Designing for Health: Interview with Karim Jessa, MD [Podcast]

Much like the syrup that flows from its majestic maple trees, the pace of digital adoption in the Canadian healthcare space has been more gradual than in the U.S. While the push for electronic health records (EHRs) in the U.S. was fueled by the federal government’s enactment of the HITECH Act in 2009, Canadian hospitals and healthcare organizations have lacked similar government incentives to further their digital growth. As provinces and individual hospitals determine the fate of their IT and digital infrastructure, safety, quality, and usability are important considerations.

On this episode of the In Network podcast feature Designing for Health, Nordic Chief Medical Officer Craig Joseph, MD, and Head of Thought Leadership Jerome Pagani, PhD, chat with Karim Jessa, MD, chief medical information officer at SickKids, The Hospital for Sick Children. Dr. Jessa shares his perspective on the Canadian healthcare landscape, including how the healthcare industry differs from that of the U.S., the state of its IT, and how its physicians interact with the EHR. He also discusses clinician burnout in Canada, EHR adoption incentives, and his work collaborating with the Creative Destruction Lab.

Listen here: 

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Show Notes:

[00:00] Intros

[02:03] Dr. Jessa’s background

[04:42] How Canadian healthcare differs from U.S. healthcare

[09:03] The state of Canadian IT

[16:19] How Canadian physicians interact with the EHR

[25:58] Clinician burnout

[32:26] Working with the Creative Destruction Lab

[40:44] Things that are so well designed, they bring Dr. Jessa joy

Transcript:

Dr. Craig Joseph: Karim Jessa, welcome to the pod.

Dr. Karim Jessa: Thanks so much, Craig. Great to be here. I'm honored to be part of such an esteemed group because I hear you’ve only had, like, presidents and prime ministers on this. And so, thanks for including me.

Dr. Craig Joseph: You're very welcome. And you're correct. We have had some secretaries of state and prime ministers of foreign countries as well. So you might not actually make the cut. We'll see if this actually gets to be released ever. But Karim, I'd like to start off by summarizing how you got into the position that you find yourself in now. And if you've been a listener, you'll note sometimes I get it wrong. So my understanding is that when you were four, you told your mother that you wanted to be a doc in the emerg at SickKids, and she thought that was odd. And, but you've always wanted to be an emergency medicine doctor, and you've always wanted to work with kids, and you've always wanted to be an IT geek. Are any of those things true?

Dr. Karim Jessa: Well, I've always wanted to be a doctor. You're incorrect. It wasn't four, it was actually five. But you know, pretty close, that's not bad. But no, I always knew that I wanted to be a physician. But about IT, that just kind of fell into my lap as I just gained more interest. And I was kind of geeky. But I really liked emergency medicine because whenever I did a rotation in medical school or anything like that, I just liked the acute stuff, like the detective work of reaching a diagnosis and just looking after the acute stuff. And then I would hand it over to the internal medicine or surgery or anything to take care of the rest of it and then move on, you know, short, short span of attention. So that's how I got into medicine. But, you know, I was even as a high school student, I was a cadet with St. John Ambulance and, you know, doing that kind of first aid at the end, like concerts and things like that. So I was really keen as a teen in high school and junior high.

Dr. Craig Joseph: Wow. Many people don't know that I also, I went to medical school to become an emergency medicine doctor, and then I spent a few nights at a hospital called Detroit Receiving in downtown Detroit as a medical student. And I said, No, I don't want to do this anymore because it's all fun and games until someone tries to die. And I don't, I didn't appreciate their attitude. So I'm glad, though, that there are people like you who were, you know, continued on and didn't give up as quickly as I did.

Dr. Karim Jessa: Yeah. You know, it's funny you mention that, because as a resident, we spent two months in shock trauma in Baltimore, and that was like one in three call that you had to do. And I remember when it came to my turn to look after a patient, a young person came in with a gunshot wound and unfortunately didn't make it. And as I'm filling out the death papers and everything, I realized that that person had the same birthday as me. And it kind of hit close to home to be able to say, wow, that's, exactly, that's exactly what I said. And, you know, it makes you realize the importance and gratitude of life and how we just have to be so appreciative of what we have. So …

Dr. Craig Joseph: Wow, that that that will kind of shock your senses. I'm glad you're on the right side of that. All right. Let's, we've gone dark pretty quickly, and normally it takes us ten or 15 minutes to get dark on this podcast. You may realize that you are the first Canadian on the pod. And I don't mean any pod, I think there have been Canadians on podcasts before, but you're the first one on this podcast, and so it might help us to get kind of a quick overview of the Canadian health system in a sentence or two. You know, I think most of us know that you have socialized medicine up there, but we're not, we don't really know what that means, does everyone work for the government? Are there private insurance companies? How do they interact? How does it differ at a high level from the experience that patients and clinicians have in the U.S. here?

Dr. Karim Jessa: Sure, so I'm by no means an expert in the Canadian healthcare system. I'm a user of the system as well. And I try to rationalize the resources as well. But in a nutshell, yeah, we are, we have a central payer, the federal government, as well as healthcare being a provincial mandate. So each province in Canada is responsible for administering the healthcare. And within the province, different regions get allocated resources. And so in the hospital, which I'm going to speak about, you know, we get a global budget, and there's different funding models based on acuity and based on volumes that is somewhat opaque. And there is private healthcare insurance, but mostly for like ancillary services or those things not covered. And more and more, we're finding is that a lot more things are becoming privatized. There's been a push shared to be able to say, do we have a two-tier system? Like do we need a private and public like to have in the NHS? You know, would that be something in Canada? But a little bit more provocative, I think we do already have a two-tiered system, like not all things are covered for in the public system. So if you've got private insurance, you can get rapid access to like mental health services or not. So, for example, like even casting and things like that, or medical devices, splints and things, in the public system, those things are not covered. You'd have to pay cash, or you get it covered through private insurance. But if you want to get just like a plaster cast, you can get that If you want a fiberglass cast, maybe not, you know, things, just things of that nature. And from a remuneration point of view, we do not become employees of the government per se, and in some hospital models, the physicians are either salaried through the hospital or you bill the province. You build the Ministry of Health on a fee-for-service basis. So it just depends what kind of a, you know, alternative funding prong, AFP or AFA or like alternative funding arrangement that you have with the facility that you're working at. So hopefully, that answers the question, and we don't have huge health systems. So the other piece of it is that each hospital really is run by its own board and can determine what they want to do. So, for example, you can have seven hospitals in Toronto on some EMR, and it's up to them to decide to either go on all in on one system or each have separate instances of, say, Cerner, Epic, Meditech. For us at SickKids, we, our CEOs between SickKids and Children's Hospital of Eastern Ontario, which is a children's hospital about 400 kilometers away from us, we made a decision to go on the same instance of Epic. Now, that doesn't mean that everything is aligned. It just means that where we need to align, we align, and where we don't, we can deviate because we have separate MACs, we have separate boards, and that. So we're trying to get more collaboration going, but it's been a great partnership so far. Hopefully, that answers that question.

Dr. Craig Joseph: Well, you know, I was just hoping for you to say it's different and then move on, but the detail, I think, was very helpful.

Dr. Jerome Pagani: Karim, what's the state of information technology like in Canada right now? Do all hospitals have electronic health records at all physician offices? And then, most importantly, do all the hospitals have a Tim Hortons in them? I mean, I need to know this because the Timbits are like near and dear to my heart.

Dr. Karim Jessa: Okay, so I'm pleased to announce that most hospitals have Tim Hortons in them. So, you know, I can, I think we’ve passed that bar, which is really great and, but the menus vary, you know, so you have to just be careful. And the best part of that is the mobile app ordering where you can sort of come up and order the Tim – but you know let's, we can talk about that in a future podcast. I would just suggest that, you know, I think from a stimulus point of view, I think the HITECH Act and the ERA Act really was stimulus for the U.S. and Meaningful Use, and billions of dollars were put in. That did not happen in Canada. As I mentioned, it's up to each hospital to determine what's in their best interest to go forward. So from a HIMSS level, you know, most hospitals in Canada are at like a HIMSS level three maybe, you know, three, 3.2, maybe four. You're getting more and more hospitals going, you know, achieving that higher growth because I think you see the benefit from a safety, quality, and usability perspective. SickKids is a HIMSS level seven, us and CHEO went through that a couple of years ago, and we're just coming up for reevaluation or revalidation in the next year. So we're looking at that. We're one of the, I think we're the first pediatric hospitals in Canada to go through that. I think it's only 3% of hospitals or 2% of hospitals are HIMSS level seven in Canada. A lot of them are, the big academic sites are five and six or are pushing towards that. And there's different levels of becoming electronic in terms of most places are now on CPOE. But clinical documentation is the other piece where it's not, you know, physician documentation is maybe on paper or might be hybrid a lot of places.

Dr. Jerome Pagani: And are there incentives in place for hospitals to climb the HIMSS level ladder, or is it really just up to the individual?

Dr. Karim Jessa: Yeah, that's a great question. So I know there were incentives in the past for family doctor's offices where, Ontario, MD, which is a subsidiary of one of the ministry branches, had incentivized physician offices to go on EMR. But they didn't say you'll go on this EMR. They didn't really build anything for interoperability between primary care and hospitals. So that information flow between the primary care office and the hospital and hospital back to the primary care is a little bit muddled in Ontario per se. But when you look at places like Alberta, potentially, who have gone province-wide on, say, Epic, they're there's more opportunity now for cross-pollination and interoperability. And you've got places like Nova Scotia and Newfoundland going to, you know, provincial-wide deployments of EMRs where hopefully that will work. But as you know, that's really based on, like, you need to have good thought leadership in terms of integration and making sure that the workflows are conducive to meaningful outcomes. So hospitals are not really incentivized to do that.

Dr. Craig Joseph: It's funny that you mentioned that it's a little questionable, a little sketchy in Ontario, getting the, you know, primary care to hospital, getting that information, in the U.S. I used to a long, long time ago work for one of those EHR vendors and we used to demo the ability for a patient to go into their primary care doctor, be seen, have some lab results done, you know, in the office and then be sent to the emergency department. And when we showed that, the doctors in the emergency department could see the note that was just quickly written by the primary care doctor and could see the point-of-care tests that had been done and the vital signs, people kind of were shocked. And nowadays, as you mentioned, you can order from Tim Hortons from your phone, and we take that for granted in the U.S., I think, the vast majority of us do, that we've come far enough that it's not, yeah, of course, I could see everything that just happened five minutes ago in the primary care doctor’s office or the urgent care before the patients referred into the emergency department. And it does take some noting that that's not the case everywhere, and I like how you mentioned some provinces are further ahead because they've been thinking about those things or actually started a little bit, maybe later, and could see some of the work that you've done in other areas.

Dr. Karim Jessa: Yeah, I think from an interoperability perspective, I think that we're creating organic opportunities, especially around the Epic sites and, you know, trying to just trying to be a vendor agnostic. But it's hard because we're leveraging state Care Everywhere in Epic to be able to share information between hospitals, between hospitals, not primary care and hospitals. So we're trying to look at different types of integration engines to be able to say, do we create an internet integration hub between Cerner hospitals and Meditech hospitals? Because we do have those in our province here. To be able to say, are we going to share CCD documents? And what have you? But then, you know, you start getting into information overload and say, how do we filter out? Because what might be an allergy at one hospital may not be either documented, be considered an allergy, maybe like, you know, all those different interoperability standards to be able to say what are we going to land on for that information to be consumed from a third party. So we're having issues with like referrals. We're having issues with lab results being showed from that when they're ordered in an outside lab, not in a SickKids lab, but, say, one of our lab testing facilities we have. So the workflow would be a child comes into SickKids but lives way far out, and we have to send them the lab requisition to be done at their local town. How does that order get closed loop so that we can get the results back in? The technical infrastructure exists to be able to do it because it all reports into the Ontario Lab Information System, OLIS, and now where there's a project to consume that information back into Epic. So, but we're having to fund and build that ourselves. There's some help from the ministry, from one-time funding and things, but that's really on our dime.

Dr. Jerome Pagani: Karim, are there differences between the way physicians in Canada and the U.S. use the EHR that aren’t necessarily dependent on sort of their level?

Dr. Karim Jessa: Yeah, it's a great question, Jerome. You know, if you look at a study I think that Chris Longhurst and Mike South did, I think they talked about the burden of documentation and the length of notes and things like that. In the U.S., you know, we kind of laugh a little bit to be able to say, well, their documentation in the U.S. is so tied to their funding and what the insurance companies will provide and level of service, and this and that, I don't even understand it, so I may just be spewing out things that may be coming out. And that's less important in Canada, not saying that documentation is not important, but, you know, what you can build for like a comprehensive and things like that, there are some loose guidelines around that. But for a consult note, like, you know, you have to make sure you have a referral, you have to know who referred, and then you have to send a note back to the clinician. That's essentially it for a consult note. You don't have to hit like five things from review of systems and seven things from physical exam or what have you. So, it's widely variable, but it's really on the question of usability and the EMRs, you know, I remember when we went live, it's like, Oh, wouldn't it be great to be able to pull in this information and pull in this information and pull in this information? But there's numerous studies that say how much of an issue is copy and paste and readability and whether you do a SOAP note or an APSO note and things like that. Right? To be able to bring the assessment and plan at the top of the note and just give me just the facts, ma'am. Just the facts. Right? If you want to just keep it simple because, you know, it's information overload versus filter failure. Right? That's the tagline I always use.

Dr. Craig Joseph: So which one is it? How do you, what do you tell your doctors about bringing in important information but not too much information? Is it every doctor for themselves, or are there some guidelines?

Dr. Karim Jessa: So it's a great question, Craig. What we did was through our physician builder program and some really talented clinicians, you know, Jennifer Russell, you know, Shawna Silver, Chia Wei Teoh, really did a great job on getting a standardized discharge summary. So discharge template where you would be able to give the clinician an option of saying, okay, do you want to just bring in the last most recent labs, the last two days’ labs, things like that. So you wouldn't automatically pull those things in because it just becomes overuse. We tried to build some flexibility and some standardization, but as you know, our EMR is, you know, the good news is it's very configurable, and the bad news is it's very configurable because everybody can sort of do their own thing. But we're trying to get there through standardization. We're not there yet, but you can send everything right to your primary care offices. And we're still on fax, by the way, a lot of us. So, you know, there's a movement towards axing the fax, and we can talk about that. But until we have good interoperability and things like that, you know, I always say you're going to axe the fax and replace it with what, lick the stamp? Like, is that where we're getting to? Because unless you can have really good solid communication between acute care and primary care, you know, unfortunately, fax technology's quite reliable, and I think maybe your podcast replies will be like, who's this Jessa guy who's in the, you know, in the dark ages, you know, fax? Are you kidding me? That's why Canadian healthcare is so bad. But dude, can you find out a machine that you can plug in, put in a phone line, and now it works, right? Without having to configure everything? So …

Dr. Craig Joseph: Hey, hey, listen …

Dr. Karim Jessa: But I digress. But I digress. I digress, Craig. Sorry.

Dr. Craig Joseph: We have plenty of fax machines in the United States, and we make excellent use of them. Now they’re, typically, I will be honest and say that they're not actually machines. They're servers that act like fax machines. And it is fun to show younger physicians a fax machine, an actual fax machine, and get their response. But no, it's no different in the U.S. when we're trying to go from one place to another. Oftentimes it's just faster and easier, and I can send you a document, and then I can call you in five minutes and know that you received that actual copy of the document. It works.

Dr. Karim Jessa: Yeah, when we had a cyber-attack at the end of December last year, and we had a lot of those network-printer-fax all-in-ones which went offline. And so we had to actually pull out some of these relics for the fax because we needed, still needed that technology. So we had to, you know, where did we store those again? And, and we had to actually bring the back, which was interesting.

Dr. Craig Joseph: Wow, with paper and whatnot.

Dr. Karim Jessa: Can you imagine?

Dr. Craig Joseph: Did you use regular paper, or was it that special fax thermal paper from 1989?

Dr. Karim Jessa: No, no. We have regular, we’ve, come on, Craig, we've progressed, man.

Dr. Craig Joseph: Yeah. So you can use regular printer paper, all right. Yeah, I'm going to hang on. I'm going to write that. I'm going to note that down. Canada’s more advanced than I thought. Just getting on note bloat a little bit more. And again, note bloat is a term we often use, especially in the United States, where we say that progress notes have just gotten down from a half a page or a page to six or seven pages sometimes because people are bringing in discrete information from the electronic health record into their note, because we've made it easy to do that. Doctors always had the ability to write down every single piece of information. They just never did because that would be work. I like to, when thinking about note bloat, disconnect the technical from the non-technical and to say, Hey, you know, I've been a doctor long enough that I was certainly writing notes on paper in the hospital. And I recall one day getting a letter at my office. This is back when we had, we got letters. There was no email from the hospital. I got a letter from the department chair and I, that's not something that one generally wants to get. And so I nervously opened it up, and it said, Dear Dr. Joseph, we have reviewed five sample progress notes from the last six months and found them to be acceptable. Congratulations. And I didn't know that that was part of the re-credentialing process, that they look at your notes and say, Hey, are you putting in what we think are important? Now, no one ever at the hospital told me what's important, but hopefully, I learned that in medical school and residency. And I think that we can do the same, you know, outside of technology. So I like that idea that you mentioned, Hey, we're trying to give you flexibility. We're trying to give you the ability to do what you need to do. But we also acknowledge that one practice might be different than another. And certainly, patients are different from one another. Do you at SickKids, and I don't think I mentioned this, SickKids, Hospital for Sick Children in Toronto, is one of the top-ranked pediatric hospitals in the world. We're not talking about North America here, in the world. Do you all have some sort of a quality system whereby you grade notes or evaluate physicians attending physicians as part of the recertification process? I know I'm putting you on the spot here, and you're not an expert in that. But does that sound like something that happens? And if so, how nervous does it make you?

Dr. Karim Jessa: So we don't. Not that I'm aware of, but, and that would come through me if it came because I chair the health records committee, too, and work closely with our chief medical officer. And we have a great team. I'm really concerned about usability and physician wellness and provider wellness, and that's a whole separate topic. We do use some of the EMR-embedded tools to look at length of notes, but we don't use it as a credentialing criteria. We use it as a flag system to say, is that part of, like, pajama time? How much time are they spending in notes? Is there opportunities to improve as well? And then we also go back and we look at some of the feedback we get from our community providers who say, Karim, your notes are way too long. Like the, what we're getting back from SickKids is way too long. Then we'll go back in and say, Yeah, do you need all that information to be sent back to the primary care providers in our community? So we do have a feedback mechanism where we do reach out to our community providers. Mostly they just complain to me about our referral process. So, you know, that's yeah, that's what it is. So no, no, no, nothing on credentials that we do as a gate.

Dr. Jerome Pagani: Karim, so what about clinician burnout? Are doctors and nurses sick and tired of being doctors and nurses in Canada? And if that's the case, you know, what are you guys doing about that?

Dr. Karim Jessa: Yeah, we treat burnout with a $10 Tim Hortons gift card, so we've eliminated it. There is no burnout in Canada. So, you know, next question, please.

Dr. Craig Joseph: Next question, move on, Jerome.

Dr. Karim Jessa: You know, I think there's so many different, multi-faceted ways of addressing burnout and especially coming out of COVID where we're all feeling really overwhelmed. Administrative tasks. So I think there's always an element of burnout. We have an important wellness team, and we're trying to take a real measure to approach. So, you know, people talk about like alert fatigue and alerts as being a component or a contributor, EMR being a contributor to burnout. You know, I think it's one piece of the puzzle where, I'll give you an example. So when we went live with Epic, I found out that some of our medical staff never signed into the EMR system even when we had it before. And so I said, you know, you're not doing that? He says, Karim, I have people for that. So trainees. So when you then go back to them and say, you know, it's really important for you to sign an admission note or an OR note that one of your fellows or trainees has done from a medical-legal perspective, from an oversight, from a learning prospecting or teaching perspective. Is that undue burden, or is that what's something that they're actually supposed to do as prescribed by the Public Hospitals Act from way back when, that a physician should sign an admission note within 24 hours of admission? So people say, Oh, the EMR is making me do this. No, this is actually part of being a physician. You had to document. So when you say I'm having to do extra work, you know, like you know, I have issues with that. But when we start looking at extra work that you're actually having to do, where's team-based work? You know, what's the use of medical directives, what's a physician-mandated order, what's in the purview of the wider health team? We don't have a lot of medical assistants. We're using more nurse practitioners. They're a godsend to our team as part of team-based care. We have some physician assistants that we're using in the emergency department as well, and in some other parts of the hospital. So, you know, long answer to this is yeah, burnout is there, but there's other things like job satisfaction and number of years of remuneration. A lot of a lot of different things, autonomy. So hopefully that helps that.

Dr. Craig Joseph: That's very helpful. I think I'm fascinated by the fact that Tim Hortons is how you solved burnout. We have pizza in the United States. I don't know if you have pizza in Canada, but we have pizza in the United States, and that's how we solve burnout.

Dr. Jerome Pagani: They are the inventors of Hawaiian pizza.

Dr. Karim Jessa: Pineapple.

Dr. Jerome Pagani: Sweet and spicy.

Dr. Karim Jessa: Or fried chicken, Craig, maybe, but. Let's see. That's another story.

Dr. Craig Joseph: We're learning a lot about traditional Canadian culinary history here. You mentioned usability with respect to notes and, you know, which is something that often people don't think about, but you're thinking about, you know, how can I incentivize, kind of push folks to make a note that is usable by the next person who's reading that note? And sometimes that next person is the future you doctor. And oftentimes, it's a specialist. Or in the U.S., often it's someone related to billing functions who's looking at your note. Thinking from that kind of design perspective, you've talked about notes and how to try to design them to maximize benefits. Are there clinical decision support tools that nudge physicians or even patients in the direction that you want them to go? And I'm not really asking you if you have them. I know you have them. Are they, do you think that they're different between Canada and U.S.? Are there different nudges or different factors that a Canadian physician would respond to differently than an American, perchance?

Dr. Karim Jessa: I'd have to give that some thought, Craig, because I don't think so. I think we want to do right by the patient and by our colleagues. So I don't think there should be. Are there differences? I haven't seen other than the fact that I guess when I’ve received transfer packages from patients have been repatriated from the states, you know, I get a volume of printout of paper, and it's just sometimes it's just repetition, but it's quite complete, and that's where you get into sort of, you know, filter failure versus information overload. Right? Just send me like a cumulative patient profile or just one discharge summary, and just tell me what I need to do. That's what we're hearing from our community providers to be able to say, yes, great, the narrative is important, but these are the next steps that we need for the next five days or what have you. And if we can empower our patients as well, like on discharge, to say this is, you know, obviously this is what you have to watch out for the next three days or four days or five days, you know, and how can sort of technology help that to not the patient potentially bounce back to the ED or how can we use tools? You know, there's tools on, take a picture of your wound. We have a project for hypospadias repair from one of our urologists. And it's a long-term follow-up. And we are sharing the pictures of what, say, a tool would be one day, what a wound would be one day, two days, three days, four days, five days a week, or ten days, two weeks after surgery so that the patient can say, oh, it's healing normally, or, you know, because sometimes it's, oh, there's discharge. But is that normal three or four days after that wound? And so you can sort of set the patient up for appropriate expectations, and they can actually upload some of their photos and keep it in through MyChart or what have you. We haven't published the results on that yet. I think they're still gathering information, but that's a research project that one of our urologists is very interested in, even for long term. So just empowering the patient as well.

Dr. Jerome Pagani: So Karim, you're a mentor at the Creative Destruction Lab, which sounds like, at first, an amazingly cathartic thing to be a part of, just thinking of creative ways to blow things up. But then I realized I got that wrong. So can you tell us a little bit about what the CDL is and how a CMIO and Emerge physician fits in with that group?

Dr. Karim Jessa: Yeah, so CDL is done through Rotman School of Management, really, really tremendous group and team. I was involved with Rotman in 2007 as part of the Advanced Health Leadership Program that I took, I was sponsored by the ministry and our hospital, and I've tried to stay in touch with the Rotman team. I've lectured there a little bit for some of their global MBA programs, and they asked for, you know, expressions of interest for me to be there, and what I do is I give the applicants, or the people going through the program, advice on how to break into the hospital system and to say as a clinician, I don't think that that would work or this is what you need to look at. So and I've had opportunity to participate in some funding arrangements as well and, you know, be part of that. And it's been great because you've got some young entrepreneurs coming through who really want to stir up the system. And sometimes I have to give them a dose of reality to say this is going to take a long time. Selling into the hospital sector is going to be a long time. Not to be a naysayer, but to be a realist, to be able to say this is where the funding where I see opportunity. Just reviewed a company, not through CDL, but through another group of companies from physicians called Halo Health, a plug for Halo Health and Luke Sheen and the team there. Great work that they're doing. But you know, think physicians are getting more and more savvy and participating. And sometimes, you know, you know what they say is, you know, for physicians, how do you make a small fortune in tech? Start with a big fortune, right? So because we're not that savvy. So, you know, it's really important so CDL has been great. I've learned a lot about how to evaluate a company as an early stage, middle stage, you know, what's the path to exit, things like that. So I provided my insight and being able to provide value to some of our participant companies as well.

Dr. Craig Joseph: So there's actually no hammers involved, is, and I'm disappointed if that's the case.

Dr. Karim Jessa: No, but there's no there's no hammers. But we do get together, and some of the people have a hammer background, so that's okay. And you know, CDL has expanded, right? It's all over the world now, and that's I think that's what we really need is to be able to bring early thought leadership, early-stage companies to say how can we go from sort of bench to bedside in the shortest matter. So, you know, we could talk about like an innovation, which is a big thing. How do you break the cycle of these big EMR behemoths? How does innovation and operational co-coexist in a hospital or in a health system? Where's the tension? Where's the synergies? And I don't know. Are you going to ask about ChatGPT? Because like, this is not me, I'm actually an avatar. So you haven't even noticed yet. So, you know, the ChatGPT I'm using is quite amazing. So and there's no answers to that. I don't have any good answers on that too.

Dr. Craig Joseph: Yeah, I don't, I don't know what that is. ChatGPT, Jerome, have you heard of this? Maybe it's a Canadian thing. Is it, do you buy it at Tim Hortons?

Dr. Karim Jessa: At Starbucks.

Dr. Craig Joseph: Oh, Starbucks, well.

Dr. Jerome Pagani: Over here we call it JeromeBot and it works very well. Yeah.

Dr. Karim Jessa: Yeah. I think that's a really interesting. I don't know. I think that whole AGI, generative AI, how much of it is on that you know that Gartner hype cycle of inflated expectations. We're going to come crashing down into these trough of disillusionment. I think there's promise here. Chris Longhurst was just on ABC, I think talking about that study where patients loved the empathetic responses from the chat engine more than they did from the physicians. And Chris aptly said, well, if you give clinicians, you know, half an hour to generate a response, of course, they're going to be empathetic. But if you just give them one second, along with the other thousands of messages that they're being bombarded by, you know, you're going to give a one-word response or two-word response, you know, blood work fine. See you in six months or see you next week, rather than your CBC looks a little bit and yada yada ... So there's a fine balance.

Dr. Craig Joseph: Yeah. My take on generative AI is that, because I've been asked where is it on the hype cycle/ And you know, my answer was, with some respect, it's not on the hype cycle because it is real, meaning I think it's really good at summarizing information and taking in a lot of information and kind of distilling it down to what's good and that ability because it doesn't have time constraints like humans do, it can sound empathetic. And so, some of those things are very helpful. And I know Epic, among other EHR vendors, are starting to try to incorporate it, not in deciding what disease you have or how best to treat it, but in how to respond to your patient message about your new symptom, or how to summarize those lab results so that I don't have to and, you know, I think that can be here very soon, and that would be a help.

Dr. Jerome Pagani: And that's, you know, that's largely where we've seen I'd be successful in healthcare anyways, those sort of extension type applications, you know. Radiology is, I think, a great example that everyone's familiar with, and I think for ChatGPT, that sort of extension framework is where we're going to again see sort of those early wins or that first path to, what does Gartner call it, the plateau of productivity. That's where you know it's those sorts of applications that it’ll land.

Dr. Karim Jessa: Yeah, we've, if I may just talk about a, we started with a pilot in our health information management. So the way the hospital is funded is every year, we have to submit our coded data to the ministry for reimbursement and things. So we need to know, you know, what's the most responsible diagnosis and what are the co-morbidities and things like that. And we used a vendor, Semantic Health, a Canadian company, to be able to look at all our notes, a lot of our notes, and be able to look to the coders to be able to say this is likely the list of issues that the patient had, and we'd validate them with the clinician and then go back forward. And I know in the U.S., you've got like massive coding teams right at the point of care, right? Like on the wards. And one of the clinicians came from the U.S. said, Karim, how come I'm not getting bombarded by nurses asking me, Dr. Jessa, is this the right, you know, MDX, or you know, can you just alter that? We don't do it like we don't have it right up front. We're trying. We do it sort of later on, but we're trying to get more real-time with that because it's still an issue for us. So we found great value in being able to go through a large number of charts in a short period of time. So you still use the coders, right? You still use the coders, but they can get through complex charts really quickly. And we found great value with that company and FTE equivalents. Like we've been able to get increased reimbursement from that as well. So I think those back-end processes are well-established, the automation and things as well.

Dr. Jerome Pagani: Karim, we ask everybody who's on the podcast the same question at the end. We just like to hear about two or three things that you interact with on a regular basis that are so well designed, and they could be outside of healthcare, but are so well-designed that they bring you joy to interact with.

Dr. Karim Jessa: So, you know, we talked about Tim Hortons. I love that Tim Hortons app to be able to, you know, it charges my credit card or my Tim card, what have you. And I can get my steep tea with one cream ready in two seconds, and I can look at my colleagues who are waiting in line and not do that. That's the one thing. The second thing that I actually love is being able to go to the gas station, pull up to the gas station, go to try to get gas. And I hit the Esso application on my phone. It knows where I am, right? It knows the gas station that I'm at. All I have to do is say pay for fuel and say which gas pump I'm at and plug in the number, and it says ready for fueling. I go fill my gas. Done. And that's it. I don't get a receipt. I get my Esso points, or now are there are PC optimum points, but it's been, that's amazing, and like you can't get spoofed with your credit card because there's, you know, those talks about people overlaying things on the gas pump for your credit card, there's that piece. The other piece that I like is, you know, as an emergency physician, our schedules change all the time. So we have a little scheduling app that we use, like MetricAid, that you can, you know, post a shift, or you could trade, and you can pick up shifts. You can see what shifts are available if I have time to work or things like that, I'm still practicing, I still do clinical work, and I use that very nicely. Rather than saying, know, phoning people or sending an email to the group and saying, Hey, can anybody trade for this shift or what have you. So that's been really great to be able to do that. So those are a few things that bring joy to my life. And then I like my golf club app too, when I book a tee time and things like that.

Dr. Craig Joseph: So they've got some of this stuff figured out. Here's my question about Timmy Horton. We have this thing I think you've mentioned called Starbucks. I don't know if you have that technology in Canada. Actually, I do because I've been to Starbucks in Canada. So that's me just being …

Dr. Karim Jessa: But $6 for a coffee? Come on.

Dr. Craig Joseph: Yeah, well, that's Canadian dollars. So it's a dollar 50 American, I think. I think that's how, I don't know what the conversion rate is. Let me ask you this. Have you ever gone and ordered something from Tim Hortons on that cool app that you mentioned, and then you go to pick it up, and they're like, oh, we don't have cream, We don't have whatever it is you wanted that you actually ordered and paid for it. That's never happened?

Dr. Karim Jessa: Never.

Dr. Craig Joseph: Okay, well.

Dr. Karim Jessa: Well, I’m, simple, right? Simple. Steeped tea with cream. I mean, you can't run out of cream as a coffee shop, like, you know, this soya beans, matcha, whatever. Like, you know.

Dr. Craig Joseph: That's my order. How did you know?

Dr. Karim Jessa: Oh, well, it's okay, Craig.

Dr. Craig Joseph: But I determine where the beans are sourced. You know, I want them from a specific area of Morocco.

Dr. Jerome Pagani: This just points to the fact that Tim Ho’s is a far, far superior experience overall.

Dr. Karim Jessa: Well, there you go. There you go. Well, I tell you, I've never, but I mean, I order simple things. I don't order a lot of things, but it's all good.

Dr. Jerome Pagani: And Starbucks doesn't have Timbits. Just saying.

Dr. Karim Jessa: They don't. They don't. I have to say I don't know when the last time I ate a Timbit though, I have to say. Because I have eaten a lot of Timbits in the past.

Dr. Jerome Pagani: That's probably where they belong.

Dr. Karim Jessa: Yeah. Yeah. It's just it's not good, you know. It's not good.

Dr. Jerome Pagani: Karim, thanks so much for joining us today. It was really a pleasure speaking with you, gentlemen.

Dr. Karim Jessa: I had a blast. I look forward to catching up with you in person. And any time you want to come to Canada eh, just come on up. I had to put the eh in. And no, I don't know your cousin who lives in Edmonton. Okay?

Dr. Craig Joseph: I thought for sure you did. All right, let me, let me finish this up. This podcast was sponsored by Tim Hortons, Tim Hortons for all your Timmybit needs, found at Tim Hortons dot com or dot CA, I don't know because I'm just making this up. And in fact, it's not sponsored by anyone. Thank you very much.