All right, everybody. I'm Matt Cook, Emerging Technologies Coordinator at OU Libraries. That is my counterpart. Zach Lashikasi will be talking shortly. I'm going to kind of lay out the agenda and sort of where we are in terms of virtual reality applications for pedagogy and research on campus. Here it is. Here's the agenda. So this is going to be our talk in a nutshell. I'm going to start out by contextualizing the project, kind of telling you all where we are right now today as of April 2017. And Zach's going to jump in for preservation challenges and research initiatives. And then we're going to end on kind of a back and forth across talk, if you will. I'll take away this slide. Right, so here's some stats just to dive right into it. Kind of a state of the union for OU Libraries. And as far as I'm concerned, OU Libraries is OU full stop in terms of virtual reality. We started looking at this technology a couple years ago. So we're pretty well developed in a couple research programs and several course integrations. The hardware element, which we have deployed right now is primarily Oculus-based. Those are Rift Consumer Version 1 headsets, eight at three campus locations that are networked. We actually have three HTC Vive workstations and a ton of cardboards laying around. The important takeaway from the hardware portion of the slide is that all of these are publicly accessible, which means we're seeing uses and adoptions and student clubs, for example, that are emerging from this that we didn't predict, which is great. It's wonderful, it's organic growth that we wanted. And then in terms of sessions, because we do data gathering at each of the sites where these workstations are deployed, we've had 1,000 plus, not necessarily unique users, but people sit down in a chair and engage with a piece of educational software. And this is as of the beginning of the year. So you're looking at essentially stats from last year up until the early part of this year. Course Touchdowns refers to full class periods that took place in one of the three, and this is one in the main library here, of our VR Workstation locations. We also kind of try to onboard people with the project and what we've done with these intro to VR workshops. You can kind of consider what I'm doing now, kind of the beginning of an intro to VR workshop that we'll give on a weekly basis for the general public, for staff, for faculty. You can walk in off the street. And importantly, even if you're not a technical person by training, which I'm not, you can get the background to get started and we'll give you the basics of how to interact with the system, what software we have, where we're going. And then of course the big win as far as I'm concerned is these kind of in-depth course integrations, which I'll talk about now. Slide, please. Here we go. So these are kind of the more in-depth, well-developed projects that we've done in the course of, I would say the last year, because prior to that we were just kind of getting our footing. Architecture is the big partner here. Particularly interior design, which would be a way for undergrads prior to being 30 years old, 35 years old and constructing their first architectural design in real life, they can be 18 and 19 years old and inhabit or cohabit with their faculty, with their student groups, a building of their own design. And this is important because what you'll hear from faculty time and time again is students only see the floor plan of their buildings when they're sketching and doing blueprint work and reddit and stuff like this. So they can walk through, this is an example of one session like that, although that's not the architecture class. These are shared network workstations, which I'll talk about in a minute. And as of two weeks ago, we finished data gathering for a study that's ongoing with the architecture college. So they're integrating this regularly on a semester by semester basis with the regular coursework. The medical imaging example, which is actually what we're looking at here, they're walking through carcinoma, lung carcinoma actually in VR. So what we're kind of trying to represent with this part of the slide is the workflows that we're kind of pioneering, at least in terms of course integration. So we're taking DICOM data, which could be MRI, CT, CAT scan data, transferring that volumetric data into a surface mesh for deployment in VR. And then we have advanced medical imaging grad level courses coming in. And scale is instantly manipulable in this landscape. There's no such thing as like a limited perspective. You can fly inside around and look at for many angle this actual medical data. I'll go on to anthropology next. Right now this week, there's a required assignment for anthropology 1114. They're going to the library or to the research campus where we have these workstations and they're comparing hominid fossil skulls, which are taken from a series of different databases in virtual reality. They're exporting perspectives from screenshots that are taken within a sagittal crest of a Neanderthal. And then they're emailing back to their professor to prove that they can locate this part of the pre-hominated anatomy. And then just in terms of a research application that had both input and output mechanisms, structural biology, visualizing protein, specifically from the protein data bank, students in advance of this class would email or upload to a Dropbox, a .pdb file, which is an interesting file format. We can get into it in the reception. But we have workflows once again, like with medical imaging, to convert that into something that you can view in virtual reality. And then they were exporting narrated video for presentation with their classmates' slide. And then this is kind of the even more context, a little bit deeper dive. So two years ago, I went to UALR, University of Arkansas, Little Rock, and I saw they had a cave system. That was impressive. I also saw they had an Oculus DK2, which was the second developer kit. We took something like that to our campus. We started showing faculty what was possible, and we had a problem, which was every single faculty we showed this to one of their own virtual reality application. So we essentially developed and deployed our own custom virtual reality workstations that allow you to remotely upload your own 3D content through the library website directly to virtual reality. And then you walk in the door and your content is waiting for you. That's what you're seeing here, the hardware aspect of it. So it's a custom design sliding rail chair assembly with the PC built below and behind the user for cable management and range of motion purposes. And then the software, like I mentioned, allows for a remote upload of an arbitrary amount of data, 3D data. So that's kind of our contribution. These stations, once again, are located all over campus. They're publicly accessible, and they're now replete with data from a whole bunch of different classes. So that's gonna take over. Thank you very much, Matt. As you can see, we have a lot of great work going on VR. And I'm gonna talk a little bit about the data curation concerns that start to come up with that around reproducibility, transparency, integrity, and insecurity. And first I'll just say I'm a Zacletia Canada. I'm a clear fellow at OU, basically working on dealing with all these great new technologies that Matt is bringing in and thinking through all the curation issues. And I'm gonna talk about two parts of this. First, the VR platform itself, software and hardware and all that, and then also the VR content. And you'll see as we're starting to bring more researchers into using this technology, these curation concerns are becoming increasingly dire. For the platform, we really have things that we've been dealing with for a while, hardware, software, obsolescence, which poses risks to continued access to this material. Also, as we move forward, maintaining access to material that we've archived. There's issues of versioning. So as Matt's team develops new software or revises the software, we wanna make sure that we're keeping track of that so that if a scholar comes in and brings in, visualizes some data in our software, they can go back to the version that they used and document that. So issues of reproducibility are a really important document there. We're looking at all these various preservation approaches. So thinking about documenting all the changes as we update drivers or bringing new pieces of, we just adopted what's the Oculus Touch. So these new controllers, we need to document that. Thinking about emulation strategies. We're monitoring standardization initiatives. For instance, the Kronos Group has this open XR initiative. They're calling it XR for augmented reality, virtual reality and everything else. And they're developing standards for VR headset, so that VR headsets can communicate with software in a standardized way. We're looking at recording the experience of VR. So in 10 years, we're like, what was it like to actually use VR in 2017? So recording users or maybe even doing oral histories, things like that. There's the old computer museum approach where we just save all the hardware and try to keep it running for as long as possible. This poses an interesting problem. I'm actually working with a grad student at NYU who's doing the history of the 1990s VR wave. And she found that, in her experience, she hasn't found a lot of software that survived. For instance, at the Living Computers Museum in Seattle, they have 23 VR headsets, 51 pieces of related hardware, but they don't have any software packages or the computers to run them on. Slide. So directions forward. Thinking about, since Matt didn't go into too much detail about this, but basically all that software that we're using to visualize 3D models was developed by his team in-house. So we have all the source code. We're keeping track of all that in a GitHub account. So we can track that. We can document that. We can encourage scholars to start citing that, that our software releases. And I've been looking at using Zenodo, which is a great platform for archiving research data, as it has this great function that will just watch your GitHub repository every time you do a release. It'll actually take that, archive it, and issue a DOI, which is really nice. So on the tech side, having some sort of automated process for that, but then getting scholars to actually cite the software they're using when they publish their research slide. VR content, it's a huge universe. 3D models, this is basically what we're dealing with most of the time in our platform. There's point cloud data, mesh data, volumetric data. We're even getting starting at 360 videos, which we haven't really talked about, but it's, the journalism department, for instance, is really excited about that. And that can include sort of just flat videos that are 360 or also binocular sort of 3D videos. Talked about software a little bit. A lot of, we're actually using other software that's produced by third parties that are bought through the Oculus store. So there's a lot of interesting issues that are around archiving those things, which they're protected by DRM and things like that. So that's a whole other project. And thinking about archiving the source code, I talked about that slide. Other things we're thinking about in terms of VR content, sustainable file formats. We've done a little research on that. Metadata is a huge issue and all the derivative data that can be produced and tying this all together to some data repositories that can help us think through, that can help us preserve and manage all this content. So we've been playing around with the file format, Kulada or Kulada, I don't know how people like it. I was thinking of coffee and Kulada. But it was developed by the Kronos Group and it was designed for interchange between software, 3D models and software packages. It's XML based, it's open, be open enough. You can put in all this metadata actually into these nodes here, you can add your own custom nodes. The most pressing thing for us when we're modeling 3D models and having researchers work with them was scale data. So if you're bringing in a 3D model of a skull, you want to be able to have information about the scale of it and so it's an accurate size representation when you bring in and you can do actual measurements in VR. So we actually are able to put in the unit measure, this is, I believe, millimeters and then you can actually orient it until how the model should be represented in that space. So that's really, really helpful. And it's been good so far, we have any problems. So I'm actually, here's some feedback on that slide. We're like, there's obviously a variety of ways in which you can make 3D content. Right now I'm looking at photogrammetry workflows. We have some researchers who are scanning things and I'm observing them and asking them, okay, what are you doing here? What's the metadata? And then I'm looking at the software they're using to see what kind of technical metadata we can pull out. And the big concerns here are being able to document at each stage the decisions that are being made and how you're processing the models and editing them so that a researcher who's getting the 3D model down the road can trust the precision and accuracy of that model. And so this is sort of the big map. This is the big high level map that we're working on here. The data repository that we're trying to put together here has to fit into this larger 3D ecosystem that I've been describing for you. Metadata needs to be tracked throughout this. On one side we have, on the far left, we have the data collection content creation. Any sort of photogrammetry workflow or laser workflow. We need to collect metadata through that and bring that in. We're basically all those right into Dropbox where you're using some cloud-based solutions and the benefit of that allows our entire team to have access to those files and instantly synchronize our files across all our platforms. And that's actually pretty critical. We have actually, and Matt's gonna talk a little bit about our off-site partners at other places. This allows us to sync our content with them too and bring it into our VR visualization analysis platform. We're in which case, and this is something we're still figuring out, is that in VR we can actually create annotations and measurements. So we need to figure out ways in which we can manage that as a form of content creation and archiving. So the metadata schemas we're developing are trying to take into account all this, things that could be derived from that, like annotations, and keep that on the whole research life cycle. Also from the Dropbox data repository side you can go for publishing or actually convert them to STLs and do 3D printing. The part we're working on now is the data catalog which will allow us to take these files from Dropbox which is sort of an archival and bring them into our archive which right now is Amazon web services S3 bucket where we're managing this data catalog. And it allows us the flexibility to when we develop our institutional repository data catalog we can bring everything in very easily. That's sort of the more medium term solution. Short term, we can curate what gets archived and what doesn't. We're still developing those policies and guidelines. So for instance, if the students bring in 3D models for their class we may not want to archive those for the future. That may be just one time, one semester late. Then we take them off the VR system. But then if you have a researcher coming in modeling things then we may want to keep those things. So setting up those policies and having, there has to be someone curating that. And so this is sort of the map and we're still working on many of these elements. So current projects, data repository, I just explained to you tracking metadata for all that, developing best practices and figuring out other ways in which we're gonna access these things and make them available. Matt, do you wanna talk a little bit about partnerships we've been having? Yeah, I'm a last form grant application is still very early stage here. But the point is that we have partners at these various institutions, strong partners at Arizona. In fact, Arizona has deployed a workstation of our design, at least the software design, which is really interesting. Because we support live voice chat as well as remote uploads. So that means right now today we could have a faculty member at Arizona and they have their own specialties and specialized data sets guide a class or lecture for eight students simultaneously on the OU campus in virtual reality. So it's basically a VR classroom in the making. It's technically feasible today. There's a couple things that are happening. Essentially, as I'm speaking, they're gonna make this more and more scalable, which is interesting. But there are the infrastructures in place, the hardware and software is in place. And if people in this room are interested, the code is available. So if you have access to Oculus hardware and we're working on a Viaport to this or working on a mobile port to this, you can deploy this software on your campus, gain access to everything our students and faculty have uploaded and then add to that collection to the point where it becomes this giant cloud-based 3D asset repository, which is something we're gonna archive as well. And then this is kind of getting towards the end. This is very, very current thinking. Two things have happened in the very recent past. Number one, I got a really nice new work computer. Thank you, Carl. It's an Alienware machine. It's portable. It has a 10 series NVIDIA GPU. It's super powerful. But the point is you can now be in virtual reality for longer than five minutes with this processing power. You can, this is going to be a productivity tool in the very near future. And what I mean is we're not just gonna be viewing models five minutes at a time and taking a screenshot. We're gonna be taking measurements and that functionality is already in place in our platform. You can shoot a laser out of your hand at one part of a skull, shoot the other laser out of your other hand and it'll take a arbitrarily detailed accurate measurement of the space in between. So you can do science in the system. You can also annotate the models in real time and export those annotations. So you can, it's content creation and then productivity within the software. And because the latency is so low with this 10 series NVIDIA GPUs, you can do it for as long as a class period lasts, which is very exciting because up until very recently you have this like spectrum of users and at the low end they're running to the bathroom after three minutes because they can't handle it. At the high end you have a couple people that can do it all day, mostly young people like eight year old people. And then in the middle you have the rest of us. But it's getting more and more to be a flatter curve which is great, it's excellent. That's why we're kind of in a, we're well positioned right now. And Zach will continue with this. Yeah, and so a couple of the other takeaways I think from our initial stages of this research is the thing about what the library's role, a library's role, any library's role in supporting VR could or should be. And I think we brought these issues of infrastructure and technology. There's obviously a buy-in that is necessary. Cost is coming way down. So the cost of the actual hardware and software. Data storage I think is gonna be where your cost is gonna be if you wanna support something like this for scholarly use. Curatorial, you also need some data experts, some data curators out there to make those policies and sort of create workflows so that we can track the metadata through this construction. Through production, through annotation. And then also thinking, going back to the research integrity questions, a lot of these become domain-specific needs. So archeology has certain needs. Architecture has certain needs. How do we track metadata in those contexts? I think we can, the partnerships we're forming are really important. Platform sharing, that's kind of what Matt was getting at the end where we're able to create this tool. We make it available. We had a tour going through the other day and someone from the business school was like, oh yeah, this is the software they use and they sell it to people. Like, we don't sell this software. We make it available freely to everyone. The more people we have using it, we benefit from that as well. So that has been really great. And then developing standards that we can, for basically all this metadata that gets created through the process is, I think, a real need that we have. And then going back to the first point, we're not just playing around here anymore. We're really using a separate scholarship. Yeah, I'd like to comment on that just further. I was at ALA in, it was in November, I forget it was the Lita, sorry, Lita. It was in Fort Worth not too long ago. And libraries are still very much in this like wow phase, novelty phase with virtual reality. We're not much further past that, but like I said, the technology, the hardware and the software, is gonna support much more broad application and deep application. I think it's important to not just be satisfied with putting a headset on the first time user and having the ooze and the oz, which is great. It feels really good, right? But that's, a lot of times, that's like third-party gaming software. We can do a lot more with our own software. We can do a lot more with network software and built-in functionality that includes productivity and content creation. We've not yet scratched the surface. The wow factor is gonna get them in the door, but you start working with faculty one-on-one and students one-on-one, grad students one-on-one. You'll see that there's gonna be long-term sustained use. We already have faculty using the system semester over semester. They're committed to it for the long-term, which is good because when we started, we had no idea what we're doing and people were just freaking out because they were in the system for too long. But the fact that it's gonna be sustainable, I think, is pretty clear now and the tools are gonna be more robust within the system. The backup archive element is gonna be in place by the time Zach finishes the clear doctor ship. And I think that's towards the end. That's it. So we saved six minutes for questions or however long you can get.


Hello, and welcome to the Dr. Gundry podcast. The topic of today's podcast actually affects 35 million Americans, so this is something that you actually might have and might not even know it. It's an autoimmune disease that attacks your thyroid, and it plagues you often with painful, frustrating, even debilitating symptoms, many of which are actually invisible to you and people who see you. So I'm talking about Hashimoto's disease, and one of my followers, Kelly Clarkson, made it very famous last year when she actually cured herself of Hashimoto's by following the plant paradox. But we've got a real expert joining us today who is Isabella Wentz. She's a pharmacist and author of Hashimoto's Food Pharmacology. And she was diagnosed with Hashimoto's disease at age 27, and Isabella began studying its root causes. And Isabella, welcome to the program, I'm so happy to have you on. I've been following your work for years. So tell me, I love personal stories. Tell me how this started with you and take it from there. Thank you so much for having me. I'm a huge fan of your work as well. So in full disclosure, I was never really interested in thyroid disease during pharmacy school. It was pretty straightforward in what we learned at the time. It was if you had an overactive thyroid, you suppressed thyroid function with certain kinds of medications. If you had an underactive thyroid, you gave more thyroid hormones. I really thought there was all there was to it, maybe some brand name, generic names and not converting between the two different types of medications. And it really wasn't until I was diagnosed myself with Hashimoto's after graduating from pharmacy school when I realized the complexity of the condition and when I realized that while medications could be helpful, they weren't the be all end all for most people with thyroid issues. I started having some strange symptoms during my first year in undergrad. I started having fatigue after a viral infection that just never seemed to really get better. Then I ended up with just not feeling like myself for pretty much the first year or two with apathy and mood changes and just that constant fatigue. Eventually I learned how to deal with it and ended up getting good enough grades to get into pharmacy school. I don't know how I did that, but during pharmacy school, it was one thing after another. I started having more and more symptoms. I started with irritable bowel syndrome, then it was panic attacks. Then after graduation, I ended up with acid reflux and carpal tunnel in both arms and hair loss and allergies. And I just felt like my body was breaking itself apart. I would go to different practitioners and I would, you know, I was a good girl. I was eating whole wheat and low-fat dairy, right? And I was exercising, trying to do the right thing. I would go to my doctor and say, hey, I'm just not feeling right. I'm tired. I'm forgetful. I'm gaining weight. Can you tell me what's going on? And the things that I heard, we could just do a whole podcast on that. One of the doctors said I was just getting older, so I was 25. 25, yeah. Time to slow down. Yeah, pretty much a geriatric at that age, right? And so I ended up eventually asking more questions and getting, pursuing additional testing. And I learned that I had Hashimoto's, which is an autoimmune attack on the thyroid gland. And at that point, part of me was really happy and relieved. I know that sounds strange, but at least I had an answer, right? I was like, okay, great. I'm going to take thyroid hormone medications and everything's going to be fixed, right? Because that's what I learned in pharmacy school. That's what I do, right? Take thyroid medications. Excellent. And then, of course, the part of me was sad because I thought, okay, there's this condition I have and there's nothing that can be done about it. My thyroid gland is going to be attacked, and maybe I'll have other types of autoimmune conditions in the future, but at least I could take medications for that. And unfortunately, the medications, they were helpful. I went from sleeping like 12 hours a night to 11 hours a night, which, of course, was great to have that extra hour. But I was still having a ton of symptoms, and I really wanted to figure out if there was anything I could do to make myself feel better and potentially reverse the condition. And so that's how I became Mahashimoto's expert slash human guinea pig, was just really trying to get my own health back. Yeah, and I think that's very true. Certainly, in my case, I thought I was doing everything right, eating whole grains and beans and low fat and running and going to the gym.  And everybody says, wow, it's your genes. Get over it. Your dad was the same way. So who did you, and I think this is really important, particularly for all of our female viewers, and I wrote about this on Women's Day last week. We, as a medical profession, don't take particularly women's complaints seriously. And I've been on a south box that when you do not feel right, somebody, you have to find someone who will actually listen to you. You guys have a gut feeling that, unfortunately, men are not good at. And this, as you know, is all coming from your gut. And it is so frustrating to meet now thousands of people, particularly women, who have gone from doctor to doctor to nurse practitioner to PAs to other nutritionists. And they're not taken seriously. Is that what you found in your journey? Unfortunately, that's the case. And being a pharmacist, if I used my credentials, I might get a little bit more attention there. But for the average woman, I mean, there are so many different statistics out there. A woman that presents with cardiac symptoms is going to be taken less seriously at an emergency room. A woman that presents with pain symptoms is going to be taken less seriously. And part of that is definitely cultural, right? So we know that men, if my husband, he would have to feel pretty bad to go to the doctor, right? And women are just not necessarily taken seriously because they are considered to be more emotional or unstable or potentially, oh, well, they're just hormonal. And their menstrual cycles make them crazy. And we've got this kind of social cultural stigma that this wades us from listening to women. And when we look at the history of various types of conditions, especially looking at thyroid conditions, which are more common in women in general for every man diagnosed, there may be anywhere from three to six women that are diagnosed with the condition. And a lot of times the initial presenting symptoms are going to be anxiety and maybe some weight gain and maybe some fatigue. And oftentimes, unfortunately, they're written off as hypochondria. And generally, women are the ones that suffer with that label, not necessarily men. And I think this is quite unfortunate in our society. And I wish I could say that I'd love for it to change. And I don't think it's going to change anytime soon. I think what's really important for women is to advocate for their own health. It's quite amazing when I connect with clients and they tell me everything that they've been dealing with. A lot of times it's almost like they don't believe themselves because people have tried to talk them out of their symptoms for so long. Oh, well, you're just getting older and it's normal to be tired. Everybody's stomach hurts, blah, blah, blah, to the point where they almost, when they're telling me these things, they almost hesitate. And I've had so many women just cry when I say, you know, this is not in your head. What you're going through, this makes perfect sense to me. I've seen so many people with thyroid disease with your similar labs, with your similar symptoms. And guess what? We can make this better. Yeah, that's so important. My practice is over 50% of my practice is now autoimmune disease. And usually, they are people who have been multiple centers. I just had a woman fly in from Toronto yesterday who has a textbook of people she's seen trying to get to the bottom of her autoimmune disease.  And yet, you know, when we look, she had four autoimmune diseases including Hashimoto's Thyroid Diabetes, but she had markers for lupus. She had markers for mixed connective tissue disease, etc.    It's that time of year. And one of the things that's interesting, particularly in women, is many women will develop Hashimoto's following a pregnancy.  And so it's very hard when you come in to tell a doctor, I'm exhausted.  You know, why wouldn't you be exhausted? So is that your experience that many times we can't sort out this the exhaustion of being a young mother and being exhausted from hypothyroidism or Hashimoto's? Yeah. And I actually think it all goes together because we know that, you know, I'm a young mother myself, too. So I have an 11-month-old and I, you know, looking back at some of my clients, I'm like, I understand why they had postpartum thyroid issues now, right? So because children don't sleep at night, and one of the fastest ways to crash our adrenals, which are connected to thyroid and autoimmune function, is going to be through sleep deprivation. And we see these young mothers, new mothers, with a lot of these sleep deprivation issues. And, of course, you're going to be tired. But at what point is this going to be Hashimoto's? And what point is this going to be just a normal part of motherhood? I really, I'm a big advocate of testing thyroid function, not just looking at the TSH, the markers of advanced disease, but also looking at the markers of early disease, like the thyroid antibodies in women who are of childbearing age and definitely in women who are postpartum. Because we know that thyroid conditions can develop specifically related to around the times of hormonal changes, and that can be pregnancy, puberty, and even perimenopause. So there's a lot of different reasons why women are more likely to have thyroid issues, and definitely hormonal shifts are going to be a part of that. And so a lot of times people get women, unfortunately, get shoved aside, right? I could go on a tangent about this whole thing, but we know that with pregnancy care, a lot of times we really, the OBs see women once a week at a certain point to make sure that the pregnancy is progressing.  There was one article I read that said that the modern care for women postpartum is you can compare it to how we treat a candy and a wrapper. So during the time that the child is in the womb, the wrapper is the mother that she's cared for, but as soon as we get the candy out of the wrapper, the wrapper's almost tossed aside. And just seeing that firsthand, this is really what happens. And women get this six-week appointment, and a lot of times the appointments may be delayed and doesn't even happen. And I feel like they should be offered thyroid screening at that appointment and every four weeks throughout just to make sure that they're doing well. Their thyroid is still working properly because that can impact so much from postpartum depression to even postpartum psychosis and milk production and just feeling human again, right? Yeah, that's a good point. So what you're saying, and I agree with this, it's not sufficient to get a TSH, thyroid-stimulating hormone. And if that's in the normal range to tell a woman you don't have a thyroid problem, is that a good starting point where that isn't what you should get? Absolutely. So what's really kind of backwards, I believe, is that when you go in to see most practitioners, most conventional docs, you'll say that I think I have a thyroid condition, I want to get tested, so on and so forth. Most of them will just test the TSH. Now, this test is excellent for advanced cases of thyroid disease, but there are five stages to Hashimoto's and the TSH is not going to be affected until maybe stage three, but generally not until stage four. And we've got stage two and three where we have these elevated thyroid antibodies in many cases and people are symptomatic, they're anxious, they're having panic attacks, they're gaining weight, they're tired, they can be having fertility challenges. And if they go to their doctor, they might have a lot of thyroid symptoms and their doctors will just test the TSH and send them away and say, there's nothing wrong with you, maybe go see a psychiatrist. And really at the stage two or three is when we can make the best interventions to prevent lifelong issues, we can prevent damage to the thyroid gland so a person may never need thyroid hormone medications and a person may never progress to other types of autoimmune conditions. I talked about the five stages of Hashimoto's. Stage two is when we start seeing the antibodies, stage four is when we start seeing this drop in TSH when the thyroid gland can no longer compensate for all the damage that that's been occurring. And stage five is progression to other autoimmune conditions. And wouldn't it be wonderful if we could pick up on these early signs and symptoms of Hashimoto's in stage two and recommend your type of diet and my type of diet and whatever the person needs to get rid of those symptoms and prevent further damage? Yeah, that's great. And that's why you wrote Hashimoto's Food Pharmacology. Because as you know and I know that the diet is really the way to fix this. So what made you consider food as the possible treatment option? I mean a pharmacologist thinking about food, that's as dumb as a heart surgeon thinking about food. I know, I was such a heretic, right? It was really crazy because we hardly learned anything about lifestyle changes in pharmacy school for thyroid. There was nothing, it was like you got a thyroid issue, here's the pill for that. Good news. Yeah, great. And other conditions we at least for high blood pressure, they at least mentioned a few things. Maybe they weren't fully aware of the lifestyle changes that are possible through functional medicine. But at least we were trying, right? With thyroid there was nothing. And at the time when I was working as a pharmacist, I was a consultant pharmacist for people with rare conditions that didn't really have standard of care approaches. So I was spending a lot of time in PubMed and patient forums and parent forums and the associations of rare disease trying to figure out what to do for my clients. And a lot of times we would see their primary care doctors weren't always, you know, up to speed on everything. And no disrespect to them, but you know these people had complicated needs. And I thought to myself, okay, so maybe my average primary care doctor doesn't know everything about Hashimoto's that's out there in the research. So I started looking into potential PubMed studies about remissions and reversals and thyroid antibodies, anything that I could really produce. And I came across the gluten celiac and Hashimoto's connection where people who had both celiac disease and Hashimoto's were able to get Hashimoto's into remission when they removed gluten from their diet. And I was like, holy cow. So I'm like, okay, let's get tested for celiac disease. Now I didn't have it. Darn. Right. So I was like, okay, back to the drawing board, right? And I was sort of in this paralysis by analysis for quite some time, as I'm sure many of us brainy people can get trying to figure out what my triggers could be. And then eventually I decided why not just give this gluten-free and dairy-free diet a try. And within three days, my acid reflux that I had for three years was gone. I was like on Tums, proton pump inhibitors, H2 blockers, like I was chugging my lantha, right? And still did not have my acid reflux resolved. And I was all of a sudden, wow, where did it go? Really? Like, is this really working? I was so skeptical about diet. I was like, I'll just try this and I'll prove all these crazy people wrong, right? I'll just go back to my diet. And then irritable bowel syndrome that had been with me for many, many years within three days gone. All of a sudden I had abs. I was like, where did these come from? And then within time, my carpal tunnel that I had in both arms, that started getting better within a few weeks. And I actually had to wear arm braces on both arms during work and at night because of the pain. And I actually left a job I really loved because I couldn't type on the computer. And now I write books and I drink coffee and do all the things that people with acid reflux aren't supposed to do. And furthermore, as I started to track my thyroid markers, those improved. So I had thyroid antibodies that were in the 2000 range. And I was able to, yeah, pretty good, right? I was able to lower them by more than 90% just with nutritional interventions. And I had to do some more functional medicine stuff as well. But really the nutrition should be the first step to taking back your health because you just don't know how many of these symptoms can disappear. Like I didn't know that I was meant to have abs. I didn't know that these things could be a part of who I was. And I thought I was meant to be anxious. And I thought I was meant to be really tired. And all those things got so much better. And getting rid of those foods revealed the person I was really meant to be. Yeah, I've been fascinating in the research. So everyone who's probably watching this hopefully knows that gluten is a lectin. And these are plant proteins that protect the plant from being eaten. And there is a lectin-like molecule in most dairy, which is casein A1. And I know you are against soy, which is one of the best lectin-containing foods I know of. And so we're all in agreement of that. What's fascinating to me from the research since you brought up anxiety is that you can take rats and inject plant lectins in their belly, in their perineum. And they will get so anxious that they will cower in the corner of their cage and will not come out and look for food. And I actually respect plants a great deal. They are sentient beings and they were here a long time before we were. And if you think about it as a plant defense system, making someone anxious is a great defense against you going out looking for food. And as I write about in the plant paradox, you may remember that cows normally don't eat corn and soybeans. And they get such heartburn from the lectins and corn and soybeans that they actually stop eating.   And half the world supply of Tums, calcium carbonate is mixed into cattle food so that they will keep eating corn and soybeans. And so you're right. When I took lectins out of my diet, all of a sudden a day later there was no heartburn. And you go, what's with that? I've always had heartburn. And it's like the plant's trying to get our attention. It's like, why didn't I listen? So yeah, so I think food and certain foods are real triggers just like you found out. And I found out and luckily my patients have been guinea pigs to let me look at their data. In fact, speaking of Hashimoto's, I saw a 50-year-old woman recently who my PA had seen six months earlier. And it was my first meeting with her and we were talking about it. She says, well, you know, I have Hashimoto's and of course that's why I'm here. But since I saw your office last, my physician, my PCP has dropped my thyroid dose in half because he said I'm on too much thyroid. And I go, that's interesting. And she said, well, you know, but I have Hashimoto's and I'm looking at her antithyroid antibodies and her antithyroglobulin antibodies. And six months ago, she was very positive. And when I saw her, she was negative. And I said, you don't have Hashimoto's. And she said, well, of course I have. That's why I'm here. And I hold up her lab sheet and I said, well, you don't have it anymore. And she said, it is true. You can cure this. You can go into remission. I said, yes, absolutely true. And so here's a 50-year-old woman and she doesn't have it anymore. And so that's why you do what you do. And that's why I do what I do. And we just have to empower particularly women to ask questions, to get these tests done. Also, talk to me about early stages of Hashimoto's can fool people because you can actually become hyperthyroid in the early stages as your gland is being attacked. And so talk me through that. Yeah, absolutely. So this can be known as Hashitoxicosis when in the early stages what's basically happening is the immune system starts to attack the thyroid gland and then there's a breakdown of thyroid tissue and some of the stored thyroid hormone can get into our blood stream. And if you were to take a lab test that day when this was happening, you may find on test results that the person will look as though they have too much thyroid hormone on board because so much is getting dumped at once. And a lot of times we'll see, and I'm sure you can appreciate that with my clients in the early stages of Hashimoto's, they'll have palpitations and they'll have a lot of these symptoms that may be more traditionally considered Graves disease or hyperthyroid symptoms where they'll say, I'm anxious, I may be shivering, I may be losing weight, my hair is a lot, I'm losing my hair and I can't sleep. But then they also might have symptoms from the hypothyroid spectrum as well where they'll say, oh, but I'm cold all the time or they might have hot flashes. And it's really quite interesting because when I was in pharmacy school, we had this picture of a woman that was cut in half and it was like, this is hypothyroid, this is hyperthyroid. And these are these symptoms and these are those symptoms. And what I've seen with my clients and even with myself is when you have Hashimoto's, you can have symptoms from both sides, especially in the early stages or when we have very high antibodies when there's a lot of that thyroid tissue breakdown happening. And so that makes you crazy. You know, unfortunately, I've seen people, I've seen people misdiagnosed with depression, anxiety, panic attacks, borderline disorder, let's say bipolar disorder. And I've also seen people who were hospitalized with psychosis. And they were, you know, placed on multiple medications. And these are heavy duty medications to anti-psychotic meds as a pharmacist, some of the my least favorite meds out there, right? And in fact, it was Hashimoto's that was causing all of this. And in many cases, we can sometimes use thyroid hormones, but definitely the lifestyle changes. And you can get rid of psychiatric diagnoses. It's quite amazing where the person is no longer quote unquote crazy once you figure out that it was their thyroid that was causing them to be all over the place. I definitely see this with bipolar disorder is in the early stages of Hashimoto's where they're like, oh, you have energy one day, and then the next day you don't, and then you're anxious, and then you're depressed. You have bipolar disorder. It's like, no, actually, it's your it's your thyroid. Okay, so you've got someone who now you're convinced or luckily lab test show that you've got Hashimoto's, you know, asking people to give up some of their favorite foods is challenging. Tell me how you work this out with someone? It can be very hard at first. And I know for me, this was very, very challenging. And I'm from Poland originally, and I grew up eating pierogi and all kinds of, you know, gluten and dairy foods pretty much that was the staple 90% of my diet, right? So I know it can be very hard to change your lifestyle. But the way that I like to think about it is, it's not going to be something that you have to do forever if it doesn't work. And if it does work, then think of all of the different things you can do in your life. I generally ask people to just commit 30 days. And if you feel better, then you get to decide if you want to keep eating that way. If you don't feel better, then you're, you're just fine going back to your old diet. And through, you know, my, my latest book, Food Pharmacology, I really just try to make it easy for people. So I've got some dietary templates, we've got meal plans, we've got recipes, we've got like what to say to waiters when you're eating out and how to get your family on board. Because sometimes, you know, we can be on board, but then we sort of have all these other things in our life that we have to work out. So kind of get our systems systems aligned and whether that's eating at work or going on, going when we're traveling or just convincing family members. And there are different ways to work through that. I made a lot of mistakes when I was first starting off. I ended up eating a lot of junk food because it was gluten free. And I was like, this is great stuff. And so now I really want to make it easy for people. And a part of it is just getting prepared and getting, you know, knowing which foods are going to serve you, which foods you want to back off of and give yourself some time to get there. Let's talk about eating in a restaurant because certainly my patients often have real challenges in restaurants. And I often find even someone, so I take care of a lot of people with celiac. And even someone who will swear on a stack of Bibles that they are gluten free when I do the advanced testing on them because they still have some symptoms. They still have a leaky gut and gluten is getting in them. And they go, that is impossible. And then we start talking about their restaurant experiences. And a lot of these of those patients tend to eat out quite a bit.  Yeah. And I think that's such a great question because a lot of people who are normally very outgoing and I would say maybe some people pleasers kind of don't like to make a fuss when they go out to eat because then they feel bad, right? They're like, well, I don't want to bother the waiter or the waiter.  And I really ask people to reframe when you go to restaurants, especially, especially decent ones, really the chefs, this is their artists. This is their passion. And they actually enjoy being creative in the kitchen and creating some of these challenges when you have to make something without an ingredient. It's actually a lot of fun for chefs. And for the waiters, waiters, most of them I would say, are out there because they like helping people. They're in the service industry. They want to serve you. And so the way that you ask is you say, you take your waiter aside or, you know, you don't, you don't kind of like make an announcement at the big table and say, hey, hey, you just say, hey, I'm trying this new diet. My doctor wants me to try or, you know, whatever, whatever the story is, can you help me out? And I found that just asking them to help you out just changes the conversation so much and say, Hey, you know, these are some of the foods that my doctor wants me to stay off of. This is something I'm trying. Can you help me out? Because a lot of times you ask somebody to help you and they feel like they're giving you a gift and it's fulfilling to them. Go ahead. Oh, I was just going to say, I've gotten so many amazing meals just because of that little reframe where I'll be eating out with, I've been eating out with colleagues who maybe were not gluten-free, dairy-free. And they were like, wow, your food looks like the best out of the entire table. And that's just a really one little trick that you can do to kind of shift the conversation. Are there any, so you're looking, I have a very good friend, Tom Guy, who I wrote about in one of my books. And Tom used to say, the menu just tells you what the chef has in the back. And so it's always, I think, great advice. You can see what the chefs got back there. And it's great to be able to ask, you know, can I have this and this and this and this?  Things like doing like a cob salad and asking to have the cheese removed, any croutons off to the side and any kind of dressings off to the side and using olive oil and lemon is one great starting point because gluten-dairy and so it can be hidden in the dressings. That's one thing that's kind of fancy that you can get. And a lot of times, just the really simple things, delicious steaks, delicious types of grilled meats, fish, and vegetables, these are going to be really go-tos even if you're somewhere out. And I grew up in the Midwest, but even if you're somewhere out in the Midwest that has never heard of gluten, a lot of times this is something that you can order without any issues. I used to be traveling sales rep for the pharmaceutical industry and I would have to go to a very rural parts of Illinois and I was able to eat that way so you can do it too. The one thing that you do want to ask about is you want to make sure that whatever meats you're eating are not going to be breaded. So we want to avoid any kind of breading and we want to clarify that they are not going to be deep fried in a deep fryer that potentially has other kinds of things. One, it could have soy, but two, it could be some of the other gluten ingredients. The other thing that I like to recommend is using a product called gluten dairy digest. I found in some cases it can minimize the reaction if you have some cross contamination issues. And this is an enzyme that you could take with the food if you're eating out.  That's not going to happen, but it will minimize some of the reaction that you may normally have. So I think something you mentioned early on, I think it's very important for people to realize, again if you have Hashimoto's it doesn't mean you don't have other autoimmune diseases. And it's amazing to me the number of people who have multiple autoimmune diseases. And unfortunately we tend to put names on these things depending on the end organ. And I think you probably agree with me that all of this I think stems at one way or another from a leaky gut. And it just whatever target happens to be on you, there are other things being targeted. I just got a paper accepted for the American Heart Association in May looking at lectins as a major cause of coronary artery disease and showing when we took lectins out of people's diets that markers for attack on their blood vessels actually subsided. So these things I think are all interconnected. So one final thought, it's certainly my impression and I'll bet you it's your impression that Hashimoto's is an epidemic that we did not see 50 years ago. Thoughts on that? That's correct and a lot of times people will say well we're just doing better screening tests right now or it's a hot topic or somebody said oh it's a trending topic and it's a fancy sounding name that's why everybody wants to have it. It's glamorous, right? That's not the case. When we look at blood samples from decades ago that were frozen and we run tests on them right now, comparatively we see lower rates of Hashimoto's in those blood samples than we do in today's blood samples from similar populations and definitely it's the number one autoimmune condition and it's one of the fastest growing ones. It used to be an older woman's condition right and now we see younger people with it, men, children, women even before they've ever had children. It used to be something that was more common postpartum. There's a lot of different potential root causes and triggers and potentially environmental toxins can be contributing. We know that Chernobyl, I actually grew up in Poland pretty close to the Ukrainian border so I was exposed downstream to Chernobyl and we know that children who were closest to that disaster had higher rates of Hashimoto's antibodies, somewhere around 80% versus children of similar genetic backgrounds who lived further away and those rates were somewhere between 20 and 30%. So we definitely know that toxins play an important role but I also believe that our diet is going to be one of the key contributors to the rates of Hashimoto's that we see. Great. Well speaking of diet, you may know that my new book, The Longevity Paradox, is out and I've got a longevity question for you. So some people would say and you're a pharmacist, well it's okay, we luckily have thyroid medications and you can do just fine taking thyroid medications and you don't have to worry about having Hashimoto's. Tell me why, from a longevity standpoint, it's a really good idea to worry about Hashimoto's. When we look at Hashimoto's, it's a progressive condition and taking thyroid hormones even if they erased all of your thyroid symptoms and normalized your thyroid function, there's still that inflammation going on and autoimmune conditions are progressive so you may end up with another autoimmune condition. Unfortunately, you may end up with lupus or rheumatoid arthritis. I know in some cases thyroidectomies were recommended for Graves disease, which is another autoimmune thyroid condition. There are some doctors that are recommending them for Hashimoto's as well and they'll say, well that's the cure. The thyroid is inflamed, well that's removed the thyroid, but it doesn't work that way. I've seen numerous people who go on to have their thyroid glands removed and then they go on to have other types of autoimmune conditions down the road because that root cause of the inflammation just wasn't addressed. Whether that's the thyroid getting addressed or vessels or another part of the body, I feel like it's really, really important to get that inflammation under control to prevent other types of autoimmune conditions. Honestly, most people who do take thyroid medications, they're not going to be feeling 100%. Every now and then people will say, oh, I feel just fine on my thyroid medications. Isabella, I don't know what you're talking about, all these sick people with Hashimoto's and then I start talking to them and they're like, oh yeah, but I only go to the bathroom once a week or yeah, I am 50 pounds heavier than I was in high school or yeah, I guess my hair is falling out or yeah, I do have to wear three sweaters and a winter jacket in the summertime. I really encourage people to look at their whole body and treat their entire body well, not just look at their thyroid gland as though it wasn't a vacuum. Additionally, when we just support one system, we might have, we might sort of set other things out of balance. There is some evidence that just taking thyroid hormone may accelerate different types of cancers and I believe it's because of the underlying inflammation that's not addressed. Yeah, good point. All right, so that has been great having you on the program and as I told you when we started off camera, we always have a viewer question and so we're going to ask the audience question, this is a follower on Instagram and they wrote, what are your thoughts on the celery juice trend? Do you feel eating food is more beneficial than drinking it? So our guest Isabella, you want to weigh in on that? Oh, that's such a great question and I've actually been seeing a lot of that lately where people will say, hey, is celery juice the cure all? Will that cure my thyroid? And this reminds me of when I was first starting off trying to figure out helpful information for myself and it was at the time it was really high-dose iodine that was the cure all for every single condition and if you had a thyroid condition, all you had to do was take high-dose iodine. We later learned that in some cases that can actually exacerbate Hashimoto's and accelerate thyroid tissue damage and sometimes symptoms very, very quickly. And then the other thing was, hey, coconut oil, that's going to be, that's going to cure your thyroid entirely and it can be helpful. It wasn't a cure all again. And I can't say that I've placed a hundred of my clients on a celery juice cleanse and tracked outcomes or done outcomes research on this, but I'm skeptical to say that that's going to be the cure all for everything. I think drinking green juice is a fantastic idea. It can be very helpful, very beneficial. Juice cleanses, just when you just drink juice by itself. We're trending a few years back as well and they were sort of touted as a cure all for many things and unfortunately I've seen the fallout of that with certain clients getting worse. Here's the thing, there's various types of root causes and triggers that we may have, our unique biology, the kind of infections that we may have, the kind of toxins that we might have. Celery juice can be helpful for some things. Just for example, I know that with the parasite giardia, it's a protozoa that lives in our guts and that can be a root cause and trigger for some people causing leaky gut. This parasite can be eradicated with a juice cleanse. With about three to five days of a juice cleanse, we can make this parasite go bye-bye and that can cure that leaky gut. In that case, you could say the juice cleanse was a cure for that person. But another person with something like blastocystis hominis, which doesn't respond to juice, they can juice cleanse all they want and that's not going to help. I say go ahead and drink the celery juice and maybe it'll help and I love that. But at the same time, please don't stop your thyroid medications. Please don't stop your supplements that have helped when you're trying something new like that. Keep an open mind, but not so open that your brain will fall out, right? All right, good. Now my two cents on this. As you know, the best part of any vegetable, including celery, is actually not in the juice. It's actually in the whole plant. And if you want to use celery, either eat it or put it in a blender like a Blendtec or a Vitamix and homogenize it and put it in your green smoothie. In fact, if you really want to use celery properly, juice it, throw the juice away and take the pulp and then eat that or make a muffin out of it from our cookbooks and you'll get far more benefit. So that's my thought on celery juice. And so I think both of us, if you want to drink celery juice, knock your socks off, but I'd rather you get the whole plant than probably you'd agree with me on that, Isabella. I would agree with you. And I also want to, I spent some time in Italy last year or last couple of years and I grew up in Europe and then lived in Europe for a little while. And what's interesting that I don't think many Americans are aware of, but raw celery is actually a very common allergen in countries like Italy and France and Switzerland. So this is something to consider here too and the thought process is because they eat a lot of it in the raw state. Yeah, celery actually contains a compound called sorrelin that celery pickers disease is actually, they burn their hands from this compound in celery. So, you know, concentrated celery to me is not a great idea.  It's very true. Just some food for thought. Yeah, food for thought. That's what we're here for. So Isabella, where can people find you? Where can they find your book? People can find me on, yeah, I've got three of them now. thyroidpharmacist.com is my website and I have articles on some of the most helpful interventions for Hashimoto's, whether that's supplements or nutrition protocols or just lifestyle changes in general, how to deal with people, right? All those things. And then my books can be found anywhere that books are sold. Amazon has all three of them. The latest one is Hashimoto's Food Pharmacology and you could see that right here. So it's all about helping people become their own nutrition gurus and make that connection within their own bodies to figure out which foods work for them and which foods don't work for them. All right, well keep up the good work. Keep getting the word out to empower women. And thanks again for being on the program. So that's it for another episode of the Dr. Gundry podcast. Tune in next week. We've got more exciting guests. Look for my new book, The Longevity Paradox. I wrote it because as you know, I am Dr. Gundry and I'm always looking out for you. See you next week.


e and information than either the payer or the provider and they are very vulnerable it just surveys doesn't cover it because by definition we don't know what care we should have gotten i understand the evidence-based approaches and quality monitoring but i just would say that i'm a little skeptical when the payers and the providers are getting together that they will end up with reduced risk and higher savings at the expense of the people whose care should be coming first it's not a question but i welcome a comment because i wasn't completely reassured by your presentation thank you so thank you for for your your statement and it it's something that we we we truly you know think about which is that what we call the member experience and everything you shared is wrapped up in that that member experience we at mvp do take that member experience incredibly serious it's part of our core values we we do what's called evidence-based innovation surveys where we do talk to our members in vermont and in new york where we get both qualitative and quantitative data information insights including those types of concerns so we can take that information as we think about our benefit design for the plans that we're offering and the other part of this is in order for us to continue to be successful no matter the level of collaboration with the providers we have to offer competitive benefits and and and price that best serves the needs of those members or they're going to move to another competitive plan design so we're hypersensitive to your thoughts we're taking the transparency incredibly seriously as matthew talked about earlier we we we're very serious about um access concerns um and helping our members navigate through that in partnership with those the provider systems and trying to make a more integrated comprehensive approach that said um your your comments and concerns are noted um and and we appreciate your your your your your skepticism and your thoughts as we think about how we can best serve vermonters thank you hey is there other public comment is there other public comment hearing none i want to thank the team from mvp um it's been a great discussion and one that uh could have gone much longer and uh i apologize that i wasn't a little bit more efficient with the uh the team before you but uh it's hard to cut off the discussion when it's uh really uh intriguing people so thanks again and and really uh thank you for uh all the efforts that you've made on value-based care and uh you know trying to uh provide the the best product to uh vermonters so thank you thank you so with that Susan i'll turn it over to you thank you mr chair so i'm going to provide to the board and to the public today an update on the wait times working group that was formed as a result of the f y 23 hospital budget guidance thank you kara kara is going to put my slides up i don't want to experience any technical glitches that we like we had this morning so um i should be brief but i do want to take this time to update all of you i'm just going to go through our progress to date our charge um at the end of this presentation i want to hear from you board members on your priorities um and let me just go through this presentation but just keep that in mind as we're as i update you on what we've done to date so this is the current language um i'll just pull out the key parts of it this language is included in our f y 23 hospital budget guidance as you recall uh we added this language after we heard from um vas and hospitals about the administrative burden of collecting wait times so we took this back um you put in this language and we formed a wait times working group the members of that group include vas they include the vermont department of financial regulation the office of the health care advocate um and other interested parties the charge of the of this working group is to determine alternative metrics for reporting wait times for the f y 23 budget uh by may 2nd of 2022 which is if i recall i think next tuesday maybe it's monday don't quote me on that um and if we this group cannot determine appropriate metrics for this group then the default is what is in the was in is in the f y 23 budget guidance which is and i'll just read these because it's technical that um if the work group is unable to determine appropriate metrics the hospital shall report the following for each hospital-owned practice for each primary care and specialty care as well as the top five most frequent imaging procedures specifically please report for each practice and imaging procedure one referral lag the percentage of appointment scheduled within two days of referral to visit lag the percentage of new patient seen within two weeks one month three months and six months of their scheduling date in each case hospital shall outline steps to resolve wait times so you can go to the next slide kara um before i get into these metrics that we've discussed i want to report that the working group has met three times to date we have another meeting scheduled on thursday of this week and we've discussed discussed several options um these are the things that we've talked about but are not moving forward at this point um we first discussed the option of utilizing the secret shopper data from the wait times report that was um released earlier this year and we were told that we were unable to use that data for this purpose so that came off the table we also talked about va measures veterans affairs measures you can see what they are at this point those are they're they're great measures they're just highly complex and and and just too much of an administrative burden in this shorter time it's something that dfr might consider as they look at wait times in the future and then we also heard from vas on a really a qualitative proposal which we then um you could see the questions there we've actually incorporated those into a dfr proposal so on the next slide kara um these are the metrics that are on the table and i just want to say out loud for i know the board is aware of this but just to bring the public along to the department of financial regulation will is starting their process in looking at wait times it's it was a recommendation out of the wait times report and they've been very very good partners in this work um with us to look at the wait times for this for this year's hospital budget guidance and want to make sure that what we do land on in terms of our hospital budget guidance whether it's the the um default measures or something we agree to in these in this working group is that they will utilize that in their work going forward over the next years in developing um wait times metrics that they will transparently report out so the metrics that we have on the table now are the uh institute for health improvement ihi third next available appointment it's a standard that's um we've collected it in the past we've heard from providers that it's not always the most accurate representation for consumers so it's not perfect but it's still on the table and then i um alluded to this earlier the department of financial regulation has a proposal on the table um and it is both a quantitative with quantitative questions and also has a qualitative assessment section um they are we are as a group have asked them and and the green mountain care board has worked with them to put together some survey um questions and that would really focus on some of the the quantitative questions that we feel um that needs to be part of that assessment so we'll hear from dfr at our working group on thursday and i can i'm happy to report that back to all of you i it's just not ready for prime time today but the working group has seen the initial draft and they are working on an updated draft to include those survey questions as part of their proposal so the next steps are as i mentioned we'll have our meeting this thursday which will be our last meeting since we are um to report back to you on the honor on what we decide if if we can come to a determination of other metrics and then if needed we can bring this up again next wednesday to update you and the public so i think there's one more slide great so i'm going to turn it back to you mr chair and to your board members what i really would like to hear from all of you is your priorities on these wait time metrics as we are finalizing this working group i wanted to check back in with all of you to hear your thoughts so what would be really helpful is to hear thoughts from um board members launch in pelham um jessica has been in on this group uh from the beginning and um has um weighed in quite heavily um tom is our other designee tom walsh um but he is out this week so i'm pinching for him and filled in at the meeting earlier this week and we'll be filling in for him again tomorrow so it would be really helpful if jess and i knew what um you were thinking robin and tom sure i can go ahead and jump in unless you want to tom um go ahead and jump in i'll be close behind you okay um so i i feel flexible and trust um the you know whatever decisions that you two come to in the work group um i do think it's important to have some sort of quantitative metric um so uh you know and certainly we've used third next available in the past so if that makes the most sense to uh you all i'm totally fine with that so i'm not going to get stuck at anything particularly specific but i do think having some sort of quantitative metric is important and then i would certainly qualitative information is always helpful to give the picture behind the numbers but i would um support you know whatever uh makes sense in the in the greater context of what's being discussed so i don't know how helpful that is because i do feel pretty flexible but um and but you know you guys are in the thick of it with the everyone else in the group so i think it's a little bit hard not being involved to to be too you know for at least for me to be too like wedded to any one thing yeah just uh for further information um i think most people agree that third next available um has its faults but one of the pushes has been from um what i would call not so much smaller but yeah kind of smaller hospitals in vermont that they don't have the capacity to do what we're really looking for with their information systems so that's where the push for the third next is coming from i do think that uvm for those three hospitals with the epic system could do um the more detailed information as far as referral lag visitation lag etc um and going into this i had wanted consistency so that everybody was reporting the same way but i'm not so sure if we're going to get that at the end of the day or we'll get information that may not be as helpful as um one would like so well my take on this is um and it's from a distance is that it's not a perfect world and and sometimes you don't get everything you want and um as i look back on this wait times issue you know i i think that dfr uh has handled it responsibly um maybe not perfectly in terms of the shopper report and some of the statistical anomalies they worried about but i think that you know at least as a board member working with other board members that that you have a strong sense of trying to minimize the administrative burden on hospitals but at the same time getting information that's usable and and that does mean information beyond just qualitative and uh so i i trust your judgments to you know to um find that balance and um pretty certain that i'd agree with it every whatever decision you uh that you may ask the question so the trade-off might be as as kevin mentioned consistency so there are some hospitals that are probably able to i think the health network might be one so that'd be three hospitals that might be able to provide the information that we asked for in terms of referral lag and um you know scheduling lag and the distribution of you know two weeks one month three months six months which i think is is more meaningful data um and is particularly in the scheduling um piece of it is more reflective of the true patient experience than third next available so would a outcome that would be uh you'd be amenable to would be those hospitals that can provide the data in the way that was requested should do so and those hospitals that can't you know tell us why and give us the data that they are already collecting which is most likely to be third next available appointment um and any benchmarks that they're using um to benchmark their wait times against would that be uh amenable to all of you if we were to propose that because that it does kevin to your point that's not going to be then necessarily consistent across hospitals but it may be more meaningful for the hospitals that are able to provide the data as we originally asked for it i mean to me it sounds like a practical solution i mean the the network hospitals are 62 percent of the pie and so it's it's not like it's three hospitals versus uh the other 11 um you know what the network can do because they've got a great amount of resources with um with epic you know we should leverage that and then work with the hospital other hospitals to do as best as they can do with what they have to work and that to me is is uh equitable um it might be different but that because of epic the network can do something better probably than the other hospitals but it still would mean that they're both doing the best they can and we did receive a proposal from laws that was forwarded to all members of the board maybe susan you could make sure that gets posted to our website so the public could see that as well sure thank you this is helpful it is helpful and it is um at the noon hour so why don't we um recess the meeting here and come back at one o'clock um nourished and uh ready to go for this afternoon so i'll put this meeting in recess till one o'clock thank you


Today's passage of a revenue package means that we avoid another lengthy impasse. Our budget is balanced this year and we have greatly reduced the Commonwealth's structural budget deficit. This package is an important step forward and includes sustainable, recurring revenue that makes significant progress toward reducing our structural deficit. When I took office, I inherited a deficit of more than $2 billion and schools that were devastated from drastic funding cuts. Recently, we also came together to pass a budget that included historic investment in education at all levels and much needed funding to combat Pennsylvania's heroin crisis. Over the last several months, I have worked together with Republicans and Democrats to achieve major progress on issues including the legalization of medical marijuana, the passage of historic liquor reform and the enactment of a fair funding formula that ensures basic education funding is distributed to schools based on a district's unique needs. I have fought hard to turn things around and move the Commonwealth forward. We've made progress. Our schools have seen historic funding increases and the deficit has been significantly reduced. We still have much work to do in the next year's budget and I look forward to continuing to work with legislative leaders on important issues facing Pennsylvania. Now that this year's budget is complete, it is imperative that we all continue working together to focus on our greatest public health crisis, Pennsylvania's opioid abuse and heroin use epidemic. While the budget allows us to expand treatment for individuals suffering from addiction, we can and we should do more to address this matter that is plaguing all of our communities. My administration will keep its focus on this issue and I will continue preparing for the upcoming special session.