Designing for Health: Interview with Adam Carewe, MD [Podcast]

A pressing issue in today’s healthcare landscape is reducing clinician burnout. The evolution and increased prevalence of progress notes and patient portal messaging has exponentially grown the time that doctors and others spend in front of a computer, in turn leading to less time in front of patients. Physicians find themselves increasingly time-strapped and unable to focus on the things that got them into medicine in the first place. Can net new technologies help physicians reduce their documentation burden and get back to the essentials of patient care?

On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, sits down with Adam Carewe, MD, CMIO at Colorado Permanente and the co-host of the NerdMDs | Efficiency Unlocked podcast. They discuss his mantra of letting doctors be doctors, the increasing promise of AI to revolutionize progress notes, and the rise of the inboxologist within health systems. They also talk about how Dr. Carewe helped start an asynchronous e-care team at Colorado Permanente, eliminating inefficiencies within clinical workflows, and how today’s advances in healthcare technology sound like science fiction from not too long ago.

Listen here:

In Network's Designing for Health podcast feature is available on all major podcasting platforms, including Apple Podcasts, Amazon Music, iHeart, Pandora, Spotify, and more. Search for 'In Network' and subscribe for updates on future episodes. Like what you hear? Leave a 5-star rating and write a review to help others find the podcast.

Want to learn more from Dr. Joseph? Order a copy of his book, Designing for Health.

Show Notes:

[00:00] Intros.

[01:16] Dr. Carewe’s background

[07:20] Letting doctors be doctors

[13:42] The evolution of progress notes

[22:53} The increasing role of artificial intelligence (AI) within healthcare

[28:48] Beginning an asynchronous e-care team

[34:45] Enhancing clinical efficiencies

[38:40] Dr. Carewe’s favorite well-designed thing

[42:01] Outros

Transcript:

Dr. Craig Joseph: Adam Carewe, welcome to the pod. How are you today?

Dr. Adam Carewe: Thank you Craig. I'm doing well.

Dr. Craig Joseph: All right. Now, I would like you, in a short, succinct, nice summary to tell our listeners about how you got to the pinnacle of podcasting as one of the two Nerd MDs. And I want you to start back when you were in kindergarten and tell us everything that got you to this point.

Dr. Adam Carewe: All right. Well, if I have to go back to that point, we'll have to kind of understand what the technology was like back then. And I think when I was in kindergarten, or maybe shortly after, I think I had one of those Fisher-Price tape recorders, you know, the brown ones. I'm sure you remember those?

Dr. Craig Joseph: Oh, absolutely.

Dr. Adam Carewe: So, I mean, the funny thing is, my sibling and friends in our neighborhood, we actually used to record things on there, and I don't know if we pretended to be radio talk show people or what, but that was, I mean, I know your question was probably serious in some way, but we used to do that. And then I think we moved on because my dad had a boombox that had dual cassette, so you could kind of get creative with recording and, you know, maybe putting in some music. Totally legally, of course. But in tapes. So no, but I think in all seriousness, I think the, you know, the podcast that we started that Dale and I started, really just came out of, I would say like a personal love and a personal need that I think that we were trying to satisfy. And that was trying to meet more people within our industry and even outside of our industry, that we felt, you know, could either broaden our minds or broaden, you know, other listener’s minds. And that was really the impetus. I mean, I think before we started the pod, we actually reached out to you kind of cold turkey. And I think that's how we met. Right? We had a Zoom call together.

Dr. Craig Joseph: I think that’s true. And I feel like I gave you all the secrets. And now you've kind of turbocharged them, and you're coming after me. And, no, I'm not happy about it, but it is what it is. All right. So, we'll talk a little bit more about Nerd MDs in a bit. But when you're not being a Nerd MD, you're the CMIO at Kaiser Permanente Colorado. Is that accurate?

Dr. Adam Carewe: That is accurate.

Dr. Craig Joseph: Excellent, so tell us, how does one become the CMIO of KP Colorado? And, you know, what do you do all day as the CMIO?

Dr. Adam Carewe: Yeah, I'd say, you know, in typical fashion, I think if I was in a lineup of people and they asked, you know, who wanted to do this job? Everyone else took a step backwards, and I was the one that was left appearing to be standing forward. No, I think honestly, I think I just, I think going back to, you know, even my, I guess, med school days, probably more like residency days, that was like when all the hospitals were starting to convert from paper to electronic. I think that's when it got kind of the first taste of wanting to understand how EHRs worked and how you could make them, you know, work best for clinicians. And so, I think when I joined KP out of residency, which was about 13 years ago, I just kind of started asking questions and trying to see how things, you know, operated inside the system. And, you know, I was just a clinic family physician, you know, starting out with my new panel and I think, you know, shortly after I started, I remember there was a new system that they updated for how physicians would get reimbursed if you went on a went to a conference or something and got reimbursed for your CME kind of funds. And the old process was jot down some notes on what you spent it on, you know, get your receipts, put it together, tape those receipts to a fax paper and fax them to someone. And magically, you would get a check in the mail, reimbursed. Well, they went to an electronic system, which I won't name the name, but it's a well-known corporate brand. And, you know, the system was not easy to use, and I think I was a few months in on my job and I was just like, well, that system was horrible, but I want to figure out how to use it. And in doing so, I actually created the first job I think I ever made de novo. And I think being as naive as I was, we had access to a send-all for like all of the physician group and our region and I just attached it as a PDF, first made sure it was right with, the HR people. But I sent it out as a send out and just said, hey, you're probably struggling with this as I was. I made this job aid, have fun and to this day, I think people still have that job aid because the system hasn't been updated since then.

Dr. Craig Joseph: Because the software still sucks, is what I'm hearing?

Dr. Adam Carewe: So, I mean, I think that is like I think got, you know, probably the plug of some folks that were kind of already in this informatics space before it was formally called informatics. And, you know, I met one of the physicians, his name’s Julian. And then I met him on another kind of wellness committee kind of thing that I volunteered for. And, and he said, you know, he's like, hey, there's a there's like three physicians who are retiring that have been doing this (again before it was called Informatics) kind of Informatics. And he said, there's probably going to be some positions, and you should apply. And so, I did, and I met the medical director, then a physician who was, again, pre-CMIO titles. And, and that's how I kind of I got started. And I think from that point on, it's just been kind of more of that pursuit to make things better for physicians and care teams and ultimately patient care.

Dr. Craig Joseph: All right. Well, those are good things to be working towards. Speaking as a physician, one of the tenets of kind of Nerd MDs, your group with one other physician is to let doctors be doctors and to try to get the technology to go in that direction. So how does one, what does that even mean? Let doctors be doctors. What are you trying to convey there? And then how do you do that?

Dr. Adam Carewe: Yeah, I mean, I think you know, like you mentioned, my buddy Dale and I, we kind of ideated around this kind of Nerd MDs thing many years ago. And I think that slogan, letting doctors be doctors was succinct enough, and it kind of allowed a little bit of your own kind of interpretation. But I think what you just kind of summed up really is it's kind of the mantra that emphasizes, you know, allowing physicians to focus on patient care. Rather than administrative tasks, which has obviously been something hot, you know, in, in the media, for the last two years. Right, with all these AI scribes and different tools. But I mean that's really what it kind of means. And then there's obviously some why behind it and, and some details. I'm happy to chat about that too.

Dr. Craig Joseph: Yeah. So, some of it's administrative. So, it sounds like, hey, this is, you know, this should not be a major part of your day in terms of trying to get expenses reimbursed when you go to a medical conference. And, but I think I would add, that a lot of it's really the poor clinical functionality things that someone has to do. But in the past, potentially, before your time, because I'm a bit older., other people did. And so, you know, when I first started, in the paper world, I had medical assistants, and they roomed my patients as a pediatrician, and would take down a lot of the history. And it wasn't everything, but it was a start. And I took over from their stuff, you could see where they were writing and then where I was writing, and sometimes, things changed when I asked the question like, oh, I told her this, but, you know, now that I've been thinking about it for ten minutes because you're late, doctor. So, now I remember it wasn't actually when I said it's this and you know, the story gets more clear as time goes on. Anyway, those kinds of things have all been flipped to, in many places, to physicians. And I think a core part of what a CMIO’s job and your job is to do is to try to say like, hey, if as everyone should, work at the top of their license and we have other people that can help us, why are we doing all the work? It's kind of like a lawyer, a paralegal, but the paralegals aren't allowed to look up cases like, well, that's what they do. They're really good at that. And they don't get it right all the time because they don't go to law school, but they get it right most of the time.

Dr. Adam Carewe: So yeah, it's definitely like you said, I think that letting doctors be doctors is definitely multifaceted, I would say. And you know I use the term administrative task, but yes, it's all that other stuff that, you know, a physician does throughout the day that really, you know, if you can either make them more efficient at that, make it seamless and easy to do or, you know, frankly, if it's something that can be delegated and offloaded to somebody else or some other system. I mean, that's all a part of it because it can help drive operational things, system things. And, you know, ultimately, you know, optimization and informatics kind of efficiency things.

Dr. Craig Joseph: How do you actually get it done? Are there times where, you hear back from either operations folks or IT folks who say, well, yeah, we could possibly let someone else do that, but it's just easier to let the physician and won’t physician do a better job anyway, really? How do you have those conversations? Like, what do you, I think one thing you could do is beat your chest and say, me, Doctor, listen. And that might actually work 30 years ago, but I don't think that works nowadays. And so, you know, what do you do? How do you make the argument? 

Dr. Adam Carewe: Yeah, I think it's tough, you know, as a CMIO, you interact with, I would say kind of the full breadth of, you know, the operational side and administrative side of healthcare and, you know, all those different representation groups have, you know, their opinion in their stance. I mean, you got legal, compliance, quality. All those people come with their own, you know, lens. And it's challenging. I mean I think a good example to give is, like around these, you know, AI ambient scribes, you know, when they, depending on the state where you're in, some states don't require some sort of consent with the patient to use them. Some do. But like assume that, you know, the default is that you do. Well many times that the, you know, groups that are launching these tools, you know, they're just they're putting it on the clinician to say, okay, every patient you say you need to say, hey, is it okay if we use this cool technology that helps me be more efficient and capture everything you discuss? And I think that's fine, especially at the onset. But I think the conversations should quickly start to shift, you know, especially if you're trying to get these things out quickly, is how can you move that consent kind of further upstream, you know. So again, I mean, not to say that the clinicians should not acknowledge a patient that has consented or not consented. You know, there should be some easy way for them to recognize if the patient has agreed or not. But, you know, to make the clinician do that with every patient, every visit. You know, I think this is an example of something that takes that conversation, and you’ve got to convince the lawyers and the compliance people and everybody else, you know that it is a better move for everyone if you move that upstream.

Dr. Craig Joseph: So, let's shift the conversation a little bit to, something that you and I love to talk about. And I think everyone loves to talk about progress notes in the electronic health record. It's a conversation sparkler, amongst everyone. Well, maybe just physicians. I don't know, you have written that progress notes as we know it will be outdated. And everyone will kind of be able to make their own note, the way that they want to, or multiple versions of a note. So, let's first talk about, you know, why? Why are we even discussing this? This was not something that we talked about a lot. Before the computer kind of came into the exam room progress notes were written on a piece of paper. They were largely illegible. And I could read my own, but maybe others couldn't get everything that they needed to get. And they were not only were they scribbled, but they were very short. Lots of abbreviations, because we didn't want to spend a ton of time, documenting things if it takes longer to actually document what you did than to actually do it. Probably a waste of time. And so, with electronic health records, notes have become much, much bigger. We call it note bloat, especially in the United States. They're much bigger than longer and more in-depth than they ever were. And I think many physicians would argue that they say less, lot more words. But it's really more difficult to understand when another clinician is reading your note. What's important, what's not important. And so, what do you think is the future of electronic health record progress notes?

Dr. Adam Carewe: Yeah. I mean, I think you've kind of outlined, and really, we're kind of alluding to that, you know, the concept of a progress note has really not changed since the inception, except with the exceptions of what you said. You know, I remember as an intern on paper, you know, seriously, like writing my little subjective objective assessment plan for every hospital patient. You know, I was seen and, you know, getting cramps in my hand and feeling like I had to go as fast as possible. And I think, you know, going way back, I think even when I was a kid and I remember, you know, interacting with my pediatrician, it was, you know, I don't even think he would write anything down when he came in the room. I mean, I don't know, maybe there's someone behind him jotting things down, but, you know, I think he had a clipboard in his hand, but to your point, I mean, we digitized the health system, you know, the electronic health record, and we didn't really do anything different with the actual note. And, and I think what's really kind of jumped in as of recently is more of these, these ambient scribes. And I think what that's made people aware of is like, well, we can capture all this conversation now, you know, as a transcript, frankly, and if those pieces of that transcript can now get into the EHR in kind of discrete areas that are really important and needed, you know, could the structure of what we consider a progress note, could that just be generated in different ways for different audiences? And I don't claim to be the originator of this idea because I've heard yourself and several others, you know, kind of mentioned it. But I think the example I like to think about is, you know, I can have patients in the emergency room, and they get seen and they get determined that they need to be admitted to the hospital. You know, the ER physician writes, you know, there have has a certain kind of form to their note. But like, that form isn't necessarily what, you know, the admitting doctor needs. And then it's definitely not what the specialist ultimately needs or specialists that see the patient. And then you can take it outside of clinical and you can say, well, the insurance needs a certain level of documentation. And you know, maybe other regulatory agencies need it. And I think just, you know, the fact that we have all this stuff digitized, it seems to me that this concept of writing a note out, like a letter, should really change with the times, too. I don't think it's necessarily going to happen overnight in any way, but I think that's the general concept of it that I think the note for the patient versus the note for the clinician versus the note for, you know, the countless other people that need this information as part of a healthcare system is going to change.

Dr. Craig Joseph: Yeah, we live in interesting times for sure. And, if there's truly going to be a microphone in the exam room and if I'll be carrying one around in the emergency department, even hospitalists, might be, carrying around a microphone aka a phone. If we can get to the point where we're just, recording every conversation that we're having with patients. And I don't mean everyone, but, you know, in the office and, in my daily exam of the patient in the hospital. Ultimately, if we can just record and keep that transcript, either a transcript or the actual, recording, because storage is becoming incredibly cheap. If we can just keep that forever, then the note becomes much less important. Right? Then the note can be, well, here's the version that the AI came up with that is minor. And it also will come up with a version for the utilization management and will also come up for the malpractice attorney. And, if anyone's ever concerned that, hey, how do we trust that version that you kind of signed off on is really accurate? Well, you can always go back to the transcript. You can always go back to the recording. You can hear exactly what happened. As long as we're willing to kind of keep that then, because right now, all we know about what happened in the exam room at the clinic is what you wrote, and everything else is, doesn't really matter. Or we have to go by what you wrote, and it will really change, though the way, the paradigm if we don't have to trust what the physician wrote and we can allow the physician to say, yeah, I was there for 25 minutes. And here are the most important things to me. And if I miss something, that's okay, because that was not important to me in terms of communicating to what others need to see. It'll be in there, but likely no one will ever see it.

Dr. Adam Carewe: Yeah. I mean, I think of this like kind of future, like, you know, the way we use, these commercial large language models like ChatGPT now, but think of a time, you could as a clinician, like if I'm seeing someone and I know they recently saw their cardiologist or maybe they I think they did. You know, like I should just be able to like query that and be like, oh, what was that? I mean, probably with your voice. And you could just say, you know, what was the cardiologists, assessment after seeing the patient most recently. And then that should just generate like I shouldn't have to go look at their note. And I think that's where I think this will ultimately evolve to. And I think that's, back to what you commented on in note bloat. It's the same thing. The reason why the notes are bloated is because you are trying to satisfy all those people. And frankly, a lot of it is like more of the legal side, you know, like you need to put all that stuff in there just to justify or protect why you came up with the assessment you did. But in reality, all I really care about is that assessment and plan. Like, that's all I really care about from even my old notes. I mean, yeah, you sometimes want to look into the details, but again, if the details are there somewhere in some sort of archive and you can always extract them, I think, I hope that's the future that we get to.

Dr. Craig Joseph: I love this idea. I've actually never heard of this. At least I've never thought of it this way that you just mentioned, like, my ability to query what the cardiologists, what that note says or you know, how that interaction is. Because in the real world with someone who we know. Right? So if you have your friendly cardiologist next door, and if you say to them, hey, what did you think of Mrs. Smith? The answer is often she's fine, right? And that's all you want. That's all I want. Hey, he said she's fine. Good. Like, what does that mean to me? Well, because I know this guy. What that means is that there's nothing life-threatening. He might have modified her meds a little bit. He might have ordered a test or something. But clearly there's nothing that I need to be worried about. Because if there were, he would have told me, you need to worry about this or that. The other, and the ability for docs who I know or maybe in some sort of network, you know, where I could just say no, just in his words. What would he have said to me? If we can get stuff when it's clearly not there, but if we could ever get sophisticated to that point where, you know, where we can have an LLM kind of as an avatar, just totally representing us because it's seeing so much of our stuff and, you know, can accurately predict. Boy, that would be an interesting, interesting world. Yeah. I don't want to read the note. I just want to know if, you know, Doctor Jones thinks Mrs. Smith is fine, and if she is, if that's what the avatar said, then great. If not, you know, Doctor Jones has concerns about this, that, or the other. Okay, let me see the note, now I want to kind of dig into more details. That's an amazing future. And it sounds like science fiction now, but.

Dr. Adam Carewe: If we were having this conversation a few years ago, I would have totally said, this is science fiction. Yeah, and it's crazy how much stuff has changed in just a short time to now. Most of these things seem very, very close, you know, to reality, if not already. Reality today, in some form.

Dr. Craig Joseph: It reminds me of some pundit was talking about, you know, what they are envisioning for the near future and was kind of saying like, well, news programs are going to be dead and it'll just be, you know, there's the news and I'll say, I'd like to hear about this, you know, tell me what's going on in politics, but speak to me as if you're Anderson Cooper from CNN, right? And because there's so much audio and written by Anderson Cooper, we the LLMs have a lot to kind of to digest on. And they know how he speaks and what he thinks and, can get pretty darn close to, you know, giving me that perspective versus a completely different perspective on the same and the same set of facts. Yeah. It's an interesting and scary, future.

Dr. Adam Carewe: Agree 100%.

Dr. Craig Joseph: Well, we've got a few years before it comes to medicine. I'm pretty confident. But it's not science fiction. It's kind of foreseeable. Let's pivot to a different aspect of kind of helping decrease physician burnout. And a big part of their burnout is dealing with messages, and what we often call the inbox or In Basket, depending on what kind of electronic health record it is. And to paint the picture again, for folks who are, essentially children such as yourself, in my mind, back in the day, you know, you would say, hey, I've got a question. I'm going to call the doctor, but you're not calling the doctor. Actually, you're calling the doctor's office, and you're going to talk to either a nurse or someone else with some kind of medical experience. You're going to say, well, this happened, and that happened. I don't know what I should do. Do I need to come into the office and, or do I need a, you know, prescription called in or something like that? And, most of those messages, I have to say, not too long ago in the late 90s and early aughts, at least for me, most of those messages never really got to me in real time. Like, I would get a bunch of charts. This is back with paper. I have a bunch of charts with little notes written on it. You know, again, as a pediatrician, it generally was adults calling about kids. you know, Mrs. Smith concerned about a child's cough. And then there would be a bunch of questions that my nurse or medical assistant would know to ask. No fever, eating well, acting while sleeping. Okay. Instructed her to try over-the-counter therapy, if not getting better in 2 to 3 days, or sooner if getting worse. Right. And I would just go, yeah, okay. And I'd sign my name to acknowledge that I read that and agreed with what they did, and I would have 20 or 30 of those, but it took me not very long to get through that. And a lot of them were like, oh, you know, Mrs. Smith called. They're all Smith. All my patients. Her name is Smith, which is odd. Mrs. Smith called. She left the amoxicillin and the liquid amoxicillin out overnight, it wasn't refrigerated. I called in another prescription for again. Oh, that was convenient, right? I'm not even a nurse. A medical assistant would call on my behalf. Call in an antibiotic. Now, I know that the only time they ever did that is if I had prescribed amoxicillin in the last ten days and that, you know, mom had left out, and so we wouldn't call it in under any other circumstances. But so lots of things happened and I didn't have to deal with that. But now with the electronic health record, we've run into this thing called this, you know, kind of in basket or inbox monster and just all of these, it's much easier for people to send a message. Certainly couldn't call my office in the middle of the night with a non-urgent message but you can send a message via the health record patient portal in the middle of the night. And then with the pandemic and clinics closing for a time and making it much more difficult to see a physician in person, lots of messages. And so physicians are dealing with these 60, 70, 100 messages a day and, and certainly, the vast, vast majority of physicians are not giving any special protected time to answer these questions. So they’re expected to do it in between seeing patients, or before clinic, or at home after clinic, pajama time, so to speak. And there have been multiple solutions offered. Not a real solutions mitigating opportunity. You know, things that can make it a little bit better, but nothing that's going to make it completely go away. But one thing that was interesting to me, I read an article about, the in-boxologist. I've heard of a gastroenterologist and a dermatologist, but I've never heard of an in-boxologist, as healthcare's newest specialty. And I was mentioning this on LinkedIn and you replied, said, hey, we kind of have that at Colorado KP, and we call it our asynchronous e-care team. And I am desperate to learn more. So tell us about how does one become maybe not an inboxologist. Maybe you don't call them that, but how does one become part of the asynchronous e-care team?

Dr. Adam Carewe: Yeah. No, I mean, honestly, that picture you just painted, and I think that even what you were describing that, you know, used to happen in your clinic on paper, you know, I think I'll just say before I talk about this asynchronous e-care. I mean, I think people like, we need to create those. We need to have those same processes in place. Even with the electronic health record. And I think there is a lot of effort to do that now. I mean, at least within Kaiser. I mean, definitely there's effort to do this. And, you know, it takes a lot of work, especially the bigger the system is, the more challenging it is. But, you know, I think all of that and what you just laid out is, is really the reason why there was this idea in our primary care department through, you know, the operational leaders, to try to have some sort of program that could also help with the volume that you're describing, of inbox stuff that ultimately does land on these, physician and advanced practitioners plates. And so I think maybe paint a picture about the why of the program. You know, I think one is just that volume piece. Number two is, you know, physicians wanted to take vacation and take time off too. And when they take time off, they either have to be in their own basket, which is not ideal, or their partners have to be in their In Basket, which they already have their own In Baskets. And so now they have like this double whammy and so on, like a personal physician level, it's this increased burden, you know, of this volume of stuff. And then on the patient side, it's also bad because if you have somebody like kind of half effort covering for you, they're not going to spend probably as much time on that stuff as you would on your own patients. And so, I think there's a chance that there could be some quality slips or potentially something even missed. As you know, you're busy in your own clinic and then you're batching at lunch and at the end of the day, you know, to quickly try and get rid of this. So that was really the genesis behind this asynchronous e-care department. And, you know, I think what was great about this, this program is, you know, our operational folks engaged with informatics at the inception of the idea, not at the conclusion of their ideation of it. So, we actually there were three of us in informatics, three physicians who, basically got to help kind of design this with the operational teams and, you know, of course, we were coming at the lens of like, okay, how can we use Epic internally? In Kaiser so we were like, okay, what tools can we make for this department? You know, so these folks that are covering this large volume of In Basket items can handle stuff in the most efficient way, in the best way. and make sure they have the tools to do that. And so that's how this, this department essentially got built and launched. And I'll tell you, it's crazy. Some of the tools we built I mean, we've been live on this now for at least a year and a half, maybe two years, and it's gone by so fast. And there's I mean, some of the tools have been tweaked. You know, we have different kind of quick actions that are kind of department specific, you know, to, to help. But like, other than small tweaks, those tools like the general tool set have stayed the same because it was able to be kind of designed at the onset, you know, with the operational intentions and desires coupled with the actual tools. I mean, it was like the perfect example of something, I think, in my whole career where we really got to do something like that together from the beginning and I mean, it's you go to the satisfaction side and yeah. Are there are some patients that are kind of miffed that, you know, someone on this asynchronous e-care team, you know, answered their email to their PCP, maybe. But, you know, they get the out-of-office message when they send a message to their doctor and, you know, and we just reply that we're just here helping and, you know, and sometimes they're the messages are appropriate for that to wait until that PCP returns. But we still reply, and we just say, hey, we got your message. We're going to save this for your doctor when they get back, and you know, they're going to be back on this day. So, expect a reply. You know, shortly after that. But it's just I mean; overall patients love it. Obviously, the physicians on vacation love it. And, frankly, the physicians and other clinicians in the office love it because now they get to, you know, concentrate on their work for the day, and all of this does come at a cost, but it's, you know, I think it's a justifiable cost. If you can figure out how to, you know, how to pay for something like this because it really, I think, is preventing people from the burnout piece and really trying to help tackle that head on. 

Dr. Craig Joseph: And that's not instead of, I'm assuming you still have, the concept of a care team, you know, for you. So, like, when you're in the office, are there nurses and assistants looking at your In Basket and plucking out messages that they can answer based on knowing you or based on any protocols that you have written? How does that work?

Dr. Adam Carewe: Yeah, I mean, I'd say like, so for if I just take primary care, for instance, I would say a lot of specialties have that kind of more, you know, specialty-specific, kind of clinic-specific someone. You know, what we've done in primary care because it's a large group. I mean, there's, I don't know, 300 physicians in our medical group that are primary care. And so what we've done on the front end is we have, a large group that we call message management. And they're essentially intaking all the stuff that was ultimately intended for those primary care physicians or APPs that have a panel and they're able to peel off a ton of stuff, you know, like you said, back in the day. And so there's been this, coupled with those efforts to really try and either peel off or more importantly, queue up, you know, so like you got your little sticky that you just had to see some things and sign off. I mean, I'll give you an example of someone I just had last week. You know, it was a patient that's in an outside facility like a nursing home. They just needed an order for a urine test. which, you know, I can't order in our system, and they'll get it because this is outside KP. and they needed, you know, some medicine that they just needed to change. And it was like a, basically an over-the-counter medicine, but still needed that physician order. And so, this came to a PCP that I was covering, and I opened up the chart or opened up the In Basket message and, you know, it was a little quick summary of what was needed. And then at the bottom, the medical assistant that cued this said, there's a letter pended with all this information. It already has the fax number for this facility. All you have to do is, you know, basically open this letter in Epic, make sure it looks okay. Did a little dot phrase for my electronic signature and I clicked send. And that went off to this facility. So, I mean it took me seconds to do that. Whereas in the past if I got that as a PCP, I would have had to like to write some sort of letter. And so, this was me covering as a part of this asynchronous e-care team, you know, so it's like I didn't even know this patient, but it made it so easy, you know, to do the right thing and to do the easy thing because that team-based care, you know, was on the front end of this too.

Dr. Craig Joseph: I think it's amazing that people are amazed by that, that you have someone that can queue up that information for you and make it so that it just works. And in most industries, people whose time is of the essence, have folks around them kind of help that and physicians, at least in the United States, we rarely have that kind of, an option. And so, yeah, it's great. And that kind of little, tiny thing really makes a big, big difference in your day. As you can see that that was ten minutes of your life that you just got back. Every time that happens, it's just ten minutes. And it's the little things that really make a big difference. Kind of intentionally designing to take some of the pain, some of the moral injury away from, away from physicians. And, and let them kind of, concentrate on what they're supposed to concentrate on. Letting doctors be doctors.

Dr. Adam Carewe: Well said, I'm going to take this. I'm going to take that clip and make it an advertisement on our Nerd MDs page.

Dr. Craig Joseph: Yet another attempt to co-opt all the goodwill that I've generated. But it's yours. I stole it from you. You can't steal it back for me. It's already been stolen So, Adam, near the end of all of our podcasts, we love to ask the folks we're talking with about a design that is so well executed that it brings them joy and happiness. So is there something or some things in your life that are so well-designed, you love interacting with them, using them. And it's an accomplishment. What do you think?

Dr. Adam Carewe: Yeah. No. Super cool question. I love these types of things in and outside of healthcare, but I'll just I'll give a really good kind of, technical, application example that I just recently stumbled upon in the last couple of weeks. I have no affiliation with this company, but they make an application that's called Rewind. And essentially you install this on they just have a Mac app right now, but you install it on your, your Mac and it's actually what we kind of talked about before Craig. You can have it always be recording what you're doing on the computer, which is scary, but also very cool in the sense of it makes it very easy to exclude certain applications, you know? So, like when I open up my Banktivity app, which is kind of like Quicken, I don't want that to be captured in this. So, I exclude those apps, but essentially what it's doing is it's capturing everything you're doing on your computer throughout the day. And you can capture audio too, if you want. So, I mean, it's kind of creepy in that way, but then you can go it's all recorded locally. And so, it's not sent off to a cloud. So, you have to have the space on your own device. What I love about it is how many times do you have that recollection where you're like, I know I was looking on maybe LinkedIn or Facebook or talking to someone and they mentioned this, you know, and I'm like, where was that? Well, with this, you can literally just queue up a little search box and you can like type in what you're looking for and you can find those things. I mean, it allows you to rewind, you know, your life and again, it's only limited by the space. And I just think it's such a beautifully designed application that it works in the background, you know, before a meeting. It'll prompt you, hey, you have a meeting on your calendar. Do you want to like, record this like with audio if you have that off, and then it does all the AI smarts, you know, it summarizes things. You know, it gives you a transcript. It's brilliant. Yeah. I can't speak highly enough of it, even despite the scariness behind it, too.

Dr. Craig Joseph: Yeah. It's super scary but I love it. And you kind of want something like that for your life, right? Like. Yeah, I mostly want something or someone to whisper in my ear. My wife does this for me now, but she doesn't scale well. I just want someone to tell me, like, the person approaching is your great aunt on your father's side, right? Like. Oh, yeah. Thank you. I knew I knew her, but I'm not exactly sure how, or you know, that's what I really need. We're not there yet, and I think Google Glass has shown us we're not going to be there for a while, but, that's an amazing app. I'm going to have to check it out and then I'm sure my, information security friends will have no trouble allowing me to put that on my work computer.

Dr. Adam Carewe: Absolutely.

Dr. Craig Joseph: Well, thank you so much. This was a great conversation. I think, you know, we learned a lot. I'm especially excited about, you know, when I hear about things like that inboxologist position or more specifically, what you've done to move kind of towards that with an asynchronous e-care team. These are the things that, and I think we need to kind of, imitate everywhere. And, and as you say, it's kind of culture dependent and organization dependent. You're going to have to tweak it. But boy, oh boy, it's a big improvement over, over where we are now. And so keep on innovating and keep on taking those baby steps and, and we'll make it. Thank you.

Dr. Adam Carewe: Yeah. No thanks. Craig, I completely agree with that closing comment. And thanks for having me on the show. I always appreciate chatting with you. This was maybe a little bit more serious than many of our conversations, but, no, it was a blast. And, yeah, I love what you're doing and have done. I love your book in the background that I can see, but no thanks for having me on the show I really appreciate it.