Do We Need To Reset The Rules Of Oncology? with Dr. Johnetta Blakely - ADAPTIVE BIOTECHNOLOGIES CORP

It feels like death by a thousand clicks. You've got to click the regimen. You're got to click to approve the medicine. You got to a click on your schedule. 22 years ago, truly, you walked into a room, you talked to the patient, and you either dictated a note or you hand wrote a note, and you really wrote it for you. Anything that can make that more simple for physicians, I think, is a win. It should not matter where you live. That should not determine the kind of care you get. If you take 10 patients that are eligible for CAR-T therapy, only two out of those 10 are getting it. I think we just have gone off the rails. As the world evolves, I think it's so important for us to re-interrogate some of the things that we've done in the past. A lot of the assumptions are being reset. How do you turn a reluctant physician into an AI advocate? I've watched it happen with today's guest, and it didn't happen overnight. Dr. Janetta Blakely agreed to be what she calls a guinea pig for an AI tool she didn't think she'd ever trust. Today, she says she wouldn't go back. Dr. Blakely is a chief medical officer for COA, the Community Oncology Alliance, and she practices three days a week as a hematologist oncologist at Tennessee Oncologie. She trained at MD Anderson, spent seven years of community oncology research at Memphis' West Clinic, and later built a rural Tennessee clinic almost from scratch. Her career has touched nearly every corner of cancer care delivery. Dr. Blakely and I have known each other for years, and I consider her a good friend at this point. Our conversation starts with how to earn a clinician's trust in an AI tool and how far Dr. Blakley takes that trust to that. From there, we get into policy, what the drug pricing rules from the Inflation Reduction Act could do to small practices, and why Dr. Blakely thinks 340B has drifted away from what it was originally built for. And we talk about a number that should bother more people. For every 10 patients eligible for a potentially curative therapy like CAR-T, only two actually get it. Dr. Bleakley doesn't hedge on any of this. And honestly, after listening to her, I don't think the rest of us should either. Let's get into it. One of the things that you called yourself, which i thought was funny but also at the same time devastating was like you called yourself like a highly paid box clicker yeah and um i think you have kind of a really refreshing kind of perspective of what it means to care for patients what it mean to be a community oncologist what it means to stay independent and i think i wouldn't see anyone more fitting for the role of being the chief medical officer of COA. Well, I appreciate that. It's my favorite meeting. So if anybody has not gone to COA, here's your plug. You got to go. It'S the most fun. I do love COA Yeah, you call yourself kind of this highly paid box clicker, almost this guinea pig. What do you mean when you say that? And why are you so willing to be a guinea Pig? Well, so the first part is the box clicker. I think what's happened in medicine is that it's become so regulated and we have to, we being the physician, have to certify or verify that we've done X, Y, or Z. And so the way that we are to do that is in our note. And they've created the notes so that we just click boxes along the way. So there's a whole section of box clicking for the exam. I can click whatever I one in the exam. Now I can write stuff in there too, but I can, but it's easy to click boxes. If I can send somebody for oral chemotherapy, I have to make sure I click that box so that I can prove that I've had a conversation with the patient. It really went from, you know, back, again, I've been doing this for 22 years. So 22 years ago, truly you walked into a room, you talk to the patient and you either dictated a note or you hand wrote a note and you really wrote it for you. You didn't write it for insurance. You did not write it for coding. You do not write necessarily even for somebody coming behind you. Now, there was sort of some push-pull there, right? If you just wrote it for you and somebody is covering for you, they may not really know what is going on just from the chart. I'm still not sure you always know what's going on just from the chart even today, but I think that is probably a little bit better. That's why, you know, the whole idea of being a box clicker. And so anything that we can do to make life easier, I mean, it is, it feels like death by a thousand clicks all the time, because it's not just clicking into a note. You've got to click the regimen. You're going to click to approve the medicine. You got to click on your schedule. You got to click into your tasks. So, I mean, I'm literally playing with some sort of mouse on my computer all day long. I'm sure I'm going to have some sort of horrible arthritis in my right hand from clicking boxes when I'm, you know, 80. And, you know, it's just anything that can make that more simple and easier for physicians, I think, is a win. And, you know that kind of goes to what the ambient AI product that you that you designed really helps with. Yeah. And I think it's almost crazy to think about how much medicine has changed in just the past 20 years, not even just thinking about the medicines, but also thinking about the delivery of care, the technology, going from paper charts to EMRs to now AI. You would think that when people are creating these rules or creating these regulations, a lot of them are well-intended. They want to make sure that patients are safe. They wanna make sure that everyone knows what's going on and it works with these systems. But what happens is over time, those things start to just compound to the point where you're adding kind of friction to the workflow and it's getting in the way of patient-centric care. I'm curious how you think about the balance between those two things, right? Like the importance of clicking the box versus just getting the job done, right. I mean, it is, you know, having worked in the operations world, I think so many times we've just said, well, just stick it in the note. But then you have to educate people that you've got to use that box. And that is easier than necessarily, you know, dictating. I spoke with the patient, told them all the, you know, horrible things that could potentially happen. That's easier is to click a box. But the idea, the regulations that are in play that say that we should be using, you know i'll take smoking cessation as an example or smoking in general so one of the regulations is that we have to ask patients every time they come about their smoking status every time i come so matt let's say i'm giving you chemotherapy and you're coming once a week i'm gonna ask somebody in my office is going to ask you about your smoking once a weak i mean that seems a little absurd um because it's probably not different than it was last week most likely. I mean, it makes, maybe it makes sense to do that once a quarter. Maybe it makes sense to doing that once every six months, but those are sort of regulations that if we don't do those, then we're not quote providing high quality care, which is just in my mind, a little bit silly, but there's, those are the rules. I means, it's sort of like at a stop sign, you still have to stop even if nobody's there, you know, and it's the rules I know some people don't do that, but some of us follow the rules. Yeah. I mean, I think the interesting thing is when a lot of these rules are made, they're made with the assumption of what the world looks like today, what reality is today. And I think when those rules were made, there wasn't this kind of really special opportunity to personalize medicine at the granularity that we are able to now with AI, right so taking the smoking cessation example you know if you have a patient that has a history of smoking cessations you know maybe you can kind of change the rule and say hey maybe we'll ask this specific patient you know every single time they come in but there's a patient has never smoked in their life asking them every single that time is probably just a waste of time for everybody or if there's somebody who is a smoker and they've told you in no uncertain terms I'm not quitting that also becomes frustrating because you know they all know they shouldn't be smoking smoking, yet if you ask them every single time, that's annoying. Exactly. And I think with AI, we're finally at the point where we're able to enable that level of personalized care. Whereas before, a lot of these rules, they get kind of jammed into an EMR. And then now there's a required field for a box that has smoking cessation for every single visit that you have. And so I think it's ultimately a design problem, right? And the constraints that we had designing these systems 20 years ago are not the same constraints that we have now and you know we have this really special opportunity to really kind of re-interrogate what these processes are and kind of reimagine what these workflows look like from scratch yeah agreed so i know ai is like a really scary thing for a lot of people right i love it and it and and it's not for everybody right i think when we first when we first met right you know you told me you're like hey this note doesn't sound it's not the way i would have written it but you know i would rather do this than go home every day and spend three hours writing notes that's right and you've saved you know a substantial amount of time you know using the using deep scribe and you knowyou've been such an amazing champion for us not just at tennessee but you know just across the community of really kind of getting physicians in that mindset of what it's going to require to adopt AI. I'm curious if you can kind of walk us into your mind when you were first thinking about using an ambient tool and what were some of the considerations there? Yeah, so I thought it was a little weird to have to take my phone in because I've always been one of those physicians that I've never had a laptop. I've ever had a computer. I've Never had my phone In there. It's just been me and maybe, you know, a piece of paper so I can take some notes. And I've always done that because I don't like it when my doctor, and this is what she does. She sits there and talks to me, types on her computer, which is fine because that's what she needs to do to get her note done. And I don'T, I mean, I donT really care, but I don'T love it. Um, and so the idea of me taking my phone in was a little bizarre. That wasn't, that was a hangup that I had that I Had to get over. But I also think just in terms of how the note looked, you know, most of us that have been practiced for a while, we have sort of curated and developed what works for us. And you kind of have to get over that a little bit with, with an ambient product. Now, not to say you can't customize things. I think there were things that I was irritated about and Matt, you were like, but the team can fix that. Why don't you just sit down and talk to the team? And I was like, oh, I can talk to The Team. I didn't know. And so you can fix some things, but some things you just can't fix. And I will say I now have gotten so used to my deep scribe notes that I don't think I would go back. I think, and I was not a wordy physician to start with, but I think some of my assessment and plan probably was a little wordy. And now the way that it's bulleted makes more sense and it's easier for somebody else to read and so i i i like that i will say and you know this in our group i think the uptick is is i don't know you know that you probably know the percentage i want to say about at tennessee yeah it's like i think 80 right now 80 80 but i think that's not all the docs like i Think the docs my age are not there are several of them that are not yep this is not their jam, but I've been able to talk to some of them, especially the younger guys or the nurse practitioners that were, or the APP, sorry, sorry for anybody who's out there. He's a PA. We love you too. But I've, I've Been able to Talk to the APP is to say, do you really care what it looks like? Like, as long as the, all the information is in there and it's in a way that is readable and understandable. And what I have found is I've Ben able to add a modifier 25 where I couldn't before, because DeepScribe caught that I was talking to them about their sinus problem. And I was going to go ahead and give them, you know, some steroids and an antibiotic where I probably would have forgotten about that when I was writing my note later that night and wouldn't have appended the modifier 25. So for me, it's been greatly beneficial. I do think for folks that are just starting, it is going to be amazing because you are not going to know any different. and the technology learned you i mean there's a there's one thing that they kept that deep scribe kept spelling wrong and i finally started to talk to my patients about it and would spell start to spell it in the room so that deep scrib would know how to spell it and now now he gets it right every time so you know they do learn from you it's crazy to think about like these technologies as amazing as they are, you know, they're the worst they'll ever be, right? I think these technologies are still in such an infant stage and for them to be able to do what they can do already is already amazing. But to think about the possibilities of where this, where we can take it is also, you Know, really is what really excites me about showing up to work every day. And it is a little creepy to have something listening to you and then spits out all this information from your appointment. And my appointments, there've been patients that I've been taking care of for 15 years. And so a lot of the appointment, we won't even talk about anything medical and it can still figure out what it should put in and what it shouldn't. Cause that was one of the complaints that people said was, well, how is it going to know? And somehow it figures it out. So I mean, for me, it's a game changer. I would say since i've started deep doing using deep scribe i've only brought home work maybe a handful of times because my notes are all done and and those times it was you know just one of those days that just completely flew off the rails and i wasn't you know i would have had every note not done if i yeah if i hadn't had deep scripe so you guys took a really rigorous process when we did you know went live with you guys and you had competition we had it we did a bake-off Yeah, you did a bake-off. I'm curious, you know, what did that process teach you, right, about picking technology vendors? I'm sure it's like a new muscle for you and for everybody in the community. I mean, I think the thing that it taught me specifically was that just because I like something doesn't mean everybody else is going to like it. And the other thing is that we really need to have, you know, seamless transition within the EMR. I mean, unfortunately, we are sort of bound by these EMRs and they are sort they are albatrosses. Sorry, that's just what they are. And if you have to work out of more than one platform, meaning if you have to walk out of your EMR and then a different platform for your ambient, um, note-taking, that's just, that probably not going to work very well. You kind of have to have everything in one place, even if it's just a Google Chrome extension or however it's overlaid, that was the biggest thing for me. Um, and I think one of the things that I also learned was, well, if you like some of the technology you're seeing in something else, maybe it's just prettier than talk to the company that you really like working with. And that has maybe, you know, checks all the other boxes except the prettiness. And I bet they can make it as pretty, um, which I wouldn't have expected. You know, I guess it's sort of like when you go to the restaurant, if you don't like peppers, maybe you just ask not to have the peppers on your, on your taco. You know? I just, it's, we're used to being served things that just are clunky and don't really work well. Because if you think about it, EMRs don't work well and they are very clunky. And we're just used to having workarounds. We're not used to a technology that's going to learn what we like and cater to us. and so asking for what you want i think is you know a reasonable thing to do and you know matt you and i have talked i mean i gave you a whole list of things that i would like deep scribe to be able to do for me in that note and you Know maybe we'll get there maybe we won't but there's certainly things that it it has been able to Do since we started using it that i think are value add yeah i mean as as i guess like obvious as you're making it sound they will say you know that's probably one of the most important parts of any partnership, right? Like the organizations that we are the most successful with are the ones that do give us feedback, right. They, they don't think that telling us they don'T want peppers in their tacos or telling us that they DON'T like their, their sentences this way, or, you know, the, this button in this place, you know they think that's would offend us or, you know that they DON'T think we'LL do anything about it. But, you KNOW, I think what I'VE learned in this market, and I say this time and time again on this podcast, is sometimes the best technology doesn't win. What really wins is, are you able to bend the technology to the end user and rapidly iterate with the customers that are using your product? And so without the feedback, we don't know what to build. I like to say that our product was built by clinicians because literally every single tweak about our product, every single placement of a button, the colors of the button how big the texts are how long the sentences are you know we've you know those those are all coming from you know our users um and so it is really special when we get to meet somebody that is willing to kind of give us that feedback even if they you know have a lot of issues that they're like i'm going to continue using this and i know it'll get better so yeah and so just i'm going to touch on something that we've i've kind of touched about is is sort of the weirdness of somebody recording. So, um, one of the things that, that I had a colleague say, well, but it's recording everything I say. And I said to this person, I said, well do you not just assume that every patient you walk into their room, that somebody in that room is recording? And the person said, no. And so will you need to change your view? Because I suspect that every patient bring me walk into someone, whether it's the patient or the caregiver is recording you because in Tennessee it's a one party state. So they can record us all day long. And I've only had one patient sort of eye me funny when I said, you know, cause I walk in and I say, Hey, you know, my phone's going to listen to us. It's recording us so that I can, it'll help me write my note later. I hope that's okay. And i've only had one patient go, not so sure. Um, and so I opened the app for her so she could see her name and what it looked like and all the things. And after that, she was OK. But I had a patient that was very upset with our interaction, basically called the office saying I was I was not nice and I had blown her off. And, you know, I hadn't done anything for her, called our compliance officer, wore her out. And the compliance officer called me. I said, just go get the deep transcribed transcript. Just go get the transcript. So we got the transcript, I'd spent an hour some odd with this lady and it had let her just ramble on and on and they were like, yeah, you were probably nicer than you normally are. So, we're going to let that one go. I know, I remember her. I do think there's sort of a benefit there. And I also think if you know something's recording, you i think it makes it so that you're on your best behavior so i do think that is somewhat helpful i mean it ultimately comes down to like how can we better take care of patients and hold people accountable for doing so at the end of the day if a physician isn't doing the right thing i think you know we we would want to know that as well we want to Know that as Well right um and when the you know i tend to think that physicians typically are doing the right thing. And sometimes when you have an angry patient that doesn't like their outcome or not getting what they want from their doctor, they might try to spin the story. And the way that I think our legal system is set up is to usually give the patients the benefit of the doubt, which is why malpractice insurance is so expensive, right? Leading a lot of doctors out of the field of medicine. Yeah. So I mean, again, I think that whole idea that it would be weird to have it recorded it helped me out in this one instance and i do i think you know you just have to in this day and age you just Have to assume everybody's recording all the time yeah i mean i think another huge benefit of ai is that it brings like it really empowers patients to give them a tool to be able to take a charge of their own care right like you know before to get information whether it's from an actual physician or from you know chat gpt a lot of people talk about oh you know chachi bt is not accurate right for especially for medical information i and i totally appreciate that right there's some things that you don't want to rely on a ion i think it's something like 68 accurate the last time i queried it you know i was talking to one of my friends dr caroline chung at md anderson and she was telling me you know you really have to think about these risks relative to their alternatives, right? You know, if you have somebody in rural Mississippi that has no access to care, you know, allowing that patient to go search something basically for free and to get information like that is so much better than nothing. Agreed. AgreED. I will say though, I mean, I, you know, I work in a rural area of Tennessee. That's where my practice is. And one of the things that we struggle with is so many of those folks are on, on things like ivermectin and vimbenzole. And, you know, there's a guy up there who will look at your iris and tell you what's wrong with you and how to fix it. So, I mean, you Know, there was stuff like that long before we had chat GPT and Claude and Gemini and, you Now, it's just here to stay. So I want to switch gears a little bit, Dr. Brinkley. You are a huge advocate for community oncology. And one of the things that we've talked about is how sometimes it's ironic to think that adoption of AI or adoption of innovation sometimes actually moves faster in the community setting than it does in the academic setting. And I think especially in this day and age where being able to adopt technology is becoming more and more of a competitive advantage, I'm curious to get your take on how technology adoption being a core competency of community practices continues to kind of be this moat that they have against consolidation into a larger academic medical center. Yeah, I mean, I think for one thing that we have is we tend to operate pretty lean. So, you know, I have access to our CEO. I can text her whenever I want to. Same with our CMO, our CFO. Like, I can talk to anybody up in that C-suite. You don't always have that in an academic center. There's so many layers of bureaucracy. And so since we run pretty lean, I think it allows us to be nimble. It allows us To pilot things when we want to, you know, within reason. And we always, as you know Because you've been through it with us, we're very, very thoughtful in how we do that. We have certain milestones that we want To make sure that we're reaching or not reaching. If we're not reaching, the pilot's done. And we want to make sure we have an idea of what does success look like for X, Y, or Z project. I'm not sure that's always the case in academia, especially in a large system where you may have competing priorities and, you know, not everyone is on the same page steering the ship in the same direction. And we we have some of that, too. I mean, we're quite large. So sometimes we do have a little bit of that. But I think we were able to figure that out probably, you know, probably quicker than than than an academic center. I means, and if you think about it, we all started at an academic Center, like, I trained at MD Anderson. So we all know what those those centers look like. My husband still works for an academic center. So I think that's one thing that really separates us. I think another thing that we have done is that we Have partnered with one oncology is our MSO, which has just allowed us to scale certain things. And it protects us from some of the outward pressures that we're seeing in independent community oncology practices. I just ran across a statistic preparing for a panel that i'm going to be on that um i think it was like five years ago there there were in terms of independent community practices something like there were like 69 percent of all oncology practices were independent community processes that's down to like 37 percent and it's all this hospital consolidation i i can fact check me i'm not sure those numbers are exactly right but it's something like that, where a significant number of these independent community practices have moved into hospital settings. And it's because of economic pressures. Our workforce is more expensive. Electricity is more expensive. Rent is more extensive. So if you put all of that together, if you're a small independent community practice, if you don't have ways to help you scale some of these things, you just aren't going to survive. And so that's one of the things that some of these MSOs have helped with. There are lots of people that don't like that. I think that part of that is just not understanding how they help. So to give you an example, I mentioned that I work in a rural area of Tennessee. It's about 80 miles kind of northeast of Nashville. And One Oncology helped us start that clinic. I started that clinic three and a half years ago. I went out one day a week. We're now five days a week with two doctors. We are, you know, growing leaps and bounds. But without the capital of one oncology backing that, I'm not sure that that clinic would have been stood up. Yet, if you look at how busy we are, it's clear we are helping that community. Before we got there, patients were waiting up to six weeks to see an oncologist. And that's crazy to me. I mean, even still with me up there, they're waiting six weeks to see those oncologists at that hospital. And it takes time, even sometimes I'll order a CT scan, it won't get done for three weeks. So, you know, again, I think what we're able to provide for that community is a different idea of what great quality care looks like. Three weeks isn't too long for a CT scan. So I'll ask them, hey, do you want to, could you travel to Nashville just to get the CT? So those are things that we can do. And I think that's a, that's a real, you know, sort of tangible look at what one oncology can help practices do. In addition, all of our benefits, so things like insurance for our employees, it looks a whole lot better now than it did before we we were with one oncology, because, you have that in economies of scale. So HR and some of the IT stuff, not all of it, but revenue cycle management, helping with things like that, drug purchasing, all of those things really help us because we can do them at a, at a scale that we didn't before. And so we're saving money. Um, and that helps us in terms of making sure that we can stay in these communities and help these, these patients. I think I know the answer to this, but for the audience, like, why is this so important to you to stay independent? Well, I think there's so many reasons. Um, I think there are just so many reasons. One is, you know, I get to, I, I think that we, we can say, okay, there's a community here that needs access. We think that we can put a clinic there. We're able to make that decision and do it. We don't have to answer to a hospital system, which is very slow and clunky, um, to make that decision. That's one reason. Another reason is that when you get infusions and my clinic versus if you got that same infusion at the hospital clinic, that's my competitor, I'm 33% less expensive, which means I'm saving you being the patient that copay by 33%. Not to mention I'm savings the federal government because of Medicare, I'm saving the insurer. So it's a lower cost of care. It's the same high quality. We were able to add cookville which is my my area we were able to add that as a research site and we've been able to bring research to clinical trials to that population which we couldn't do before um and so i think it's it's really important that we keep these independent practices the other thing that happens is that independent practices are in places that hospitals don't want to go because it may not be financially uh may not for them make financial sense but for the community it's everything. You know, we have clinics where we operate one day a week. And while we're there one day a year, we're able to give them full service one day, a week, and maybe that's all that community needs. But a hospital system isn't going to do that or a university setting, either one. Yeah. I think a lot of people don't realize that, that, you know, even though the majority of oncologists are at academic medical centers, the majority of cancer care is actually delivered through the community that's right um and so percent of all cancer care is delivered in independent community practices with fewer doctors and when you say academic i think we need to clarify it includes hospitals too so community hospitals that may not necessarily be affiliated with the university so yeah hospital systems it's a not common knowledge i would say outside of the community just because you know as the general public when they watch the super bowl They're seeing MD Anderson's commercial come up on the big screen and not the community oncology practices. But you really kind of think about and peel back the onion in terms of how cancer care is actually delivered in America. It's really in this community that you're a part of. And to be fair and to be clear, we need those academic centers. I mean, there are things that I do not want to take care of up in my little community. You know, there Are rare tumors, or there are very young people, or There are very big complications, or Sometimes there are new therapies that we just haven't gotten yet. And so it's really important that it's an ecosystem, we are all part of that ecosystem, and every piece of it is important. But if all of the independent community practices left today, those hospital-based practices and the university settings could not handle the volume of patients. So that's why I say we're an ecosystem and we all need to try to figure out how we work together rather than, you know, I think that we're all important. I don't think that independent community practice is the only way to go. I think we need the academic centers and we need some of the hospital-based systems because if those close, then those areas aren't going to have access. And for me, the most important thing is that the patient have access, I feel very, very strongly that it should not matter where you live and that should not determine the kind of care you get. So whether you're in rural Mississippi or you are in Manhattan, you should have the same access or at least the opportunity to have the same access to quality care. We don't have that in this country right now, but it could be worse. That's what we don't want to have happen. Yeah, and if there were no community practices, it would be way worse. Way worse. Way worse, yeah. Well, you brought up the, you know, you said something about, you know, a lot of the newest therapies are at the AMCs, not in the community, but I know you spearheaded and, you know, that effort to bring therapies like CAR T and bispecifics into community practices so that they can get those, that type of care, you know, closer to home. Can you tell us a little bit about that? Like what has to be true for a community practice to be able to offer treatment like that? Well, I think one is you have to have physicians that are willing to do it. I mean, these are complicated therapies. They require a lot of intensive monitoring and you have to have a playbook and a plan in place. I means that you can't just sort of say one day, okay, we're going to do CAR T. You can't do that. So you really have to have a plan and place. But one of the things that's really concerning to me is if you look at CAR T, which can be curative for some cancers. So this isn't just like a fly by night kind of thing. This is curative, proven to be curative. Out of, if you take 10 patients that are eligible for CAR T therapy, like they've already gotten through all the eligibility, only two out of those 10 are getting it. And part of the reason is the access. Folks in certain communities are not going to drive, you know, more than an hour to go get therapies like this. And so we have to figure this out. I'm really very proud of Tennessee Oncology. We do have a CAR-T program. We actually just had our review for FACT accreditation, which is FACT is an accreditation that you get for like bone marrow transplant. And it is really sort of been a bane of our existence. And I'm now speaking as co-CMO because FACT Accreditation has been one of the things that's been a hang-up to community practices being able to stand up a CAR T program because many insurers will not pay for a CAR-T procedure or treatment if you're not FACT accredited. Well, you can't get FACT-accredited until you've done at least five CAR-Ts. So it's sort of a chicken and an egg. Cash 22. Yes, but it can be done. Again, you have to really be thoughtful about it. You have to think about how you're going to monitor these patients. You have to have the capability of those patients being able to come in on the weekends, you know, extended hours and other things, but it can be done. And more and more practices are looking into doing that. I also believe this is very similar to lots of other things. So if you, if you go back in time, 25 years ago, we were, well, 25, 30 years ago, we were giving things like Taxol in the ICU because when you give Taxol, you can have an allergic reaction. We would never think about giving Taxol on the ICU. It's something we give every day. And some patients get it weekly. So I think that's kind of where we are with CAR-T and then another type of medicine called Bispecifics, which is another type of immune modulated medication that also requires intensive monitoring. And so I think it's sort of one of those things that once we get there, we'll be fine. There's another medicine called Rituxan when, and I was, I was a baby doctor when it first came down and we, we did, we gave it to people in the ICU because you could have these horrible reactions. We would never think about doing that today. So it's really kind of like right now we have this endeavor, Pat, who's one of my dear friends at Texas Oncology says this all the time. You know, it's like we have these Ferraris, but we don't have the road to drive them on quite yet. But we're building it. So we're building it as we're driving. Yeah, she said that on my podcast. Oh, yeah, I quoted her. It's true. That's it's it'S so very true. Yeah. And I think it really speaks to the constant challenge of running a community practice, right? As these medicines evolve, you need to figure out how do you evolve your clinical operations to make sure that you're able to support patients on that and shorten the life cycle between when the science emerges and when the patient actually delivers that care. There are studies out there that say it takes 10 years for something to become known to be life-saving to a patient and for patients to actually get it as part of the standard of care. I mean, it's crazy to me. Yeah, for sure. I mean, that's true. That's that's this whole idea that, you know, that's a little plug for my husband. This is what his mind works on all the time. He's an implementation science scientist. Like that's what he likes to figure out. How do you you know you've now got this great therapy? How do you get it into practice? Or you found out this therapy is terrible. How Do you get out of practice? And I think that we are slow to do that. I think in oncology, we're a little better just because there's so much riding on it. And again, even to that point, if you think about Daraxarib, I don't know if I'm saying it right, but the pan-KRAS drug for pancreatic cancer, I mean, within days of the ASCO presentation, Tennessee Oncology had the EAP program up and running. I mean I have a patient on it, we can do that and do that very, very quickly. It's just For some of these newer therapies, newer modalities, we have to have, you know, monitoring in place more than, you know, checking in with patients, you know, during office hours. Yeah. I mean, that's the most infuriating thing to me. Like, I hear instances like this every day and, you know, the oncologist that I talk to all the time tell me about, you know, instances where they see this where they're like, wow, like, it's really just this kind of gap between the science that exists and the care that's delivered. And it's because a community oncologist, they're not a subspecialist in a very specific type of cancer. They see prostate cancer patient in the morning and then a lung cancer patient. And there's 88 guidelines that they keep up with and they change over 200 times a year. And so it's like, how do you keep up with all this stuff? And I think there's this really interesting kind of opportunity to use technology to really help close that gap and to raise the floor of the type of care that patients are getting. And that's hopefully what we will be able to do together with DeepScribe as the product evolves. Right. Yeah, for sure. So I know the one thing that we haven't talked about yet, but you spent a lot of time on, is on policy. And you're very vocal in some of the really important kind of regulations that are happening, you know, on the community. You know, you have 340B, you've got the IRA. Can you share a little bit about kind of what you're working on? Sure. So right now is comment letter season. Basically what happens in that, you know, during the recess, a lot of the senators may have legislation they're interested in and they'll put it out there and ask for comments. They call them RFIs, request for information. Um, same with, um, July, we had the proposed rule for the outpatient, um. Facilities for hospitals. And then we had The Proposed Rule for what's called the Physician Fee Schedule. And there's lots of detail in these. It is, if you want to go to sleep, um... You could go to bed with them. They're very long. They're Very tedious. And I did have my friend, Chat, um summarize both of them for me, which helped. so that I could get the, you know, just get an outline. I did read them, but I also did that. We're working on all of those things. I think the thing that keeps me up at night mostly is some of the unintended consequences of the IRA. And there are two big ones that I think are not well understood. And I want to be very clear. I think what the IRA intended to do, and the IRA does not the Irish Republican Army, It's the Inflation Reduction Act. But the Ininflation Redduction Act that was passed, the idea was that we would we being the United States would negotiate drug pricing commiserate to what folks in Europe or Japan, you know, or, you know, China pay for the same product, you know, because what's happened is all this R and D and all of this stuff has kind of fallen to the backs of, of the U S because we're paying a whole lot more than some of these other countries. And I think that is very, very valuable. I thinkthat's something that we should be doing. And I believe COA believes, and I know COA beliefs the same. The problem is that there's two problems. One is that as you start to negotiate prices, which is what's going to start to happen. So it's already happening for some drugs. In 2026, there were five drugs. And then in 2027, there's some more. Those are mainly oral drugs. And it's hit oncology a little bit, but not terribly. But in 2028, they start to initiate IV drugs, which are part of part B. So oral is D, B is the IV. And when that happens, there are some drugs that are going to be negotiated. And when they negotiate, what they do is they negotiate down typically anywhere from 35% to 60% off the retail price or the average sales price. Currently in oncology, we get paid for that drug, average sales prize plus, quote, 6%, which is really not 6%. It's 4.3% because of sequestration. So that's what we get played. The reason that's important is we buy those drugs before. So what can happen is, let's say in 2020, December of 2027, I buy drug A at the average sales price. And now I'm going to infuse it in early 2028, and it's been negotiated. And And what happens with the difference at the moment between what we buy the drug for and what we sell the drug for, that margin, if you will, that money goes toward our nursing staff. It goes toward the pumps. It go towards the, you know, all of the overhead, whether it's the lights on, the computer system, the shipping, the storage of these drugs. So it's not like it's going in my pocket. It's going back into the overhead and the cost of making sure that we are able to deliver these drugs. So if that gets cut by 35% or 60%, we won't be able to do that very long. That's part of the problem. And there's some fixes that are out there that we would like to see happen, and Congress can do that. It's just, everybody knows that at the federal level, things are a little sticky right now. What do you think should happen? Is it like a rebate that that occurs? So there actually is a bill in the House that's been introduced that's likely to get marked up in September. Dr. Greg Murphy is the author of that bill. We do have bipartisan support. And basically, that's exactly what happens is what they have said is that we will be able to still do buy and build the same way we always have. And what would happen is that the pharmaceutical industry would negotiate the price and whatever the difference between that ASP and the negotiated prices, the pharmaceutical company will rebate CMS directly. So it just kind of takes us out and it, you know, holds us harmless, keeps us whole. And there is a Senate bill, but it has not been introduced yet. We're still working on that. That would be, it's called, it is an IRA technical fix. It is not changing anything else. It's just make it's the rebates going to go to CMS directly, which would be great. The other problem that happens with, which is a very big unintended consequence in oncology is that because the life cycle of these drugs is no longer as long as they used to be, you know, they can get negotiated earlier, then there are certain, so one of the things that happens with oncology drugs is that, you know, if I have drug A and I'm going to, I've done this big study and I show it works in lung cancer, it gets approved for lung cancer. Well, the money I make from that, I may put back into R&D and look at it in breast cancer or colon cancer or in pediatric tumors or in sarcomas or things that are very rare because I have the money to do that. If I don't have the money to doing that, there is a risk that we will not see some of those add-on indications and some of these at-risk populations that are like orphan status, for example, sarcoma, pediatric tumors may not ever see the opportunity to see some of these really cool drugs. And again, I don't think, and I don' t know what the fix for that is, but I don''t think that was the intended, I dont think anybody intended that when they developed the IRA. And I, again, think we want patients to pay less, we want the U.S. to pay less, but we''ve also got to protect our intellectual property. Because the scary part about what I just talked about is that if we don't do it, there is a country that will do it. And in that country, I'm not entirely convinced that they are going to have the same standards in terms of data quality the way we do. In fact, we've known that. We found that out from a couple of, there were, there was a vaccine study, a cancer vaccine study that was published by China and come to find out it was all fake so you know again i what we don't want to do is to see some of what we we have been you know we being the united states we have ben the on the cutting edge we have been the main people that are shepherding all of these new and novel innovative therapies we don t want that to go to china that would be terrible for us and it s it is happening it will continue to happen unless we do some sort of fix. And you're seeing it already with the clinical trials, right? A lot of them are going to Australia. A lot of them aren't going to China. And it's really because the regulatory process to get a new drug approved in the U.S. is just so arduous. That's right. It's much easier to get kind of evidence elsewhere that have less stringent requirements around that. But if you don't have stringent requirements, then you can have data that's published that's not true. Not true. Exactly. And then you harm people and that's scary. Yeah, I think from a patient's perspective, right? I think when, you know, a lot of patients read the news about the IRA or 340B, they're like, that doesn't apply to me. Oh, it does. But, you Know, I Think from a Patient's Perspective, I Don't Think They Realize The Real Impact That That Will Have To Access. Yeah. They Won't Realize the Real Impact That's Going To Have To New Therapies Being Developed label expansions from one drug that works to other disease areas um to your point and you know this is you know really important a really important topic not just for the oncology community but for patients and we are ai community but you know we're all patients and well this is gonna affect everybody yeah but even i mean just for your i want to touch on two things for sure but just for your you know your industry you know one of the things that people are really upset about are data centers. Well, guess what? To have AI, you got to have a data center. And there are ways to make data centers, build them where it is sort of eco-friendly. You can have water that's recycled. You can make sure that those data centers are propping up their own grids. You Can Make Sure That They're Giving Back to the Community. In Memphis, there's actually a data centre that has generated, I think the community was only getting like $500,000 a year in tax revenue, like net they're now 3.5 million because of a data center that's there because the data center is required to give you know not only taxes but other things to the community and their property taxes have all gone down well that's so cool right but i think that that they've gotten a bad rap because they can be built in a very horrible way that completely destroys the environment but if we don't build them here and do it in a really good way guess who's going to build them and they're not going to keep up the environment. So I think that's, that's again, I think you can't just say I'm not for data centers or I'm just only for the IRA. I think you've got to look at it in a more holistic way. And you mentioned 340B and I also want to make it very clear. 340D, when it was developed, its intention was very, very good. It was to really safeguard these clinics, not hospitals, but clinics that were serving these underserved populations, and they wanted to make sure that these clinics still had access to these medicines, and so they were allowed to buy medicines at such a deep, deep discount. But I can tell you right now, I don't think that Beverly Hills Hospital is an underserved area, and neither is New York Presbyterian. So I think we just have gone off the rails. Yeah. I mean, I think with a lot of these things, we spoke earlier, even something as little as a click box inside the EHR about smoking cessation starts with, you know, well-intended things, right? Right. But, you Know, as the world evolves, as things change, I think it's so important for us to re-interrogate some of the things that we've done in the past and not just think about the decisions we've made as, you Now, things that always are true or always are the best way to do things because, You know, I Think one of the Things that the world is teaching us right now is that a lot of the assumptions are being reset, right? Like even in our own approach, building technology, a lot Of these assumptions are reset, right? The typical product process was designed around, you know, engineering being the most sacred resource. And, you know, and now that it's not everyone, you know, I live in San Francisco, everyone in San Francisco is like, how do we run product teams? How do we think about engineering? How we think about design and it's it's really in my opinion refreshing to see because it's almost this kind of like forcing function i i think like during covid you know as horrible as covid was covid really was a forcing function for health care to really kind of rethink a lot of the way they were doing things yeah right and out of covid happened you and i would not be here yeah to be honest i mean i think i think that covid is what put health care it pushed health care to start to think about technology because we had to move to telemedicine exactly we had to we you know there wasn't another way to do that and we hadと rethink a lot of things because of covid so and i think technology was one of the bigger things we had то use yeah but let's not wait for another horrific event like covid to happen right we had this amazing new technology called ai you know come to the market now and i think that's really kind of like a forcing function for us to rethink a lot of the things that we're doing so agree agree yeah for sure i know we're almost out of time and i always like to end you know our conversations with Kind of like a two-sided question. That's scary. I'm curious, like, if there was one thing that you wished more oncologists understood about technology, what would it be? And vice versa. Like, what Would you wish technologists really understood about oncology that they probably don't today? Wow. So in terms of the oncologist understanding about technology, it's not as simple as a plug and play. I think that many oncologists, you know, many doctors, what we understand how kind of understand how to use our phones and the laptops. I think the younger generation are a little bit better than, than some of us, but it's not as simple as saying, Hey, Matt, um, you know, I don't like this blue. Can you make it green for me? Because that means a coder has to go back and code for that color. Um, and, you Know, basically it's a coders coding every single step in this process. I don t think that, that doctors really understand that. Um, so while yes, AI can make our life easier, sometimes changing what's already there is not necessarily as simple as the ask, although it can be done. It's just not always that simple. Um, because if the coder didn't say, well, you can have any color in the rainbow, you just have to plug this letter in to get your, your color. Then you got to go back and recode it, um, to make it do any color in the rainbow. And then in terms of coders or in terms of AI folks, what they should understand about doctors is that we are very regimented people. We're regimented. We are, most of us are type A. We don't like change. And, you know, for us, sometimes trying something new in a clinic is just a, it's just a nuisance. It's like a little bee buzzing in your ear because now you're now you've disrupted my workflow um and so when you have the opportunity to introduce something new making sure that you've got a couple of champions that have already kind of figured out the kinks know what the what the pain points are going to be and how to answer those i would say awesome i couldn't agree with you more i think you know i work with a lot of oncologists and they are very regimented for sure. And they won't listen to me, but they'll listen to their peers that are oncologists. And sometimes they'll probably listen to the person that they wouldn't have thought would adopt technology the most. That's why Larry has me as his guinea pig because I'm old. I'm regimented. I don't like trying new things, but I will. Well, Dr. Blakely, I want to thank you so much again for your time. And I really enjoyed the conversation today. And I'm sure the audience will learn a lot from it. Well, thanks for having me. I appreciate it.