title, Digital Health is Undermining the Practice of Clinical Medicine. The second reason for why this is a special session is we have a debate, and I love debates. And the debaters are actually, both of them are giants in the field. So this will be really interesting. Before we start, I want to remind the debaters that each of you has 10 minutes to present. And then after the first 20 minutes of debating, we're going to open it up for discussion, and we have an esteemed panel of experts with us here. I'm going to ask each of them to introduce themselves, starting with you, please. Good morning. Dr. Herman Williams, president of HW Healthcare Consulting and a long history as a chief clinical officer for several national healthcare chains. Hello. My name is Junaid Zaman. I'm an electrophysiologist based in Los Angeles, and I have a deep interest in bedside medicine, having founded a society called the Society of Bedside Medicine to try to kind of keep the values of clinical medicine astute in modern practice and clinicians, and have been involved with a program in bedside medicine at Stanford University for the past seven years to try to set up a conference, again, to develop faculty of clinical awareness on how to improve bedside teaching skills. So, pleasure to join you all. Great. Clyde. Good morning. Clyde Yancy, professor and chief of cardiology at Northwestern University Feinberg School of Medicine, Vice Dean Diversity, Equity, and Inclusion, associate director of our Cardiovascular Institute. Thanks. Good morning. My name is Sanu Thomas. I'm here, really, because a dear colleague of mine, Dr. Nasreen Ibrahim, who is a powerhouse in her own right, was unable to come due to COVID, and so I was pulled off the bench. So, thank you for allowing me to be here. I am the current medical director of mechanical circulatory support and the director of interventional heart failure at the University of Washington, having moved from Boston in November, and working in an environment where we are a quaternary center supporting five different states. The goal is to use whatever technologies we can to advance the mission of advanced heart failure and intervention to those who are in need and where we can overcome the barriers of geography. Thank you. Good morning, everybody. I'm Jag Singh. I am a professor of medicine at Mass General Hospital, Harvard Medical School. Excited to be here. Well, many thanks to all the panelists here, and special thanks to you, Dr. Thomas, for being here on such a short notice. We really appreciate it. So, with this, just as a reminder, you guys, please submit questions. We'd like this to also be interactive with the audience, not just among ourselves. And I'll turn it over to Clyde, who will present the protagonist view. Well, good morning, again. I'm delighted to be a part of this HRX meeting, and I'm delighted to not really have a debate, but to have a really important conversation with a colleague, a peer, and especially a friend. I don't think that means that there won't be polarization. Don't think that doesn't mean we won't have different points of view, but it does mean that we intentionally want to have a conversation that informs the landscape. My task is to take the argument that digital health is undermining the practice of medicine. Jag is going to convince us that digital health is the only solution for the future practice of medicine, and I'm going to agree. But I'm going to agree with the caveat, yes, but. Any of us that use a device understands that there's a new language, a new vernacular in our world, and that's the digital experience. It's no longer a toy. It's no longer a gimmick. It really is a part of our lives. The only way I got up this morning was as this phone woke me up. The only way I can have my conversation with you in lieu of PowerPoint is because I have my talking points on this phone. The digital experience is here. Let me start with a thought experiment. I need everyone to kind of look this way and just engage with me for 90 seconds in a thought experiment. First question. Since you've arrived at HRX, have you been served by anyone in a fast food restaurant or bar? Beer, pizza, hamburger. This isn't a heart healthy quiz. You don't need to raise your hand. Have you been served by anyone in a restaurant? Question number two. Since arriving at HRX, have you noticed anyone in a hotel who's not a guest but an employee? Question number three. Since arriving at HRX, have you either hired a car or taken a ride in a taxi, and either the driver of the hired car or the taxi was clearly an immigrant? So if you think about this, in the last 72 hours, you've touched the face of digital poverty. This is the central theme. No one can argue that we don't have technology now that can do more than it's ever done. No one can argue that we don't need digital health and medicine. How else can we keep up with the flow of information? And no one can argue that during the pandemic, the digital platform did indeed provide access to care in a way that we never experienced. So it would be foolish for me to take the point that digital health, digital medicine isn't an enabler in the practice of medicine. But the caveat is, yes, but. And the but is all based on a single theme, the digital divide. If you're not aware of the digital divide, it is real, it is sinister, because it exerts a toll on those that don't have access to digital technologies, and it is harmful. Let me give you a few things to think about when we talk about the digital divide. First, let's take the essential ingredient. Why is this meeting so fun and so engaging? At each kiosk, we have a separate digital platform that's easily accessible through a smartphone app. That means we have not only broadband access in this room, but we have very fast broadband access in this room. If we walk away from this environment and think about that platform and the rest of this country, you're going to discover something very sobering. Living in rural America, in the upper Midwest, either there's no access whatsoever to broadband, and the access that is there is very slow. So I'm starting with digital divide, and I'm defining digital access. The second thing that we need to think about with digital divide is costs. Give you a few pointers here. Many children are only able to accomplish their homework via access to digital technologies. Get ready for this. 30% of children in this country have insufficient access to digital technology to accomplish their homework, meaning we have an entire class of people coming forward whose only skill set will be the lowest-paying skills, the few jobs that still are sourced with manual labor. Because if we take highly skilled jobs, low-skilled jobs, and intermediate-skilled jobs, 80% of the intermediate-skilled jobs require some component of digital proficiency. So I've outlined the digital divide as the yes-but, and first I talked to you about digital access, and now I'm talking to you about digital costs. What do you think is the minimum cost per month to just have access to broadband across the country? There are any number of entities that execute this calculus, about $10 per month. What do you think is the cost per month to have the kind of speed and the kind of access to actually negotiate capably through digital platforms, $60 per month? I started with this thought experiment about poverty and convinced you that you touched the face of digital poverty because these are people that may have a cell phone but not much else. Let me tell you what poverty means in this country. It's a definition established in 1963. It's based on food and nothing else. It was an approximation that your budget for food should be no more than one-third of your income. If it's more than one-third of your income, that's the definition of poverty. By that definition, today, still, 12% of the population in this country is impoverished. Now we in medicine, particularly in biostatistics, life sciences, and clinical trials, we talk about statistics and we talk about percentages all the time, but let's make that number real. That's 40 million people, 40 million people. Put that another way, it's about two out of every 10 people you know or could know. How can we launch new technology and leave that many people behind? I have one other point that I want to make in this opening set of conversations because I think it's really relevant. Everyone remembers 2009, 2010, and the Affordable Care Act. I remember it because I was on Capitol Hill as president of the American Heart Association in the offices of senators and congresspersons advocating for change. How many people today still don't have health insurance? Thirty million people. What's the backbone of our insurance industry? It is a for-profit industry. I'm not quibbling with that, but that's reality. What's the backbone of our digital architecture? It's a for-profit industry, predominantly driven by three purveyors, Verizon, Comcast, and AT&T. Think about the objectives here. Both Jag and I want this digital platform to be the answer, but we're fighting corporate entities that have a very different set of priorities. I really applaud the nation of India. India has a program called India Digital, or India Program, and they're making the investment infrastructure to guarantee that everyone in India has access to broadband. We need to start understanding something fundamentally important. Digital rights have become the new civil rights, and let me remind you of one other thing that we heard yesterday. I was stunned, and I applauded. Dr. Adel Wunino, who is seated next to me from Mayo Clinic, describing her work caring for women at risk for peripartum cardiomyopathy, made this statement. Digital access is the new super social determinant of health. It will define how we access health and healthcare. Yes, yes, digital health is, in fact, our answer going forward, but we cannot allow to leave people behind yet again, and let that thought resonate in your mind. Digital access is the new super social determinant of health. Without such, your health and your healthcare will falter. We made a vow as physicians to do no harm. If we bring digital technologies forward and intentionally leave people behind, the same people we left behind before, if we intentionally overlook, dismiss, and discount poor people, we are doing harm. We are violating our oath if we don't do this right. Yes, digital health is exactly the investment we need to make in the future of healthcare, but it's a yes, but. Thank you very much. Thank you very much, Clyde. Now, we turn it over to Jack to present the antagonist of you. Thank you, Clyde. That was, you're a class act, you're a formidable opponent, and I think you really kind of made the argument for me that digital health really is the future strategy, so we're not really undermining clinical practice. I can actually drop the mic out here and say, game done. We just need to fix a couple of things, but digital health is kind of, you know, already there. I think with keeping the title in mind, I think digital health proponents are not looking to undermine clinical practice. You know, if at all, if we're doing something, our intention is to enhance the level of care out there, but there are three glaring issues that I think really are important, and Clyde has touched on them, and we agree on, I think, 100% of what you said, so I'm going to just reinforce some of the aspects of why, for those who still believe that digital health may undermine clinical practice, that it's not going to. So the three things are, you know, health care in its current form is non-sustainable. Clinical care in its current form is non-sustainable, and I say that because, you know, 20% of our GDP, or 17%, to be exact, or $4 trillion, whatever you want to look at it, go towards health care, and we in the United States are still amongst, I mean, that's equivalent to the economy of a developed nation in Europe. But despite that, we are really, I would say, underplaying on every quality of metric out there. So that's one. One is non-sustainable. I think it's really important to recognize that. Second is physician burnout in the way clinical practices practice today is a big deal, right? Everybody agrees with me on that. Three, I think we know that the patient experience right now, irrespective of the digital divide across the entire country, across the world, is a suboptimal experience. And we put this all together, I think we, the care we deliver, the clinical practice we have right now is indefensible in any of the quality of care metrics, whether it's life expectancy, whether it's, you know, patient experience, whether it's cost effectiveness. I think at this point in time, clinical practice is inept, is ineffective, and I would certainly say inequitable. But the biggest thing is that it's opaque, right? It's opaque. And that lack of transparency in the way reimbursement occurs, that lack of transparency in the way we practice medicine and the regional variance or local variance in practice is what has added to making healthcare in the way it's practiced untenable. And I think having digital health as a part of that strategy creates a level of transparency that does not exist at this point in time, and it elevates the level of care and accountability between the way we practice medicine. So I've heard Clyde say this, and I love this saying. He said it once a long time ago when we were on a panel. It was this quote from Francis Peabody. He said, the secret of the care of the patient, Jag, is lying and caring for the patient, right? And that's really true. But if you're burnt out and you have no empathy in the way clinical practices practice today, I mean, how can you care for the patient? And that's a big challenge out here, and I think that's where digital health, this burgeoning metamorphosis of digital health is going to actually transform the way we deliver and receive care, the way we forecast, and the way we avert disease. So clearly I think we understand that there are many lacunae out there that need to be fulfilled. Now, the first point that, you know, Clyde alluded to was access, and I think that is such an important thing. If you want health care to be equitable, if you want to be able to prevent, predict, and avert disease, you have to enhance access, and one of the only ways of actually enhancing access across all demographics, rural, urban, you know, ethnicities is digital technology that can allow us to actually be there in a continuous fashion and proactively provide the care that we need to. You know, sometimes people say that, you know, oh, we should be spending more time talking to our patients, which I totally agree and I'm going to reinforce. But you know, eliciting the presence or absence of fluid, and Junaid might bring this up later on, you know, we need to have our clinical skill sets out there also fine-tuned. But do we really need all of that in this digital environment where you can do things digitally fairly quickly and then spend more time talking to patients? And I think at this point in time, that was a mic drop moment for sure. And let that mic drop moment is that we are blessed. We are blessed with continuous data right now. We are blessed with unlimited connectivity. We are blessed with massive processing power that we did not have in the recent past that allows us to actually provide more personalized care than we ever have been able to provide in the past. And that is because artificial intelligence strategies and this digital technology that we talk about allow us to look at the future of care. Because it allows us to look below the surface, look at all that. If you look at the iceberg analogy, there is visible data in our EMRs that we're aware of, and there's this invisible data, which is below the surface, which includes all this dark data. This dark data is cultural, social, environmental data. It is genomics, proteomics that actually help us predict disease, prevent disease. And we cannot do any of that without digital care, without digital medicine, because we need AI strategies to actually allow us to do that. One thing that, you know, Clyde touched on, I think access is really important because the digital divide really gets potentiated. But one of the biggest things is despite access, despite having our clinical contact and talking with our patients on a regular basis, there is this lack of adherence. There's lack of engagement. And I don't think healthcare in its current form is sustainable in any way without having patients engage, have more skin in the game, have more self-management strategies. And the only way to have those self-management strategies are digital technologies. And I think Clyde said this, and I totally agree that these digital technologies, like, you know, for example, like continuous glucose monitoring, have transformed diabetes care. Variables like watches and the potential of estimating and predicting atrial fibrillation and downstream impacts of stroke will transform care. And I think it's important to recognize that it will transform care and proactively ensure that we don't repeat the mistakes of the past and allow that digital divide to continue. We have to proactively engage in a way that we're not retracing our steps to backfill the gaps, but actively, proactively, as we move forward into this digital arena, ensuring that we're providing the access and being able to really engage patients. You know, I think that it's important when we talk about compassion, trust, but at this point in time, with the way clinical practices, practice is more indifference. There is more irritability. There's more apathy. And I think digital medicine will give us that gift of time. Let me tell you how. I think we've heard, Clyde mentioned this yesterday, he had a beautiful presentation where he talked about Chad GPT and large language models and what the potential impact can be. Now, some of that impact can be negative through its hallucinations, but the potential of large language models and generative AI for actually liberating us from our keyboards, unchaining us from mundane activities like prescription writing and backend preauthorizations and administrative tasks, will transform the way we can actually interface, interact with the patient because it'll give us the gift of time. And it'll also enhance the transparency in how this care is delivered. Medicine is not about diagnosing a disease alone. Medicine is about patients having a tenable life around that disease. It's not about that seven-minute or 12-minute narrative when you actually interface with the patient on a six-monthly or 12-monthly basis. It is about having a form of being able to continually embrace them across their life cycle of disease. And the only way possible for that is digital health. So there's another saying that I've heard Clyde say in the past, and this is from Hippocrates. He said that cure sometimes, relieve often, comfort always. Digital health will allow us the opportunity to prevent, cure, relieve, and comfort always in the future. Thank you very much for your time. Thank you very much. I'll give you a couple of minutes to respond, and then I'll open it up for the discussion. Go ahead, Clyde. Thanks very much, Jack. Always really a learning experience when we engage, and I mean that sincerely. Let me respond to a couple of things, not really to take the negative, but to help you keep your thought process fluid, dynamic, and just understanding the space that we're entering. Very importantly, Jack mentioned the importance of physician wellness. And it's just not physician wellness, but healthcare worker and everyone that touches a patient, and suggested that digital health by means of efficiency would allow that to happen. How many of you use Epic? What was your wellness pre-Epic versus post-Epic? Don't answer, but you understand my point. If the platform by design is not ideal, then we may have the whole phenomenon of unintended consequences. So that's the first thing. The second thing, does anybody know what happened in 1983? Anyone in the room know what happened in 1983? The internet began. So anyone who was in the world pre-1983, you are a digital immigrant. Anyone after 1983, you're a digital native because you learned to speak the language. And Jack is exactly right. Even if we could distribute broadband equitably, even if we could find simple, inexpensive, readily accessible platforms engaged with broadband, we have a populace that is naive, fearful, and not completely facile. We're educable, but that's going to take some time. That's another inertia point. And the third thing, and this is the one that makes me smile every time I hear this term, artificial intelligence. Does anybody see the humor in that? Artificial intelligence? Data are powerful. I said this yesterday. But intelligence is precious. We have not understood yet how to create algorithms that introduce judgment. Maybe Jack has a laptop that comforts him, but not a single device in my possession has ever comforted me at all. So we have to work on that piece. But in the absence of that ability, and I'm being facetious, but I'm going to be serious. At the bedside, even in the office as a leader, the one asset that I value the most, the one asset that I teach and train the most is listening. William Osler said, if you but listen, the patient will tell you what you need to know. These systems don't listen. They don't understand, and they can't act on what's heard, and they can't contextualize. And so, as others have said, Atul Bhutte, in fact, and I mentioned this yesterday, digital health, yes, but it's got to be digital health and the physician and the care provider. So my first argument was yes, but, and my second argument is yes, and. We have to keep these issues, these ideas, these concepts top of mind, very fluid, and understand exactly the space we're entering. Great, thank you. Jack, please go ahead. Just 30 seconds, because I know the other panelists are itching to speak out here. I at least modified the but to and, so I'm really kind of happy I did that. You know, I just want to say I 100% agree with every point you made. I think this is a collaboration between machine and man, or machine and woman, or however you want to put it. AI, actually, somebody told me it stands for actually Indian, but I just heard this yesterday. So they said, well, the AI technology actually is going somewhere to India, and that's why I think it's way back. And some, there are 20 people out there reading it manually. I just want to, I just want to say one thing. I think it's really important, and because, you know, Clyde brought up this epic thing. I think it's important to understand the difference between being digitized and being digital. Being digital is really putting in digital care pathways that have this conjunction of both human touch as well as digital care pathways out there. It's changing the value proposition of care. It's much more than being just digitized. And I think we have to get there, and it's going to be a process. Many more interesting points, but I'll let Sana get on with the discussion, and thank you so much. Many thanks for our debaters. We have actually quite a few questions from the audience, which is wonderful. Thank you so much for sending in your questions. But before we tackle these questions, I'd like each of our panelists to address the question as to whether digital health is undermining the practice of clinical medicine, but also react to what you heard from Clyde and from Jag. We'll start with you, Dr. Herman. Thank you. Three quick clarifiers. One of the things we've got to realize is, as I like to say, the genie's already out of the bottle, right? So, we're really talking about what are we going to do? It's not, is it going to harm or not? It's out of the bottle. Second, let's assume that this AI and digital capability has no sentience. And what I mean by that, it doesn't think. It literally collects information that already exists and then pushes out information that you ask based on what exists. I will also say I'm an orthopedic surgeon by training, but the reason why I'm here is I'm a 32-year survivor of a cardiac arrest and have had many people commit to a great life. So, I'm an eternal optimist. So, don't misunderstand my comments here. But I will say that I'm very concerned. This is probably the first time in my lifetime where I literally think this country is divided squarely down the middle. And so, this whole notion of AI, my concern is going to be used to further empower the dissonance and the separation rather than bring us together. As an example, I can ask CHAT GPT, give me a list of all the people who based on their PO2 should be triaged to the ICU during COVID so that they can get appropriate treatment. And many people here will remember latest research that comes out that shows African-Americans were disproportionately measured by that form because of the content of their skin. And so, they were completely misrepresented on their need and inequitably not triaged for ICU care. So, that's a whole genetic group of people that missed out on an opportunity to benefit from artificial intelligence. And that's just to name a few. There are some more sinister. So, my point to the audience here is that it's here to stay. It's not going to change. But the responsibility lies with us on how we are going to use it. I'm going to use one more example, which is always very interesting to travel. I live in Tennessee, which is a state where they are on a mission to actually get rid of any research that mentions the word slavery or race because they don't want to hurt anyone's feelings. So, this whole AI thing is going to help them take a whole part of our history that we could potentially learn from and literally sequester it and put in a bottle so that we all can live happy lives and not repeat the perils of the past. So, I'm just very concerned about the way we're headed as a country and this dichotomy that really just is, I mean, it's just amazingly sinister. And so, I love, Clyde, I love you introducing that whole notion of digital poverty. It's just another potential form of creating a group of people and leaving them out of our society based on not having access to or equal access to the tools that will make you capable and able to succeed in the society. So, thank you very much. Thank you. Dr. Zamaan, same thing. What are your thoughts about whether digital health is undermining the practice of medicine and your reaction to everything you've heard, including the comments made by Dr. Herman? Thanks. So, I think on the first topic that Clyde raised about digital poverty, that's something that's going to be a priority for beyond the condition level at an infrastructure level as to how to equitize access to broadband and Wi-Fi. The example you raised about the All India Digital Project is a great one. The country I'm originally from, Bangladesh, has a very successful program in the microfinance initiative that Muhammad Yunus led in terms of how to access finance based on a smartphone app and democratization of lending of credit, for example. So, it's possible, but it requires more than just physician and stakeholder. It requires infrastructural change to achieve that. But without that, we're going to create a very split society in terms of how digital healthcare can touch these patients. The second point I'd like to raise as a clinician who likes the diagnostic art of medicine, to your point, Jag, is there is a ritual part of medicine that is completely opaque to the patient. And yes, people who are practitioners of this art and skill probably hype up the aspect slightly too much, but the best clinicians and the best teachers involve the patient from the outset in that journey. And when you demonstrate to a patient the physical sign that you're trying to elicit, be it fluid in the chest or be it while you're sitting forward to listen to a heart murmur, you are, by definition, engaging that patient in part of the understanding of that disease. And that can only be extrapolated and benefited by sensor technology. For example, if there was a sensor that measured fluid levels in the chest over a Gershwin volume, you would help empower that patient to understand what the line in the sand is that you're drawing as a clinician between health and disease. So I completely agree it can only help the practice of clinical medicine, but we have to remember that there is an important aspect of integrating this data that you do as a clinician every single day of the week and communicating it adequately to the patient in a structured action plan. And the final thing I'd like to say about physician burnout, I think there's plenty of speakers who will tell you that the EHR, the electronic medical record, does not help this one bit. And so part of the society that we help set up of the Society of Medicine is in order to address physician burnout. Because by just the simple act of bringing physicians back to the bedside, or at least promoting them to spend time with a patient, either digitally to communicate with them and to reduce the mundane tasks that occupy 80% of your clinical activity, you engage physicians and promote wellness in a way that actually instills why most people went into medicine, which is the patient is the key. So digital healthcare clearly is here to stay. Digital healthcare will clearly augment clinical medicine in most aspects, but access to equity, the integration of how this disease's definitions are changing, and promoting how it can make physicians more engaged with their patients is key. Thank you. Dr. Thomas. Thank you. And I have to say, I've heard Dr. Yancy give grand rounds at MGH, and I've worked with Dr. Singh, and it is always a pleasure to hear two eloquent individuals speak so passionately about such deep topics. Strategically, I've had to sit between both of them, and so I'm trying not to sway either way in terms of which way I am leaning in terms of their arguments. The reality is, to Dr. Herman's point, the genie is out of the bottle. Since, I believe, in the fall of 2022 when CHAT-GPT came out, I believe some 1 billion people logged on to CHAT-GPT, and that is not just for the purpose of non-medical issues, but even for the purpose of morphing Arnold Schwarzenegger into Whitney Houston so that she can sing, I Want to Dance with Somebody, which was just recently I saw on a social media post. The reality is that artificial intelligence, these evolving neural networks and large language constructs have been in play and have been evolving, and the number of CHAT-GPT versions continue to evolve. We are at this point where we're on a ship where just as it's about to embark, disembark rather, there is turbulence in the water. But we know that there needs to be smooth sailing. And the power of this technology is not to be an antagonist to medicine, but to determine how we use this as a tool. And what's interesting and amazing to hear is Dr. Yancey brings up in his discussion many of the aspects to access to this care. How do we ensure that all individuals have that right to the care that they need, which is how we provide quality. I'm Canadian, and so in the last 12 years I have had the great honor and privilege of being in this incredible country. And for me there has always been this challenge of trying to understand the nuances of universal access where, you know, on Capitol Hill they use various other words to describe this, but the concept of universal care with universal access that is equitable. There is no perfect system. And as you hear from Dr. Singh, it's how we deliver and the processes of that care. If you take a step back, these are the debates that go on independent of the digital age. These are the debates that go on to how we ensure a just society, and importantly, an informed society. But in order to have an informed society, you have to have an informed citizen. And the only way to do that is to figure out how we can use this technology, which actually is so profound that we democratize it in a way that is both beneficial to the patient, but importantly to the provider and the systems in which we practice. What's amazing is that historically the smartest person in your medical school was the person who studied the most, learned the most, did the best on the exam. And I remember when I was at the University of Toronto, when we had Palm Pilots and the availability of smart technologies, it was no longer who remembered the most. It was who had access to the right apps. And then importantly, as this convention informs us how we can use those technologies and how those technologies evolve. Now you've got neural networks with all of these types of conditioned systems that can be trained to now diagnose retinopathy beyond that which the human eye can actually evaluate. We now are operating beyond conditions that are simply binary. I live in the world of cardiogenic shock where in reality the mortality rate is still exceptionally high, but it is so heterogeneous as a clinical syndrome that our ability to truly prognosticate patients is challenged. AI creates the incredible opportunity for us to understand complex variables that go beyond the human capacity. But in order for us to be able to do that, we have to ensure that as practitioners we learn the language. This becomes part of medical education. And importantly, there will be the evolution of the digital medical provider. Very much as we have had APPs who have now taken on roles that were traditionally physicians and we see the evolution of medicine. But importantly, as we as a society ensure if we can, despite what government challenges may be, through policy and such things, if we can ensure that individuals each are being able to be learned of this, then I believe that we can use this technology for the betterment of our health. Thank you very much. That was very well said. And many thanks to all of you for sharing your perspective. The focus here is on solutions and I know several of you proposed solutions as we were discussing things earlier. Dr. Herman, you brought up an excellent point with regard to as we think through these different digital tools, we do need to take into account diversity and differences among people. Those need to be taken into account to make sure that we don't think that one size fits all. Not every tool is going to work for everybody the same. So kind of taking that into account, I think that was an excellent point that you made. And all the other points were excellent. I do want to get to the many questions that we received from the audience. We have a lot of engagement here. So let me start with the first here, which is, this is a question that always comes up. Will digital health replace the clinician? Will patients start trusting their devices more than their doctor? Will doctors start trusting the devices more than their own judgment? And will this undermine the practice of medicine? Excellent questions. Thank you for submitting this question. Who would like to go first? We'll let you go and then Jack, please. I'm happy to go first on this because I think the answer is no. I think there will be some task for which a digital algorithm potentially may be able to provide a simplistic answer in terms of what to do about your dosage of medication, what to do about your specific disease. But as I alluded to, you need an integrative aspect to your health care, which a provider, a digitally trained health care provider, will be astute enough to try to integrate that into their clinical practice. So I don't believe digital health care and AI is going to replace clinicians, but it will probably leave behind a generation of clinicians who are unwilling or unable to engage. That still doesn't at all address the access issue that Clyde raised up front, which is we need to address that first, but it won't replace it or just augment it for certain people. And it's about sharing that journey, how to hone your diagnostic skills when you have this data, yet still provide personalized, compassionate care to the patient because they still need a doctor. Excellent. Jack? Yeah, I won't take up too much time because – go ahead, Clyde, you want to – yeah. You know, so you can get more questions in. I think it's not going to replace the physician, and it should not under any circumstances, but it is going to redefine many job descriptions. And for folks who don't kind of adapt to that change, I think we'll be left in the lurch and we'll need to kind of adapt and re-modify. I think the whole, for example, the transforming of the construct of remote monitoring platforms across disease states. We're talking about it just here in EP, but you know it's going to go across disease states, and all these disease states will be interlinked with some common digital dashboard that will allow us to actually look at the persona of every patient in greater detail. That's going to require job – you know, the job definition will change. People will be repurposed and redeployed. So I think it will always remain complementary. Clyde, go ahead. The answer is yes. I mean, we have to be very frank here. You talk about the genie being out of the bottle, Dr. Howard. I call it the toothpaste hypothesis. It's already out of the tube. We're already challenging the office based on what someone brings in via their own sleuthing about of a variety of trusted and not-so-well-trusted sources. But even more importantly, and this is the most sobering thing, for the first time ever, those of us in medicine, those of us in science, are no longer among the most trusted professions in our society. So people enter the room with mistrust of us as professionals, and they are equipped, maybe even armed, with information that they believe is the truth. So I think it's already happened. I would say, however, that – and Jack, I know you want to add something. I think the fact that we are aware of all of this, we are working on it, we are trying to stay in the forefront and in control of it, I think we can definitely continue to be relevant and have a part to play. This is something that came up during a couple of the sessions yesterday is how far do we go and what kind of guardrails can we put in place to ensure that as this plays out, it plays out the right way. Now, obviously, there will be challenges, there will be issues, but I do think that the human factor will never be lost. Patients want to still, in my view at least, connect with a human being to not only hear from them their thoughts, their judgment, what have you, but also feel that empathy and be able to connect as a human to human, which will help them during their whole journey, as you pointed out earlier, Jack. Please go ahead. No, I was just going to say exactly what you said. We've had the Internet since 1983 and subsequently we've had Dr. Google since the 1990s or early 2000s for sure and patients coming in oftentimes are armed with information and are questioning your judgment. That's going to always continue and I think patients will be more empowered and I think in a way, we also have to look at it, it enhances our desire to be more accountable because medicine can be very paternalistic and I think it's important that if there is empowerment of patients, there can be a dialogue and there will always be patients with personalities that will undermine the physician, but I think overall, it will be a collaborative effort and I think the physician will still play an important role and a lot of the power dynamic, though, will shift to some extent. Great. Okay, go ahead. Again, I just think if we just take where we are right now and understand the challenges, I think the biggest challenge for healthcare is implicit bias and how does that play out and if we don't deal with that and maybe we need AI to tell us how much bias we've already experienced, then once we change that, the equitable decisions will come forth, but if you've already got a system set up that misrepresents the diversity of our population and the people who are delivering the care, those decisions are always going to be fraught with implicit bias and all of the AI, again, it has no sentience. It just repeats back everything that we've done. All the research, all the biased research we've done is going to pump it back out in a faster fashion. So that's where we have to be alert. How can we make ourselves more intuitive about implicit bias, drive that out, and then we'll begin to make equitable decisions. Wonderful. Thank you. Second question, which clinicians will be left behind in this iteration of the digital revolution in healthcare? Using digital health, I would say. The ones who aren't using the EMR today. I think people always talk about radiologists being left behind, but I think they've reconfigured that statement by saying that radiologists who don't use AI will be left behind. So I think there will be an adaptive process and redefining of almost every physician's specialty. I think, however, advances in medicine, there's this whole concept I've been thinking about called disappearing disciplines, and I'd love to write something with you on this, Clyde, but I think there are certain, for example, there are certain medicines also that have actually now started changing certain disease states, for example, obesity or HFPEF with newer medications, that I think that certain disciplines 20 years down the line will actually not exist anymore, and that's what might influence. It's just like polio. There are some clinicians who practice polio medicine and were involved in the microbiology of polio, after 20 years found themselves without jobs and could not get jobs again because polio dissipated. So I think that's something that needs to be put in the background. Great. So two questions that are somewhat related. One is should the broadband be part of our national infrastructure like highways and bridges? And then the other, it was mostly a comment. They said that this topic has come up frequently during the meeting. To do something about it and take the next step, we should have legislators and payers here, government leaders, CMS, private payers. Hard to do. We tried actually to get them here, but they are necessary voices if we're going to turn critiques and ideas into action. So without them, we are preaching to the choir, is the comment here. So your thoughts? So I'll take this one, and I'll be really pithy here. In 2021, post-pandemic, the Congress in a bipartisan way passed the jobs program, incorporated in that, with $60 billion to actually create a nationwide infrastructure for broadband access, $42 billion of which is designated for the rural area because the greatest inequity, the greatest inequity in this space is in the rural populations in this country. The coastal areas don't know what this problem is. The rural areas do. So that's the first response. The second response is that we should all appreciate that we have 100%, 100% broadband coverage for this country via satellite, but we only have access, or only 7% of our population accesses satellite technology for broadband access. That's a cost variable, but those are two immediate responses to the question. And from a legislative standpoint, this term net neutrality is not quite as benign as it sounds. It is a very important concept which is intended via legislation to make access to the Internet and information available to all. The Obama administration championed net neutrality. The subsequent administration took it out of law. And so to Dr. Ha, this divide actually happens legislatively as well in the digital space. Great. Another comment there? No, no, yeah. Okay. So another question from the audience. They said as the volume of practicing practitioners decreases, what do you feel is the best use of digital health in the future in that regard? Well, I'll speak as someone that works for organizations that deliver care. I think one is we'll be able to level the playing field by taking the big tertiary centers and having them help the rural areas through digital capability. And I talked about how we like to use remote ICUs to provide that capability to rural organizations. But I think ultimately we are going to have to use that technology to leverage care. Of course, it's also going to, I think, allow an emergence of more mid-levels, taking on more responsibility, and then having them have that access where physicians are not available. I'll say this very quickly. Jag has referred to a couple of things I've said over the years. There's a Chinese proverb that I refer to all the time. A mediocre physician saves lives. A good physician treats disease. A great physician prevents disease. I think the greatest opportunity for digital health is in prevention. By raising awareness, by understanding patterns of behavior before diseases emerge, by allowing us to target earlier interventions that are easier to do with less consequence that can prevent unavoidable conditions. I really think that's not been the topic of conversation today, but that is where we can unleash the power of digital health. We just have to create business models and make that make sense. Go ahead. To echo that comment, I think it's going to change the definition of disease. For many disease states, it's going to actually make the clinician have to redraw the line of what is health and what is disease. If that can be done, that is a very empowering tool for the field as a whole. In the remaining few minutes, what I'd like to do, and I apologize to the people. We couldn't get to all the questions, but I do want each of you to take a minute and share with the audience the one point that you want them to leave this meeting with. What is the one thing you want them to leave with today? Starting with you, Jack. I would say that digital health solutions are going to enhance care, but not in isolation. They have to be in conjunction with the human touch and the human bond. Thank you. Dr. Thomas? We are living right now in a period of disruption. That disruption can be positive, but in order for us to be able to ensure the democratization of these technologies, we have to become learned. As physicians, it is our responsibility to not only learn amongst ourselves, but to ensure our patients are also empowered to learn. That includes the systems in which we all practice. Dr. Yancy? I have a practice every morning of thought and meditation in a very quiet space. Fortuitously enough, one of the themes this morning was this. What is your life? For you are a mist that appears for a little while and then vanishes. Why is that important? This needs to be owned by everyone. We have a very precious amount of time to make a difference for the next generation. Use your insight. Use your privilege. Use your voice to appreciate the great opportunities and the real challenges. The one takeaway, make an effort to really support what may be the new language of medicine. Everyone needs to be at the table. Great. Dr. Zaman? The digital healthcare revolution has started already. You can either choose to engage and try to mold it to be the best possible fit for patient, provider, and system, or choose to try to ignore it and see if it will just go away. It won't. You have to adapt. You have to adapt to the clinician and empower your patients to use that data and to help improve outcomes overall. Great. Dr. Herman? If I can refine on that, you want to practice at the top of your license. The way you do that is the 70% that just comes with a typical presentation that doesn't need any thought. Let AI deal with that. You want to focus on the 10% that presents with the unusual capabilities that allows you to use your brain. So, for clinicians, don't be afraid of this. Use it as a tool so that you can practice at the top of your license. Excellent. Many thanks to you all for sharing your insights with us. Let's give them a round of applause, please. And many thanks to you for your engagement and your attention, and enjoy the rest of the meeting. Hey there, welcome to HRX, where we're innovators at heart. While you're here, be sure to visit the BMS Pfizer booth to learn about the new A-Fib Quality Improvement Framework, CARDI-Q, a digital resource developed in collaboration with HRS, BMS, and Pfizer that offers a quality improvement roadmap for patients with atrial fibrillation. Once again, that's the BMS Pfizer booth, number 707. Have a great conference. Visit the Abbott booth, where human-powered health meets life-changing technology designed to save and improve lives. All the data, one platform. As the only comprehensive cardiac remote monitoring solution, Pacemate Live streamlines your workflows, enabling you to store and access all the data from every type of cardiac device in one place. 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digital technologies

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equitable access

broadband

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prevention

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