Module 134 in production analysis we are going to study Cobb-Douglas production function. Generally Cobb-Douglas production function is the one that is mostly utilized in the analysis of the production. Likewise the other production function it exhibits many properties that has to be explained in very much detail in various coming sessions. But here we see related to the elasticity of substitution. So any production function that has elasticity of substitution equal to 1 that will be called the Cobb-Douglas production function. And in the Cobb-Douglas production function the isoquants they are usually the normal of the convex shape that we mostly explain in our all types of the analysis. And in other words we can say that mostly the shape of the isoquant in the Cobb-Douglas production function is similar to the indifference curve that we have explained in our consumer analysis. And the mathematical form of the Cobb-Douglas production function is just equal that mean quantity is the function of capital and labor. And that function is equal to A for technology, K for capital and alpha labor. But with the chain that here alpha and beta that are the respective output or the production elasticity of the input they are put at the power of that capital and labor. So here production function will be equal to A K for its output elasticity of production means alpha and for labor its own elasticity of production beta. Now coming to the next slide we explain that these two elasticities of production of the respective inputs that are alpha and beta they are in the manner that alpha plus beta it will be equal to 1. So when it will be equal to 1 we will say that the Cobb-Douglas production function it exhibits the constant returns to scale and these returns to scale we will explain in the next slide. And at the same time if we take the same formula of our returns to scale that if the inputs they are multiplied by a unit t or a scalar value we expect that the same scalar value will be exhibited to be multiplied by our output. So in this manner this alpha plus beta it will also be summed up for the power of that function. And so alpha plus beta if will equal to be 1 here also it will be the constant returns to scale and if this power of alpha plus beta will be greater than 1 then we will expect that it is increasing returns to scale and if this alpha plus beta is less than 1 then we will say that it is decreasing returns to scale case. So in this manner the Cobb-Douglas production function has the property that it can exhibit the three all returns to scale constant increasing and the decreasing. So if we have to explain that the elasticity of substitution equal to 1 this we will explain and here the Cobb-Douglas production function has also proved that in very other applications of the production it is linear in the logarithm means it is very simple to add up all the these factors. When we convert this Cobb-Douglas production in the form of the log we just convert this q into form of natural log of q and this part of technology into natural log and this alpha natural log K and beta natural log L. So in this way the effects of technology effects of capital and effects of labor they can be decomposed and then further summed up to have their contribution in the total output and here the constant this alpha this beta and they both they give the capital input and the labor input ratio and they are basically the elasticities of these inputs. Now coming to that elasticity of substitution is equal to 1 we can derive in the manner. So now coming to that as we know that elasticity of substitution when we explain through theta it is basically the ratio of change in capital and labor ratio divided by their respective change in rate of technical substitution and here we can say this rate of technical substitution is basically is change in capital due to change in labor and that gives equal to marginal physical productivity of labor divide by marginal physical productivity of capital. So when we explain this and we utilize with respect to the Cobb-Douglas production function where Cobb-Douglas production function is given by q equal to a k power alpha and l power beta and here rate of technical substitution will be equal to MPL by MPK. So when we derive MPL we will take first derivative of this function with respect to l that will be equal to this beta a k power alpha and then l beta minus 1 and now it will be divided by marginal physical productivity of capital for which we will take the first derivative of again this function. But now with respect to k and it will be again equal to this alpha a k power alpha minus 1 and then l power beta. So now when we simplify we can say this beta by alpha and this a will be cancelled by this and now this k power alpha into k power alpha plus 1 mean this k alpha minus 1 we will take above and l power beta and then again l beta plus 1 this will be taken downward. So this will be crossed by this and the resultant will be beta by alpha into this k by l. So this rate of technical substitution here it will just come up to this and when we have to now calculate this elasticity it will be equal to k by l change in k by l divided by change in RTS. So when we will substitute its values it will just come equal to 1 and now here we have read that elasticity of substitution will be substituted for this value and this value and it will give us the unit that is equal to 1 and now coming again to the same that we can utilize the same equation function in the form of the logarithm if we say. So again we can say that when q is equal to a k power alpha and labour power beta. So the Cobb-Douglas production function when given in this form so we can also write in the form of the log where rate of technical substitution is given in the form of log like this that it is equal to natural log of beta by alpha plus natural log of k by l. So in this way now when we write our elasticity of substitution it will be equal to the change in the natural log of k by l and then change in like this. So again it will give us the result of 1. So this is the proof that Cobb-Douglas production function has elasticity of substitution equal to 1 and with the various changes of this alpha plus beta we can have the three various types of the returns to scale. Thank you.


Good morning, good afternoon, and good evening for more every reviewing today. My name is Nico Arsino, and I lead strategic partnerships at Kaiser Permanente. Today, we're profiling two of our partnerships, Samsung and Microsoft in this round table dialogue. Before we get started, I'd like to just do a bit of housekeeping. Today, we are not allowing any video recording of any kind.  Thodcast is an initiative we started a couple of years ago, profiling the relationships we built with technology companies and the problems they can solve at Kaiser Permanente. We've had a few events over the last few years across AI, hardware design, consumer technology, and ethics. I'd like to first introduce my co-host Vivian Tan, who is the Strategic Information Management and Global Relationships Vice President, and we're going to have a quick conversation to start. Welcome, Vivian. Hi, Nico. How are you? I'm doing good, and thanks for joining us today. No, thank you for having me. This is wonderful. Why don't we start off with a quick question? Can you tell us a little bit about your role and background at Kaiser Permanente? Sure, I'd love to do that. But maybe before I go in, I'd like to actually recognize the impact COVID-19 has had on patients, members, and families, and communities. I'd like to also really personally thank all of Kaiser Permanente's clinicians, providers, and frontline teams who've really had shown amazing dedication and amazing care. They are truly the heroes in this pandemic. It's challenging times, and we will get through it together. As you know, I run an analytics team called KP Insight. We have been very busy, you know, across the organization, across multiple analytic teams. We have received 2,500 requests, data and analytic requests, and they seem to be growing by the day. It's been hard work, delivering timely, actionable, and accurate data to our key partners and stakeholders. And it's been also quite challenging developing and evolving useful data and analytic models and forecasts for the organization as well. We're definitely in the mode of really acceleration and innovation, and actually very open to learning and trying new things. Indeed, indeed. And can you tell me a little bit more? I understand you managed a relationship with the World Economic Forum. Yeah, I do. I spend quite a bit of time with the, with WEF's health and healthcare communities. And I focus on many different topics, including, you know, the adoption and use of virtual care.  In places like Singapore, where I grew up, there have been a thousand over percent increase in virtual visits, even just within a short four week period. Same with Sweden, they saw a similar increase for their virtual video visits in two weeks. And amazingly, I think the Canada's healthcare system for primary care has actually seen a jump of virtual telehealth from sort of, you know, that 4% range to 60%. Yeah, that's very interesting. And we see that growing across the US as well as the world, so thanks for sharing that. Can you tell us, speaking of international, can you tell us about your role at KP International and its charter? Yeah, I'm really, I think I've got the best job at Kaiser. I am also involved in KP International. It's educational subsidiary that really runs really informative and innovative learning programs throughout the year. We've gone virtual given, you know, the situation and they continue to be, I'm just amazed, they continue to be such great interests in KP's model, our approach, our strategic initiatives and our work. I'm really wanting to learn best practices. We host anywhere from about 1,000 people a year and we've had people from 85 different countries. One of the most important topics or the topic of most interest to people is actually virtual care again. So when you reached out and wanted to collaborate with us and partner with us on any thought costs, I thought this was a perfect topic for us to dive into. Absolutely, and thank you for your collaboration on this event and this topic. I think it's even more so pressing in this time of COVID-19. And as a result of that, I think, you know, this theme is growing both in our workforce and how it affects people in our lives, our daily lives and what it's doing to us and how we're reacting to it. How do you see, and I know we'll get more into this in our discussion a little bit here, but how do you see virtual care evolving the future of healthcare? Again, a great question.  And even we have seen how virtual care operations have really, you know, kicked up to a different level, especially for primary and specialty care. About 80% of our visits appointments have been conducted over the phone or by video in the month of April alone. And actually for mental health, it's at 90%. And, you know, one, it's so important that people have the right access and care to mental health, especially during this time. Virtual visits have truly skyrocketed. We're doing about 40,000 visits on average each weekday. And that's actually, you know, really impressive numbers, even for a system our size and scale. I think the most important thing to maybe call out is that member satisfaction is really high. 89% of people who have actually had a virtual visit are very interested in actually continuing and using it again. Great, that's interesting to hear. And I know we'll hear a lot more from our roundtable in just a bit. We do have a video that we wanted to present and this is on cardiac rehab. And I know you mentioned just how things are changing and people are reacting. This is one of the partnerships we wanted to highlight today. And we wanted to give you a sense of what that looks like a KP as an example of what virtual care and the use of remote patient monitoring looks like. So why don't we just take a moment to watch the video. I've been active going to the gym as long as I can remember. I started having chest pain when I was working out to the point where I couldn't really even enjoy the simple things that I like to do. But I was thinking I'm 42, I'm too young for this. It was a good thing to find the blockage when they found it. It could have been very traumatic. Might not be sitting here today. Michelle had a very, very complex coronary lesion. However, and we've gotten so good at taking care of these events. After you have a stent delivered, even a complex stent, you don't have a prolonged admission within a Kaiser Permanente facility. You come and meet your home cardiologist. I really didn't know what to expect after this. And I remember telling my husband, what if I eat the wrong thing? And all of a sudden I have this major heart attack. I was scared. If you have major cardiac surgery, the healing and recovery from that event takes several weeks. So with the home-based cardiac rehab program, we're actually able to extend care, healing and recovery into those critical moments for patients and their families. And I think that's the key. Eight weeks they're receiving telephone appointments from their cardiac care team. That's unparalleled in any cardiac rehab program. We're equipping patients with a wearable device where we're able to monitor their steps. We're able to monitor their heart rate. And all that information is being analyzed by our nurse case managers. My role as a case manager is engaging with the patient during those eight weeks to listen, answering their questions regarding their medications, questions regarding their exercise regimen. The reassurance came from knowing that I could call her if I had any questions. I don't know that that's available anywhere else that you go. We have a clinical dashboard so we can monitor our patients so we can see what they're doing at home. Knowing that I had to talk to her every Friday, it gave me some accountability. The team that I had with Dr. Price and Azure, it was a different level of involvement than what I'm used to. It gave me hope. I had this extreme thing happen to me and it's not the end for me. I can still live my life as I did before it happened. That was a great video. Vivian, thank you so much for your collaboration and partnership on this event and appreciate you spending some time with us today. You're welcome. Now I'd like to introduce our moderator, Jane Magcath. Jane is the co-founder and CEO of Neolife and the co-founder of Wired Magazine. Neolife is a company she started in 2017 to explore the Neobiological Revolution. Welcome, Jane. Hi, well, thank you so much, Niko. I appreciate the opportunity to come and talk to everybody. It's great working with you and the entire ThoughtCast team so I appreciate the opportunity. And I'm looking forward to hearing from all the people you've gathered here who are on the front lines of transforming medicine and figuring out what virtual care can be. So I just want to say that today we're going to talk about where we are in terms of virtual care, what the technologies are and the protocols and behavior changes that are going to be required to really implement this in its highest form and also think about the future, what we see the trends being and what the panelists see the opportunities are. So I'll just start by introducing who we have here today. For Kaiser Permanente, I want to introduce Dr. Bill Marsh, who is the Vice President of Care Delivery and IT Products for the Permanente Federation. Good morning. Good morning. We have Pratt Vimana, who is the Chief Digital Officer for Kaiser Permanente Hype Pratt. Good morning and pleasure to be here. Representing a key strategic partner for Kaiser is David Rue, who is the Chief Medical Officer and the Vice President of Healthcare for the worldwide commercial business at Microsoft. Hi, David. Hi, everyone. Glad to be here. And then we have Vinu Olak, who is the President and CEO of the Center for Care Innovations. Hi, Vinu. Hi, nice to be here as well. Thank you. For those of you who don't know the Center for Care Innovations, they're really working to strengthen the healthcare safety net by bringing technology and innovation to in healthcare to underserved communities. So I think we have a lovely mix of people and perspectives. And so with that, I wanna just jump right in and ask you guys to start out with helping me understand how you think about virtual care, starting with the definition. I mean, what is the difference between virtual care and telehealth and telemedicine? Are these distinct things? Do you see them used interchangeably? I'd love to hear what you guys on the front line are doing semantically. Virtual care really is about using digital technologies to enable care anywhere, anytime for any individual. And as we've been looking at that, we're talking about things such as virtualizing an ICU. That has been particularly relevant during the COVID crisis where we found that the need to virtualize the ability to monitor the different ventilators and all the different pieces within a unit can not only improve care but also decrease the use of PPE and decrease risk of exposure. We've seen virtual care being performed in the context of individuals receiving a more comprehensive care plan. And many of you are familiar with the virtual cardiac rehabilitation program which has been rolled out. It is an opportunity for us to start thinking about how we can virtualize programs that are done typically in facilities. And this does involve some level of remodering but it really is just a whole general concept of how we can take whatever is being implemented in healthcare and create it into a more virtual digital experience. So I just wanted to be able to provide some broader context in terms of ways that we can think about virtual care. I think of virtual care as all the ways that a clinician can interact with their patients whether they use a digital channel or a telecommunications tool. I also think of it as a combination of tools whether they be synchronous, asynchronous or remote patient monitoring. I must admit that I think of telehealth and virtual care as synonymous. Telemedicine in some purviews is a little bit narrower view and yet in others people use telehealth and telemedicine exchangeably. You know, access to care in any shape or form remotely has a bigger role to play. So Dr. Marsh summarized it really well. You know, telemedicine to telehealth is the broader construct if you will. It goes into the health and wellness and behavioral health and what not. Telemedicine is at the time of care at the time of need. So really, you know, everybody's using all these three terms very interchangeably but what it really means is that could we manage our health and wellness anywhere we are, everywhere we are in the way we want it to be. What are the key technologies and protocols that go into making up the offerings, the virtual care offerings at Kaiser? There are two sides to this puzzle, right? We tell this all the time, like so, it's like a stethoscope. One end of the, you know, one end is the patient or the member or the other end is the caregiver or the clinician, right? So, you know, and there are different modalities, right? So you could chat with a doctor, you can call a doctor, you can have a video visit with a doctor, a nurse and a physician can talk and a physician and a physician can talk. So there's like lots of modalities in which we can enable. So all of these modalities play a role on how they get connected. And today what we are seeing in the industry is there are specialization in technologies. The, you know, number one, you know, all of these technologies needs to be HIPAA compliant. That means that, you know, there are very high standards and rules that to play in the space. So when you look at the video with the visit platforms, the chat platforms, the telehealth platforms, each one of these is, you know, grew up organically in the current system, but there are multiple technologies coming together to truly give the telehealth end to end. Dr. Marsh, clearly we have seen an enormous increase in the amount of virtual care happening as a result of the pandemic. So I'm just curious, how has Kaiser responded to that? How is that demand transforming what you guys are experiencing and planning for? If you defined telehealth pre-COVID for Kaiser Permanente narrowly in terms of just simply scheduled telephone visits or video visits, probably 15% of all of our visits were telehealth. In the midst of COVID, those numbers increased. Kind of high, isn't it? Well, not when you look at what happened in COVID. In COVID, we increased to 80% of all of our interactions were via those two telehealth channels. So we saw a 25-fold increase in video visits during COVID. We saw a 300% increase rapidly in chat demand in some of our regions. So across multiple channels, we saw huge increases in demand over a two-week period. Are you seeing demand rise and fluctuate with our sense, at least in the states, where you operate with how we're doing with the pandemic? Of course, the sense that we've had this first wave and so everyone's relaxing a little bit, so are more people coming in or is it just steady? No, it's not steady. I think we are riding the roller coaster, so to speak, of COVID. What I mean by that is if we went from 15% of our visits being telephone and video pre-COVID to 81% after, as we began to reopen, reopen for elective procedures in particular, though that telehealth percentage has actually dropped to around 60% now. Having said that, as you all are well aware, as of today, COVID is on the rise in a huge way across many of our regions right now, so whether we moderate that balance between COVID demand within the hospitals and elective procedures, we'll have to modulate probably by not only state, but maybe even by medical service area. What can we point to as accomplishment so far and results? If we were to say what good COVID brought in, if anything, is that access to care is fundamentally changing. In terms of how you access care, telehealth is like, you know, forefront of it. We are also seeing like contactless interactions, right? So ability to have need for contactless interactions, that is going up and the reach of virtual care is also much broader now. It's not just specialty, it's not just primary care, it's not, you know, during the first visit, it's like everywhere, right? So I think that is another massive change and that changes on both sides, you know, both from consumer side in terms of adoption and also from a physician side in terms of adoption actually, right? So I think that is, you know, one of the bigger changes that we are seeing.  So quite a bit of changes actually in terms of not only how the care is delivered, but how the care is accessed. What does the future of virtual care look like in two years, for instance? Let's say the pandemic is behind us in two years. I think that we're in that weird transitional interface until we get a vaccine for COVID, where we're gonna ride that roller coaster up and down, flexing with electric procedures that really do need to take place. There are some things that we put off and we know that some patients put off things they should not have put off and it's actually causes harm. So we're gonna have to find that balance in this weird transitional time. When we get past this transition, so let's imagine that we have a vaccine in the future and we're past this roller coaster wave, I think what we will end up is a much higher use of virtual care, telehealth in the future state than what we experienced pre-COVID. And that's across multiple different channels. What about the patients? What is their experience like? Are they happier? Are they anxious? Is this a novelty or is this just a huge relief? And I think they're enjoying the convenience in a good way. So if you think about a 20 minute visit, it takes at least two hours out of your work day to go and do a visit. Three in five people, employees don't show up because of work priorities change. Nine in 10 prioritized work over going to the facility and getting a visit. So when you really look at convenience as an aspect, virtual care really helps to be, it saves time, it's very efficient, and also access care faster than you would actually access otherwise. So it's actually, the patients are really very welcoming in terms of what virtual care is actually bringing to the table. When you look at our, we measure constantly, are they satisfied with the visit? Are they happy with this type of delivery of visit? This modality of care, this type of care is actually getting a very good adoption among the patients. So we work with a lot of safety net healthcare systems, which are the clinics that care for the most vulnerable Medicaid and uninsured populations. And what we're also seeing in addition to what Pratt and Dr. Marsh said is that in a lot of areas we work in the clinics are, there's a lot of rural regions. And so it's been, this has been such a great thing. We're seeing access points for patients that have never had access before. Or we're seeing no show rates, which especially for mental health services, we're quite high, almost at zero. It just feels like what we're hearing from the clinics that we work with, it's just introducing a whole new way of working. And for many of the patients, they don't wanna go back. They like having this new option of accessing care. So just wanted to provide that from a sort of the underserved communities perspective as well. Well, of course, taking time off of work and having to get on a bus and stand in line. And for many people, it's just not an option. Now that's super exciting. And I'm curious, are you seeing a difference between different demographic groups? I mean, we mentioned rural areas, the low income people. I'm curious about, for instance, millennials who are perhaps digitally savvy, but also perhaps a little bit less respectful. So I don't know if going to an office, you have one experience and if it's just an app on your phone, if it's another. But what about the trust gap?  I think one of the things that we're recognizing is that millennials generally tend to be more receptive to technology. But where I think we've been surprised and I think it has really allowed us to be able to think beyond COVID is the fact that we're now starting to see folks who generally don't use some of these technologies, adopt them pretty readily. Oftentimes the biggest barrier to adoption is just trying it. And once people are able to try it and get that initial setup, they're finding it to be quite easy. And in fact, that we suspect is one of the reasons why virtual care will likely stay even beyond COVID. One of the things that we want our patients to do is to be able to engage with us in a way that they feel is most appropriate and comfortable with. And for some of these folks, they may not feel comfortable coming back into the clinic for a while. And so we'll see that, whether they're millennial, they're a senior, they're individuals with chronic disease. But this is probably gonna be something that we'll see beyond the current COVID crisis. Okay, well, I would like to resume the question of different responses from different communities. So we've heard about perhaps people in underserved areas, rural communities, people for whom going to an office is a burden or a hardship. We've heard about millennials being pretty savvy and excited about this. What about different disease types? Are we seeing any difference in adoption or acceptance of virtual care, depending on what's wrong with the patient? Marsh, I would say pretty much all specialties are up and running now, right? Would you say that? Yeah, I think we have disproportionate use of all telehealth channels, probably in primary care, mental health, OB-GYN and medical specialties, maybe somewhat less than surgical, but multiple surgical specialties are also engaging their patients in various ways as well. So I don't think that this is limited to a specific demographic or a specific disease entity. It's very broad. What about across like home monitoring versus telehealth versus like post-acute care? Are you seeing it sort of across the board evenly or more people engaged in one than the other? Well, when it comes to home monitoring, usually in that case you're looking at either a chronic condition or higher acuity like hospital at home. And we have remote monitoring for diabetes, blood pressure, congestive heart failure just starting, and those patients as in general tend to be older with multiple chronic conditions at the same time. So there may be disproportionately using those or remote patient monitoring services. Hospital at home can vary depending on the diagnosis, whether it's community acquired pneumonia or other diagnosis for which they're admitted at home. Could I just add another perspective on that? Just for clinics outside of Kaiser, especially in some of the safety net communities, this issue of remote patient monitoring is so new to a lot of the clinics that this is probably the area where we're playing catch up and trying to figure out how do you actually manage people with chronic conditions from their homes and how do these devices work? What are the issues of how to integrate it into workflow? So I think this is an area that like now that we're over the first initial hump of getting everyone on telehealth and video that we're really trying to figure out what are the next devices that'll help? Can you do diagnostics from home? How do these tools actually integrate into workflow? How does interpreter services integrate in as well? But an area that I think needs a lot more emphasis, especially in some of these underserved communities who might not have these tools at home right now. Well, and of course then there's the telerobotic surgery. Yes, absolutely. Yeah, and I think one of the things that we're starting to see is that many organizations had, when COVID first hit, were very ready to do some of the things such as telemedicine and they started ramping up the ability for them to be able to do more of these visits. Where we're starting to see a greater interest is now in terms of looking at ways that we can create more virtual programs than areas that we hadn't been doing in the past, like virtual ICUs, virtual robotics and also virtual rehabilitations. Chronic disease management will probably be a big part of that as we move forward. Right, so then it's continuous monitoring, I presume, with chronic disease management. That's right. Chronic disease management will involve everything from continuous monitoring to episodic and as well as patient engagement. So how have things changed at your organization as a result of the pandemic? Right, so when you look at employees, hundreds of thousands of them moving quickly to work from home, what does that mean and how do we actually collaborate and still deliver the care that the front lines, the support that the front lines are looking for? That was not an easy shift. Moving very quickly into that. And then in technology case, a lot of work also happens offshore as well, onshore offshore, when you look at those models, not only US was moving into work from home, other countries were moving work from home as well. So what does it mean to really remote enable workforce in such a large scale? As you can imagine, we used to have clean rooms where people will come and work there and now all of a sudden they have to be virtualized in a way that they can come in remotely and work within the systems. So a lot of this had to be wired up and done at the speed that we've never would have expected actually. So I think that's important. Second thing that we're also seeing is the collaboration tools. If you look at collaboration among employees, products like Microsoft Teams, where we can actually get on and have a conversation used to be mostly a set of people, whether in technology or in operations, used to have it, but now it's like everybody's using it. In fact, within Kaiser system, when we look at Kaiser Permanente, when we look at caregivers, nurses, physicians, their collaboration went up through using these online tools and technology. So as much as there is a shift in the how care is delivered internally to organize ourselves to deliver the kind of care, if we needed to adapt very, very fast, our employees needed to adapt very, very fast as well. And what about the cost of all of this?  I know of course there's regulatory and reimbursement issues around this, but just where you're sitting right now today. You know, one of the things that we saw from federal government is the rapid response from CMS to at least temporarily get the reimbursements going for televisits, as well as, you know, we saw cross-border consult opportunities as well.  For Kaiser being an integrated care provider, I think, you know, we rallied behind as quickly as possible to get as much as care possible online, digital, virtual, as fast as we can. So I think in a way as a health system, the integrated care system Kaiser Permanente is, has been very effective, especially during these times. The issue of cost is actually a really interesting one because there's a cost to implementing it, but then there's a cost to the actual benefits that you're getting and the cost savings that could be accrued from using something that's a lot more convenient. So if you think of it from the patient perspective, if I'm getting a visit that's a lot more convenient, one that I can base on my own schedule, they perhaps even be more accessible, that is something that in all likelihood will lead to greater adherence to the visits, greater potential opportunities for more of these opportunities to engage with the healthcare system. I think that can lead to better engagement, better outcomes, overall lower cost. So the fact that we can do this digitally creates an opportunity for us to start thinking about how can we use this as a means to stay more engaged with the patients, have the patients become more engaged. And ultimately that is something that we haven't seen measured out in terms of total cost, but the total cost of care most likely will be lower. I think one of the other things that we're starting to see is when we think about virtual tools, Pratt was talking about this earlier, one of the things that we saw on Teams was that Teams can be used by not just physician or clinician to patient, but also clinician to clinician. There's so many virtual consults that occur, there's so many opportunities for clinicians to talk to families, virtual tumor boards, you know, just incredible opportunities for us to start thinking about how we can use these tools in ways that we hadn't done in the past, but now we're recognizing that there's real tremendous value. And there's cost savings to that as well, as well as efficiency. And what about the doctors themselves? How are they responding to this?  They've got yet new systems that they have to learn. They're still angry about their electronic health records and having to spend so much time inputting data. Is this new technology that they have to adjust to seen as a burden or is it seen as a boon? Is this doing anything to inspire the physicians or address physician burnout in any way? I think it depends. And what I mean by that is for some clinicians, they are facile at virtual visits and all aspects via all channels. So they leap to this, love it. During COVID, they can work at home and be very efficient in doing that. For other physicians that weren't already engaged in some of the channels, there's a learning curve. There's a learning curve on the member end. There's a learning curve on the physician end. And some of them definitely were challenged. I think there's an underlying critical underpinning. And that is whether it's the member or whether it's the clinician, there's a couple of things they need. We need to make it easy for them. So the technology matters. If it's easy, they're more likely to adopt on both ends. I would say also both the members and the clinicians need just in time information. So insofar as we're able to replicate what we often do in an office visit and we can do that with just in time information virtually when they're remote, we'll meet all needs, I think. So I think in terms of long-term burnout, I think that virtual care offers many clinicians a change of pace in their day-to-day work and actually could protect against burnout. One of the cautions that we're hearing is we also need to support our providers in different ways. So if we're switching just from an in-person just to a phone or video, if sometimes it's feeling overwhelming and you're feeling disconnected and people are trying to squeeze in more and more visits because you can do it more efficiently, but you're not creating the space to create the relationships, trying to figure out how to add breaks. Like some of our providers were joking that they don't even have time to run to the restroom any longer because they've been squeezing in so many visits. So I think there's an opportunity to think about how the full care team can support the provider so that the visits they have are meaningful. I worry a little bit that if we just flip from doing the same thing in a video or phone format that we might burn people out. But so this is where I think the sort of rethinking what the models could look like is really important and how medical assistants could do maybe some of the screeners or is there a way to just think about the different team partners to help support the provider so there isn't burnout? Yeah, and I'd also add to that. There's so many elements that may add to the time spent that are what we call non-value added elements. And this could be everything from just the technical setup to trying to make sure that the person who you're talking to understands kind of what the specific time frames are and just the scheduling of it, the ability for you to actually have it working properly to make sure that you're able to do this efficiently. All of that adds to the time spent with that patient. So the more efficient that we can make that process the better it is for the clinician. So on our end, what we had heard and things that we had learned that technology could be very helpful is just in the mere process of scheduling it. You know, a lot of times these calls come in and this is especially true during the COVID, the significant amount of interest and questions that people had around COVID, there needed to be a separate triage process just for COVID responses questions to versus your traditional maybe urgent care and or chronic disease questions. So that process could oftentimes be done through an automated bot. And what we learned is to put an automated AI based technology in the front end that allows you to be able to then streamline and get to the right person so that you have the right information relevant or the right resource available. That's a really important front end tool. And then similarly, you know, even on the back end tool even post discharge or post conversation having a bot to kind of provide some level of post encounter discussions. You know, how do you use technology to enable that? A bookings app is something that we had to kind of figure out how this would need to be incorporated into the EMR or HIS systems. That was another piece that we started looking and is now is live. And these are really interesting technologies from administrative standpoint. And the last thing I'll share is that just simply that note itself having them to go back into the electronic health record and then rewrite or document that if there's ways that we could use that conversation that was had and through another technology we refer to as ambient clinical intelligence that conversation is captured. It's essentially voice to text. It's codified on the back end and then it's integrated into the electronic health record. We've been doing this one of our other partners nuance and that's another possibility to be able to then take some of these newer technologies, implement them within telemedicine or telehealth visit and then make this process a lot more streamlined. So these are the kind of the steps that technology can be used or the ways that technology can be used to make this whole process more streamlined and easier. I think there's a take home message here that I'd like to comment on and that is anything that we can do whether it's via AI or other support, rooming a patient with your MRA virtually just like the MA did face to face anything that we can do to lighten the administrative burden on physicians will really help. Yeah, in some of our clinics, one thing that they've added sort of a new role or rethought about a role where there's actually someone called like a patient representative because some of our patients haven't used video before in the past and need a little more hand holding. So they're literally calling people the day before making sure they understand how the technology works, doing any prep work ahead of time. They're just like starting to rethink that role completely so that the physician's not having to spend time doing technical support and making sure that it's really used to the optimal way. We are doing tech checks right now within Kaiser Permanente, but they're very person dependent. I think in the new world to broaden this, to be able to automate that tech check support in advance of any virtual visit, particularly video is really needed. Yeah, digital definitely has a role for pre-visit, during-visit, post-visit, all three, right? I mean, there is automation and optimization that needs to happen on preparing the patient or understanding the patient. And during the visit, AI and ML, how far it can go and post-visit as well, post-visit, visit, what does it mean to finish up that visit but also have the more digital follow on so that the journey is complete actually. So that's something that healthcare will be embracing quite fast, quite rapidly. One other thought is also the handoffs. And what we've seen is we're talking largely about scheduled visits, but a lot of care occurs in an unscheduled manner. An individual has a question, a concern. How do they engage the system? And oftentimes it is through the website, it's through a phone call to the call center. And so that handoff from let's say a call center agent to a telehealth or a chat bot on the website to the telehealth, the ability for you to go from telehealth and then go to the electronic health records. So these handoffs are so critical and we've been looking at ways that we can streamline all of that. And a lot of it has to do with just understanding all the different use cases. This is a good example of organically, if you want to launch a service, we used to launch an 800 number for this, 800 number for that. And physically also we had different services. You can go to this facility to get this kind of services and for this facility for another kind of service, digital friend doors change all of that. There is only one friend door that they're walking in. What does it mean to actually bring all that together for the member, for the patient, so that there aren't many doors that they need to walk in, they have clear access to what they need through that one friend door. And I think that's the key. And in that front door, if I called a member service for claims and another member service for appointments, that was two different 800 numbers. In a world of chat, I may seamlessly switch between claims, I just asked for a benefits or a claims question to quickly to a scheduling an appointment based on that. That is two different care service units that used to come together to provide that service, if you will. So technology is a big role to play how digital can make lives a lot more easier for the patients and the members. So some of this is kind of straightforward, the use of bots and basically just branching systems. What about the use of artificial intelligence? How is this being deployed in virtual care settings? Well, behind the bot is actually an AI framework. So to some degree, to create the tools that we're very familiar with, sometimes it seems pretty straightforward because the user interface is so elegant and nice. But behind the scenes, if you lift the hood up, so to speak, you'll see that required a significant amount of understanding of typical examples of questions and concerns. So give you an idea, like within the bot framework, when an individual is typing things that go, we'll say, outside of the norm. This is a person who's complaining about a foot ulcer. There might be key terms or words or phrases in which there might be an escalation path so that rather than just continuing down the path of just simply leading to a document or some information, it could trigger a call center action or it could potentially schedule something else that is interrelated. There's a certain amount of intelligence that can be built into these systems. Some of it could be protocolized, but also some of it could be personalized based on the existing type of conversations you're having. So I think that that's one element. I mentioned the voice piece. That's actually artificial intelligence as well. On the back end, it wasn't just a voice to text. There was an element of trying to understand what is the conversation? What are you talking about? Is there a clinical component to this? How do the terms then get translated? Somebody may be talking about something that's specific for diabetes or specific to heart failure. Then you have to use that context to understand to make sure that those terms get put into a wave that it could then be accessed later on because what we're trying to do is we're trying to make sure that once it gets codified, we can then use those as mechanisms for we'll say clinical decision support. So we have to understand not just kind of how to translate it into specific words, but then understand what those words mean. And that's where the AI comes in. And what are the constraints on those systems right now? Well, there's a lot of really interesting technologies that are being deployed in many different capacities. I'd say generally speaking, there's a lot of information that needs to be computed very quickly. So storage and compute are really the two variables that oftentimes we look at, which is part of the reason why there's been such a movement towards cloud computing because it's real time. It allows you to be able to access large amounts of data due to the computations fairly quickly. It can sit on top of a variety of applications. There's so many other factors. There might be what we'll refer to as machine learning where you'll actually then go and learn from what the prior responses are and then build off of that, in which case then you'll need to have an underlying AI framework, but then there'll be some additional computing on top of it. This is all really exciting stuff. And I think what we're learning is that there's so many great use cases for them. And David, would you add, when you think about the linguistics of this and the dictionary of this, the ability to, how a customer or a patient or a member expresses their symptoms and conditions and what they are experiencing to how it gets translated in clinical terms, in medical terms, and what does that bridge look like? How do we understand both sides of the puzzle? I think that is a lot of that is with physicians now and how do you teach the machines to do that so that they can help physicians catalog, organize the information as a video call is happening so that they can take that information, put it in the EMR or EHR systems. So I think that is another area where it has to grow fast and rapidly. And a lot of that knowledge is actually built into a lot of the health systems. And how do you access that? And how do you actually create that goodness for everyone actually? So what about interoperability? It's obviously a major part of what we're all trying to accomplish here. The data elements themselves need to be interoperable. We need to agree on the standards. HL7 fire would probably be a great starting point, but we're going to need to go beyond that. HL7 fire obviously is going to continue to evolve. We're looking at not just EMR types of data elements and claims data sets, but we're now looking at data sets that involve genomics. We're looking at imaging. We're looking at a variety of other ways. So interoperability has a lot of ways that we can go in terms of breadth, in terms of scope of other types of data sets. And then also in terms of the depth of the understanding of like within those contexts, you know, are we going deep enough to cover all the different elements? So it is absolutely probably one of the cornerstones of a lot of what healthcare technology is based on. Going to be critical for both adoption of remote care and quality of the remote care or virtual care as well. When you think about remote devices, there are many innovations going on around monitoring, glucose monitoring, blood sugar levels, monitoring various aspects of the vital signs. The communication between those devices and back to the systems, I think the standards help a lot in terms of, you know, we're going to live in a world where multiple devices are going to exist. The interoperability makes it easier for us to consume that data, bring that back in and process it in the right way so that we can expand and scale and not stuck with, you know, one or two devices, but really a broader ecosystem. This pandemic has got us thinking about global health in a way that most people haven't until now. And I'm curious how what we're doing in the United States differs from what's happening in other countries, both because we're experiencing the pandemic differently here than in other countries. But I'm also curious about the systems and the reactions to that. What are we seeing? And how are things different regionally and globally? So I can maybe jump in here. When COVID hit in December, at least when we became more aware of it, I, as a background, I'm an infectious disease physician. So I was kind of in a good position to be able to understand that both what was happening from a disease and infection standpoint and how we could use technologies. One of the real interesting things is that every country developed a program for how they would deal with this slightly differently. Some of this was based on the fact that they had prior experience with other types of outbreaks and they knew what they needed to do to kind of get in front of it. So some of the countries that we saw that were dealing with this in a way that was probably the ways that we should have been all doing it were some of the ones in the Far East were specifically like Taiwan and then Hong Kong as well, South Korea where they got in front of it by implementing a widespread public policy efforts around masking and social distancing and even shutting down the systems fairly early. And then of course, lab testing. They did a significant amount of testing to do and look to see what the surveillance was. So this whole concept of testing, isolating, contact tracing was done very sort of like secondhand nature. I think what we started recognizing when it started hitting in the United States was that we were dealing with more than just simply that it started becoming clear that our systems were getting overwhelmed. And so in that scenario, we ended up having to deal with some of the issues around how do we then control that within the health systems? How do we enable us to get more PPE, more ventilators, more support, protect the frontline workers? So we really kind of started happening very quickly within the US. So we had to deal with a lot more but ultimately we're getting to the point right now where we're starting to recognize that those same principles are still gonna be very helpful as we start continuing to battle this virus. And how are we seeing the growth in virtual care differ from the US to other regions or other specific countries? I think we've been fairly advanced in terms of our virtual care. A lot of the virtual care systems were in place. We've been able to adopt and increase the utilization of them, take advantage of some of the infrastructure around that. Certainly some other countries have been able to do that as well. But the US is from a virtual care standpoint, I think done a fairly good job responding to it. The numbers speak well. You can take a look at across the board, virtual care visits. There was one site I remember talking to the CMIO, they said that prior to COVID-19, they had done zero or like close to zero. They were all at almost maximal capacity on virtual care as of like three weeks later. So the ability to ramp up so quickly on a technology that they hadn't even implemented for apart from just some pilots or betas was pretty remarkable. So I think we did a pretty good job from that standpoint, but there were a few other, several other deficiencies in areas that we could have improved upon. And I think also, I think there's a lot of variation too. So I think in systems like Kaiser where a lot of the infrastructure was already in place, it was a lot quicker. I think some of the clinics that we work with, some were able to nimbly like within days make that pivot. And then there's others that we work with, some of the big public hospital systems that have very little video visits still. It's mostly all phones. So it's virtual, but it's virtual via primarily like 80 to 90% phone. And they're trying to play catch up now and figure out, I mean, even getting for some of the clinics, even getting laptops and cameras enough so that people can be working from home has been a challenge because everyone's now in that mode. So there's a shortage in getting some of that critical equipment in addition to the PPE and other equipments that are missing. So I also do think that in this country, there definitely is some organizations have been able to get up and going quickly and others, especially in communities, underserved communities where there may be just small two-person providers caring for the black and brown communities don't have those tools yet. So I just wanna point out that there is some, quite a bit of variation in this country as well. I'd say one of the real, the interesting and also a tragic things that this has highlighted is the fact that many of the systems in place work well for those that had good infrastructure that were fairly large in size. It could afford the hit on their bottom line. For the smaller ones, the ones that were perhaps, maybe it could be small ambulatory practices, small hospitals, they really struggled and given the economic impact that they had, they were in many ways not able to do the virtual care because they were actually not able to even support themselves financially. So I think there's so many elements to this. There's the element of could you technologically do it? Do you have the business robustness, the ability to be able to build that infrastructure and be able to do that? And if you don't, it's really hard. The reimbursements were coming in sort of midstream. It didn't come in at a level that could really support a lot of these organizations.  So I think that this is one of the challenges that we run into, our systems are very fragile at certain points. And it also raises some of the challenges with how the payments and how healthcare is paid. So the fact that many of our clinics have had to furlough employees, close down clinics, just because everything has been on a fee for service, which is obviously different than the Kaiser's model, but it has been very challenging to keep the doors open in communities that are hit hardest by this. So I think it's exposed a lot of the cracks and as you said, some of our fragile healthcare system. Well, so that's probably a good moment to segue into the future. So what are the, what are the constraints going forward? What are the opportunities that we have? How do you see this playing out in terms of, I don't know, maternal health or specifically tailored messages to patients? I'll leave it quite open because you probably have specific areas that you care about and then we can just dive into individual ones. I think the biggest challenge is a mind shift. And what I mean by that is historically we have looked at healthcare as being patients come in to see us in a physical facility. The mind shift that has to take place, I think in the future, is we may meet patients where they are. Now they may be on the go, they'll be probably disproportionately at home and they may come into a facility. So what's the mind shift that we provide them the convenience and the ease that they need wherever they are so that their healthcare outcomes are best met? I think it starts with a mind shift. There are challenges, there's technological challenges, there's workforce challenges, there's regulatory challenges. But I think the biggest challenge is let's embrace the future with that mind shift that needs to occur most foremost right now. I think that's a big tall challenging order. And something organizational, behavioral organizations are thinking about what about the shift to personalized medicine? I mean, there's obviously an enormous cost that goes into this very individualized treatment and bringing all these different technological systems to bear. Can we really get closer now to personalized medicine? What are the technological ways then? What are the mind shift ways and how can where we are right now be a pivot point for that? I'll talk about personalization and we'll get to the personalized medicine. So when I think about personalization, especially I coming from retail industry for the last 10 years, where you don't need to go search for 100 million products and you search for one keyword and it gets you the right product that you need actually. So when I think about personalization, healthcare is a space where personalization is gonna really matter and we can actually do it. Today the personalization in healthcare when I think about it's about providing access to the records and access to the data that you need access to. That's how digital systems are built almost across the nation when you go, you log into any one of these systems. It gives you access to your previous lab records, previous pharmacy records. And yeah, you can have some transactions but the value add that we can provide understanding who that person is, looking at their comprehensive health, ability to not only first of all, if they're in a need for care, we can actually do much better job in terms of providing the right kind of reminder, touch points, ability to actually coach them, nudge them, things of that nature. But then when you get out a little bit into behavioral health, mental health, lot more continuum, we can be there all the time actually that digital can play a bigger role.  What are the good, healthy habits that we can promote and keep? So when I look at personalization overall, what do we understand about a person and what can we do for their holistic health and wellness to the point of caregiving? I think there's huge opportunity. And I think healthcare has a tremendous potential to actually change many people's lives and touch many people's lives. I think this is a perfect moment to talk about the cardiac rehab program. I know we've just seen that video. Can you tell us about the design, about the challenges and about the outcomes that you've experienced with this program? And Dave, you were one of the early ones to kick this off. You wanna talk to this? Sure. Well, this was a fantastic project that was initiated a couple of years ago, really through some innovative work and work design that we, this is the time in which I was at Samsung, but we continued this post. It's essentially a mechanism to take the in-facility cardiac rehabilitation program and virtualize it. And in that process, what we asked ourselves was, do you have to do all the things that you traditionally do in the in-person or in-facility? Turns out that you don't. And this was a real big light bulb moment for all of us. I'm an internist in infections of these doc. I kind of assumed that most of the patients that need virtual rehab or would need, I said cardiac rehab would need like an EKG and you'd need to have people with defibrillators next to them and not at all. Most of them are actually low risk. And the primary goal is just to get them to exercise. So, of course you'd like to see it, what their exercise tolerances and you'd like to see what the performance over time is and you want them taking their medicines. So these are all parts of the program. When we boiled it down to the fact that it could be done in what we'll refer to as like a six-minute walk test that could be administered every day, we realized that that could be done virtually on a smartwatch. And so we got together a multidisciplinary team of throughout, it started out in Kaiser Southern, California, there were a lot of design sessions to really understand the workflows, to understand from the patient perspective, from the physician perspective, the case manager, the nurse, you name it, the pharmacist, huge amounts of whiteboarding and then rapid design. And we did some iterations on this and ultimately it was piloted. It was then further tested. And then this has continued as you're well aware to now sort of become more widely accepted within all of KP. So it was really a great example of how we can start with this concept of the patient and understanding their journey first. Again, what is it today that we asked them to do? Come into a facility on our schedule to do it a significant amount of time. We're taking time out of your schedule to do that as opposed to why don't you do this at your schedule and then if something happens or you have questions you can respond to us. It really shifted the balance as we were talking about earlier to now a patient-centric balance and that increased the adoption rate tremendously. And we saw a near doubling of the completion rate from like the mid-40s to close to mid-80s. And why is that important? Because literally for every, anywhere between seven to 17 patients you treat, you save one life. I mean, significant dramatic improvements in quality of care. And also the measurement of the readmissions, the readmission rate just plummeted dramatically. So I'd say so many great benefits. It was patient-centric, it was something that was done in a very collaborative manner. We saw benefits from in terms of quality of care as well as reductions in readmission. No wonder why it's something that KP is adopting more widely. Right, exactly. Well, and I think it's really interesting to look at programs like that and look at things like the FDA recently approving the use of Achilles Health's video game to treat ADHD, right? So if you're getting prescriptions now approved by the FDA for digital health interventions, I can imagine the opportunities here are just extraordinary for complete transformation of the medical system. So I'm really curious. I mean, you know, digital health applications for mental health, for treatment, diagnostics, even anticipating, you know, what potential drugs could be best suited for individual patients. Addiction, you know, the ability to stay connected to the patient, to see the patient in their own environment instead of the patient coming into the healthcare environment. You know, I think early detection of things like Alzheimer's, you know, once we have better treatment for them, I think the possibilities are just enormous. And this kind of transformation can only come about if the regulatory hurdles, you know, are removed and the reimbursements are put in place and so forth. So, you know, what other digital tools do you guys see happening next? What are the most exciting ones? Where should we look for the new stories and the transformed outcomes? It's a great example of right technology for the right purpose, working with the like-minded, forward-thinking physicians coming together to help improve patients' outcome. I mean, I think this is very, very important, right? So there are lots of technologies available, but how do we actually pull it together in a meaningful way and done right? I think that's where you're gonna see the adoption. I think, you know, it's a good example of now, Dr. Marsh, you know, you know, he's driving adoption across nationally for us actually, like, you know, because of the outcomes. I wanna call out, when it comes to technology, there are two things that we need to look at. One is that there is devices and online application of AI, ML, and technologies. There is offline models and impact there as well.  How do we actually help data detect the people and bring them to the facility so that they can get the care? And so, when you think about accessibility, equality, and ability to have, you know, access to care for all the population, data can play a big role. Machine learning models really helps us to, you know, detect the patients who should be, we should be seeing, we are not seeing, you know, and do the right kind of intervention. So we cannot, as much as we are thinking about online technologies and online interactions, there are offline models that are making big impact as well. And that's going to be very, very important. Excellent. So I think you mentioned a very important point, which is equity. It's very hard in this day and age to not be extremely focused on the healthcare inequities in our society and how they drive things like poverty and violence and police brutality and all the rest of it. You know, what role can virtual care play in reducing healthcare inequities in our society? I have a lot of opinions on this one. I agree that as we've been saying, there are certain communities that have been hit particularly hard by COVID and making sure that we're equipping both those patients and the providers that care for them so that we aren't increasing disparities and actually increasing inequities by not seeing that not everyone has the same access to technology. A lot of our communities, there isn't any broadband. So what do we do about that? How do we get people access to WiFi? How do we make sure that people have, that we incorporate medical interpreter services in a meaningful way and also leverage community health workers and other types of staff as a way to actually engage communities. So I think there's definitely a way to be able to address some of these inequities, but there needs to be a thoughtful sort of intentional way of doing that. I think what's exciting is that in the past, there'd been a lot of assumptions that patients didn't have these tools or the people in underserved communities didn't have these tools or didn't want to use them. And I think we've blown that apart. I think there's clearly a lot of interest in having more convenient care. Transportation has been a big challenge for people in getting access to service. And now all of a sudden we can bring care to people in a very, very different way. I think there's more to learn about how tools like some of the more future forward tools that have not made it into our communities yet. We're working with basics like texting and phones and video. So we're far from having bots and even home devices. So making sure that whatever we start building works for everyone, that we're testing how remote patient monitoring and home diagnostics also work within these different communities and how patients accept it. So I think there's a lot of work to be done to make sure that we don't increase disparities, but I feel hopeful that we can do that. To add to that, there are many technologies that can help. But one of the biggest questions is around will the individuals who need them the most use those technologies? And oftentimes the answer's no. So what they oftentimes find themselves doing is they access it through traditional mechanisms like calling into a call center would be a good example. So what we're now looking to do is empowering those call center agents with the tools, the information needed to be able to implement and address some of those issues. So for instance, let's say I'm an individual who has had many issues around transportation not able to make it to the clinic visits. Well, in that scenario, what you could envision would be an ability to pull directly from the EMR and other systems the history of whether or not they've been able to make it to those visits. And then in the context of that conversation with the call center agent, they're now aware of that and they could ask the questions and potentially then respond in so by setting up a ride share or like a Uber lift ride for that individual to be delivered to have them delivered to that facility. You could also ask questions around medication history. Let's say there was a potential individual who just couldn't afford the medicines and for over the past six months they've just not been taking the medicines. Well, that information oftentimes doesn't surface until they actually see the doctor or the pharmacist in which case that may not even come up. It may get missed because of these visits being so fast or perhaps other issues coming up. But let's say there was a process where you saw that the person wasn't refilling their meds. You could actually pull that up and these questions can be brought and asked in a very non-confrontational way to that individual. And then there could be a series of questions that could be all sort of automated. Is it because of cost? In which case you would have a social worker or someone address those issues. Is it because of side effects in which a pharmacist could potentially then be engaged or because it's just not working in which a physician. So you can think of like now these new in a virtual world you have new players and they need new tools. You need a virtual care navigator and those virtual care navigators can leverage the types of tools and connectivity that we're talking about. The telehealth piece, the call center piece, the ability for us to implement clinical decision support. And so what's really exciting is that we're starting to see a lot of those systems starting to be built out and we're starting to hopefully see some real value be created. What about quality of care? How does virtual care improve the quality of care? And how does it improve the human experience? I think it remains to be seen where virtual care improves the quality experience. And when we find that, we should really move to virtual first in those cases where the outcomes are better with virtual care than they are with face to face. But I think it's a huge area of exploration both within Kaiser Permanente but also in other regulatory agencies how will we ensure that we provide the same great quality of care with the virtual care that we do with a face to face visit? I think the story's still out in that to a great degree. I completely agree. And I think what's gonna be interesting to figure out is we've been forced to sort of flip everything to virtual but in the future what lends itself best for phone? What lends itself best for video, for in-person and for these other tools? I think that's the work that we're trying to figure out how to help people get to because it's obviously not the same for all those modalities. And I think there's a lot more research and understanding to understand which ones actually do impact quality in a positive way and which ones maybe we shouldn't be doing virtually. So yeah, lots to learn there. I think the opportunity is, if you're looking at virtual care is simply a way to virtualize it a traditional in-person visit. There's not a huge amount of opportunity to improve the care apart from maybe saying that you've made it more convenient they're more likely to attend. But if you're thinking about it from the context of the broader sense of virtual care where perhaps we can implement some monitoring elements like the cardiac rehab would be a great one where you've got now a program that lasts every single day the people are able to implement and sort of escalate and you can identify before things get bad that something is actually gonna happen. That's where the opportunity lies because then we can look at not only the data but apply some AI ML algorithms on top of it identify before bad things happen. That's the key. And so we can't do that if it's gonna be based on an episodic visit it's gotta be based on multiple data points over a longer period of time. So that's gonna require that the technology has to be seamless, it's gotta be inexpensive it's gotta be something that can be applied for anyone in any setting, you name it. But those are the types of things that will allow us to be able to start seeing that virtual care has a huge role in terms of overall improvement in quality. And one thing to just add to that I think is how do we make sure that we don't lose the important part of that connection and relationship with the provider and find ways to, I think one of the things we're seeing is we're having to help providers retool to say how do you actually do a empathic phone visit? How do you build that relationship with someone maybe you haven't met yet in a different way? So how do we make sure we don't lose that human connection which I think is such an essential part of healthcare because there's lots of tools and technologies we can add on but we don't wanna strip and lose that aspect of care. There's a real interesting we work with the National Health Services on a program to use one of our hollow lenses in the setting of COVID. And what we did, or I should say what the clinicians did is they went into patients rooms that were infected with COVID-19. And as you can imagine, they're all geared up, they have the hollow lens on. But in the background, they had an entire care team with that person coaching them, advising them, looking at the patient, doing all these other things. And in that one visit, they not only saved PPE or preserved PPE, but they actually had a true multidisciplinary visit in counter with that patient. And this is the opportunity as we think about these virtual care visits to have greater engagement with multiple stakeholders to be able to think through how we can support each other. Maybe there's mechanisms that you can pull directly from the past medical history, other types of information, whether it's an image or trends and things like that that could inform us. It's almost like giving a real-time decision support tool when you need it, when you're seeing the patient. Those are the things that we've oftentimes talked about. It hasn't been something that people have adopted in a traditional visit, but in the setting of COVID, where you're essentially thinking about how do you minimize this, it made perfect sense. Beautiful. Well, that's a lovely place to wrap up, but I want to be mindful that others may have a parting thought before we do. COVID-19 thrusted virtual telehealth, telemedicine into forefront when we were not ready in the harness in many ways, right? So I think the opportunity, but leveraging that opportunity to make it better, make it useful, make it reachable, this is huge, huge in every aspect. So we want to utilize that, we want to leverage it. That will actually make healthcare better for not just for one segment or the segment, overall for everyone actually. So there's one good thing that comes out of it is the rapid adoption of technology, meeting health expertise and the members adoption. I think that will be a big win for everyone. And I would just add, I've been working on telehealth for 20 years of my life. And it's been a little bit like banging my head against the wall and within a week things flipped. And I think it's really exciting to see what the possibilities are and where we could be heading into the future. I think the one thing I wanna make sure happens is we don't just flip in-person visits for phone or video, but that we're really intentional about how to design a system that actually leverages the strengths. And so I think it's a really exciting time to just like rethink what healthcare delivery could be and where these tools can help. So I'm really optimistic about the future. I think we're at a reset point within healthcare right now. We have the opportunity to re-examine all of our prior assumptions, all of our long-thought care delivery models and turn them on their head because we have an opportunity in applying the digital and telecommunications tools to meet patients where they are, not where we are. And that re-imagining can happen right now if we're willing to take the time and effort to make it happen. I'd like to build off of everything that everyone else, like fellow panelists have said, totally agree on all of those points. I would love to challenge all of us to sort of rethink what virtual care could be. Today, in large part, it is a virtual replica of the in-person experience where it should be and where it could be is sort of a redesign of how healthcare can be delivered using digital tools involving an entire care continuum and involving multiple stakeholders embedded with the intelligence that we know from the systems to empower each of the caregivers to be smarter in terms of the decision-making and also to empower the patients and their families. Magnificent. This has been an amazing conversation. You guys are all extremely impressive individuals. The work you're doing is remarkably inspiring. I think the opportunity here to anticipate patient health and to integrate health into their lives and into everybody's lives to really just transform people's access to health and wellness and vitality is really exciting. And listening to you guys, getting these bulletins from the front lines has been really a treat today. So I just wanna thank you all for participating. I wanna thank Kaiser Permanente for hosting this and Nico with his Thoughtcast program. This has been really exceptional. I wish you all continued success in your research and design and implementation. And I hope that this will continue to make meaningful improvements in the health and vitality of everyone. So thank you. Thank you. Thank you very much. Thank you. And so now I'd like to turn this to Karen Cook who is the Director of Kaiser Permanente International. And one of the things that I think is interesting about Karen's background is that prior to that, she was the Director of Tech Innovation and the Innovation Fund for Technology. Thank you to all of the online participants. We have a great set of questions that we have about 10 or 15 minutes to go through. So Dr. Marsh, there's a question for you right at the start. What's a day like for you? What's the clinicians point of view when you're doing mostly virtual visits? Are there some situations that are better than others? Well, most of the clinicians right now are working from home. And I would say in talking to several of them, it's challenging. Challenging to do back to back to back to back to back video visits, particularly all day long, is grueling at times, particularly if you can't interspersed with that face-to-face component that we had pre-COVID. So it's tough for a long day and they're jamming in oftentimes many visits within that day that they didn't historically in the past maybe. Great. Thank you. I can imagine there's lots of sometimes background noise, lots of friendly dogs and pets making an entrance as well at times. Also, have any of you had experience providing patient education via virtual visits? Vinu, I know you've talked about patient representatives working with patients in advance. Have there been other examples of providing maybe group education classes as well? Yeah, it's been interesting to see, especially in the organizations that we work with, group visits is a very common model of delivering care for populations. And I think people are still trying to do it with Zoom. I'll give a quick story because my sister is a nurse practitioner and she was leading a pediatric obesity visit and she was able to engage her kids in doing the exercise and showing how you could cook. So I think people are getting creative about doing group education through group visits, leveraging texting to outreach and do a little bit of education. And then I think a lot of the patient representatives or our patient ambassadors who are doing some outreach are also using that as well. Great, thank you. So there are a number of questions and I'll try to do them all justice by combining them together. But really, and we've talked about this about ensuring that those underserved populations with less technology access, maybe less tech savvy, how do we not exacerbate the disparities that currently exist, whether it's racial or socioeconomic and does policy play a role in that as well? Yeah, so I can start. We definitely see that as a big challenge right now and in the efforts we're doing, we're just launching a program with about almost 30 organizations from all across the state, representing small provider offices, representing federally qualified health centers, public hospitals, trying to collect the data by race and ethnicity, by payer type, by gender age, seeing where there are some disparities and then spending a lot of time. There's a whole focus on how do we engage patients with digital barriers, whether that be around literacy, around getting the tools they need. Some of the county systems we work with, the providers don't even have cameras on their computer so they can't even do video visits. So how do we also make sure that the providers who are engaging with those patients have what they need to be able to engage patients in virtual means? So I think it's both on the provider and on the patient end and getting them the tools and Wi-Fi and support they really need to be able to do that. Yeah, from a technology perspective, there are many things that we can do to help close that gap. Certainly, Wi-Fi and the ability for us to have broadband more widely would be a good starting point. The ability for us to be able to provide devices and other tools that people might need to use. But beyond that, just even the technology itself, is it in the language that we all understand? So translation services that can be automated through the artificial intelligence engines. Is there a mechanism where some of these tools could be utilized by more than just the individuals? So maybe caregivers support figuring out how that could be applied. Even within a simple video context, we can use, because there are many folks that are hard of hearing, simple things such as the closed captioning piece to help better understand and enable us to be able to provide that level of understanding from the patient perspective. As they're listening in, they can hear and see and then really participate more actively in the conversation. So many different types of tools. We've also recognized that as we start deploying these tools for individuals, some of these tools sometimes are geared towards sort of the tech savvy, but we can simplify the user experience. Some of the things that we've done at Microsoft are taking a look at like Xbox controllers. Could we use some of those to be able to make things easier for those with disabilities? So extending beyond just what we traditionally think of as the typical disparities around race and socioeconomic by looking at age, disabilities, and other types of limitations. That's great. And it's a great segue to the next question that Dave, I think you and Pratt might want to start with is how do you personalize the patient journey? What can we do to make both a personalized and seamless experience with all of these digital capabilities? I think personalization has a big role, as I said. So it could be initiated by both the physician on how they're personalizing as well as the member in a self-service mode. I think you can do both sides. When it comes to physician, whether it's episodic treatment or whether it's chronic condition management, taking a step back and looking at holistically how you could connect the dots, if you will, especially when multidisciplinary aspects needs to be connected together is a huge opportunity. And we do this quite well in the physical setting, but how do you scale that in a digital environment? And it comes to the consumer engagement. Personalized journey means a lot. When I'm putting in my conditions, when I'm actually expressing the symptoms that I have to seek for an appointment, it's much easier to understand, did I have these previous conditions and should I actually have you and what type of care, what kind of modality worked for me before? And could you put me into that modality automatically? So ability to actually really understand the patient, understand their preferences and providing the right type of care at the right time. I think in a huge opportunity, especially when we bring in technologies together. So David? Yeah, when you think of it from a technology perspective, when we get the best experiences, it's because the system knows our history. They know what we've done, what we've liked, the preferences and that can be gathered through multiple different touch points. And then what it does is it sometimes makes suggestions and the suggestions would be things that would be appropriate, things that would be based on what traditional individuals or perhaps we ourselves would know to be best practices. So you translate that to a healthcare setting. We have an ability for organizations, for individuals to be able to pull information from different data sets and pull it into streamlined ways for us to understand what that history is. Now it's difficult if you just simply have access to it and you don't have really time to be able to sit through all of that. So it's gonna require some algorithms and some structure for us to process that and then convert that into actionable insights. So the example that I provided earlier, if we know an individual has been non-compliant or missing or not refilling his medications or medications, what we could then do in that context of that same visit is have a chatbot that would then allow us to be able to ask a series of questions, pre-structured questions such as, is it due to cost? Is it due to side effects? Is it due to the fact that it's not working? And allow us to be able to then act on that. So that level of personalization occurs only when we have multiple data streams coming in, interoperability is huge for that. Then a decision support or some kind of a mechanism for it to be presented back to the individual or the people serving that individual. That's great. I know interoperability is certainly a big opportunity as we shift more and more to virtual care. We have a number of questions on artificial intelligence and Vivian, I wanted to see if you might comment on some of the examples that you've seen in your work with the World Economic Forum and KP International about AI use globally. And if you have some best practices that you know of. Great, there's a lot going on and there are many actually innovative examples of the use of AI across the world. I probably maybe call up into just two areas. Of course, one can see the benefits of the use of AI in various different vaccine development trials that are going on and that shortening of the timeline that it takes for vaccine development has been greatly enabled by data and analytics. And there are many great examples of that around the world. Maybe the other one to call out and it both highlights the ability and the power and the potential of public and private partnerships in the country of South Korea, which has been a very good example of a country that has been able to manage and contain COVID, the pandemic. They actually had a partnership between the South Korea CDC and a commercial testing company. Again, using AI algorithms, they were able to develop and scale their COVID testing kits within three weeks. So they were able to deliver a mass amount of test kits within three weeks, which would have actually taken three months of development time when I've been talking to the analytics team over there. So again, the power of data and analytics in action. That's great. We've had several questions and Vivian, if you wanna start this off and we can have others chime in as well about how do you really ensure that artificial intelligence and machine learning really accounts for different cultural language differences and it's not increasing the bias that might already exist? Yeah. I mean, like how long do we have? We can start for hours about bias in AI. Maybe let me just talk more generally about bias, both in data and analytics and then link it back to social culture and language. So clearly the first way to combat bias is the data itself. Are we collecting the most comprehensive, representative data that doesn't have biases in it? And are we collecting it from different people, different channels, different modalities and different kinds of data? In the actual model building as well, there are techniques to actually reduce bias that's even how you think about what data to train your model on and what data to validate your model. There are techniques being able to maybe use high probability constraints, especially if you're using sort of self-reinforced learning algorithms, right? The third way to combat bias is true. They talk about AI being a black box. Let's make it a light box. Let's shine a light on the AI. Let's shine a light on, let's explain, try to explain the model and let's try to explain the model using, bouncing it up against real-world and real-time outcomes to check for the equity of outcomes and equity of opportunities. Finally, I think people talk so much about AI as this machine. It's as much about the people and the talent and the teams working on data and analytics and diversity of thought around data teams. This is critically important. I have a good friend who's the Uber analytics officer and she told me she was going to hire last year a female data analytics team and people potentially without sort of a background that she was going to train. She hired somebody who was an acrobat from Cirque du Soleil and this lady happens to turn up to be one of her staff and AI data scientists on a team. Who figured? So acrobatics probably can translate in different domains and injecting that diversity of teams is so important. I could add to Vivian. So when we look at online personalization or ability to have applied AI in influencing the personalization and personalized experiences, we have to watch out for unconscious bias, ability to actually have these neural models to be impactful. And in fact, Dr. Marsh and I and Dr. Lee, they've partnered with neuroscientists actually who are looking at the models to make sure that we are thinking holistically, not just one angle or the other, but really thinking holistically. So there's a lot to be done in this space and explainable AI is one of the key aspects to this. But I think to Vivian's point, it's everything that we do, this has to be one of the first and foremost thoughts. I think that'll help us shape through in many ways. That's great. So we'll shift back to a slightly different topic. We have a couple of questions about how does virtual care reach into other care settings? So one example is nursing homes, acute care, skilled nursing. And another question was related to employer-based clinics and how my virtual care reached those different venues of care. Pratt, do you wanna talk a little bit about anything that we're doing in those areas? I don't know, Dr. Monsch started something, Dr. Monsch. Well, I think it's important for us to look at the whole continuum of care for opportunities in this space. Admittedly, we've been disproportionately focused on ambulatory space, but we're also looking at hospital, we're looking at the continuum, we're looking at SNFs. We need to meet the patient wherever they are and they could be any place in that continuum of care. And so we're looking at all of those various touch points where the member could be at any one given moment to try to meet them where they are. We're not limiting that to just ambulatory by any means. Yeah, I also wanna add to that. I think that, again, one other paradigm shift is we think of virtual care as patient-doctor. That's sort of a default assumption. But in many cases, this is a clinician-to-clinician or a clinician-to-caregiver or multidisciplinary team. And when you think about, especially in nursing homes, skilled nursing facilities, it is a team approach. There are multiple different folks looking at everything from the medical, social, the emotional elements, and how do you address all of those things as a team? And that's where I think the virtual care actually probably has to be in-person because we tend to be a little bit more one-on-one with in-person. We're starting to recognize that there's great value in terms of having team collaboration, being able to share and see the same type of information, be able to then just have an open discussion with the family members, and then also empower other individuals. Because the people at the end of the day who are gonna be taking care of that individual will be the nurse, the caregiver, the individual who's basically staying their bedside. And in order for us to do that, we have to include them as part of the conversation. And we're also seeing, I think it's interesting to see the impact it's had on behavioral health, which is an area that virtual has flipped more and more people getting services, reducing stigma. And I think in the past, we had a lot of challenges with people not showing up for appointments and that changing. So it's been interesting to see where virtual's even, it's improved the care quality for people and their experiences. Great, well, thank you all for answering these questions. And we did not get to all of the questions, but we will be following up because there's still a lot of good conversation going on in the Q&A. So with that, I'll turn it over to Nico to wrap up the session. Great, thank you, Karen. It's been a great session and I just wanna say thank you all for coming and we really hope you enjoyed this digital experience. I'd also like to thank my co-host, Vivian Tan, as well as Jane Metcalf and you, Karen, for moderating. And of course, our speakers, Vinu Alak, Prat, Vimana, Dr. Marsh and David Rue from Microsoft. This has been an exciting dialogue and I hope you all enjoyed the time. Lastly, I'd like to acknowledge the team behind us. It takes a lot to put on these events and so there's left field labs who built this platform for us. There's Dialogue who actually creates the content and designs these conversations. And of course my team, Strategic Partnerships. With that, I'd like to end and ask you all to stay here and enjoy the chat feature. Please engage with each other. We don't get enough chances to network these days. I know there's a lot of Zoom, but this is a different way to interact. Please stay and talk to each other and look for our next event on the future of home care. Thank you.


Half of the world's population is still not connected to the internet, that's 3.7 billion people. The digital divide is now a global crisis and we must address this inequality urgently. Connecting the unconnected is a key priority for the UN Broadband Commission. The problem is that it's just not commercially viable to roll out mobile or fixed networks in many rural and hard to reach areas in Africa, parts of Asia, the Pacific Islands and South America and it's going to be expensive. We're talking about hundreds of billions of dollars if not a trillion dollars in total. Solving this serious problem means that there can be no sacred cows. We need to find new funding models that oblige businesses that benefit from using these networks to contribute towards the cost of the network rollouts in these regions. The over the top service providers or OTTs make hundreds of billions of dollars in revenue and contribute little or nothing to the cost of building these new networks. New taxes and revenue shares on OTTs are part of the solution and new regulations must permit revenue share and incentivize contributions from OTTs to fund this much needed infrastructure. Some innovative thinking is needed but it definitely can be done. If we're really serious about a global and inclusive digital economy reaching these 3.7 billion new subscribers and customers then OTTs need to play and pay their part. Thank you.