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The Voice of Healthcare - Episode 1

Co-hosts: Dr. Matt Cybulsky (Principal, Ionia) and Bradley Metrock (CEO, Score Publishing)

Duration: 27 minutes, 32 seconds

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Bradley Metrock: [00:00:01] Hi, and welcome to the first-ever episode of The Voice of Healthcare, a new show on the podcast network VoiceFirst.FM. My name is Bradley Metrock. I'm CEO of Score Publishing, a company based in Nashville, Tennessee, whose mission is to help people become better interactive content creators.


Bradley Metrock: [00:00:20] Our sponsors for this show are the Alexa Conference, which is a conference we run, which is the annual gathering of Alexa developers and enthusiasts from across the country and the world. It's coming up in January in Chattanooga, and the keynote speaker for that is Dr. Ahmed Bouzid, the original head of product for Alexa and connected homes for Amazon.


Bradley Metrock: [00:00:44] And our other sponsor for this episode is Fourthcast. F O U R T H C A S T dot com. It's a software as a service on the internet that will turn your podcast into an Alexa skill - check it out at


Bradley Metrock: [00:01:02] This show will be every month for about half an hour to an hour and will involve different guests. But for today, it'll be me interviewing my co-host, my friend of many years, Dr. Matt Cybulsky. Matt, say hello.


Dr. Matt Cybulsky: [00:01:16] Hey Bradley. Hello everyone out there.


Bradley Metrock: [00:01:19] Thanks for joining us Matt. The purpose of this show will be to examine the growing intersection between voice-first technology and the healthcare industry. And so let's start out with Matt talk to us a little bit about your background and how you sort of got to this point in terms of your education and your experience.


Dr. Matt Cybulsky: [00:01:46] Sure Bradley. I think like most people where you end up tends to sometimes be a combination of luck, exposure, and effort, and will. I certainly didn't come across using voice technology in healthcare as something that I wanted to do a decade ago. I came across mostly voice-first because from training I'm a behavioral economist, so I'm very much interested in behaviorally-informed approaches to solutions and healthcare, opposed to spreadsheet driven, reviewed approaches to problem solving.


Dr. Matt Cybulsky: [00:02:33] I think that when it comes to getting people to modify behaviors having physicians and surgeons, providers, nurses, whoever, interact more fluidly with tools and technology that's growing at a logarithmic pace in health care. We've got to have a way to do it that's hands free where the data transfer is lossless and more contextually personalized for humans. As a psychologist, I've been working in quality and safety for some time now - my career and health care started out largely in health care finance. I moved to get some deeper training in behavioral economics simply because I realized people had a hard time understanding their bills, their invoices, and their insurance reimbursement. So I was lucky enough to be part of an organization - Tenet Healthcare - who had some forward-thinking executives, and upon a conversation with one of them, Steve Mooney of Conifer Health Solutions, and Norma Zarang of Conifer Health Solutions - they encouraged me and supported me in the pursuit of getting a Ph.D., all in the name of modifying invoices, studying consumer behavior, in order that we'd get them into a situation where they are not as likely to go bankrupt or turn their accounts into bad debt, really hurting their credit score and their ability to get loans, pay off debt, and be healthy. We had some great success together.


Dr. Matt Cybulsky: [00:04:07] This turned out to be a way for me to become a professor at a medical school where I was working closely with surgeons and practitioners at UAB School of Medicine on improving quality and safety using mostly spreadsheet-driven condition-specific protocol to reduce things like length of stay, readmissions, utilizing supplies properly, and reducing error. I knew as a psychologist that there was a lot of benefit from us looking at the same problems of remission reduction, quality length of stay error, utilizing behaviorally-informed approaches. But I didn't know until recently that the growth of these voice-first tools would be such rapid advances and ease of use that we could start deploying them in health care. And it wasn't until the last year and a half that I got very serious about how we could use something like Alexa, for example, to interact with both providers and patients to make the care that they deliver, or the care that they receive, more accessible, more transparent, extended their reach, and provide the financial stability that I was looking to help patients and providers with years ago, and do it in such a vivid and unique manner. So, yeah, long story short, I ended up being involved with Alexa and voice-first technology, one because I wanted to make a difference, but two was largely accidental, and being in the right place at the right time.


Bradley Metrock: [00:05:56] Well you did a great job at the first-ever Alexa Conference that was this past January in Nashville. And we appreciate you joining us for that.


Dr. Matt Cybulsky: [00:06:07] It was a total pleasure, by the way. I won't miss it again for the following year.


Bradley Metrock: [00:06:12] It was very insightful and it will be great to have you back. Share with us about the last week and a half for you, and share with the audience what you spent your time doing presenting to folks who run the Alexa Fund, and what the Alexa Fund is, and why you were doing that at Carnegie Mellon.


Dr. Matt Cybulsky: [00:06:35] Yeah. Well, first of all, thanks for the kudos from last year. I was luckily invited to come speak about what these voice-first technologies could offer medicine and how it could be changed. There are some amazing things going on across the country with voice-first. One of my favorite examples is Boston Children's Hospital uses the Alexa tool for children in the burn and ICU units, and they use it for entertainment, to change channels or, you know, what is this disease I have? How do I take care of myself? What are the medications I take, and when do I take them? And importantly, communication with staff. In the burn unit, especially, having something like Alexa is wildly, wildly important. It reduces the risk of infection because there's less people that need to interact physically with the patient. But importantly, and also tragically, when these patients, these pediatric burn patients, are in the unit, a lot of times they can't move, or they're instructed not to, or they're in a lot of pain. But they can use their voice. And so if you can use your voice, and you have Alexa, or a Dot or an Echo Show, the world is yours, as long as it's connected appropriately. They've had some really interesting success there. But back to the topic at hand. I wouldn't miss this upcoming conference, also, Bradley, because I've been named the lead of the health care section, and I'm really happy to do that, and I'm very excited about the speakers we have, as well as the presentations and the networking that's going to be available there. Last year you could really feel the spark and the spirit in that place. So I'm honored to be leading it on the health care side for the following year of course with the guidance from Score Publishing.


Dr. Matt Cybulsky: [00:08:30] But secondly, your other question: why CMU and what the heck am I doing there? Well I've been really fortunate to have great mentors along the way. I have part of my personality is really extroverted if you know me. I don't really meet strangers and I also get very very energized by being around people.


Dr. Matt Cybulsky: [00:08:54] So any time I see someone doing something interesting or that has some dynamism or charismatic qualities, I want to know who they are and I want to befriend them. They're fascinating to me. The human creature is fascinating to me. But leaders and mentors are really fascinating to me. I've had some good ones over the years. Luckily for me I've got two really good leaders right now that I'm working with. At CMU, there was a fellow named Joe Marks who leads their innovation center or one of their innovation centers. He's a very dynamic fellow. He's been involved quite a bit with lots of work in the healthcare space over the years. He works closely with another behavioral economist. And Joe has been really instrumental in opening my eyes to the entrepreneurial world.


Dr. Matt Cybulsky: [00:09:45] As such, I've been working closely with a CEO at Signature Healthcare in the Boston area - Signature Healthcare system.


Dr. Matt Cybulsky: [00:09:54] Kim Holland, who is a well-known CEO and leader in the American College of Healthcare Executives, and very encouraging of our collaboration together as a behavioral economist - we partnered together to cover various vectors in this hospital.


Dr. Matt Cybulsky: [00:10:09] The reason that I bring up Joe and Kim is because they both have been really encouraging about using voice-first technology in the handling of population health, and optimizing care, given the need to do so with a minimal amount of providers and a shrinking amount of providers in comparison to the demands of the modern health care consumer. Kim has been open to me using Alexa technology to reduce readmissions and we're really starting in the space with chronic obstructive pulmonary disease otherwise known as COPD. The primary cause of which is smoking. And for people over the age of 65, or approaching 60 years old, is a massive problem. It's a $50 billion dollar cost to the United States health care system a year. Twenty four million people in the United States are purported to have this disease. Only about half of them have been diagnosed. So symptoms over time will exacerbate to about 24 million. It's about $11000 per re-admission for COPD. That's about one hundred eighteen percent more expensive.


Bradley Metrock: [00:11:27] And so when you say a re-admission that's someone who's been treated and the treatment didn't work, and so now they're back within what a 30 day time horizon?


Dr. Matt Cybulsky: [00:11:40] Yeah. Essentially what's happened is they've been discharged for a disease - in this case it's COPD - and within 30 days they end up back in the hospital because whatever treatment they've been doing either wasn't appropriate for their needs, wasn't compliant for their needs, or some other reason that we look at as a failure of modern medicine. So yes, that's $11000 average, but the median is probably higher than that. What you're looking at is on top of those readmission numbers, Bradley, the federal government - for certain levels of readmissions percentages - so I think the national average for COPD is something like 17 percent re-admission which is pretty high. If you don't get it below 11 or 10 percent, I think by the next year, CMS is going to reduce the reimbursement from Medicare to your particular system or health entity. There is a lot of complicated math and also algorithms involved in how they calculate that. The big story here is that the more people come into the hospital after a discharge for a chronic condition like COPD, the more risk to them and their health primarily, but secondarily, the larger risk to your health system and its financial stability because the federal government will reimburse you less because they're penalizing you for not offering the right care the first time.


Dr. Matt Cybulsky: [00:13:12] Back to CMU: basically with Kim Holland and Joe Marks, through their stewardship and through my interest in voice-first technology and what I think Alexa is bringing to the digital experience and the health care experience, have developed with a partner of mine out of L.A. who I'll leave unnamed - she is working with another entity at the moment - a tool where we can send patients home on discharge with an Echo Dot and they have some customizations connected to their phone. They, like the pediatric patients in the burn unit, at home have access to instructionals about COPD - what is it? How do I take my meds, and when do I take them?


Dr. Matt Cybulsky: [00:13:57] We've also added prompts to nudge them into making sure they're taking their meds appropriately, as well as tracking health data, prompting them to respond to the Echo and Alexa by telling Alexa how they feel. They give three levels: green being "I feel fine." Yellow, "I'm having some trouble here and I need some help." And red which is "911, Alexa, stop" which is 911 and emergency services. The purpose of all of those being the patient themselves, when they're reporting, can get the help they need through the Echo Dot. Now that it allows phone calls, can be connected to a nurse or provider which can instruct them to take meds that they need, and on an emergency basis, clean equipment if it's necessary, or maybe they have something set up wrong. Alexa has protocols in cascades of questions that we programmed into it in order to reduce the amount of time a patient might spend in seeking care at the E.R. or God forbid having a readmission. More importantly than that, as a behavioral economist, you can take all those things together and we can also drive incentives for this daily use.


Dr. Matt Cybulsky: [00:15:16] We can rank them amongst other people that had COPD. We can compare them to others by incentivizing good habits they have and showing them a percentage or telling them their percentage of odds that they have of not going back to the hospital or that they're being rewarded for taking care of themselves well. We could also inform them if they're not responding to the Alexa or they're not or they're responding that they're not compliant with medications is appropriate that they can do a better job and if they don't they risk going back to a hospital or something worse.


Bradley Metrock: [00:15:48] So you've got a plan that you put together that you pitched to the Alexa Fund people with Amazon, that they can get involved with it, and you were part of their Pitch Day.


Dr. Matt Cybulsky: [00:16:00] That's right. I'm sorry. Yes. So I was invited by Joe Marks after this creation, at Kim Holland's health system, to present what were going to be providing the patients. And Amazon was very interested in hearing from us.


Bradley Metrock: [00:16:17] Yeah, I bet they were! So on the first show that we launched on VoiceFirst.FM, which is simply called the Alexa Podcast.


Dr. Matt Cybulsky: [00:16:25] Yeah, I listened to that. It was great.


Dr. Matt Cybulsky: [00:16:27] Well I appreciate that. So we talked about on that show some other news that's come out in the last week or so about Amazon's Echo Show and Echo Look and I specifically want to ask you about the Echo Look first and get your opinion on this. So the Echo Look, if you haven't heard of it or know what it is, is a combination of the Alexa technology - the microphone and the voice interaction - with a camera and the way it is presented by Amazon to the marketplace is that this is going to be a device that you put in your bedroom or near your bedroom that helps with your fashion sense so it helps you select better looking clothes and...


Dr. Matt Cybulsky: [00:17:13] I need all the help I can get, Bradley.


Bradley Metrock: [00:17:15] Well yeah. I think we all do. But it's designed you know at least it appears to be marketed primarily more toward women at least at first. And what I find interesting about it...and on The Alexa Podcast, I was recounting that my wife saw an advertisement on for the Echo Look and was asking me "what is this?" And she thought it was very interesting, and her only concern about it was does it actually work. She didn't voice any privacy concerns about having a camera in the bedroom or the closet.


Dr. Matt Cybulsky: [00:17:48] Privacy's a whole other show we should do. But I will contend that most of the country's sense of privacy is definitely out the window so that doesn't surprise me she was not concerned about it.


Bradley Metrock: [00:17:59] Yeah. Well I think you're right, it's a commentary unto itself and I'm sure every pisode of this show will probably cover privacy to some degree. But I wanted to ask you know to me this device - the Echo Look - has a lot of potential health care implications because it's taken a minimum it knows what you look like. And so that's healthcare data by itself. But tell me about what you think about how that strikes you and sort of where you see all this stuff going.


Dr. Matt Cybulsky: [00:18:35] Well there's, you know, the Echo Look is a fascinating tool that and Amazon hae come out with. At the CMU conference at Carnegie Mellon, I was listening to a presentation in which they were using Alexa with a special kind of Spectro chrome...chromatography I guess is what it's called...?


Dr. Matt Cybulsky: [00:19:19] So there was a special kind of camera, let's just say that, on the Alexa that would be able to look upon all kinds of equipment and measure the vibration of it. And by measuring the micro vibrations in it what they're able to do is they can inform you what's running in the house - the fridge, the sink disposal, the dishwasher, the clothes washer, all the vibrations. What's even more interesting, and with tools like Echo Look at this other tool that was presented at Carnegie Mellon, if you have a patient who is not feeling well their color, the temperature that they have coming off of their skin...even their breathing rate can be measured using that tool, which sends all kinds of really important data back to health care professionals. Now if that can be integrated properly into an EMR, and even more importantly, if you can take this out of the AWS Lambda tool and connect it with other vectors that are important for someone's health who has COPD or diabetes or CHF - even for swelling with CHF, for example - there can be alerts. There can be alerts that either are automatic, or are from an actual person. This is a profound change in how health care can be delivered on a day to day basis.


Dr. Matt Cybulsky: [00:20:38] I mean think about it. If you and I just go to the doctor twice a year four times a year we're missing about 5000 hours of waking time I'm not being catered to by a physician. Now reduce the amount of physicians that are available in the world, and give yourself a chronic condition, and that ratio gets even worse. So having tools like this with Alexa to me is the harbinger of change. You know you're looking basically at a future where there are less big box hospitals. But there are big box areas with floors full of practitioners who are monitoring or speaking with patients in their homes or through their phones using Alexa-type products dealing with their day to day and preventing any sort of catastrophic event.


Bradley Metrock: [00:21:24] Cool.


Dr. Matt Cybulsky: [00:21:26] I didn't realize the Echo Look was already out of the market.


Bradley Metrock: [00:21:30] Oh I don't know if it's out on the market. I just know it was being advertised. I'm not sure when...I think what it is is that it's invitation only. So I think Amazon is giving it to just a select few people, if I remember right.


Bradley Metrock: [00:21:45] Let me ask you about Ionia - share with us what Ionia is, and what you're doing with it.


Dr. Matt Cybulsky: [00:21:53] Well, Ionia is my consulting firm but it's also a product firm. So basically what we strive to do is make things...make changes in healthcare delivery that matter, using behaviorally-informed approaches instead of only spreadsheet-driven approaches. I've had some work in my past where it was a spreadsheet, and we were just going to cut our way to prosperity. You know we're going to get rid of overhead, we're going to get rid of the expensive supplies, we're only going to allow orthopedic surgeons to use certain implants for knees and hips, and we're only going to go with certain drugs for anathesia, et cetera.


Dr. Matt Cybulsky: [00:22:33] That isn't sustainable over a long time. And I realize that, working in health care. And as a behavioral economist, I wanted to create something that got beyond saving money, that got beyond cutting physical costs, and really promoted social engagement as the blockbuster drug of the century. And so I started Ionia and I started with one client and I never realized that I would take off the way I did. But I've been very fortunate to do so.


Dr. Matt Cybulsky: [00:23:01] I have three clients now one in the Bay Area one in Boston and one in Nashville - might be adding another one in North Alabama soon. So our first goal together with Ionia is to engage with clients in order to create delivery protocols that really work closely with how we know the human body, the human mind, and human emotions optimize for best outcomes period. And that does mean combining talent and combining effort with folks that do work on cutting costs and looking at metrics and spreadsheet-driven ideas. But what we're really after is a change in the delivery model to promote social engagement - to look at behavioral economic methodologies like comparisons and rankings in frequency and Prospect Theory - in getting people to be influenced to take care of themselves and habituate change for better, whether it's a provider or a patient. That's our first goal. Our second goal is to create software products that are our own, that we can sell a subscription to really help reduce readmissions, length of stay, make the ease of use in the OR more apparent, or any other tool that we can provide on a mass basis to health care from an insurance perspective or a healthcare delivery perspective.


Dr. Matt Cybulsky: [00:24:22] Our COPD tool involves that with Alexa. Our third vector is having health systems, insurers, or other healthcare entities come to us and say look we have a problem but we'd like to solve it with less people because we just don't have them. Can you help us create something using Alexa or other tools and behavioral economics to effect change on a large scale system, given the problem we brought to you? So it's really kind of a customized solution vector that we're offering - all three together. We all hope that we can effect a lot of change to a lot of people in simple but vivid and unique ways, allowing the patient and the provider to connect and engage in ways we never had the capability to do before.


Bradley Metrock: [00:25:12] Awesome. So thank you for sharing all of that. And thank you for sharing all of your experience and your perspective over this show and I'm going to wrap this up by saying every month the two of us will host this show. We will have on all sorts of guests in the health care sector. A lot of this show focused on Alexa, sort of out of necessity, you know - it's got such a clear market leader position. But you know as Google catches up and starts to do some unique things, and as Apple rolls something out over the summer, you know we'll incorporate that.


Dr. Matt Cybulsky: [00:25:53] I'm really excited about all these major players delivering their voice-first technologies, and seeing who's going to win that game. And I bet you, Bradley, some people are going to be better at certain facets than others. And I really look forward to talking to these experts as changes come out with you and vetting these for the general public to discuss.


Bradley Metrock: [00:26:14] Yeah absolutely and competition in the space will be good and it'll be great to have Amazon and Apple and Microsoft and Google and any number of small to medium sized companies are competing to create compelling voice-first products and services. All of it, as it comes out, will be evaluated here as it pertains to health care. And we're excited to have the show as part of VoiceFirst.FM.


Dr. Matt Cybulsky: [00:26:40] Yeah, Bradley, we're going to learn a lot. I think we're going to be blown away a lot too, and I'm happy to do it along with you.


Bradley Metrock: [00:26:46] Yeah I'm not part of the industry - I'm just sort of here - and I'm here to ask the dumb questions that nobody else will ask, and I'm totally comfortable with that.


Bradley Metrock: [00:26:56] But Matt, thank you for sharing your time with us. And until next time... 

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