology colleagues or whomever, or with those people knowledgeable about what we're going to be doing so that any complications that come up can be ultimately managed. So I'm just going to put it all together in a 23-second slide. POEM. And so when we went to introduce POEM, I don't know how many years ago, we started with training. So we got grant funding in order to send us to both a formal course down in Portland, and then also ran an animal lab where we brought mentors to help us to do this. We hired a mentor. So at the course, I met a fellow. We hired the fellow to come stand next to me for the first 15 cases. That fellow had a ton of experience in doing POEM and helped us to gain a level of expertise after which point they were no longer needed. We put a business plan together for additional equipment. We brought our nursing leadership and surgeons to be trained alongside with the endoscopist. We worked with our CMS carrier and local commercial carriers to help them to understand what we were doing so that we could reduce the burden of prior auth. Nutrition wrote up dietary recs for post-op and actually trained our dietary teams in patient, trained our radiologists that when they do an upper GI and there's pneumoperitoneum, not to freak out. And the hospitalists, when the patient has pain and they did a chest x-ray and the patient had pneumomediastinum, not to call surgery. We wrote up credentialing criteria, and we did the first 20 cases or so in the OR. We never cracked an OR tray, but we were prepared in case something happened. So in summary, new technologies are part of an endoscopy, and you, as practicing endoscopists, are part of the new technology, and you should expect to do these during your career. Training and mentorship are keys to ensuring safe implementation, and always having a method to implement and undertake change management is absolutely critical. Preparation, partnership, integration, it makes integrating these new technologies easier. Get your administrators involved. They're not sinister. They're not there to say no. They're just trying to do a good job on behalf of all of the patients accessing a health system. Get your staff involved. Get your endoscopy staff and other supportive services involved. And I'll leave you here with this term on the left side. The term is nemawashi. It's a Japanese term, and the literal translation is roots around. But what it really means is tilling the field. And so in order to implement any sort of change, you need to prepare the soil. And that's really the key to implementation of new technology safely and successfully in your endoscopy unit. Thanks so much for your time. Thank you.

endoscopy

change management

Kotter's eight-step model

technological adoption

collaboration

nemawashi