Shaping the Future of Healthcare: Data-Driven, Patient-Centered and Value-Based Care with Dr. Tripp Buckley

With all good intention, registries typically receive data, but then they don't provide insights back. When you give data up to a registry that aggregates the data and does averages, you get averages across all these different low environments and different patient populations and averages are what we need, what we need is feedback for our own patients, our local environments. You're listening to data nerds in the OR, a search and journey toward value-based care. The podcast focused on data and data science as the keys to a better health care system. Ideas brought to life by the vision and experience of host Dr. Bruce Remsha. Each week Dr. Remsha sits down with different players in the health care system to discuss how data is used today and what it could do if it were used effectively. How it could improve surgical quality, education, outcomes, and drive better patient care. Let's dive into the latest episode. Here's your host Dr. Bruce Remsha. So I'm with Dr. Tripp Buckley for this podcast. Thank you very much. Typing, I am really excited to talk with you. Tripp has been a friend and colleague for many, many years and we've had lots of discussions about data and health care. Tripp has many apps. You'll hear about them throughout this podcast, but Tripp is at Del Medical School of UT Austin. He helps run or he found it and runs the Forget program there. I want him to introduce himself it more of his backrow. So Tripp, thank you very much for joining us today. Sure, my great pleasure. And as you said, we've been friends for a long time. So I'm a general surgeon. I do exclusively Forget surgery now, but really my journey to where we are today began way back even before I was a medical student in doing research with a gastroenterologist named Gene Overhold. And he was a private guy, but for those who are history nerds, and this is data nerds, but history nerds, he invented the flexible sigmoituscope. He also pioneered photodynamic therapy for unresectable esophageal cancer. That's where I was working with them. And then also founded the first ASC Jacob certified ASC in the country. All out of Vinoxal Tennessee and all in private practice. He's the only private practice person I know. And I'm sure there's others that has two articles in New England Journal of Medicine. And he to me epitomized what a physician should be, but also not just doing good work for good work's sake, but also analyzing the work that you're doing and also excellence in surgery and gastroenterology. But he, one time we were doing a case and this long before I even thought I would do a salvageal work, and he said, Okay, send this person to talk to us and there's send this person to Vanderbilt for a nissen fund application. And I asked them like, I don't know what a nissen is, but why go to Nashville from Knoxville? And this person is the only surgeon that I trust to do those cases. And I kind of always wanted to be that person, but I think more importantly, it really drove home to me that we need to be able to have a more little democratization of certain procedures. And the only way we can do that is by understanding our own data and really learning from it and then trying to see what insights, if you will, we can gain from that data and constantly trying to get better. And as the years have gone by, I've worked on collaborating with gastroenterology. And so yeah, UT, we were able to create a digestive health program and integrated truly integrated program with gastroenterologists. And throughout the entire digestive tract, we all are in the same clinic and share the same resources. So it's really co-habitation of two specialties that don't always mix super well together. And so from forgot, we've got forgot folks on the GI side and then mid gut and colorectal. And so we pair those diads throughout the digestive tract. And it's been really exciting and challenging and all those things works. I'm excited about it. And so I have a diet who leads the gastroenterology side and it's been a lot of fun. That's so important. When I was starting to learn some of these principles at University of Missouri, I was chief of the Division General Surgery. And I saw the need to build resources around the patient problem as you're doing and as you've done. And I could not get the support from gastroenterology of the dean to do that because everybody was siloed. And they were always turf battles and competition. And it was just so frustrating. So congratulations. I think that's the right way to do it. It's to do it around the patient and all work together for the good of it shouldn't matter whether it's surgery or medicine or whatever's best for the patient. I think we should be doing it. And I think it in our heart, we know that. But in our business model that's failing in health fear, it's all fragmented and siloed and that has to go away. So congratulations on it. It's true that I'll just make quick comment that we talk about patient centered care all the time and yet our institutions and sometimes the specialists. But I think it's more institutional really put us in silos and it's unfortunate. Yeah. And I think it's going to change and we're going to hopefully help lead that change. Let me go back then to from a data perspective and some of the fragmentation and silos, what's your experience historically in the use of data in healthcare and patient area? I think I know your answer. But I think data is a mess in health there. But I want to get your perspective on the traditionally how we've been doing data in health care. Obviously not very well. I mean, the way I look at it, I guess, is like, you know, the first amount of data that you start to get is maybe as a resident, at least in surgery and through M&M. And we talk about our failures and our challenges and how we can get better. But, you know, you just chalk that in the back of your brain. It's not anywhere. And then maybe you start to build a Excel spreadsheet and put your own patients in there. Well, it turns out that's a lot of work. We did it for a variety of reasons that for me started probably about 10 years ago, more for patient tracking. But we started to put some other data stuff in there so we could really tease it out. That's crazy primitive. We've got when I first became board certified, I used the American College of Surgeons, Registries and things like that. That's neat. But that's just pure data. There's no analysis there. There's no other contextualizing factors that really help you. I don't think. I mean, we're competitive and they know that. So we like to see how we're doing against everybody else in the country. We've got things in the hospitals. Maybe they have NISQIP or something else. And that's also really primitive when you think about it. It's not that it's bad. It's just that it's very select. First of all, it's a select number of hospitals because it's super expensive. That it's a select number of patients because to do that analysis takes human beings. And so you've got to pay all these nurse coordinators to extract data. Then it's only aliquots. It's not the whole picture. So we don't have it. And it's really frustrating. Well, that's what got me so focused on this is as I got in leadership and began to look at the problems with healthcare. At first, I saw the need to build resources around the patient. But then eventually I saw we are not using data appropriately in healthcare. It's all fragmented. It's poor quality. And it took us years of working with a team of data scientists to realize that it's but the science is all about measurement and improvement. If you can measure something and use data tools appropriately, you can improve it. And we realized we need to start learning how to measure value and put the financial data with the outcomes data in the context of each whole definable patient process. And yeah, I guess that leads maybe talking about Dell medical stool in the vision around Dell and how that happened. And you know, the good is the people in the vision. I think you're right in line with everything I've learned. The challenge is it hasn't reached the potential that I think we need it to reach. And we need to do all together to truly transform our healthcare. It may talk about that history in your part in that your view of how that's going. Yeah, I'll go back just a second. One of my biggest pet peeves is we don't have a lot of our own data and people that should don't get their own data. So with the other form of data that we have, and I know this, I think is a pet peeve of yours too, is quote unquote research, right? And so if Memorial Sloan Kettering or MD Anderson says, oh, we did a thousand pancreaticemies in our leak rate is x percent, that's what gets quoted to the patient. It likely has nothing to do with your leak rate. So telling patients national data about big operations drives me buzzer unless it's your own data. And we've got a lot of that going on. And this is where we all again, myself included, need to get better by having our own data and say, hey, this is my leak rate. This is my recurrence rate. Is it in line? Is it not in line? I don't know. Make changes quickly and be able to pivot quickly. Dell Medical School. So, Dell Medical School is an interesting school very young. I think I may be wrong in this, but I think seven, eight years old. And it was the first school in something like 50 or more years that was built on it in a research institution. So lots of many schools around in Texas. We've got a ton, but they're all like, say, UT stop Western or UT Houston. They're all their own entities. They're not on a university campus. And so it allowed us a great opportunity to really collaborate with one of the premier research institutions. And they, a lot of the leaders that started the school, my chairman included, are value-based care folks. So to us, value-based care is value equals the outcomes that matter to patients, not just outcomes, but those that matter to patients over the cost of an episode of care. But sounds great to your point. And then it starts to break down when you start to struggle with figuring out what outcomes do matter to patients. Especially on the orthopedic side and our institution, there's a lot of work done around that. And small groups, pre-surgery, post-surgery, things of that nature turns out that's really expensive. So that ended fairly quickly. But they really learned a lot in understanding what some patient reported outcomes are in any given person's specialty. Those are out there usually and available. But then it's really time-consuming to get that data. We do it, but it's just, it's tough. And not every clinic and we call them integrated practice units are resource to be able to do that. And then you get to the really hard part. As if that's not hard enough, then it's trying to figure out the cost of an episode of care. Our institution does not have it own its own hospital. And fairly quickly, no one was really interested in sharing financial data. So while we hold ourselves out there, we even have an institute for value and care. And we can get that to that at the end because I have a good book for you. But it's just a, it's a real struggle to get that financial data in there. And getting institutions to buy into the idea that this doesn't have to be super secret data that you're giving us. We even just a little bit of data. We can do big things with it. We can help you save money. Perhaps that's not the goal of value-based care I would argue. We might argue that the amount of money that we spend the United States on healthcare is appropriate for the wealthiest nation on the planet. Probably not, but we, somebody, I'd argue that, but at least we want to get value out of it. And we for sure aren't getting the maximum value that we can out of the healthcare dollars spent. And out of the, and especially from the patient's perspective, a lot of work to be done. We're scratching the surface. Just recently it was announced that UT is building their own hospital for many reasons. But one of them is out of this frustration of we can't integrate all of the, we can't do value-based care currently because we don't have a good partner to do it. We're trying to solve really hard and we've done a lot of good work on solving the top part of the equation. We don't have the denominator there yet, but hopefully we'll see. And I think you bring up some of the barriers, but also the focus on value-based outcomes, a byproduct of that should be the cost of go down. Hospitals can improve their financial outcomes. And I think to your point, I've had the same struggles trying to do this as a surgeon in a leadership position. The hospitals weren't ready. They didn't want to share the financial data, but I think as we demonstrate that the biggest financial winner is going to be the facility when you data appropriately. And it's not a bad thing to put financial data without comes data. So we can all have a sustainable healthcare system globally. Then I think we'll see that change happen pretty soon. And it may be led by a group that has their own hospital like you're about to do. You know, I mean, you have some data that maybe you talk about in another podcast that is just so amazing. It's mind-bending that hospitals don't want people like you or me to be doing this work. And it's almost sometimes it's almost like a bad word to try to save money, and but that's the love language of hospitals. You know, and I don't hold them accountable for caring for patients. Institutions are, I'm, we took a note, the care for patients. That's my job. We'll do the care side and make it better for the patients. But at a bare minimum, at least hold yourself to your own fiduciary responsibilities and try to work on the bottom line. Let us help you. Well, that's a thing. Let's work together because when you do it separately, like we continue to do it in healthcare, it doesn't work. When you're only looking at financial, you end up doing cost reduction. And then when you're only looking at patient outcomes, your flying blind is to what's the best value. And we have to learn how to put that together. And again, it took me years to figure that out working with a lot of smarter people than me, data scientists and engineers. But once we learned that, there was a lot of clarity in that. It was like, oh my gosh, yeah, if we can measure value and work together, we can improve it. And so that's what we're working for. Just briefly, I want to give a little bit of context and history. A lot of this came out of Harvard Business School early around when I was trying to learn how to do this when I was at Missouri. I started reading some of the articles coming out of Harvard and was a good foundation. Now, some of the articles and some of the descriptions were a little bit overwhelming. The shift to activity based accounting from cost accounting and the need to do every single little penny that was costed throughout the activity. We learned you don't have to do that. You want to really just focus on what matters the most and get rid of the noise. You don't have to get all the data. You need the data that really matters. So that was a big learning we went through as we tried to apply some of those Harvard Business Principles and a lot of the good people that started that are now in Austin, Texas working with you. There you go. That's a tip for later. Maybe let's shift to your practice and your forget program and talk about what's the value of getting data there. And I know we worked a little together in this value model. And we built some of your data into our interactive data visualization tool where you can't begin to see, you know, if a patient comes in with these factors, what's the impact on outcomes? And I know we haven't done it a lot lately, but some of the work we did together a few years ago and how that impacted your thinking about value for your forget program. Yeah, going back to the idea of having your own data. So we kept out a lot of data in Excel spreadsheet and then red cap as a lot of people do. And we were looking at a lot of things, patient reported outcomes, some other objective measures as well. And you can run that data as if you're doing a retrospective review for recurrence rate or dysphasia. But really in getting to know you, that's so simple when you can do so much more with that data. And then also we were lucky enough to have you come down, meet with our people. We just were talking about outcomes that matter to patients. Well, frankly, never occurred to me to like get the entire team all the way down from the MAs, your medical assistance to the nursing staff to everybody like, what do you guys think matters? And there's a lot of ideas. And then, you know, you start to figure out maybe I as the physician don't have all the answers here. And I think where you and the work that you've done really crystallizes a lot of this is in getting a useful data visualization tool that starts to take into lots of factors or parsing down, parsing out and narrowing down factors. So when we have a bunch of patients in a database, you can start to say, Hey, for you, you have these characteristics, this is your likely outcome based on my experience. But that and that's where the beauty starts in to come. And and we use that tool and also our own data like very quickly pivot to and away from certain meshes, for example, or techniques fund application. But it's only by looking at that that I continue to learn at the rate I want to learn. I'm even though we said I'm out 20 years, I'm still excited to learn and get better. And and I think that's part and parcel of being a physician. And I think most physicians want that. And we just don't have the tools. We may have the tools, but we don't have the ease of use to do that and execute on that on a daily basis across academics, private practice, large multispecialink groups. So that's where you, Bruce and Cara syntax and people like Toki are going to come in and then help us out. Yeah. And that was very kind of you to allow us to come down there. We had spent over a decade learning to do this, but only in our own complex hernia program. I think you made in the first other clinical site that we actually traveled to and it was before the pandemic. And your team was great. You were receptive. And like you said, some of the aha moments that you have when you bring the whole team together and the perspectives, I remember something about I might get the exact thing wrong. But as we were going through the discovery and building the whiteboard, what factors are most important, what outcomes measures measure value. We do this liver shrinking diet that we think is really important. So we give it to every patient. And your MA and your frontline staff, we're like, no, we don't. We only give it to these patients. Like, oh, you can know that things like that when you get everybody, you get the team and you all have to do it every day for five hours. But just, you know, every few months just checking it and getting a race perspective and learning from each other and then applying that knowledge and then getting insights through the data and the interaction with the data. That's the continuous improvement method that we're trying to scale across health care. Question from the audience, if you will, we're talking about your visit down to UT Dell and the work that you did with Dr. Buckley's group. The audience is asking, how did that happen? You said maybe they were the first you worked with. Was it because UT Dell was so focused on this in the first place or was this before Dr. Buckley even had that backdrop of the Value-Based Care Initiative around, like, how did you go about connecting? Yeah, so I think it started with the relationship, for sure. And Tripp spent probably too much time they wanted to spend in my office when I was chair of surgery at University of Tennessee. And he was coming by and interested in a possible position. And I started showing him all the data we were collecting. And it started there. And then he ended up at UT Austin and the Value-Based Care stuff. I just really wanted to work with him in that environment. And then we did get some funding, a little bit of funding from one of the industry partners to fund that. So Tripp, maybe you can talk about your perspective of how that happened. Yeah, that's pretty right. But it's one of my favorite stories is I grew up in Knoxville and Bruce was there and I just got in touch with him and said it. Can I come by? I was thinking maybe of a move. And I think we have 15 minutes to talk. But then it turned into I don't even know how long I was in there, but because Bruce had all these papers all over the place, like Doc Matrix pronounced like three miles long. And I'm like, what is all what's going on here? And anyway, we started talking that I that the conversation just took off from there. And it was, oh, it was fun. He got to see what a data nerd looks like with their not sure. So let's give it a little bit and talk about the American Forgot Society. It's something that you've been a part of since it was created your co founder. And now we're starting to talk about how do we take these data science principles and implement them at the society level. How do you see that the CQI concepts, the data science principles could be beneficial for members of a society like the AFS? Yeah, again, especially in Forgot, there's a lot of witchcraft there is what I say. We don't have a lot of really good prospective randomized trials. In a lot of the things that we do, so it's a lot of witchcraft. And that's okay. I mean, some people, especially like Bruce, say, hey, we don't need a prospective randomized trial for every single thing that we do. But what we do need is good data and the good understanding and to be able to again pivot quickly. So the American Forgot Society is a society of surgeons and gastroenterologists that are hyper focused on the Forgot, which is a great collaboration again and has been really successful. We would like to set up much in the way of America's Forgot Society or ACS, a repository and the membership wants a repository to track their outcomes. And again, that could be very primitive or we can do it in my view correctly and do it via a robust CQI methodology that will be really way more valuable to the individual gastroenterologists or surgeon and especially to the patients. And and of course, again, our membership is all over the place, academics, big multi-specialty groups and private practice and something that we're going to be offering it for free to all the membership on making that hope, you know, really robust and meaningful to both the individual and also the patients that we serve. Yeah, and that's very rewarding to see organizations like FAS and I think we're getting more and more interest from other societies because with all good intention, registries typically receive data, but then they don't provide insights back. When you give data up to a registry that aggregates the data and does averages, you get averages across all these different low environments and different patient populations and averages are what we need, what we need is feedback for our own patients, our local environment. You highlighted that earlier in this and I've heard surgeons who regularly participate in registries and they give their data up and they get nothing really back that helps them in there for their patients, you know, working together to do that. And that's a basic data science principle is the data requires context, but it also requires decentralization in each local environment to really, and that's where you want to do the initial analysis. You can pull the data to look at bigger numbers and lower signals and you can network algorithms that come out of that to get higher predictability, but if you don't start decentralized in context, you lose all ability to gain those kinds of insights that we're talking about. Yeah, and I think being able to do that, again, we think of ourselves as a rather unique society and that will continue that uniqueness trend and gets more distributed across societies and bigger organizations. I do have to follow up questions here. I'd love to jump in here really quickly. Dr. Buckley, you talked about UT Dell and what you're doing and essentially you found that you have a problem extracting outcomes information, financial information, because you didn't own the hospital. So what's your solution? You're going to build a hospital. Okay, so vertically integrating, right? This is business 101. Have you thought about, or is there a consideration on the insurer payer side as well, because that's the true financial payer pay, that's the value equation, right? The benefit to the patient over a cost of that procedure, the true cost is borne by the insurer of the payer. What is UT Dell's thoughts about that? Well, I think a lot of places and departments and even individuals, myself included, I've gone to Blue Cross Blue Shield and said, hey, I do more of these in the state of Texas. It would seem to me if you guys are paying that out the dollars that you might somehow create a narrow network or something. And I will tell you that our chairman of surgery Kevin Bozik is well known as a leader in value-based care. And even though their outcomes, and they've shown the cost of the procedures that they do, and their whole system, I shouldn't say the procedures, procedure costs is the procedure costs. But the way that they go about treating the patients and through an integrated practice, practice unit with physical therapy and all nutrition, everything integrated into one place, the cost is way low. And he has been turned down by insurance company after insurance company. They're like, this sounds too big. We'd love to save money, but this is just too much for us. I don't get it. I saw, I don't, I've got no insight, if you will, into why they do not seem to care about they'll let anybody do a nissen, they'll let anybody do a knee replacement. I'm a miffed, befuddled. I don't get it. And I think that maybe when the numbers get so big through an entire institution that that will help, I know that Baylor Scott White, for example, they've got from my understanding, they've got really good contracting. Because the system overall seems to deliver care and a lower cost, makes sense, because they're wildly vertically integrated, including with their own insurance product. But yes, you would think that the insurers would be clamoring for us to do this. And it seems like United has a research group. And they actually came to a bunch of surgeons at one point in time talking about LPR, because it turns out loringo, pharyngeal reflux disease costs them like three times as much money as traditional guard. They're like, why is this? Because patients are bouncing around the system and they ask the group of us to help out. See, Dan Smith was one of them. But anyway, I don't get it. I don't understand. I don't. Yeah, I think that making so much money, they just don't care. Well, I think it's a lot of cognitive dissonance and healthcare people on leadership positions and doing things. They don't want to have a bad system or a bad company or a bad business plan. They want to see patients do well. But it's just attractive to just charge more every year, right? Less benefits. And that's essentially maybe not intentionally, but that's what has happened. But we have had meetings with insurance companies. They're starting to change that thinking. They're starting to think that business model is not sustainable. Large employees, employers are moving out of private insurance and doing their own insurance. And now we're starting to hear a little bit of insurance company say, hey, let's partner together and go into the clinical environment together and let's help improve value-based outcomes. And with the method that we developed, that is something that is doable, predictable if you measure the new state of tools appropriately, you can improve it. So I think we're just beginning to have a good timing. It's still early, especially from a private insurance perspective. But we are having dialogues with private interest that are talking that language now, which is refreshing because I hadn't heard that like you've struggled and Kevin has struggled. But maybe we're seeing the beginning of that change. And hopefully the more we can demonstrate it, the faster the change will happen. So that's one of my last questions is we all know we have to go through this change. Maybe Chip, talk about what you think is the future of value-based care. How is this transition going to happen? What kind of timeframe do you think it's going to happen in? Do you see any kind of thoughts about the future for value-based care? Yeah, well, I think since care is right in the word, you know, we're talking about how insurers, they're not obligated to care. Hospitals are not obligated to care. We are obligated to care. And so I think it's going to start with us. And then hopefully with companies like care syntax, being able to finally show some value, get some start shipping away at the financial piece. And then really showing that this can have value for both patients and institutions and insurers that will start to build some momentum and get the holy grail. How long is it going to take? 15 years to take whole and really be going. I think the first five years are going to be the most exciting. And then maybe between five and ten people start, I don't know, maybe I'll shorten that. Then five and ten, like you can see that you're on this train or you're not on this train. And the people that are on the train, the patients are happier, patients go to places where they're going to be happier. Patients are very sophisticated these days. Probably at least the third of my practice is from over four hours away from almost every state. Patients know where they're going to get good care. They know places that want to provide good care. Kevin Bozak tells a story about someone who was shopping around for knee surgery or hip replacement. And they wouldn't, and there was an institution. I can't remember what it was like, we're terrible. And they published all this. We're terrible at these things, but we're getting better. And this patient who was like a CEO of some company is like, I'm going there because they care about getting better. And so I think that patients are sophisticated, patients, institutions, and health insurers need patients to get, make money. And I think you'll need to be on that train or you'll be off that train. And I think that's my view. And so maybe it's 15 years, maybe it's 10 years, I don't know. Yeah, I think it's getting faster and faster. And you know, a lot of things are coming together that LLM and Gen AI technologies, that's going to help facilitate data management, data cleaning, so much better than the manual and challenging rules that we have to build in the curd software. For me, it's really refreshing because when I started to talk about this over a decade ago, the common answer was, Oh, this is not going to happen in our lifetime. It's going to take generations. And I think we're seeing, no, it's going to happen. And it's going to be not tomorrow, not next year, but it's going to be a reasonable amount of time because all of this is coming together, both good and bad. We're seeing, I think the pandemic opened a lot of people's eyes in healthcare that we treated the pandemic the same way we did 400 years ago with bubotic. Because we had the same science and we didn't have a data and analytics infrastructure in place where we could have identified who gets this and has problems who gets that and doesn't have problems and what treatment is better for what subpopulation. So yeah, that's refreshing. 10 to 15 years, I'll take that. In healthcare tech, we didn't have companies like care syntax, right? And data integration and cleaning and using AI and all those things. It's going to be hopefully a paradigm shift for all of us to be able to have access to that data and really be able to learn from it. And we just haven't had it. That it's encouraging and on ask a final question to end on a high note, you know, what kinds of books or movies or resources have you had experienced with that is encouraging about this that is hopeful for our global healthcare system. I'll just throw out a movie and that's trading places, which has nothing to do with healthcare or this, but you should watch trading places because it's my favorite movie. Now from a book's perspective, so going back to DelMed, so you're right, Dr. Thysberg and Scott Wallace founded the Value Institute for Health and Care. And also I think Dr. Porter was at Harvard, but Dr. Thysberg and Porter wrote a book called Redefining, Healthcare, Creating Value-Based Competition on Results. And that is a great starter for someone trying to get into Value-Based Care. Dr. Bosick, I know also has a book for the Orthopedic Surgeons, Value-Based Healthcare in Orthopedics, I think is what it is. But really the Porter and Thysberg book is a great place to start and start to dig in. And there's a lot to good examples of places that do little bits of this in aliquots. Again, no one's doing it amazingly well across large institutions, but that's the goal. Yeah, that's great. That was definitely one of the books I read early in my evolution to understand these concepts. I would be remiss if I did not ask a question about the third or fourth leg of the stool that we didn't talk about. And Dr. Buckley, we talked about the surgeons like yourself and the societies trying to hopefully adopt Value-Based Care. We've talked about the insurers, the payers, and of course the points of care of the hospitals, ASCs. What about, or what are your thoughts, or have you seen any change in activity from industry, meaning from a MedTech, and those making the tools or the things you are using on a day-to-day basis toward a value-based system? I can't say that I have. You may have examples and I can comment, or I can't say that I have. I mean, I just haven't. You take, I mean, we have a new potassium inhibitors. It's a third-generation PI. Basically, it's not a PI. It's a completely different drug. But the way that they're rolling that out is exactly the way every other companies roll out their drug, tech companies, mesh companies. It's all the same. I haven't seen it. When I have seen is companies wanting to accrue data and wanting that metadata, and that's where societies can come into play and for sure that data is valuable to them because it's real-world data. And so, I think maybe this will change and help drive some different innovations in the way they go about business and really vetting products rather than getting surgeon champions to go out there and give a podium presentation and a dinner talk and all these other things that we're going to accrue data quickly and really be able to act on it. I haven't seen any big side of the changes currently though, maybe some examples. Yeah, I think we can do that. We've done that a little bit. There's been some companies that are truly interested in understanding the value of their product and they're okay with understanding where there's not value, but it's not the norm. Like you said, trip, the norm is volume sales and commissions based on volume sales. And so, you're incentivized to just sell. Hopefully thing is with societies like America Borges Society, if we get this data and analytics infrastructure, like you said, we can create value innovation networks and then companies can plug their product in and we can help define. Where is their value? Where is their not value? Because ultimately, that's going to be a better long-term financial outcome for the company than when it's used in the areas where complications happen. I'll use, you mentioned Hurrimash. There's huge product liability lawsuits around Hurrimash. And if we could show companies where their products don't have value where they make contribute to complications and also where they do have value, they can sell and market into that and that'll be a much more sustainable and long-term financial method than just sell. So hopefully we can help facilitate that change. Yeah, it's interesting. So full disclosure, I sit on the medical advisory board for fathom pharmaceuticals that have come out with the first FDA approved competitive, potassium competitive inhibitor and it's PPI. Well, it's stronger than a PPI, but it's easier to take and more effective. Where they rolled this out initially is like for H. Pylory and then of course, it's going to be really expensive and then they then they got an indication on the small-ish study for a roast of the suffigitis and it's like the same thing. But I will say that they are interested and they've come to the AFS and said, okay, how can we look at this differently? Because obviously, they want to take over the world and it's in a pretty amazing drug, but they want to decrease their cost to market is the reality, right? We've got a good product. How do we get through the FDA and all these other things and get an indication? Millions and millions of dollars. Hey, if they're only look at it from the way of getting a decrease in their cost to market and we get great data and really understand where it can be used effectively versus thumbs or roll aids, that's great. Everybody wins. That's the future trip. I really appreciate your time and your friendship. I think this was a really fascinating discussion and especially with the experience you had there at Dell Medical School of UT Austin and I hope we're going to do as much as we've been able to dip our toe in the water with CQI and value-based data and science. I think in the next few years we can do a whole lot of stuff together and help me at least some of the people that help lead the transformation of health here. So thank you very much for your time. My great pleasure and I'm ready to get soaked. I think that the tones is been fun but let's get soaked. That was great. Thanks for your time. Thanks for joining us for another episode of Data Nerds in the OR, a surgeon's journey toward value-based care. You'll find links in the show notes to any resources mentioned in today's show. If you're enjoying our podcast, please subscribe so you never miss an episode and if you want more content like this, you can always sign up for our smart surgery blog via the link in the show notes. Or if you want to ask Dr. Remshaw or the team a question directly, please send an email to [email protected]. This episode is brought to you by CARE Syntax, the leading vendor-neutral surgical intelligence partner. The CARE Syntax platform can ingest and analyze data throughout the surgical workflow, including clinical, operational, financial, and outcomes data to capture a complete picture of the surgical pattern. That data can produce actionable insights to enhance efficiency and innovation for surgical teams, hospital administrators, and medtech developers. Driving innovation for the future of health care delivery, CARE Syntax impacts over 3,000 ORs and more than 3 million annual procedures across the globe. Learn more at www.caresyntax.com.