Vermont Legislature SmartTranscripts:

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: It's just me.

[Alyssa Black (Chair)]: Hi, welcome back. So we are pivoting to H84. If the committee members that were here year recall, we did a walkthrough of this bill last year. We took a little bit of testimony on it. Then throughout the session, things got other things came up. But I'd like us to look at this again. So we've got Jen to do a refresher walk through on this.

[Jen Carvey, Office of Legislative Counsel]: Good afternoon. Jen Carvey from the Office of Legislative Council. We're gonna look at h 84. I'm trying to put up on the screen right

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: now.

[Jen Carvey, Office of Legislative Counsel]: Right. It's a short bill. It's two pages, but one page is just the cosponsors and the statement of purpose. So this is kinda summed up in the title, an act relating to allowing telehealth appointments to be recorded with patient and provider consent. And you can see there's two fairly similar sections. Sections one and two are amending existing statutes relating to the provision of health care services through telemedicine or by store and forward means. That's the first section, and by audio only telephone, that's the second section. And in both cases in existing law, there is a prohibition. It said under current law, the not underlined part says neither a healthcare provider nor a patient shall create or cause to be created a recording of a provider's either telemedicine or telephone consultation with a patient. And then this would add language in both to say unless both the patient and the provider consent to the recording. So currently there is a prohibition on anyone recording a telemedicine or audio only telephone appointment. If this language were to go into effect, then recording would be allowed as long as both the patient and the provider get their consent. Take it back down, Pesc.

[Alyssa Black (Chair)]: Shortest walkthrough in the history of walkthroughs.

[Leslie Goldman (Member)]: I know, but

[Jen Carvey, Office of Legislative Counsel]: I would put it down for five minutes.

[Alyssa Black (Chair)]: Okay. Can you refresh us of what kind of the definition of telehealth is, store and forward is, and audio only?

[Jen Carvey, Office of Legislative Counsel]: Yes, so I may pull some of these up, but under existing law, telemedicine is the it was harder to explain before we did start doing things remotely, but basically, like the Zoom. So the the remote audio video connected consultation between a patient and provider. So you can see and hear, but you're not in the same physical location, video and the patient can be anywhere. When we first started out, they had to be in a health care facility, and it's been amended many times over the years to say patient can be anywhere. So that's telemedicine. So that's real time audio video. Store and forward is when information is captured in some form and provided to given to a provider to review at a different point in time without the patient present, and there's no audio or video connection or or interaction required. And that's not affected by this recording piece. It's sort of arguably part of it anyway for store and board. And then audio only telephone is what it sounds like. It's a just a phone call. So just audio, not audio and video.

[Alyssa Black (Chair)]: Should've asked Sebastian to bring his whiteboard back then. That was his I just remember he had a telephone with, like, the curly little cord on it. Any questions for Jen?

[Brian Cina (Member)]: Statute's not up there, but it says that this would be adding a phrase allowing for a recording to be made with consent, but I don't see any further language about the use of the recording. So that means if we pass this bill without any guardrails, the recording could be used, the data collected in that recording could be used in any way. Well, mean, from the provider side in any way

[Jen Carvey, Office of Legislative Counsel]: that complies with HIPAA, they still have requirements around confidentiality.

[Brian Cina (Member)]: And so questions I have that we may not be able to answer today, but we might want to get answered before we vote on the bill, are around how data in these recordings are going to be used by artificial intelligence systems and the companies that make them once consent is given, and how much information are both provider and patient going to have about how that recording is used once it's taken and so without going down the matrix rabbit hole too much here with this stuff. The intent might be to screen the recording and pick out clinically relevant information and then use a generative AI or whatever text to whatever it's called, I may be using the wrong term, to create some kind of textual representation of conversation that a human reviews and says, yes, or let me correct this thing it got wrong, and that's now the note. But are we also letting these companies take our voice and use data from our voice to analyze emotion that they are then integrating into other products? Are we allowing them to track us as individuals in a way separate from that medical record? Because that stuff, is that covered by HIPAA? Is that covered by high-tech? Is it covered by the new law, which name I can't remember that came out because there's a new one, a new federal law regarding AI and healthcare. It was in training I did recently for UB Medical Center. It has to do with, it's the law that says that a patient portal, your medical record needs to be instantly available to you now. I don't know, we can look into this. The point is that it's a simple phrase. It may seem like it's harmless, but if we don't look at how the recording is used, then it could cause unintended harm down the road because of the lack of regulation of artificial intelligence systems and how they might circumvent law because they are evolving so quickly. Anyway, I'll stop there.

[Jen Carvey, Office of Legislative Counsel]: Yes, to be clear, this was the request from the original sponsor. This is the bill as introduced was simply to allow patients and providers to consent. This is not can't doesn't

[Brian Cina (Member)]: No, I guess what I'm saying is I was clarifying that indeed, this does not have guardrails around all that stuff.

[Jen Carvey, Office of Legislative Counsel]: No, to the extent that existing state and federal laws apply, no, this does not create guardrails around what is done with that regard. That's all. Leslie, not to like it.

[Leslie Goldman (Member)]: So I don't think this was a question for Jen necessarily, but I'm curious to know why the sponsor sometimes we have sponsors come in and say why they wanted a bill. Like, I'm not sure what bill is solved, what problem this bill is solving. Wow! Thank you for teeing up our next witness.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Okay, great. Thank you.

[Alyssa Black (Chair)]: Any other questions for Jen on the brevity of the language?

[Jen Carvey, Office of Legislative Counsel]: All so

[Alyssa Black (Chair)]: Justin, want to come on up? I just want to Okay. I'll level set here. We took this up last year for all of about two hours. And frankly, I'm still traumatized by I asked Justin to come in because I think that we need to level set with the committee things around what is your medical record, what goes into your medical record, How is your medical record developed? What happens to it once it's out there? And this bill was brought forward because it's funny to hear Jen talk about store and forward and all, because that was such a foreign concept five years ago. And now I think we all realize how integral it has become in our healthcare system. And in fact, having to do with affordability and access and how it's been able to help us with that. So I asked him to come in and share with us why this bill is necessary and what's going on now and how all of this works. How is this work? What is an EMR?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Well, thank you for having me first. So I'm Justin Smith Donnelly. I am a physician. I work for UVM Health in the capacity of the Chief Health Information Officer. So in that capacity, I oversee IT team that support our overall clinical and revenue cycle suite of IT applications. I have been a physician in Vermont since 2010. I was trained at what was Walter Allen at the time, so at UVM in internal medicine. I then went from that training to Central Vermont Medical Center, where I began my attending practice in adult hospital medicine and continue in that practice at CVMC to this day. Along the way, I started to get interested and did work kind of in the intersection of care delivery, how we provide healthcare, and honestly, technology. And it's been a really fascinating and exciting fifteen years in that space. And I think I'm sure this committee can appreciate how that space is only accelerating at this point, as we have a whole suite of different tools that we, in my opinion, have a very important role, that this group has an important role. Me and my teams and health care systems have an important role to really understand how we leverage these to impact the health care and our ability to deliver health care in an affordable way to our friends and neighbors. So that is my driving force behind this, is that I truly believe that when appropriately deployed, technology can be a net positive impact on the ultimate health outcomes of the people that we serve. I'm board certified in internal medicine and also a board certification in what's called clinical informatics, which is a fairly new discipline, which is really focused on that intersection. Because you can't solve any problem with only technology. And a lot of times, people need technology in order to solve problems. So the intersection between those two groups is critically important, and how you actually implement and deploy these sets of solutions really matters to the outcomes that you will achieve. So it's from within that framework that I'm just approaching, and I'm happy to answer questions along the way. What I was hoping to do with the committee today is to walk you through a set of about 11 slides, just to share a story that we have had specifically related to a technology called ambient technology, which the member had already kind of referenced a little bit about creating notes after reporting from voice. And so this is a technology that we're utilizing today. I'd like to share the impact that that technology has had predominantly on our provider population, but also on patients. And then we can actually do a quick demo. I would open it up to members of the committee. If you would like to be my patient, we can do a very simple visit where I will interview you, we'll record, and we'll show you how it appears. So if anybody is willing for that, that's fine. And that'll take about five minutes. And then with the remaining time, I didn't come with slides to answer the question of what is an EMR specifically. That is a very, very broad topic. But I am eager to hear your thoughts on what would be helpful or any questions that I may be able to answer or, in the future bring additional subject matter experts that could answer them for you. Okay.

[Alyssa Black (Chair)]: Sound good? Sounds great.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: All right. So let me get to Zoom. Okay, next steps. So I did my introduction. So what is Ambient? And you're going hear a couple of different words here, but I tend to reference this suite of technologies as Ambient. You might also hear the word a bridge. A bridge is the vendor that we have contracted with to deploy Ambient technology. So Ambient, I view as the overall framework for this type of technology. And then a bridge is a specific, one of many, actually, companies that deploys this technology to health care systems. So at its core, this technology does use artificial intelligence that uses large language models specifically that are trained and have engineered prompts to generate a clinical note based on audio input. So that at the core is what we're talking about right now. Sure. So a large language model is something akin to what you might know as ChatGPT or Google Gemini. Yeah, so I'm going to Thank you. So this solution set provided within these tools is not static. So each company continues to evolve their product to try to solve problems that providers experience in their day to day lives when it has to do with documentation burden and what I would call the friction of practicing in today's electronic world. And so I have no doubt that this will continue to evolve over time. And excitingly, additional features will become available to our practicing providers. And the whole goal is to reduce the documentation burden that they experience. This can be things like the different type of specialties that are supported specifically within the application, different languages. So they have more than 20, up to 30 different languages that they're able to handle now, leveraging technology. Visit types, so we talk a little bit about telephone visits or maybe well child visits or different specific visit types that they're able to support. Personalization of documentation templates so your documentation looks and feels the way that you want it to look and feel actually queuing up orders for review. So instead of me having to go back and change my focus from the patient that is in front of me in an exam room or in a hospital bed, I'm able to speak that out loud. And then it will actually queue it up for me to go and review. And then I ultimately will sign it. Then finally, there are coding recommendations that it will make as part of this overall suite of technologies. So at a really high level, the workflow is fairly simple. You'll see this here in a moment when we do the demo. But the first step is to obtain permission. So many things that we do in medicine, obtain permission for today. We obtain permission to do a physical exam. We have the conversation to share our clinical knowledge and assessment and plan with you. So that's how it starts, and I'll show this here. Then you basically put the secure device down, and you have a conversation. You just conduct the interview and exam, probably like most people have experienced when you go see your primary care physician or advanced practice provider. And you just have that conversation. When that conversation is done, or when the visit is concluded, you basically end the recording and you push a button on the app, and it sends it to be processed. The processing takes, on average, about thirty seconds or so, sometimes faster, sometimes a little slower if it's a really, really long visit. But then it returns a draft of a specific clinical note that you then read through, you edit for clarity or for anything that you want to make sure is there. And then you're done, and you sign it. There's also some additional functions that are available, like patient instructions, if you were to choose to use them, where it writes out patient instructions based on the conversation that you had with the patient. And it tries to change those instructions a little bit, so they're a little less medical and a little bit more focused on patient friendly verbiage. And then finally, sign it. So that's the workflow.

[Lori Houghton (Member)]: So just a quick question. So that means that the doctor or physician, whoever, is no longer staring at their EMR screen, correct?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: You got it. So I'll get into this a little bit. But we did a pilot when we started about two years ago. And that was one of the things that we routinely got back from our patients is that they felt like for, in some cases, the first time that they had undivided of attention. And so I do hospital medicine. So I'm visiting patients when ER colleague of mine has determined that patient was to be admitted to the hospital. So it usually means something serious is going on. I can say utilizing this technology for me personally, it decreases the cognitive switching that you have to do as a physician as you're going through that. And you can really just focus on that conversation that you're having. I feel like I'm ringing around, but when you're actually interviewing a patient, it's one on one or maybe with their family. And think it's an incredible experience for the patient, but it's also a win win because it's also an incredible experience for many of our physicians and APPs. Because it takes stress down, and we'll show data to support this. In being able to just be there in the moment. And I know it's taking notes for me. And if I don't quite remember something, it's there. And it's interesting to look back over the course of the past twelve to thirteen years for me as an attending, utilizing this technology, it's very clear to me that there were things that I clearly missed. Because I'll read notes now and I'm like, they didn't really say that, right? And then I look back and I can literally listen to them. Yes, they definitely said that. I just was in that moment in time thinking about what order am I going to place or if you're always trying to stay ahead. Thinking. Yeah.

[Alyssa Black (Chair)]: Can you give us maybe just your own personal history, historical context? Let's say ten years ago. So you're a hospitalist, which means you're essentially rounding on patients that are in the inpatient setting. A sense of, let's say you spent fifteen minutes face to face with the patient, about how much time ten years ago were you spending documenting that visit and also the time between the actual face to face and when you were doing your documentation as opposed to where you are now, you feel?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah, I might go back Anecdotal. So we'd be able to go back about thirteen years. Okay, thirteen. Because I think my experience is important. So when I left residency at Ledron at the time, Medical Center, they had been live on Epic since 2009, so for about four years. So that was my I had, as a medical student, a pre Epic exposure there. And then as a residency, the only thing I really knew was EPIC as their electronic health record during the three years of my training. So I was very comfortable with that system, efficient with that system. You spent a lot of time with it. When I left Doctor. Allen and went to Central Vermont Medical Center, the systems that they had were completely different. They included paper. They included a telephone that I typed my own code into and the code for the note that I wanted to make. And I distinctly remember my neck being extremely sore that first year because it was kind of like this all the time as I was dictating. But the challenge was the way that I had been trained was different because I was very used to kind of crafting a note episodically as opposed to when you pick up a telephone. I don't know if there are others in the room that have done this, but you you kind of need to go from the start all the way to the finish. It's not something that you can kind of do part of, put it down, go do a whole bunch of other things, and then pick it back up. That's very, very inefficient. So I do retrain my brain a little bit in that new system. The other systems that I encountered, was just a completely different EMR. So CVMC used Meditech at the time. Our emergency department used ICES Pulse Check. So, a completely different system didn't talk to each other. So, when the patient moved from the emergency department into the hospital, we had to navigate both of those systems. And then we also had to literally write down the orders that I would place as the attending of record for that patient onto paper, which was experience. And then we would have pharmacists or unit secretaries who would then transcribe those orders into Meditech. And that's the way it was. And the way that I started in informatics was actually my hospitalist medical director at the time saying, Hey, we have to do this thing called CPOE, which stands for Essentially, the providers put their own orders in through computer provider order entry. There we go. And IT needed a little bit of help to design the system so that it was usable for the providers and that we would be able to continue to do the things that we needed to do. So it was a huge change as I made that. And then we, over a sequence of years, implemented a whole bunch of different solution sets within the electronic health record to help move along that continuum. So it wasn't exactly I'm going to get to the question that you asked, but that was my experience moving from Fletcher Allen, UVM Medical Center, CVMC, and then over the subsequent six, seven years, moving now back into an integrated Epic system that is basically the same between CVMC, UVM Medical Center, and Porter and our ambulatory practices. And I should have mentioned that all of the ambulatory practices, so the family medicine physicians that patients would see, cardiologists, etcetera, were on a third system, also called eClinicalWorks. So that's a third thing that you have to log into that all looks completely different and information is stored in different ways. So that was the start. As far as how much time does it take, I think for me, I don't know that the total time that you spend on an admission with a patient has dramatically changed. For me, every patient is different, but it typically takes about an hour to do a full review, see the patient, synthesize your plan, communicate with consultants if that's appropriate, and then do all of your documentation. Sometimes it takes longer, sometimes it's a little bit shorter. Just depends on the situation. But the way that I spend that time in 2026 is very different than the way that I spent that time in 2013. Because I spend a lot more I spend, I would say, about the same amount of time with the patient and their panel, But I've now shifted, so I spend more time on the chart review and putting together the patient's medical story based on the documentation that's within their chart. Today, I'd probably spend maybe a little bit more time on the orders than I would have with a piece of paper where you just check, check, check, check. But then there's a whole downstream impact of that because then there's a lot of calls back and forth and clarifying orders and that type of thing. So I don't know if it's dramatically changed, but I think that the way I spend my time is a lot better than it was in 2013. And the information becomes available to all of the care team members, and importantly, the patient, honestly, because these things become available to the patient almost instantaneously via patient portals. And that was never the case when we were on paper. Lori?

[Lori Houghton (Member)]: Do you feel that although the time you're taking is not the same, the actual time, Do you feel like you're more connected, engaged and available for the patient in the time that you have? Do you feel that your mental capacity, that doesn't sound right, but you know what I mean, like your brain space, your focus, thank you,

[Jen Carvey, Office of Legislative Counsel]: has changed at all?

[Lori Houghton (Member)]: Not that you weren't always

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah, yeah, No, no.

[Brian Cina (Member)]: That's not

[Lori Houghton (Member)]: what I'm trying to I'm trying to figure

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: out how to answer this the best way. So there are a lot of really good things about digitizing our health care records. There are things that we can do today that you cannot do when it is a huge stack of papers that literally physically travels around, following the patient from site of care to site of care. The past fifteen, twenty years, though, of that journey through really a lot of investment that was made by our country through the Meaningful Use program in digitizing patients' medical records has not been friendly to physicians and APPs and all of my colleagues. And as an informaticist who has implemented these, I significantly feel that. It is, I would say, easier to check a whole bunch of things on a piece of paper than to put orders directly into the system. So I agree that the experience of providing care in that continuum over the past fifteen years, if you're looking at the median physician or APP, has decreased. And that you may feel, and I think patients feel it as well, that their care provider is connected to this thing. Many of you may have seen it. There's a great illustration that was put into place in the American Journal of Pediatrics from a young patient who did a drawing basically of her pediatrician. And I think it's from the early 2010s. And it's literally this drawing of a pediatrician staring at a computer on a wall with her and her family off to the side. And it's really powerful because that's her impression of what that encounter was like. And so I think I want to set that stage because in the subsequent slides, I'm actually going to tell a little bit of a story on how that can change. And I am really hopeful will change if we're able to effectively adopt some of these technologies. And within set guardrails because our North Star is always making sure that they are safe, that we protect patient confidentiality and data because it is ultimately the patient's information, and they should be choosing who they share it with or who they share it with. And that we implement these things very thoughtfully across the entire care team. Leslie? Let's get to the

[Leslie Goldman (Member)]: rest of the slides. On your second slide, you talked about coding recommendations. Yes. And I've heard of whiffs about up coding and that and you may not want to answer that now necessarily, but that's sort of an issue that I've heard about.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah. So the way that the system that we use, a bridge, works is it uses very specific criteria. It's called MEAT, N E A T criteria. And it leverages some algorithms and make a recommendation that based on the criteria that's put forth through the coding recommendations, this office visit or follow-up office visit would be recommended to be a level two or a level three or a level four or a level five. So I think but it is always a recommendation. The ultimate decision is first, at least in our system, based for the provider that is seeing the patient, and they will put in a code. And then depending on the situation, there may be a professional coding review as well that goes in and determines whether or not the documentation that is supplied as part of that encounter meets the criteria for those various different levels. So it actually has the potential to improve the accuracy of the coding in totality when we're looking at the entire population.

[Leslie Goldman (Member)]: We're, of course, very worried about the costs of care in Vermont. So that's why I bring it up, how does that going to imply? But we don't have to go there. But I think it could have an impact.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah, I think our goal is to make sure that the documentation, the diagnostic coding, and any coding, whether that be professional coding for submitting a bill for the services that you provide, is as accurate as possible. Okay. Okay, thank you. So when I talk about at UVM Health, I just want to give you a really high level timeline. So we started looking at this just over two years ago. This is when this technology really took a leapfrog. A lot of the technology, when it came to scribes, was really human scribes. You either had a and maybe some of you have experienced this where the provider may have a third person in the room with them who is taking notes or typing on the computer or doing those sorts of things. That's a difficult thing to scale. It's difficult one to hire. It's difficult to afford. It's difficult to keep in some cases, because it tends to be a position that people take for maybe a year as they're preparing to go to medical school or PA school or things like that. And then they move on. So you're in this constant turnover experience. Around the 2023, the technology got to a point where we were feeling like, yeah, there's really something there. We want to look at it deeper. We did a pilot that I referenced from February to April with two different providers of this technology at that period of time. We trialed it with 50 different primary care providers, so both physicians and APPs across UVM Health Network. So it wasn't just located in Chittenden County. It was really any of our primary care practice sites, including family medicine and general material medicine. And then they utilized each system, they crossed over after thirty days. And then ultimately, our medical group governance made a decision to move forward with a bridge, which is our provider of this technology until today. We signed a contract with them. We did some research over the 2024 that I'm going to talk about in a subsequent slide, utilizing AHEC medical students, actually. So great program there, and I want to do a call out for that to really ask the question of, what is the note quality compared to a human? And we'll go there. And then we really had a sequential rollout. Because it was new, we determined that we wanted to be very purposeful in how we rolled this out. And so we went clinic by clinic by clinic, provided support, provided at the elbow training, and really tried to coach as much as we could to the providers as they adopted this. I will say two years later, the rollout strategy for this is now completely different. It is a fast rollout because we have learned that we are able to scale this very, very quickly. And then, really, about a year ago, a little under a year ago, we went live in the emergency department so that the entire emergency department clinics could leverage this technology. They've been utilizing it since then. And now we're more in a steady state where we're looking at the functions that are coming out. We're starting to ask questions around our providers that are not adopting us, and are they missing something, or are they just happy with the way that they're documenting today? So that's where we are in our rollout.

[Alyssa Black (Chair)]: Is UVM still using scribes, like human scribes?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: I know that the scribe there was a scribe program in the emergency department at UVM Medical Center, and I believe that that has stopped. There may be some pockets of scribes in the ambulatory setting. I'm thinking about ophthalmology. We can provide a follow-up on that if you'd like.

[Leslie Goldman (Member)]: I know they're doing it in

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: the ophthalmology, because I will say yes, they Okay, perfect. Yeah.

[Alyssa Black (Chair)]: Amy, we said you had to make

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: that profit. You've seen one, I recall. Right.

[Brian Cina (Member)]: When you say ambient rollout, are you referring only to the clinical voice component of ambient artificial intelligence use or are you also talking about the other components that are out there such as sensors on patients that the medical record system is documenting and the optical sensors where there's optical sensors. So if you don't know what this is, you're probably not using it yet, but there's actual cameras filming things and then the computer's tracking that. Is all that a part of this? No. So so UVM is only using the clinical voice or is this a different company than the Ambien? Because if you look up online, there's lots of articles from the Institute of Health, etcetera, the National Institute of Health about ambient intelligence, technologies, etcetera? So

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: when I in its current state today, when I talk about ambient, what I'm talking about is the recording of audio, audio only. So there's no video involved in any of this. That then is utilized to generate some amount of information that is then passed back to the provider where they edit it, and then they authenticate.

[Brian Cina (Member)]: The large language model or what you Yeah. Call And what is the company, what is the corporation or the product called?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: So the company that we have contracted with is named Abridge. Thank you, that's helpful. Abridge, they're out of Pittsburgh, that's why they're named Bridges because there's like a 100 Abridge?

[Brian Cina (Member)]: Okay, thanks. I want to keep moving. I just wanted to ask that now because you're talking about rolling out the ambient, and I was just not sure how you were defining ambient, but it sounds like we're really sticking to this one component available.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: So this is our user growth. On the left hand side, you can see this is the number of encounters that were done with this technology by month from the beginning in February '4 up until April '5. So we went up to just under 25,000 encounters per month over that time frame, sticking with our recording users. So this is the gradual ramp that I talked about. So we went up three fifty, 400 users over that time frame. Yes.

[Leslie Goldman (Member)]: How many encounters of the denominator? Total encounters that we do? You say 25,000 in April, and I'm just wondering what the denominator is.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: So I'll take it back from the exact number. We do, I believe it's about 1,200,000 ambulatory encounters per year. So 100,000 ish a month.

[Leslie Goldman (Member)]: Okay, so this is $25,000 per month. Is that what you're saying?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yes, and actually, it's gone up since then. So these are more data the way that we recorded it changed, so that's why it looks different. So you can see we hit our all time high in October. So we hit 43,000 at that point. You see a little dip, you always see this in November and December because of the Thanksgiving holiday and because of the Christmas holiday, so the number of encounters just goes down. We'll see how what January shapes up with. But now we're at this 40,000 encounter per month number. And we continue to see it has definitely leveled off because I think we have some saturation. But we have in December, it was six seventy three individual providers that had logged in and used it at least once. And what's the denominator there? That's a really good question. We have around 1,200 physicians and APPs as part of our integrated medical group. And then residents are able to utilize this technology, so you need to add another just under 300 or so to that. So the total number is around 1,500. But this is not targeted at all provider types. So there are certain provider types where it just doesn't make sense, like pathology, radiology, anesthesia. I estimate it's probably around 900 that is the total marketable

[Leslie Goldman (Member)]: So you're getting two thirds.

[Brian Cina (Member)]: Yeah. Sounds good.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah. And it's not permanent. There are some people who are very happy with the way that they die. Sure.

[Leslie Goldman (Member)]: Unless you get into your routine.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: This is a thing that is nice because each provider can choose what encounters to use it on and if they want to use it at all. So I had mentioned the AHEC report. So this is available. There's a link here if you want to click at it and look at the entire poster. So big call out to Edward, Francisco, Michel, and my colleague Alicia Jacobs, who is actually the clinical lead for this program and is one of my informaticist colleagues. But basically, what we did was we took notes from that initial pilot, and we used a standardized scoring mechanism to look at matched human made notes, the notes that were made with a bridge and the notes that were made with the other vendor that we evaluated. And they looked at various different categories that are listed here. In short, what they found is that they were non inferior. In all those categories, you put it all together, the quality of the note was about the same.

[Alyssa Black (Chair)]: This was just on the pilot, correct? And the pilot was 50 providers. Primary Was an analysis done in the pilot to Leslie's question, was there a comparison to non abridged users and level of coding? Level of coding, no.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Will say, this

[Alyssa Black (Chair)]: question, when this was up last year, the rollout of a bridge coincided with a huge claims surge, which put our only domiciled insurance company in peril, and it was based upon acuity and utilization, and that was driven by one health network.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah. I don't think this Yeah. There was a concern because we

[Alyssa Black (Chair)]: were aware that this was being rolled out.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah. I don't believe this is what's driving that. But a lot of what's driving that, to my understanding, is really around the the volume and the number of services provided as opposed to we had a large number of services that were would previously have been coded as a level three that are now a four or a five. We're not seeing that kind of change in our view that would account for that type of talking.

[Brian Cina (Member)]: Patients informed that generative AI is being used in their medical records explicitly, or do they just come in and do the visit and they're not told that they're actually being recorded in person by the because I looked ahead in your presentation just to not ask a question that you're going to answer, and you talk about you or the presentation talks about how currently the issue is that in telehealth, can't record people to use but in person, there's nothing prohibiting recording them. So they are being recorded right now.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: With consent. Yeah, but are they being told that generative AI is being used explicitly? Yeah, so we provide guidance that at the beginning of the visit, we need to get permission to do the audio recording. And I would say most of my colleagues, you get very used to that phrasing. And most will say, I use a secure, you'll see in the demo, actually. I'll share the way that I do this. And it's really so that there's a recording happening, and it's going to help me generate the clinical note so that I can focus on you during the visit. I would say most people do not go into extreme detail about AI and exactly how that works. We have done a lot of due diligence around this company and their technology generally that we are comfortable with the way that they leverage it. And for many visits, they're short. So you want to balance how much time do you spend starting this versus getting into the meat of why the patient is there to see the provider. So these are our outcomes when it comes to provider burnout and provider professional fulfillment. And so you can see at the beginning of and this is not unique. We have data that is outside of the pilot participants, but this is the most robust data I have thus far. And we're going to survey them again in a month or so to get our two year data. But you can see before entering the pilot, sixty nine percent of the fifty primary care providers reported significant signs of professional burnout. Within eight weeks, that had dropped to thirty eight percent. Within four months, it went down to twenty four percent. And then one year ago, which was just under one year ago, it did rebound a little bit, but nowhere near the pre, to thirty six percent. So in one year, we see a forty eight percent reduction in burnout rates for this particular cohort utilizing this technology. I want to express this is not repeated anywhere else in any type of burnout intervention that we are able to provide to our providers. Before this, if we got 5% delta, like small grilling, this is good, we're really making progress. This is life changing for some of our providers. These are conversations that I have with my colleagues, that they don't want to retire early anymore. They enjoy going to work. They are able to leave, go to a soccer game for their kids, engage with their spouse at home. Like, all of those kind of real life impacts, it is real. I had in this pilot group, honestly, some providers were panicked that we would take this away from them because of the impact they would have on how they practice and the overall professional quality of life that they have. So it is really fundamentally changing how they interact with their patients and how they experience delivering care. And these are frontline physicians and APPs seeing patients every single day. And the best way, in my opinion, that we can increase access is to reduce the continuous decrease in clinical FTE that our providers experience because they are burned out and they are not able to see as many patients as they want to see in a given week. They work incredibly hard. We see similar results when it comes to professional fulfillment. The Stanford professional fulfillment scoring system is a validated scoring system. We see pretty notable increases there. So in my role, and just generally, I think security and privacy of our patients' protected information is one of the most important things that we do. At UVM Health, we have a number of systems in place to guard against this. So in one case, all applications that come into our IT environment undergo a rigorous security and privacy assessment before we even engage in contracting or certainly bring that application into our environment and deploy it to our end users. Any technology which involves artificial intelligence goes through a specific council that is multidisciplinary. Am the co chair of that council. And we have an intake process for not only the vendor that is providing that technology, but importantly, also the business we call it the business owner but the accountable person within our organization that will be deploying this technology in the care of patients or on the revenue side so that we understand how they plan to monitor for the effectiveness of that technology. What is the report out period going to be? What are their measures going to be? And we ask them questions about that based on how they fill out that business owner questionnaire. So that is our AI council process. And that's been in place for just over two years now. We review all of our contracts very, very closely with an eye towards patient privacy, security, data use. And then specific to Ambient, the recordings for this and the transcripts are retained for thirty days because that provides the amount of time for providers to be able to go in and make the edits that they need and finalize them, and those are no longer available after thirty days. A subset of those this is in our contract are able to be de identified by a bridge, and they are only able to utilize those de identified recordings or transcripts for improvement of their system. So making it so that their algorithm performs at a higher level that requires less editing by our providers. So there's a small subset that they utilize for that after a fairly robust de identification process. So lots of questions to walk away, which is great.

[Alyssa Black (Chair)]: Right. Oh, go ahead, Brian.

[Brian Cina (Member)]: I looked, and I just want to confirm that because UVM Health Network, or is that still the name?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: UVM Health is now. UVM Health, sorry.

[Brian Cina (Member)]: When I first started being in the emergency room, so it should change it, so I'm going to be sensitive to the I don't want to misidentify you. UBM Health, because you are a private organization, even though you intersect with the public healthcare, you're a private organization, you're not an extension of state government, you're not required to report the use of AI on inventory, on our state inventory, and I just reviewed it, and I don't see a bridge on there. So I don't want to get into it now, because I want to do the demonstration, but I am curious if maybe later we could hear testimony or you could follow-up with us on if your AI council internally is using the same standard as the state AI council, because we have an inventory with its statute required disclosure to the public of certain attributes of any use of AI by government. You're not required to do that yet, but you may be doing it already. So if I forward maybe to Devin a link to the state inventory, it'd be interesting either to hear testimony letter or some follow-up. You may say, Oh yeah, we do this. We answer all these questions. Or you might say, We don't. Or you might say, Oh, maybe we should, or whatever. But that's a remaining question I have that I don't want to get distracted by because I want to do the demo, but I can send it to you. But if you're not aware of the inventory, would be if you're not aware of that exists, then that's a sign that maybe it's time that we start those conversations. If the state's doing it, maybe state funded efforts like healthcare need to have a similar standard. You may already be doing it. You may have a higher standard.

[Alyssa Black (Chair)]: Let's get started, and I just want to give a caveat before, and I'm really sorry to miss this, I have to run here in a couple minutes, so I may walk out in the middle, and Copper is going to take over.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Oh yeah.

[Alyssa Black (Chair)]: So let's get started. Is the patient.

[Brian Cina (Member)]: Okay. Oh, there's only one?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: So I can't show you my phone, but it's really boring. I basically hit a record button. That's the only thing that I do with my phone. Want to say this app on this is my personal Android phone. It works on iOS. It works on Android. The app is containerized, so it is completely secure within my phone, and the authentication happens through our system. So you cannot access the app without having an active account within UVM. And I'm only going to be showing you the bridge portion. Our preferred workflow is actually fully integrated within Epic, and they're particular, but the concept is exactly the same. How complex do you want to be? Know. I'm a little nervous right now. So let's shoot for like five minutes. Is that you can choose that to be benign.

[Leslie Goldman (Member)]: Well, can be benign or I could be benign.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Whatever. I am game with you. So, Leslie, right? Yes. So, Leslie, thank you for coming in today. Before we get started, I use a secure app on my phone to record our conversation. It helps me with documentation. It'll give me a note back, and I'll review that note, edit it for accuracy. And then once I sign it, it'll become available to you on your portal to review. Would it be okay if I recorded our conversation today? How long is it on the portal? How long is it on the portal? Your note will be on the portal. I mean, us, we don't ever delete notes off the portal, so forever.

[Leslie Goldman (Member)]: Thank you.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yes. Okay, great. So what brings you in today?

[Leslie Goldman (Member)]: I had a cough.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Okay, and how long has that cough been happening for? About three months. Oh, geez. And how severe is it? Is it something that you're not able to sleep? Or tell me a little

[Leslie Goldman (Member)]: bit more about it. I get up to bed at

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: night, but sometimes it's with exercise or cold air. Okay. And does anything you've mentioned cold air seems to make it worse than exercise. Anything else that has made it worse? Mm-mm. Anything that's made it better? Halls. I'm sorry?

[Leslie Goldman (Member)]: Halls. Halls. Halls.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Halls drops. Okay. Have you ever experienced this before? No. Okay. Any other symptoms that you've noticed in addition to the cough?

[Leslie Goldman (Member)]: I've had some weight loss. Not necessarily intentional,

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: but appreciated. Gotcha. And how much weight have you lost?

[Leslie Goldman (Member)]: About 15 pounds.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: And over what period of time? About three months. Okay. Any other symptoms that you've noticed? Occasional sore throat.

[Leslie Goldman (Member)]: No. Other than that, no. Maybe fatigue, but it's a busy life.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yeah, I'd like to ask you a couple other questions if that's okay. In addition to wake up, have you been experiencing any fevers? No. Okay. And do you ever wake up in the middle of the night to sweating or maybe your sheets are drenched with sweat? No. Okay. Have you been coughing up any sputum or anything abnormal out of your lungs? No. Okay. Any problems with your sinuses or your ears or your mouth?

[Leslie Goldman (Member)]: I've had to clear my ears more frequently than before. Okay. But they clear.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Alright, any chest pain?

[Leslie Goldman (Member)]: Occasionally, but not necessarily related to the cough. That was fun.

[Alyssa Black (Chair)]: I'm going

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: to talk about the chest pain just to keep us in a time bound box here. And no shortness of breath or things like that. And do you have any medical history that I should be aware of?

[Leslie Goldman (Member)]: No. I do have gestational diabetes. I did.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: You had gestational diabetes, but you haven't ever been diagnosed outside of the gestational or post delivery period with diabetes or pre diabetes? No. And do you take any medications on a routine basis? I do. What do you take?

[Leslie Goldman (Member)]: I take Tylenol and Gabapentin. Okay.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Do you know your dosage of Gabapentin? I do. What is it? Whatever. So you take six hundred milligrams of Gabapentin three times a day?

[Leslie Goldman (Member)]: Three hundred, three hundred, twelve.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: It doesn't have to be real.

[Leslie Goldman (Member)]: Something like that, yeah. Okay, alright.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: And are you allergic to any medications? No. Alright. I'm sorry, don't want to know if I already asked this, but do you have any other past medical history that I should be aware of? No. Have you had any surgeries? Yes. Okay, and what kind of surgeries have you had? A list. I I

[Leslie Goldman (Member)]: don't need to say it here.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: But no surgery. It doesn't have to be exact. I know. It's weird. I just want to think about myself. So we'll say no surgeries. And where do you live? Vermont, in Southern Vermont. And do you live with anyone? No. And do you have any pets in the house? A dog. But you don't have any other exotic pets? No birds, no other things like that? No. Have Okay. You had any recent travel?

[Leslie Goldman (Member)]: Yes, I've been to Papua New Guinea.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Papua New Guinea? Okay. When did you go to Papua New Guinea? In November. So was that about the time that the coughs turned?

[Leslie Goldman (Member)]: No, I think it actually may have started before that.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Okay, thank you. So I'd like to go into an exam now. What I'm going do is I'm going to do a physical exam. What I'll do is I'm going to speak through my exam. So it's going have some medical terms and you can ask me any questions that you want along the way. Would that be okay? Yes. Alright. So your head is atraumatic, your eyes are anicteric, your pupils appear to be equal. They're reactive to light. Your oropharynx is clear. I don't see any pharyngeal exudates. I'm palpating your lymph nodes. I don't feel any lymphadenopathy. There's no lymphadenopathy under your cervical, clavicular chains. I'm listening to your lungs. They sound completely clear to me. I don't hear any expiratory wheezes. You have full breaths. Your chest rises symmetrical. Your heart rate is regular. There's no murmurs, ruts or gallops. And your abdomen is soft and untender without any organomegaly. I don't appreciate any rashes or joint effusions. You seem to have movement in all four of your extremities with equal strength. Your face is symmetric. You seem the alert and oriented times three and are responding appropriately to all of my questions. So I'm not sure what exactly is causing your cough, but I would like to do some additional testing to try to get to the bottom of that. Would that be okay? Yeah. All right. So the first thing that I'm thinking about is that sometimes when you have chronic cough, it can be undiagnosed, something like an undiagnosed asthma. Have you ever had asthma or have you had wheezing with this? No. Okay. So maybe in the office here, I'd like to do a brief spirometry test just to see if that shows us anything that could help us understand what's the underlying cause. I'd also like to get some basic blood work for you. So we're going to have our phlebotomist come and draw that. I'd like to just start with a simple CBC and a complete metabolic panel, and then we'll take it from there as a start. Would that be okay? Yeah. All right. Was there anything else that you wanted to talk about today?

[Leslie Goldman (Member)]: No, but I thought your physical exam was scary.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Okay, is there anything that I can help with?

[Leslie Goldman (Member)]: Yeah, I mean, I were a patient, that

[Alyssa Black (Chair)]: would be

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: like And I'm rushing a little bit here to No, get quite

[Leslie Goldman (Member)]: it. It's very typical, but I know that's a lot for someone to take it.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: It's funny, each patient responds a little bit differently to that. Some like it. If they

[Leslie Goldman (Member)]: know what it means.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: So, yeah. Yeah.

[Brian Cina (Member)]: Do you ever Is this still recording?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: It is recording, so let me just hold So on one the other thing I just wanted to show, if we banter a little bit, so that happens in the doctor's office, I'd really like to know what did you think of the playoff games and that type of thing this past weekend? It does a quite a good job of stripping that out from the clinical. Okay? So I'm actually going to stop the recording. We're at seven minutes, so not bad. So the recording stops. I just say create note, and then I can show you here in a second. It looks like I lost my share.

[Brian Cina (Member)]: Ask a question. Please

[Lori Houghton (Member)]: turn it back on.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Send requests. Oh. Okay. Yeah. Go on. For that. Did you have another question first? Can I be next?

[Brian Cina (Member)]: I do a mental health evaluation on Penny Demo just to see how it responds to mental health problems. That's not an insulting thing. I would love to use that and see how it actually writes a mental health note, but not to digress down that road, do you find that sometimes because you are narrating what you're doing, it's actually an opportunity to educate the patient about their own body? If I can see that benefit actually explaining what it means to them, and they're learning about their own body, then they might notice something in the future or develop hypochondria, but there may.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Different So physicians and APPs have different experiences adopting this. Many people need to change the way that you conduct your interview because it doesn't read your mind. Is no neural link sensor in your brain to tell it exactly what's happening. It requires you to say out loud what you're thinking, what your assessment is, and what the plan is. And for some of our providers, it's super easy. They already do that very, very well. They don't have to change anything to get a really comprehensive good note that they're satisfied with. Some of our providers do need to change a little bit in the way I need to do this, in the way that I walk through my assessment and my plan, in order to generate the note that I want to generate. And that, in my view, is actually a really positive thing because the technology itself, I believe, can actually improve that communication piece. Because you may have thought that you said it, or you may have thought that maybe the patient walked away understanding it, but they maybe didn't. And so this actually, to get that good note, it really does require you to articulate exactly what you're thinking, exactly what you're finding, and what your recommendations and plan are. So I don't know, Brian, does that help with the question? Oh, yeah. Any other questions? Oh, thank you. Sorry.

[Jen Carvey, Office of Legislative Counsel]: You said that it can translate

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: all your medical terms for me if I

[Jen Carvey, Office of Legislative Counsel]: don't understand. Does that happen? Is that a pronoun?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: No, no, no. It won't I am happy to explain to a patient by medical terms, but I want my medical terms to be present within my physical exam. That's how we communicate as care team members using very specific language. So for me, when I'm talking about my physical exam, that's really important that that is captured within the documentation. So this is the note that it made. This is always a little risky on weakness.

[Leslie Goldman (Member)]: I thought that looked pretty good.

[Brian Cina (Member)]: So far so. It's not done yet. I'm curious what's below. Here we go.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: And the

[Leslie Goldman (Member)]: Papua New Guinea part is tricky because there's endemic TB. I like how

[Brian Cina (Member)]: it's Oh good,

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: where are we going?

[Brian Cina (Member)]: So it's naturally sorting information into predetermined categories

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: that

[Brian Cina (Member)]: a party can Yeah, I

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: like that. Love it. The physical exam, there are different selections for the provider. You can actually The way that I do this, I chart by exclusion. So I have my standard physical exam, and then I will delete out things that do not make sense or that I did not do. And then it will add things that I found. I did a very normal physical exam, so it's not this this I could have done something a little different in hindsight. I didn't review any active results. But if I had said, you know, these are your labs. This is the result of your chest X-ray, those types of things, it would show up there. And then this is its assessment. And so what I would do at that point after reviewing all of this is making sure that it's accurate, and then I would make any additional edits that I felt were required.

[Lori Houghton (Member)]: When do you do the review?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Right away or later? As a hospitalist, a hospitalist, my focus is actually getting orders in on the patient so that they can flow through the emergency department and up into So the medical I will tend to do the review at some point later. Sometimes if it's very, very busy, it may not be until hours later because I'm really focused on that flow so that we can de load the emergency department and the patients who are waiting can be seen. In an ambulatory setting, there may be some variability in the work workflows that they use. Some providers will, I'm certain, do it right there when the patient is there. Some will do it in that in between time between patients' roommate and that type of thing.

[Brian Cina (Member)]: So there's a little

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: bit of variability. Some will do it later in the day or even not the same day. We really like to see notes completed the same day. This has helped with that. So we've seen some really great success stories where people are closing their notes days far too long into the future. And they may not get to the point of closing them the same day, but they're moving from sometimes double digit day counts into single digit day counts. And that's meaningful.

[Leslie Goldman (Member)]: Can I follow-up real quick, Sim? So

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: once you're over here after that,

[Leslie Goldman (Member)]: and then those of who have a question.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: So I'm gonna stop my chair, if that's okay, but I think you get

[Leslie Goldman (Member)]: the idea of how Oh,

[Brian Cina (Member)]: I'll get in line, I'll in line.

[Lori Houghton (Member)]: So my follow-up to that is, before this, depending on the physician, they still could have been taking days to review notes. Correct. So that's not an issue that it might probably has helped speed things doctors

[Leslie Goldman (Member)]: remember.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Yes. There some of our providers that this has made a really meaningful difference in their days to their notes being signed. Okay, thank you. Like days and days and days. Great.

[Leslie Goldman (Member)]: You can't bill until you're done.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: That is one of many of the The accuracy of the medical record, in my view, is the primary reason, but you're absolutely right. You cannot bill until that chart is booked. So having a chart open for twenty days is not helpful for anybody. So

[Leslie Goldman (Member)]: I'm just looking at your privacy. So it looks like there's two pathways. One is that ambient only retains it for thirty days as opposed to the EMR. So that you were referring to the EMR that it's always present, whereas ambient

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: scrubs it or wherever it comes. But I would think it would

[Leslie Goldman (Member)]: be hackable or not, or am I being clerical? I

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: think they use very strong security precautions. In this day and age, can't say to Six Sigma that nothing can ever, ever be hacked. But the abridge met all of our requirements as part of that technology intake review, I know that they, like us and like Epic and others, very focused on making sure their system is as bulletproof as possible.

[Leslie Goldman (Member)]: And I have a question for Jen, if I may. So there's only one line being added, and so we could not do this legally without changing the statute. Is that the point? I'm just trying to understand I what we're

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: have one more slide, actually, if I could go to that. Would that be okay? Because I think that might help answer that Or generally Okay. Sorry, I got to get back to Okay, so why here we go. So why HR 84 is the question. I included kind of a leaflet from the Vermont Medical Society and our Academy of Family Practice colleagues because this is very important, I think, to provide us one who utilizes technology across the state. So so the issue that we have is our reading of the current statutory language is that this would constitute a recording, and therefore, we cannot, record as part of our telehealth visits for the purposes of generating this documentation. So that is the reason. We have a sizable number of our providers that do telehealth visits. It's good for providers. It's good for patients. Some of our highest users are in our psychiatry, psychology areas. We also see it used highly in places like oncology. And so it is a major dissatisfier for our providers that in one care setting, a patient is in front of them, they are able to utilize this technology. But in another care setting, they are not able to utilize this technology. And so if you put yourselves in their seats, that doesn't really make a lot of sense to them. And it doesn't make a lot of sense to me either, honestly. So our goal is really just to allow the use of this technology recording that audio interaction, whether there's a video associated with that or not, to help our providers reduce burnout, increase professional satisfaction. And I think those are all aims that we all have while making sure that we're utilizing secure systems at the same time. So this is the why.

[Leslie Goldman (Member)]: So if I may, so the dot dot dot in the bill is where that language says we can't do it.

[Jen Carvey, Office of Legislative Counsel]: When you look at the bill, you can see there is a language there that isn't the underlying language, but it's showing in the bill says nobody can record a telehealth or audio only in physics. That's the part that currently says you can't record the telehealth

[Leslie Goldman (Member)]: consultation. Okay, so by adding that line it changes that above Got it, thank you.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Don't know, just theoretically, do you have any sense that this makes life a bit easier, but so much easier that the scrutiny of the chart as it ends up happening with this technology, they go, it looks pretty good. Or is that really intense scrutiny of charting still present? And then if the ambient recording disappears within thirty days, how do you go back and go, Oh yeah, I missed this or that's there? There's certain standards around what's called the designated record set when you're talking about medical records. And so the product that is part of the designated record set and recording of that visit is the clinical note that is signed and authenticated by a licensed health care provider. So that is the note and that is the record of that visit from a designated record set standpoint. And that's why that is kept our we don't delete anything. But there's, I believe, statutory policy around how long you are required to keep that. And it's like ten years if they don't quote me exactly. But that is the legal record, and that is what the licensed provider is attesting by digitally signing that they, under their license, are documenting the contents of that visit. The storage for thirty days is a transitory thing that allows that provider then to take that initial draft, edit it, and then ultimately apply their signature and therefore their license under however their license to that document.

[Leslie Goldman (Member)]: Just before we go to I'm good. That's good.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Does that information go into the patient's record? Which information? The ambience. The actual audio recording, no, it does not.

[Leslie Goldman (Member)]: It doesn't. So you put different information in the patient's record.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Are putting the documentation by the licensed provider is in the patient's record. Shouldn't answer. Okay. Thank you very Oh, I'm sorry. It's okay.

[Brian Cina (Member)]: I'm sorry if I missed any of this, but does UVM Health's use of a bridge include any of the following: flagging of any missing pieces, like does it say, you didn't ask this, you didn't ask that? There's three things, so that's the first one. Does it give you any warnings like you forgot to ask about social history, or if you don't ask, it

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: just leaves a blank? No, however. On the roadmap for many of these companies is inclusion of things like decision support and nudges for those purposes. But it is not an active feature, that is something that we would evaluate if or when it becomes available as a feature.

[Brian Cina (Member)]: Yeah, and so there's two other things like that. So my guess is you're going have the same answer, but I'm going to ask anybody instead of assuming that. Does it present possible diagnoses and does it make treatment recommendations?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: It does present diagnoses. It does that already. Yep, it does present diagnoses today that are editable and you can basically select and it'll give you similar So clinical diagnosing is really complicated and there are tens of thousands of different diagnoses all attached to different ICD-ten codes. So our goal is always to get the most accurate diagnosis for that patient. But certain things like depression is a great example, is not a particularly specific diagnosis when it comes to the ICD-ten taxonomy. It will the ICD-ten diagnostic taxonomy. And so it will present different selections that you can then choose from that would be most appropriate for that patient. I'm not feeling like I'm answering your question. You are. I don't know if

[Brian Cina (Member)]: you know I'm a clinical provider. So you're answering exactly as I would expect. Does it ever say, or maybe not yet, but does it ever say, depression is indicated, why don't you give them the adult, I'm trying to think of one of the screenings. Didn't do a They said this comment that suggests suicidality, do a Columbia CSSRS. Does it have that kind of feature yet? No. Cool. It could though, eventually, which could be a strength. Can flag things That to

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: will happen. The only thing that's uncertain is the timeline.

[Brian Cina (Member)]: Okay. And then I think I might have asked, does it ever give recommendations? Does it say, you might want to prescribe these medicines, or you aren't prescribing these things, do you want to? Or it ever do things like that? There was an evidence based practice with float. I might get this wrong because I'm not a prescriber, but it might've been called medication management or something where there was flow charts that doctors would use. This is old. There was this thing they used to use. You know what I'm talking about?

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: I think so. Vermont has a very long history here with Lueders, honestly. And I'm forgetting Larry's Originally, it was through the Department of Defense, and then it was through a company around providing providers decision support. For people who don't know, Larry Lueders was a physician in Vermont who's very focused on kind of medical records back when they were pieces of paper and how you categorize them. And I can send you all a link, but there's a beautiful presentation that he gives at Grand Rounds at Johns Hopkins in the nineteen sixties. And I really view that as kinda like the the birthplace to some degree of how you begin to really organize what is a very, very complicated set of of records. And so Larry and his company, you know, basically created a full set of kind of flow sheet like algorithms to answer the question of are we providing the most evidence based care for a given patient? And I think, honestly, he was just early in the technology ramp cycle in that there wasn't the underlying kind of systems to support that way of thinking and it became unscalable. But the technology ramp cycle has now changed and we have new tools within large language models, artificial intelligence, etcetera that make that possible. Now how do you responsibly deploy that, at scale in a health system is a really important question, and something that we'll continue to look at. We're not doing it today, but it holds a lot of opportunity because we know that if we can make subtle nudges along the way or, hey, none of us are infallible in our kind of like diagnostic journey if it is a aid to to the licensed human that also brings judgment, compassion, you know, experience, all of those types of things, those two things, when you put them together, can be very summative, and it can really result in better outcomes. But it but it is a little bit early, because I don't have a particular product to respond to right now, but there are many companies working in that space. Like, how do you how do you do that effectively, impactfully, in a way that is not abrasive, honestly?

[Brian Cina (Member)]: And so this is just an extension of that question, in terms of the treatment recommendations. If this product, or I don't know what else to call it, this method of note taking, trying to use neutral language so it doesn't That's not scary. It's another tool. It's a method of note taking. If this method of note taking evolves in such a way where it can nudge providers or provide instant access to additional screening options or hone their medical record for information and bring that to the provider in that moment immediately. Like, Hey, we found this thing about the patient that they're not telling you. And so you can be like, Oh, the chart is saying that you had a surgery. They're like, Oh, I forgot about that surgery five years ago. Maybe there's metal in me still, or I don't know. So I don't know. You get my point. That could achieve delivery. It wouldn't just make the provider's experience better, but it could save patients. I'm 100% I'm sorry. So the last piece is just precision medicine. When it comes down to, you smile, so this isn't totally So how do you see precision, or maybe you can explain as the witness what that is to people and how that might eventually tie into this, like when you're doing a screening, how it might So

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: my view of precision medicine, I would define, I'm sure there's a technical definition around it, it's essentially utilizing clinical data that is unique to one individual to guide the treatment decisions that are applied to that individual. And that can be for a whole host of that can be based kind of their genetic profile. So one of them is pharmacogenomics is a great example of that. Different patients respond differently to pharmaceuticals because of their genetic makeup and how they process those pharmaceutical drugs. So if you know based on genetic testing that Justin is not going to respond effectively to clopidogrel as an example because I have a CYP inhibitor, then I would make a different decision about what medication I prescribe, Justin. And then we need to scale that because it's the same thing across a whole suite of different genetic alleles. And then it's also, once you get into specific disease categories, not everybody's non small cell lung cancer is exactly the same. Each one of those individual lung cancers has its own kind of set of unique genetics and biology. And therefore you can treat that same core diagnosis, non small cell lung cancer, with different biologic targets depending on what the actual makeup is of that tumor cell. So those are all the pieces that are very, very exciting, very complicated from a healthcare system standpoint because many of those treatments can be quite expensive, but they can also be quite effective if they are targeted at the right disease process. But then there is a scaling piece to all of this. So as you have more and more targeted therapies that are dependent on many, many, many different genetic markers or other physiologic things, need some decision. In my view, we need decision support to really say, okay, does this match up for this particular patient? Because it gets very, very broad, very, very complicated quickly. And really what we want to ask the question is, what is the likelihood of this particular therapeutic intervention being successful in this patient for whatever goal that is? And you want to make sure that you narrow that down so that the likelihood of success is as high as possible and the likelihood of harm or non value add expense is as low as possible. And so my technology and some of this decision support that you're talking about is a key component to doing that successfully.

[Brian Cina (Member)]: Thanks for getting into that. Sorry.

[Lori Houghton (Member)]: One last thing. Great questions, great answers, love it. And I want to ground us back into what this bill does. And this bill is today, we are allowed to record in a person visit, and this bill is saying we want to allow recording in a telehealth visit. That is all this bill is doing. Thank you.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Thank you. Okay, thank

[Leslie Goldman (Member)]: you very much. Appreciate you coming in.

[Brian Cina (Member)]: That's great.

[Dr. Justin Smith Donnelly, Chief Health Information Officer, UVM Health]: Thank you very much. I have some things that we need to talk about. On the record, agree on the record.

[Brian Cina (Member)]: Okay, so it's about policy, It's not like, you know,

[Alyssa Black (Chair)]: we're gonna do this. Everybody Sorry. I'm sorry. Tomorrow. 10:00 eighty four, we're gonna get into that some more. We may even vote on it.

[Leslie Goldman (Member)]: This list that you got, look at it tonight.

[Alyssa Black (Chair)]: We're gonna talk about this tomorrow. What we want you to do is pick out those areas that you would like further information about. Make yourself stay here.

[Lori Houghton (Member)]: Don't come in and say, These top 15 are my priority.

[Brian Cina (Member)]: What if there's things that aren't on here yet that are coming?

[Alyssa Black (Chair)]: No, this is all we look for tomorrow.

[Brian Cina (Member)]: Come back to those other things. We don't have them yet. As long as there's a way to include

[Alyssa Black (Chair)]: them later, then I won't worry about it. But some things come in today. Yeah, okay. It's a very good thing. Thank you. Okay?

[Lori Houghton (Member)]: Not it.

[Alyssa Black (Chair)]: Thank you. Anything else? Okay, we're done. Thanks very much.

[Leslie Goldman (Member)]: Should we go out there?