135 Digital Diagnostics and Therapeutics in Pediatrics, Promises, and Perils.

Drs. Braham, Rogu, and Bravo have a fascinating real conversation about Digital Therapeutics. The intersection of digital innovations in pediatric healthcare with a focus on diagnosing and treating autism using AI technology like Canvas DX. It delves into challenges such as scarce specialists, early intervention's significance, regulatory processes, and the evolving role of pediatricians. Additionally, it addresses broader healthcare challenges, including insurance reimbursement complexities, policy considerations, and the pivotal role of collaboration and equity in improving patient outcomes. Dr. Sharief Taraman is the CEO of Cognoa, a leading pediatric behavioral health and data company developing AI-based technologies to enable early and equitable diagnosis and care for children living with developmental and behavioral health conditions.

00:00 Welcome and Introduction to Pediatric Innovation Sessions

00:33 Introducing Dr. Sharif Taraman: A Journey from Pediatric Neurology to Health Tech Leadership

02:28 Exploring the Brain's Complexity and Digital Therapeutics

04:21 The Evolution and Impact of Digital Diagnostics and Therapeutics

07:05 Navigating the FDA Process and Addressing Pediatric Research Challenges

14:01 The Real-World Application of Digital Health Tools in Pediatrics

20:51 Addressing the Challenges of Pediatric Healthcare Delivery

26:36 The Future of Pediatric Care: Digital Solutions and Systemic Changes

32:24 Advocating for Early Prevention and the Role of Primary Care in Pediatric Health

40:01 Understanding Care Coordination and the Importance of Early Detection

41:13 Exploring the Multifaceted World of Care Coordination

43:10 The Impact of Insurance in Care Coordination

44:28 Navigating AI and Bias in Healthcare

47:48 Innovating Autism Diagnosis with CanvasDX

52:19 Challenges and Solutions in Medicaid Coverage

01:05:37 The Future of Pediatric Care and Digital Health

Transcript

Digital Diagnostics and Therapeutics in Pediatrics, Promises, and Perils.

[00:00:00] Dr. Bravo: Good morning, George. It's great to see you. This is the afternoon. How are you doing? I'm 

[00:00:04] Dr. Rogu: doing great, Herb. Today we have a special session on the Pediatric Innovation Sessions that's going to be run by Dr. Sabrina Brum. And today's guest is Dr. Sharif Taraman. And the topic of discussion is going to be a very interesting one.

[00:00:22] Dr. Rogu: Digital Diagnostics and Therapeutics in Pediatrics, Promises, and Perils. Take it away, 

[00:00:29] Dr. Braham: Sabrina. Thank you. Good to be here, guys. So today we have Sharif Chariman. He is a pediatric neurologist at the Children's Hospital of Orange County with board certifications in both child neurology and clinical informatics.

[00:00:44] Dr. Braham: In addition to his many pediatric leadership roles he currently serves as CEO of Cognoa, a digital health company that has created Canvas DX, which is the first FDA authorized AI based software assisting in the diagnosis of [00:01:00] autism. CanvasDX utilizes a machine learning algorithm that incorporates input from patients sorry, from parents, caregivers, video analysts, and healthcare providers to provide to support clinicians in assessing a patient's risk of the disorder.

[00:01:17] Dr. Braham: So welcome, Sharif. We're really excited to talk to you today. 

[00:01:20] Dr. Taraman: Pleasure. Thank you for having me. So 

[00:01:24] Dr. Braham: we always like to start with your journey, your story. So let's open with what made you become a pediatric neurologist and how did you end up becoming the CEO of a health tech company? 

[00:01:36] Dr. Taraman: Thank you. So if you don't know, my daughter was actually born the first day of med school.

[00:01:40] Dr. Taraman: So I think I was automatically primed to become a pediatrician. And then in a former life, I've actually had many former lives. I think I've reinvented myself at least a dozen times. But I actually was in it and, Worked at Ford Motor Company and did databases and cool stuff like that before I went to med school.

[00:01:58] Dr. Taraman: And so I've always been this kind of tech [00:02:00] key person and a neurology is all about wires and computing power. That's really like what the brain is. And so I just had this great affinity towards neurology. And like Anthony Chang always says, don't let anyone tell you can't do more than two things.

[00:02:14] Dr. Taraman: And innovation comes when you combine two things. And for me, it was. Pediatrics, neurology those are my first combinations, then pediatric neurology and information technology and AI is my second sort of invention, reinvention and innovation of myself. So I have a question. 

[00:02:30] Dr. Bravo: I have a question. I'm kidding. But you say that the brain is full of wires like a computer. Where is the off on button to reboot it when it doesn't work? 

[00:02:43] Dr. Taraman: So actually it's really interesting. Sleep is probably when you reset it's like the nightly reboot of the server is actually during sleep. And there's this really interesting thing this theory of Scaffolding temporal scaffolding that happens in the brain where you're actually like [00:03:00] reprocessing everything that you did as a reboot reset that happens during sleep.

[00:03:04] Dr. Taraman: And we're actually learning from neuroscience, how to make AI better. And one of the interesting things, and this was out of, I think, university of Rochester, they're looking at this temporal scaffolding hypothesis of resetting the brain. And doing low power computing and seeing how can you apply that to AI and actually do the same thing.

[00:03:23] Dr. Taraman: But anyways 

[00:03:24] Dr. Bravo: very cool. I thought it was electric compulsive therapy, but that's 

[00:03:28] Dr. Taraman: also a good that's like a defibrillator for the brain. 

[00:03:31] Dr. Bravo: There really is your reboot nothing's the blue screen to death and just. 

[00:03:36] Dr. Taraman: There's some cool, there's some cool tech we're getting way off topic, but I love it. That's the point of the show, right? Some really cool tech of like responsive neural stimulators to reset seizures. So when you see abnormal electricity, In the brain, which causes an, a convulsive seizure or an epileptic seizure you can actually send an impulse and disrupt that just like a defibrillator does in the brain.

[00:03:58] Dr. Taraman: So it's a different type [00:04:00] of electroconvulsive therapy. It's focused and it's just to reset that abnormal pathway that's coming. There's a lot of other cool stuff. I'm happy to talk about way off topic. Maybe it's a different podcast. Actually, I 

[00:04:13] Dr. Braham: think that's perfectly on topic because I think what you mentioned is an example of a digital therapeutic, right?

[00:04:19] Dr. Taraman: In a way, yeah. So it's a, it's so digital therapeutics and digital diagnostics are this kind of just new emerging area. But it's not that different from like just regular medical devices in some ways. So some of these are like hybrid where there's a physical device, like the RNS is a physical device, but then uses an AI algorithm to detect and interfere with the signal that's coming in.

[00:04:44] Dr. Taraman: We 

[00:04:44] Dr. Bravo: have some experience with that. I guess the people in pediatrics are most advanced on that are the people that treat diabetes, right? With continuous glucose monitoring and then the machine knows an [00:05:00] algorithm knows how much insulin to release. So that's been around for a while. They're probably the furthest ahead in the pediatric world.

[00:05:09] Dr. Bravo: Yeah, that, 

[00:05:09] Dr. Taraman: and probably the other ones are, there's a lot of really cool work being done in like the radiology and cardiology spaces as well. And then everything that I'm going to talk about is always going to go back to neuro space. So sorry, it's neuro Ben. It's the one that's the most fascinating to me.

[00:05:26] Dr. Taraman: All right. 

[00:05:28] Dr. Rogu: So keep going. 

[00:05:29] Dr. Braham: So on that topic, how do you, can you help us understand the scope of what a digital diagnostic or therapeutic is, how you think about them and how they're currently being used in the pediatric 

[00:05:39] Dr. Taraman: space? Yeah, so I actually like to start maybe at the higher order like the animal kingdom, so that the animal kingdom is digital in general, right?

[00:05:48] Dr. Taraman: And I think that there's a lot of misperceptions or misunderstanding around digital, because everything really is digitized now in medicine, with the exception of, people that are still on paper, unfortunately. [00:06:00] And so this concept of oh, digital health doesn't need to be scary because we've digitized everything.

[00:06:04] Dr. Taraman: We digitize our electronic medical records. We digitize our EEGs. Our radiology is not on film anymore. It's all digital, right? So there's this kind of just digital undercurrent that's happening in healthcare and it's just part of, technology advancing. And then under that subtopic, there's all kinds of digital applications. which could include, monitoring, could include wellness applications, types of things. And then the FDA under a regulatory classification actually created software as a medical device. Specifically, if you are going to either diagnose or treat using a digital you know, technology that actually has a regulatory category to it, which is called Sam D or software as a medical device.

[00:06:51] Dr. Taraman: And it's a little bit different than these clinical decision support tools, which are like helping me think about how to help a patient in a digital format, which [00:07:00] is also a regulatory or regulated class of devices as well. And 

[00:07:05] Dr. Braham: so when you're talking about digital diagnostics and therapeutics, are you speaking specifically about FDA regulated interventions whether they be devices or software based or software informed devices?

[00:07:17] Dr. Taraman: Yeah, so that, that's probably the safest way to talk about these things. Again, if it's a, if it's truly a digital diagnostic, if it's truly a digital therapeutic, just given how we operate in the world of medicine and the medical legal world, Aspects of it. Those things really should be regulated.

[00:07:33] Dr. Taraman: And the reason that you have regulation is for patient safety because you want to make sure two things. So is this device safe and is it accurate, right? That's what the FDA is looking at primarily not to speak for them because I'm not part of the FDA. But that's generally how we got. Think about them. 

[00:07:48] Dr. Taraman: And then everything else in that digital space It's something other than a digital diagnostic and digital therapeutic, and they have their applications and they have their place, but they're distinctly different than a [00:08:00] diagnostic or a therapeutic. Can you help 

[00:08:02] Dr. Braham: us understand the FDA process a little bit?

[00:08:05] Dr. Braham: Because that features prominently in how companies like Cognoa and other digital therapeutic companies are are coming to market, right? Because it's an expensive and time consuming process. 

[00:08:17] Dr. Taraman: Yeah, absolutely. I think it's an important one, though. I think, I, as a clinician who, many of us are kind of skeptics, I don't know if I would necessarily adopt something that was trying to either diagnose or treat something if it had not gone through the regulatory process, right?

[00:08:32] Dr. Taraman: Now, that doesn't mean we don't use things off label in pediatrics, especially in pediatric neurology all the time. I would think almost 70 percent of my practice, unfortunately, is off label. Clinically, because just nobody experiments quote unquote in Children, right? They haven't invested in doing the clinical trials and that's an overarching bigger issue that we have in medicine right and that and it leads to this kind of concept of bias.

[00:08:57] Dr. Taraman: So what we're doing is we're not only biasing [00:09:00] the Children because we didn't test these things in a pediatric population, and there's a lot of really good efforts. Bassoon Paris, who's the head of special populations and pediatrics at the FDA on the device side of the A house is really helping, try and equalize that and really encourage companies to say, Hey, you know what?

[00:09:20] Dr. Taraman: I don't want to just make this thing for an adult population. I actually do want to help kids or I need to design something for a pediatric population. But even more so this one, we're excluding pediatrics from our research studies. We're excluding pediatrics from our device development, unfortunately.

[00:09:34] Dr. Taraman: As a theme, and then it's either further compounded because females are underrepresented, minorities or minoritized individual groups are underrepresented, or low socioeconomic status is underrepresented. And then, even in our U. S. population, we have a really bad tendency of not including the indigenous population in our studies.

[00:09:55] Dr. Taraman: And so if you create a device, regardless if it's digital or not, or even [00:10:00] just research in general, because people always talk about bias in AI, but our research just in general is biased across the board. But there's 

[00:10:10] Dr. Bravo: some good reasons for that, right? Can never be pregnant. So if you're going to study a new drug on me, you don't have to worry about harming an unborn child.

[00:10:22] Dr. Bravo: So it's not just an inherent bias or I don't want to study drugs in women. If I want to study drugs in women between the age of 14 and 45, there is a risk that one of these is not going to follow the protocol and is going to be pregnant. And then we realize that this drug unfortunately causes some malformation.

[00:10:43] Dr. Bravo: And it's a disaster. The same thing happens in pediatrics, although I would love to see more research in pediatrics. The truth is the child is a developing, evolving human, and the adult is more [00:11:00] static. And so sometimes we don't want to take the risk of putting a medication in the body that's still growing, a brain that's still developing.

[00:11:10] Dr. Bravo: There's a lot of inherent risk when we do that. And we are all, especially pediatricians, inherently risk averse, right? And the industry is even more risk averse. The last thing I want to do is study a drug in children first and figure out that it delays their development or ruins their brain in some way.

[00:11:33] Dr. Bravo: It's tough questions and obviously we want to have more data and we want to be inclusive. However, we have to be very mindful that our efforts to be inclusive. does not cause undue 

[00:11:46] Dr. Taraman: harm. No, absolutely. I actually heard this as a great conversation because what we're seeing is this push both on the clinician side, but also on the regulatory side to actually do and use real world data.

[00:11:59] Dr. Taraman: So again, [00:12:00] most of the drugs that we use in pediatric neurology, never tested in children, never approved in children, but guess what? We're dealing with kids with infracted refractory epilepsy and you've, you use the ones that are FDA approved. And then you're like, Oh my gosh, None of those are working, so then you go to your non FDA authorized drugs and you start working on them.

[00:12:19] Dr. Taraman: Just a fun fact, by the way, Phenobarbital has never been approved by the FDA. It was grandparented in because it's so freakin old that nobody actually looked at it and said, Is this FDA authorized. It's not. Any kid you put on phenobarbital, any time a pediatric neurologist puts a kid on phenobarbital, they're using it technically off label because it's never been authorized by the FDA 

[00:12:41] Dr. Bravo: or approved by the FDA.

[00:12:41] Dr. Bravo: I'm gonna misquote this, but I think Tylenol was not studied for management of fevers. It was only studied for pain management, and we've been using it off label for 50 years. 

[00:12:55] Dr. Braham: But, and as an aside, what is the incentive once something on the [00:13:00] market, when something is already on the market, like phenobarbital, to collect real world data in children so that we can better understand both efficacy and side effects?

[00:13:10] Dr. Taraman: So this is one of the projects, yeah, this is one of the projects that American Academy of Pediatrics is working on. So I serve on one of the committees that's helping develop the child registry, and that's, the intent of that is really to be able to collect national data on children so we can understand, especially things that are more rare, better, and get better population health information and understand, are there groups where this medication or this device works better in or doesn't work as well in, and, even thinking about AI algorithms, we have to be very intentional, Herb If you train up an algorithm, especially in the space that I'm working in, if I train an algorithm on a population of people who all live in, I don't know, Boston, let's say, and then I try and apply that to a California population, it's less likely to work just given just [00:14:00] diversity.

[00:14:01] Dr. Taraman: I've actually trained up algorithms at the Children's Hospital, and we can actually test it in like a pseudo environment at other Children's hospitals and a data set that we have access to. And I can actually see, but if this Children's Hospital X, it does not work well, and the reason it doesn't work well is the population is different.

[00:14:19] Dr. Taraman: Yeah, 

[00:14:20] Dr. Bravo: it's fascinating. I live in Northern Virginia and it's not San Francisco, but, here the stratification of the population is by income and education, but you could be having dinner chicken curry with AI one night. And then the next day you'd be maybe eating dinner with a Mexican doctor that's giving you tacos.

[00:14:47] Dr. Bravo: And then you go to other areas of the country, and they're either all, more Latino driven, Texas and California, certain areas, or they may just be just [00:15:00] white, rural, and each one is so different. It's hard not to crack. 

[00:15:06] Dr. Rogu: Yeah, that's why in the past I'd seen clinically, when they came up with something, a vaccine, a medication or whatever it is.

[00:15:13] Dr. Rogu: Yeah. They first studied it, they put it out for adults, they use it for a number of years in adults. Then they brought it down to older children, teenagers. Then they brought it down to younger kids. Then they brought it down to little kids and little infants after it's been used for many years. Do you know the scopolamine patches?

[00:15:33] Dr. Rogu: That's not approved for less than 18 years of age, yet I've seen it being used on children that has cerebral palsy to help with the secretions because it dries your mouth. 

[00:15:43] Dr. Taraman: But also think about but there's also as much as we're risk adverse as pediatric populations are in action is an action and there are children who are dying and there are children who are not benefiting because we are not deploying something that's a solution that is available [00:16:00] on the market because we have a fear of, like again, at some point we have to stop practicing paternalistic medicine and we have to really start engaging families and saying, Hey, look, here's an option for you.

[00:16:11] Dr. Taraman: This is what I know is risks or non risks. These are, this is the, the status of this thing, right? And you have some, shared decision making capability with these families. And honestly, like I've seen this in the rare disease space and it's super frustrating where, they're like, oh, do a bigger clinical trial.

[00:16:30] Dr. Taraman: To approve this thing. And it's I got kids with Barth syndrome who could benefit from a medication, but it's not been approved because we can't recruit enough patients for the trial. So yes, I'm all about let's study stuff and get it regulated and through. But also I think we have to be realistic and say, sometimes it's not going to happen and our inaction is also an action and we have to do what's right for families or at least offer, treatment options.

[00:16:58] Dr. Bravo: So you remind me of Dr. [00:17:00] Paul Offit, who says the cruel, the cruelty of the double blind study, which is, that's the standard of how we figure whether something works. But it's really cruel when you have, a chronic disease or a life ending disease or a disease that deteriorates your brain, your capacity to live life fully.

[00:17:20] Dr. Bravo: And you get put on the placebo side and you die before the study's completed. Armed and does get the intervention shows our improvement. 

[00:17:33] Dr. Taraman: Especially for rare diseases. Natural history. That's really hard. That's really hard. Paul's right on Paul. Paul's got down. Yeah, I saw his podcast with you all.

[00:17:44] Dr. Taraman: Thank you. 

[00:17:45] Dr. Bravo: And then, science changes. When we look at what diabetes is today, type one diabetes and what I learned in medical school is totally different. Yet there's a tremendous pushback on the pediatric community to [00:18:00] start screening children because we simply don't have time and we don't know how we're going to get paid if we kept these kids that test positive and we don't exactly know when they're going to be insulin dependent and it's such a It's just what you said.

[00:18:17] Dr. Bravo: I look at it and, Barbara Davis can get a kid diagnosed before they require insulin, before their glucose gets elevated, educate them and prevent decay 90 percent of the time. And it's in the research field. It's not such a rare disease. It's 1 in 300. And yet, it's not in the exam room. So all these things you're talking about and again to what you're.

[00:18:44] Dr. Bravo: Alluding to who's at highest risk, the very young, the people of color, and those are on Medicaid, the most vulnerable population. So how we envision these things, not just from a technology point of view, [00:19:00] but how we maintain that balance of, I always tell people in the exam room, the difference between me and a witch doctor is that I read the journals.

[00:19:10] Dr. Bravo: I hope I get it right. It's true. If I read tomorrow on, I'm going to be mean, but slate or business week or the wall street journal that hyperdoses of vitamin D cure depression. I can't really do that in the exam or until I see that in a peer review article and feel like I'm actually still doing the right thing for the kid.

[00:19:35] Dr. Bravo: And I know a lot of these things do work because you see it when you send someone to a specialist And they do things that are not in a peer review article, but they work. It's a constant tension when it's difficult, because you are definitely leaving children behind. There's 

[00:19:53] Dr. Braham: a place, I think, where that starts to fall apart for me, and I think it relates specifically to digital health, which is that one of the [00:20:00] promises of technology scalable.

[00:20:02] Dr. Braham: And so if we're thinking about health equity, and we're thinking about being able to scale high quality interventions to All populations, that's something technology can do, but our current health system is not doing it, right? And so one of the things in the literature around evaluating quality of tools is what is the relative risk of implementing a solution or scaling a solution when the alternative is there is no solution, right?

[00:20:28] Dr. Braham: And so 

[00:20:29] Dr. Taraman: go ahead. Sorry, Sabrina. No, go ahead. No, I was gonna say you're hitting it right on the dot. And I think, having I know your Stanford X, design principles, right? This is important, right? We have to design for the patient, right? We have to do human centered design. And so really, some of the digital stuff out there.

[00:20:46] Dr. Taraman: I'm not gonna lie. It's Hey, I've got this shiny boy. Let me go find a problem and apply it. What we were doing at Cogno in the Oh, I never answered the question how I ended up becoming the chief medical officers, but I was the division chief of the [00:21:00] hospital and I have this huge wait list and I go, let me hire more neurologists.

[00:21:03] Dr. Taraman: And it's you can't hire enough specialists to meet that demand. And so I ended up meeting the founder. We were talking on a panel on artificial intelligence and neuroscience together. And I'm like, Oh, he's got a real solution to a real problem. Let me go visit him up in Palo Alto and see what he's working on.

[00:21:18] Dr. Taraman: The next thing you know, I was like, Oh, you're here to be the chief medical officer. But I think to your point, What we were trying to do with Canvas DX is do exactly that, which is scale it. So how do I make my specialist more efficient? Take an evaluation that takes three hours and two hours of charting, five hour ordeal and turn it into, distributed.

[00:21:37] Dr. Taraman: I can see rural patients, over telemedicine, and this can be done asynchronously. And the documentation gets all done for you automatically. And then also put a pediatric neurologist in every primary care, developmental specialist in every primary care pediatricians pocket so that they're not having to refer all the kids for a developmental evaluation or to get an autism diagnosis.

[00:21:59] Dr. Taraman: They can do it in a [00:22:00] primary care setting. And so that's, that's what Canvas CX does. It scales and it scales in a way that is equitable. Across the board, actually, I'm 

[00:22:09] Dr. Bravo: going to paraphrase something before you get into that, that I was told by a room full of bright positions. Okay. So now I use your tool to diagnose a child with autism and what I still don't have where to send them.

[00:22:23] Dr. Bravo: Who's going to counsel him? How do I deliver news to the parent? 

[00:22:27] Dr. Taraman: But you do, Herb, right? So look, pediatricians are really smart, bright people and very capable. And guess what? You're doing developmental evaluations all day long. You're just not getting paid for it. And you're giving parents advice all day long.

[00:22:41] Dr. Taraman: And there are a bunch of actually therapy places that you can refer patients to. There's a ton of resources in the community. So there is some education left, but you, So again, this is like saying you don't want to do ACEs screening because you don't want to, you don't know where to send the patient. I'm not 

[00:22:57] Dr. Bravo: disagreeing with you.

[00:22:58] Dr. Bravo: I'm just telling you what I was [00:23:00] told and I can tell you that in Northern Virginia and I use this example, and I'm tired of using it. Okay. We have National Children's Hospital, Hopkins, University of Maryland, Fairfax, University of Virginia, Medical College of Virginia, all within a two hour radius.

[00:23:20] Dr. Bravo: You cannot get a child into a developmental pediatrician or a pediatric psychiatrist. The mental pediatricians no longer even have a wait list. Yeah, they're closed So if I diagnose somebody with autism,

[00:23:38] Dr. Bravo: I'm like, okay Here's a list call see if we can find you a psychiatrist to manage your medications But it's at least six months out and here's a list Call, keep calling until one of the mental pediatricians will actually coordinate the care that you need for your kid. 

[00:23:59] Dr. Braham: And that's the [00:24:00] diagnostic problem, right?

[00:24:01] Dr. Bravo: The diagnostic is, now I know because I used this product, so I know this kid's likely got autism. Yeah, but I'm not trained to treat it. 

[00:24:09] Dr. Taraman: Why? You treat ADHD. I'm going to challenge you, Herb, and the pediatricians that you're talking to, which is, look, you send kids for speech therapy. If the kid has a speech delay, send them to speech therapy.

[00:24:20] Dr. Taraman: If the child has a behavioral issue, send them to behavioral therapy, right? You know how to do that stuff, right? And by the way, in the medical home, versus a specialist, right? You know how to treat constipation, which a lot of these kids have, right? What, why would we abdicate that responsibility out of our medical home?

[00:24:36] Dr. Taraman: And there are collaborative models that we can work with. To help primary care pediatricians manage a lot of this stuff and most kids on autism on who have autism or autism spectrum don't actually require medication because the only two medications that are FDA authorized are two atypical antipsychotics.

[00:24:52] Dr. Taraman: Respiral and Abilify, which, by the way, most of us on the specialty side don't want to put the kids on. So me, 

[00:24:59] Dr. Bravo: I have [00:25:00] a question for you. Why don't you want to put them on that because of the amount of side effects or you don't think they're very effective or you don't have experience 

[00:25:06] Dr. Taraman: with it? No, not the latter.

[00:25:08] Dr. Taraman: The first two, right? They're not really, they were never designed for these kids. And then secondly the kid has to have some really severe behaviors. Which, again, if you catch these kids early, guess what? They don't develop those really severe behaviors. There's really good evidence.

[00:25:23] Dr. Taraman: Not only does the amount of care that these kids need. The recent Boston Children's Study, by the way, nearly 4, it was 37%, 4 in almost every 10 children, when you get them early and you get them early intervention, speech therapy, OT, and behavioral therapy, They actually lose the diagnosis of autism, meaning that they no longer have such severe presentations that these kids actually do well.

[00:25:45] Dr. Taraman: So get them when they're 18 months, when they're 24 months. Let's not wait till they're four years old, which has been the average age of diagnosis for the past 20 years. And we're failing as a country because guess what? If you look at the 20, 30 people, healthy people goals. We're actually getting [00:26:00] worse.

[00:26:00] Dr. Taraman: Our intervention time is worse. We're like it's maddening. So let's not abdicate our responsibility to the specialists. We as pediatricians, and I put myself in that category, are very capable of managing, at least at a primary level, and just because we don't think we can treat doesn't mean we shouldn't diagnose.

[00:26:20] Dr. Taraman: Diagnosed, there's a lot of things you can do that doesn't need a pediatric neurologist or a DVP. It's because guess what? There's only 758 DVPs in the country, and I'm one of only 1, 500 pediatric neurologists. 

[00:26:31] Dr. Bravo: That's true of neurology, behavioral pediatrics, endocrinologists. The real, and this is why I think Sabrina is a big voice, and I think this is what you're doing a great job at, is trying to get tools, in the digital space is one tool to be able to help diagnose people quickly.

[00:26:51] Dr. Bravo: But there is a reality in the community, at least in Northern Virginia I don't, I've never practiced in California, but in Northern Virginia. [00:27:00] To get somebody to a good therapist if they don't have 250 a week, even when they have 250 a week. And I know the therapist because I worked with them before.

[00:27:16] Dr. Bravo: They're just like, Herb, I can't help. I'm booked solid for six months. I would love to finish the educational evaluation of this child and write the IAP and call the school, all those things that you think are needed. And the parent's I got the 5, 000, I'll pay for it, which is not most parents.

[00:27:38] Dr. Bravo: They're like, They're gonna have to 

[00:27:40] Dr. Taraman: wait six months. But Herb, you're hitting also a really great point, which is this population health level thing, right? Yeah. So if we look at your developmental centers across the United States, all the autism centers, and you go do survey, and you ask them how much of your resources are you spending on diagnosis versus treating the kids?

[00:27:55] Dr. Taraman: It's all diagnosis. It's 85 percent diagnosis. It's totally backwards, right? [00:28:00] Let the pediatricians, which is, by the way, one of the top resolutions last year of the AAP, diagnose the autism, free up the specialists so that when you have the kid that's complicated and you're like, I'm at my wit's end and they need medication, which is again, maybe 15 percent max.

[00:28:16] Dr. Taraman: Or, Hey, this kid's really struggling and they're not responding to therapy. Then, on the specialty side, rather than us using 85 percent of our resource on diagnosing, we can actually refocus on treatment for the kids. Hold 

[00:28:29] Dr. Rogu: on. Hold on. Hold on. I 

[00:28:31] Dr. Bravo: haven't been talking to her for so much time. Everybody under your desk.

[00:28:36] Dr. Bravo: I'm 

[00:28:37] Dr. Braham: your general pediatrician, 

[00:28:42] Dr. Rogu: I have a lot of experience. I can walk into a room, do an mchat, look at the kid, ask a couple of questions and probably be really darn close to say, yeah, I think this kid has autism without any scientific anything, just gut feeling, but that's not good. And then you have to send [00:29:00] them over to a neurologist who in New York will not see them.

[00:29:03] Dr. Rogu: You have to get them to early intervention services, who you'll probably get some psychologists, social workers. They'll do a whole bunch of screening tests and then they'll come up with the diagnosis. They'll spend a whole lot of time on it, and then they'll set them up for early intervention, speech therapy, psychological therapy, all the therapies that the kids need.

[00:29:19] Dr. Rogu: And yes, I have seen it help children a lot. We don't have diagnoses at four years of age. We have them at two, 18 months. It's a little bit early, you can see it. But I don't think a general pediatrician is going to be able to break the news to a parent. Your child has autism in 50 minutes.

[00:29:43] Dr. Taraman: Don't push back on that, but it shouldn't be in 15 minutes, right? This, but this is how we made the tool, right? So you say, Hey, look, I'm worried about your child's development. Let me have you do this FDA device, right? That's going to help us figure out is this [00:30:00] autism or some other neurodevelopmental disorder.

[00:30:02] Dr. Taraman: You're going to get the results, not going to be shared with the patient. Now, Hey, look, I got to spend, I'm going to schedule this kid for a 30 minute visit or an hour visit. If you really know that the parents are going to struggle with this. And then you do it at the end of the day and you bill on time, right?

[00:30:17] Dr. Taraman: And you say, Hey, look, I, we have this tool, but, and by the way, because now the parents engage and they have a relationship with you, you're more able to give that diagnosis in a way that they're going to respond positively to, and they've been engaged in the process versus go see a specialist, wait 18 months.

[00:30:34] Dr. Taraman: Drive maybe two three hours to go see that person the kid shows up And then they're acting differently because they're hungry and they're tired and they don't know me and it's a long I was gonna swear a long day for the kid and then the parents like That's not how my kid normally acts and No, they don't do that.

[00:30:51] Dr. Taraman: And then and then the specialist is saying hell by the way, this is autism And then they're like, no, I don't believe you go. I want a second opinion How many times have you gotten that where you send them and then they're like, I [00:31:00] don't agree with the specialist I want a second opinion

[00:31:02] Dr. Bravo: I'm only pushing back because I'm having fun being the devil's advocate. Here's a term that I've coined and I really feel this honestly, and I know you'll all three are going to be very angry after I say these two things. Number one is in general, primary care physicians have no more time and no money to spend on To do anything more than what we're doing, and we're doing a terrible job on what we're doing because of the lack of time and the lack of payment for the services and we, and, I can't make Medicaid in Virginia pay me what I'm worth.

[00:31:38] Dr. Bravo: And so I, there's a limit to what I can advocate and change for the other big problem is that I think your solution is wonderful. I think it will be extremely helpful on mental illness, behavioral disorders, neurology have always been more complicated because there's not a simple [00:32:00] blood test or a CT scan or an MRI.

[00:32:05] Dr. Bravo: And of course. Except for the text was the pediatric infectious disease that used to say when you suspect HSV encephalitis biopsy the brain, nobody. No, that was on the textbooks. I know. Nobody really wants to be biopsying children brains. So the problem that we're facing in pediatrics, and it's really been.

[00:32:31] Dr. Bravo: Accelerating in a very rapid stage is that we are no longer infectious disease driven. We have become chronic disease managers and there's tremendous amount of gain to use a product like yours for early intervention. And that's true of depression, anxiety, suicide. It's true of. Detecting the [00:33:00] autoantibiotics for diabetes before the kid needs insulin preventing DKA.

[00:33:04] Dr. Bravo: It is true of early diagnosis of high cholesterol. It is true of early diagnosis of autism. However, we need to retrain all of our general pediatricians that are practicing in a reach like model for that, for that, that mental health course with men and fellowships. And partnerships. and champions at every state level that can hold our hands as we go through the process. Even the simple process, some things are easier said, it's terrible. I'm sorry. I shouldn't say this out loud, but if I lose a child in a code, it's very hard to tell the family, but it's over.

[00:33:50] Dr. Bravo: That there is no second opinions, there is no second guessing. The baby's dead. On these other chronic illnesses, [00:34:00] there is second guessing. Does he really have diabetes? You don't need insulin. All the other diabetics that my family knows needs insulin. He just behaves like my other kid, and you never had any problems.

[00:34:12] Dr. Bravo: He's just a little slow. My kids don't have any. 

[00:34:15] Dr. Braham: Who's best to help with that? That's, that I think, that's where the issue is. We need to be reclaimed. He should be the primary care doctor. Yes, but we need to be 

[00:34:23] Dr. Taraman: reclaimed. Who continues to 

[00:34:23] Dr. Bravo: shepherd them. We need to be retrained. We 

[00:34:26] Dr. Taraman: need modeling, refresher for sure.

[00:34:29] Dr. Taraman: Look, there's a lot of modeling 

[00:34:30] Dr. Bravo: that says, look, I've got this great tool that can diagnose or lead you to the diagnosis. of autism at 20 months at 18 months. We know if we do early interventions like any other disease we save a lot of human suffering. There's no doubt about that. Here's the script of how you deliver those news.

[00:34:55] Dr. Bravo: Here is what you should expect the pushback is going to be from the family [00:35:00] because You're giving them devastating news, 

[00:35:04] Dr. Taraman: But it doesn't have to be devastating. I think that you can frame it in a way of, look, this is positive. You're going to work on interventions. Interventions are known to have huge impacts, and we're going to give your child the best option and chance to have the greatest developmental success.

[00:35:18] Dr. Taraman: And I would say, yes, as part of adoption of anything, you need to know how to use it, how to deliver this message, right? We've done a lot of education in that space. And then I think to your first point that you were making, though, is the reimbursement is super important. Because the reality is, and George, you were saying it too, Look, we're expecting primary care physicians to do Herculean things.

[00:35:40] Dr. Taraman: And it doesn't make sense if the reimbursement's not there. We've been successful at least with one of the commercial plans, which is called Highmark Health, to make it so that the physicians are actually adequately reimbursed for using our diagnostic and have the time to actually use it and deliver a diagnosis in a way that is above what you would normally get [00:36:00] reimbursed as A pediatrician.

[00:36:01] Dr. Taraman: So you're getting a specialty level payment or doing the thing because we're asking you to do something that was normally sent to the specialist. And so we've structured that into our reimbursement discussions with the players. And I think that this is a greater advocacy thing that we need to do as pediatricians, collectively, both specialists and primary care is say, look, there is a specialty shortage.

[00:36:26] Dr. Taraman: And as a country, we have to invest in our children. Otherwise there's going to be the downfall of the United States and Biden and anyone else in Congress. And the Senate, please listen and pay attention. If you don't allocate funds for children and pay the pediatricians appropriately for the work that's being done, our country will be devastated.

[00:36:47] Dr. Taraman: And so we must help the kids and we must invest in them. And part of that investment means paying the pediatricians and the primary care doctors in appropriate ways. Not to treat disease and disorders, but to [00:37:00] prevent them, right? We don't pay for preventative medicine. We don't even pay for thinking. We pay for a procedure.

[00:37:05] Dr. Taraman: I go cut, make money. No, come on. That's broken. The healthcare system is broken. And to your, to Sabrina's point earlier about like these digital tools and Herb, you were talking about them. We've got this really great technology, but again, the healthcare system is so dysfunctional. That we don't even understand like really how to pay for some of this stuff and then it's guess what some of these great Devices go and they disappear because they couldn't figure out the insurance side of the house and I'll give you just on the adult side There was a great we have an opioid crisis in the United States and it's actually coming into the pediatric population now I don't know if people are paying attention, but there was a device it was on the market and it worked really well to prevent opioid like people dependence on opioids.

[00:37:52] Dr. Taraman: It was called reset O's from pair therapeutics. And they could not, they started getting some insurance reimbursement. They couldn't get it fast enough. And the company went bankrupt. [00:38:00] Yeah. So now it's guess what? You can't get a psychiatrist and a psychologist to help you not be opioid dependent. And now we don't have a device on the market that could help, which we knew.

[00:38:11] Dr. Bravo: Yes. And so you hit it right on the nail, which is in, in, George will pipe in. He has a phenomenal partner that does nothing but lipid management and obesity care. And he's great at it. He's boarded in both when he didn't do those in their large practice. He is one of the top revenue producers.

[00:38:33] Dr. Bravo: Now, he's not because to talk to somebody about their hyperlipidemia and lifestyle changes that has a huge impact takes time. And so you're right. And then there's, here's the Holy grail, which makes me go into seizures is when people say, but you're an advocate. You don't need to make money.

[00:38:58] Dr. Bravo: Okay, fine. I [00:39:00] won't make money off vaccinations. So neither does the salesperson from Merck, Sanofi, or Glaxo doesn't get paid. They're advocates. Glasgow, Sanofi, and Merck, you have to give us the vaccines at production cost. Because you shouldn't make money from them either, and when we do that, then they will stop producing them, they won't do research, they won't buy innovative companies, and we won't have before this, because why would they go out and spend several billion dollars to buy a drug that works really good, if they're not going to get a return on investment?

[00:39:44] Dr. Bravo: And you're absolutely right. It is a policy problem. We need to pay for early prevention, early detection, and counseling. 

[00:39:56] Dr. Braham: And care coordination is the other piece. I think what hasn't been mentioned is [00:40:00] workflow, right? So reimbursement is really important. So to get one of these technologies to solve these problems for us you need, we need to be able to reimburse for them.

[00:40:10] Dr. Braham: I totally agree that these should be in the hands of primary care pediatricians. But the other piece, and I think, yes, there's some hesitance to be able to give that news to a family, but in my experience, it's not the news that keeps me from feeling comfort. It's actually that I don't have any. I don't have anything to give them to help with the problem, but if I had a care coordinator who works with the regional center of the school or, whoever is going to be then providing services and someone to connect them with community groups or whatever, the variety of other needs that family has, then I have more comfort to do the diagnostic piece once it's covered.

[00:40:49] Dr. Braham: And so I think that's something that digital therapeutics and diagnostic companies need to be aware of is really understanding the intricacies of the workflow and how that impacts the patient. The [00:41:00] daily practice. 

[00:41:01] Dr. Rogu: So this care coordination pops up. This conversation pops up all the time.

[00:41:06] Dr. Rogu: What is care 

[00:41:07] Dr. Bravo: coordination? Do you know? 

[00:41:09] Dr. Taraman: Is that a question to me or is that to Herb? Herb knows. Sabrina knows. To you or to 

[00:41:14] Dr. Rogu: Sabrina. What is care coordination? 

[00:41:16] Dr. Braham: I think it depends on the population you're talking about. But actually, we had a guest previously, Ryan Pedrez, and I was talking to him yesterday about in our FQHC, what it looks like is a combination of social work and a school coordinator.

[00:41:29] Dr. Braham: So for the majority of our patients, the issues that they're facing are not, really medical. There's some medical issues, but in most cases there is some intersection with the school district that needs to happen, and we don't have the expertise or the time to do it. So in a primary care FQHC, care coordination looks like social worker school coordination.

[00:41:49] Dr. Braham: I think in in, you might also need a care coordinator to coordinate between specialties for a highly complex population, right? So it can vary. 

[00:41:59] Dr. Taraman: And it's [00:42:00] very 

[00:42:00] Dr. Bravo: different and, in AltaMed in Los Angeles, care coordination sometimes is a Spanish speaker health promoter that actually goes to the family's home.

[00:42:11] Dr. Bravo: Care coordination means a dentist within the clinic that does the fluoride varnishes and has time to go ahead and start working on the cavities for the kid. Care coordination and Juan Espinosa's the boss from Brentwood is three of, I think he's got three persons that do nothing but when he says this child needs to see an orthopedic surgeon before they leave the appointment, that person is, before they leave the office, that person is made the appointment for them, given them a card and an address where they need to show up and make sure that they have an Uber ride to get to the appointment.

[00:42:55] Dr. Bravo: So that is care coordinator coordination. That's a 

[00:42:58] Dr. Rogu: great thing. Care [00:43:00] coordination gets people to go where they got to go. It helps them to navigate through the complexities of the big university systems, get people appointments. That's great. 

[00:43:10] Dr. Bravo: By the way, I don't 

[00:43:11] Dr. Taraman: know if you're responsible to fund this.

[00:43:13] Dr. Taraman: So can I, let me wait, my favorite care 

[00:43:16] Dr. Braham: coordination, my 

[00:43:18] Dr. Taraman: favorite care coordination in my, I don't do outpatient medicine anymore by the way, I just, I couldn't, it's too much, but when I was, I do outpatient, I can't be a CEO and do outpatient clinic, I'm not I mean he's got kids. Yeah, no, they're older.

[00:43:34] Dr. Taraman: It's fine. They're basically like self sufficient. I don't know what they're doing. They're burning the house down. No. So the insurance companies actually have a lot of care coordination resources. You just have to demand it. And it'll work really well depending on the insurance, but you're right.

[00:43:48] Dr. Taraman: This is an insurance thing. Yes. And forcing the insurance companies to do this, I think is a is an important mandate. Now, obviously, yes, they're not going to be a dentist in the clinic. That's a different type of [00:44:00] coordination. 

[00:44:00] Dr. Braham: And they're not intersecting with schools, by the way.

[00:44:02] Dr. Taraman: The other thing you're yes, school nurses are amazing. And we've done some really cool stuff out of chalk where we've connected the school nurses to our electronic medical record and a bidirectional interface that actually allows us also as, so when you are a general pediatrician at chalk, you can actually now start seeing what is the child's attendance and what are their grades, which is really helpful.

[00:44:25] Dr. Taraman: Yeah. More connected. I want 

[00:44:28] Dr. Braham: to make sure that we get to touch on, we may not have a lot more time, but I want to make sure that we get to touch on this issue of AI and bias. Just because I think it's such an interesting topic as it relates to this particular software. My understanding is that AI can cut both ways in terms of introducing or mitigating bias in these tools.

[00:44:49] Dr. Braham: So I wonder if you can talk a little bit about that and how, in the example of CanvasDX, it's been addressed and how, what else needs to be done to address 

[00:44:58] Dr. Taraman: it? So I [00:45:00] would say if anybody is working in the AI space, you must be intentional about this. So we have this undercurrent of bias that exists within our medical records and our healthcare system.

[00:45:10] Dr. Taraman: And AI will amplify it when applied without intentionality around what is the bias that exists in there. So in the current state of evaluation for developmental disorders, Females, for example, are diagnosed on average 1. 5 years later than their male counterparts. And then persons of color, lower socioeconomic status often are either misdiagnosed or diagnosed even much later, oftentimes after the age of seven or eight.

[00:45:37] Dr. Taraman: It's getting slightly better because there's been a sub focus on it, but the status quo prior to Canvas DX Continues to propagate a lot of bias again. 

[00:45:46] Dr. Braham: That's human based. That's human based bias that exists in our 

[00:45:49] Dr. Taraman: approach. It's human based, and it's also the research instruments that we repurpose for clinical care, just like you can train up an algorithm on all white [00:46:00] males.

[00:46:00] Dr. Taraman: We're trained up on predominantly affluent white males and not a very diverse sample of patients. So our reference data is also biased and skewed. So one of the things, the first thing that I did when I came in as a chief medical officer was said, okay let me look at the data sets and how balanced are they from male to female?

[00:46:17] Dr. Taraman: Do we have adequate representation of persons of color? And then do we have representation from the indigenous population and very intentionally went out, we recruited patients from the Indian health services. We had a site actually in one of our clinical trials in Arizona, two sites actually, they're recruiting from the indigenous population.

[00:46:38] Dr. Taraman: And then we were able to make sure that our training sets were diverse and represented the U. S. population. And then in our clinical trial, by doing a distributed clinical trial, we actually recruited and were very intentional about setting up sites like in. Like I said, the indigenous population in Arizona, Hattiesburg, Mississippi, Dayton, Ohio were clinical sites to make sure that we got a very diverse sample [00:47:00] of patients.

[00:47:00] Dr. Taraman: And then I'm actually proud to say in our clinical trial, when you look at the U. S. population versus our clinical trial population, diversity wise, we were almost equivalent to the U. S. population demographics. And then, which is actually really hard to do, we actually recruited a socioeconomic status lower than the national average.

[00:47:19] Dr. Taraman: Which I've actually never seen in the most clinical trials, but we were able to do it with the trial. But we were very intentional about it. It was like very purposeful. I need to make sure we get a good representation from rural America as an example. So having a site in Missouri 

[00:47:34] Dr. Braham: And that's hard to do in the pediatric population specifically just because the actual numbers are small.

[00:47:40] Dr. Taraman: Absolutely. Absolutely. And so are you intentional about it and you do distributed clinical trials, it works actually really well. 

[00:47:48] Dr. Bravo: So tell me how your product not, not the algorithm, but as a general pediatrician, how would I implement, cause these are all questions of implementation. How, when [00:48:00] would I use this tool?

[00:48:02] Dr. Bravo: In my office and let's forget about let's assume that I have all the time in the world and I am independently wealthy. I'm the pediatrician married to Mark Zuckerberg. So I only do this for the fun of it. Yeah. How would I use your tool? So you just take those things away, so those aren't.

[00:48:18] Dr. Taraman: We designed it. We designed it to work in that setting though, or which is the reality. So the reality is that again, I'm working on the insurance side of the house to make sure that it gets covered and Medicaid. Let's forget about that. That's it. It's out of our way. You have a kid who shows up in your clinic and either you're concerned or the parents concerned you prescribe, and I use air quotes on it because it's a weird concept to prescribe additional something, but that's how we have regulation.

[00:48:43] Dr. Taraman: So you order the test. When the test is ordered, the parents get a text message and a email saying, download this application called Canvas DX. They download the application. They answer a brief question set. They upload two home videos. Those videos are analyzed, the question sets [00:49:00] analyzed, and then we ask the clinician either 13 or 15 questions that take, when you get really good at using it, less than 5 minutes.

[00:49:10] Dr. Taraman: And that's with 

[00:49:11] Dr. Braham: the patient in the room? You 

[00:49:12] Dr. Taraman: can do it whenever you want. If you know the patient and they're a historical patient and you know them really well, you don't even need to see them, you can just answer the questions. If you haven't seen them in a long time or post a, child visit, you can answer those questions.

[00:49:25] Dr. Taraman: You can also delegate it to someone who knows 

[00:49:27] Dr. Braham: the patient well. Are they clinical observations, though? Or what are the, what's the nature of those questions? 

[00:49:30] Dr. Taraman: There are straightforward ones like, Hey, tell me about this child's development today, let me know what you think about their eye contact along the way, by the way, everywhere, the algorithms always given a, everyone's given an, I don't know, I'm not sure option, which is really important.

[00:49:45] Dr. Taraman: Cause what we don't want to do is face false label the kids. And if the algorithm can't tell you with a high degree of accuracy that it's autism or not, it'll say, I don't know as well, but give you all the information. So the algorithm instantaneously analyzes all that information. Information that we just captured [00:50:00] and then gives you not only is it autism or not, because obviously that's one part of it, but hey, here's all the developmental domains that we looked at.

[00:50:08] Dr. Taraman: Here's where the kids having challenges. Here are the child's developmental strengths, and then everything gets automatically mapped to DSM five criteria for you, so you don't have to do a huge amount of documentation. And then again, what we've heard from pediatricians, it allows them to just spend time with the family saying, Hey, this test came back and it's positive for autism.

[00:50:27] Dr. Taraman: This is what it means. Here's some resources to get you connected with families in the area that have autism. So here's our local, the Azure autism support group. Here are the areas that I think you need help in speech therapy, developmental therapy, whatever. And, calling craft, who's a former president of the AP.

[00:50:45] Dr. Taraman: Has a really nice hey, this is how I use this thing in practice, and this is how a pediatrician would do this in a normal, regular visit. Maybe, plus, I wouldn't try and do this in a 15 minute visit, personally. I think you need probably a half hour with the [00:51:00] family, because you're going to get a bunch of questions.

[00:51:02] Dr. Taraman: Is generally what I recommend for pediatricians. 

[00:51:04] Dr. Braham: It's the idea that you get a positive MCHAT, and then you schedule them for a longer visit to do this. process or how would you think? 

[00:51:13] Dr. Taraman: Yeah, so definitely if they fail the AmChat, say, Okay, hey, we know that you need an evaluation. Do this Canvas DX.

[00:51:19] Dr. Taraman: And then you're going to get the result back before they get scheduled again. So depending on the result, you can then schedule appropriately. Because if it comes back negative, you can say, Hey, look, We don't need to really worry about autism. It's a high degree. It's 96 percent accurate when it says not autism, which is better than the status quo, which is only about 85 percent negative predictive value.

[00:51:40] Dr. Taraman: And so you can say, this is not autism. Hey, you look at the report and you can see, Oh, this looks like an isolated speech. Let's just get you into some speech therapy. That's a quick 15. That could even be a phone call, honestly. I'd probably see them in clinic so you could build. So let me 

[00:51:53] Dr. Bravo: ask you a couple of questions, just practical questions.

[00:51:55] Dr. Bravo: Is how long, once all the data is submitted, how long before the [00:52:00] results come back? 

[00:52:00] Dr. Taraman: It's instantaneous. Is 

[00:52:04] Dr. Bravo: it in another language other than English? It might if my Spanish, this is a Spanish speaking population, can they see in Spanish and then how much does it cost? Because who's going to pay for it?

[00:52:19] Dr. Taraman: Yeah, so that's that great. So this is where I need you to advocate for me, Herb and George and Sabrina. So look, right now we have commercial coverage through Highmark insurance. We're actively negotiating with a number of other insurances. We look like we're probably close to starting with our first Medicaid as commercial.

[00:52:39] Dr. Taraman: We have a bunch of Medicaid programs that are You know, in early engagement with us and using it, but not yet updated their medical policy and fee schedules. The goal is to have it covered by insurances across the board. And then we are, we've been donating to very low income families. We've got a couple champions who use it in low [00:53:00] income environments just to try and support that.

[00:53:03] Dr. Taraman: But again, to your point, right? Like I can only do so much of that. Yeah. Because the health economics need to be sustainable. So we've got a philanthropy side of the house, doing it as just charity work. 

[00:53:13] Dr. Bravo: Let's be real. Now I'm not married to Mark Zuckerberg anymore. 

[00:53:18] Dr. Taraman: I help with one day.

[00:53:18] Dr. Taraman: That's too bad. That's really too bad. I know. 

[00:53:20] Dr. Bravo: I know. Cause then I could do whatever I want. I could write you a check. Mark Zuckerberg should write a check for this. But you know why I'm saying that. Hey Mark, write a check. Mark Zuckerberg. Yeah, he's married. So we 

[00:53:30] Dr. Taraman: have, yeah, we have, but we have, 

[00:53:33] Dr. Bravo: we have families.

[00:53:34] Dr. Bravo: I'm in the clinics. 85 percent is on Medicaid. I joke with my dad that, it's a rare day that where I see a white person how much would it cost a Medicaid patient in my clinic when they failed the MCHAP to go through this, to speed them up in the 

[00:53:48] Dr. Taraman: process? You can't, we can't charge them. You can't 

[00:53:52] Dr. Bravo: charge them.

[00:53:53] Dr. Bravo: They're just basically not able to use the technology at this point until Virginia Medicaid decides they will pay for [00:54:00] it. If 

[00:54:00] Dr. Taraman: Virginia Medicaid will pay for it, then we can use it. Otherwise, we have some charity options, which I can work individually with you. Any clinician, we can figure out and we can donate some to try and help a couple kids.

[00:54:13] Dr. Taraman: From an equity perspective, look, like at the end of the day, I am huge on equity. It's a big thing of being a pediatrician, right? We're always fighting for it. Yeah. I know though, if I can get one commercial kid off the waitlist, then that opens the waitlist up for the Medicaid patient. Ideally though, I'm not resting until every waitlist is eliminated.

[00:54:32] Dr. Taraman: And if there's any specialist who's wearing their waitlist as a badge of honor, then shame on you because we shouldn't have those waitlists. And we have a better option. And the insurances and the Medicaid directors, come talk to me because I want to work with you and the health economics work out.

[00:54:48] Dr. Taraman: We did an Optum study with about 10, 000 lives. And while those kids are waiting for an evaluation, their health care costs are twice, two times the kids that got diagnosed early. [00:55:00] And, I don't need to go, you guys know, every pediatrician should know this. So we need the health, medical directors of the health plans to say, Hey, this is a priority.

[00:55:10] Dr. Taraman: Yeah, it's not diabetes and it's not hypertension and it's not obesity, which are huge problems and issues that we need to address. But look, this is one in four kids have a concern for a delay. One in six are going to get diagnosed with the delay and one in 36 are going to have autism. And that number keeps going up.

[00:55:26] Dr. Taraman: It's probably closer to one in 25. Problem 

[00:55:29] Dr. Bravo: is that the problem is that the whole, the problem is that the interests are not aligned and the people that could have the megaphone for this, they're not aligned with our interests at this point. So from the MCOs perspective, Spending a thousand dollars a month on Ozempic to have a 280 pound 15-year-old be healthy. No. [00:56:00] So Medicaid doesn't cover is spending the money on your software, which makes total sense. No I don't see the return on investment this quarter. 

[00:56:09] Dr. Braham: Yeah. If I'm not mistaken, early intervention is part of the core set On from, for CMS. Part of sort of the metrics, the quality metrics.

[00:56:18] Dr. Taraman: It is CMS. If you're listening. We'd love to figure out how we can get this to every kid who has Medicaid. But, the problem with the Medicaid though, is we're disjointed. We actually don't have a national Medicaid system. It's a state by state Medicaid system. And then every state has managed Medicaid's that are part of it.

[00:56:34] Dr. Taraman: Honestly it's so dysfunctional. Yeah. And it's not to say I'm discouraged by any means. 

[00:56:40] Dr. Bravo: No. It's just 

[00:56:41] Dr. Taraman: reality. It's the reality, right? This is a challenge for anybody trying to bring something. I still don't understand. I still 

[00:56:47] Dr. Bravo: don't understand because sometimes I read that for under the ACA, when you expand Medicaid for children, the feds are still paying 90 percent of it.

[00:56:57] Dr. Bravo: So you have tremendous leverage because if you can [00:57:00] convince the people in DC to change it, You can make every state change it, and that sometimes I read it's a 50 50 partnership. And so then, if you're a responsible state where you balance your budget and you're not allowed to borrow money, that reality hits.

[00:57:18] Dr. Bravo: I have a budget for school teachers, which is very important. A budget for police officers, which is very important. A budget for EMS. Which is very important because if you can't get to the hospital when you're sick, what good am I as a government and now I got a budget to help these kids, that are below the poverty line.

[00:57:40] Dr. Bravo: And where do I put the pennies that I have because I have to balance my budget. Absolutely. 

[00:57:46] Dr. Bravo: It's not that they're evil. It's just they're playing the balancing game. 

[00:57:50] Dr. Taraman: No, 100%. But I think that this budget concept is actually really interesting. So I know if I look at a state budget, if you miss the kids [00:58:00] in primary care and the kids end up showing up in second grade and you're like, Oh my gosh, this child has autism that we've missed.

[00:58:07] Dr. Taraman: And now they're really struggling. I know the likelihood that they're going to need a special education self contained classroom is way higher. It's about 75 percent higher if I don't get them early. But then we're like no, that's the education budget, not Medicaid budget. And they don't know. And it's who at the state level is making these decisions, right?

[00:58:29] Dr. Taraman: Somebody needs to look at this at a macro environment level and go, Hey, Okay, yes, we have an educational budget, but we're spending all this money on special education that if we could actually just identify these kids earlier there has to be a shift 

[00:58:43] Dr. Bravo: in allocation. But here's where the problem is with that thinking, right?

[00:58:48] Dr. Bravo: It's the same problem with pension plans. For municipal workers, so that is far into the future. So I will sign off on that [00:59:00] debt because I will not be what our mayor of this town. Manager of the county. Governor is 

[00:59:07] Dr. Taraman: calling the governor. That's what she's doing with her phone. She had to get she's getting the governor on the phone right now.

[00:59:12] Dr. Taraman: Sabrina call the governor. He's 

[00:59:14] Dr. Bravo: all in. He's all. I won't be governor. You heard that governor when that child gets to 2nd grade, so it won't be my problem at that point from a budgetary point of view. I know. I know what is really pressing on me today. That's what I gotta get solved. 

[00:59:30] Dr. Taraman: But that's why we did the health economic data now to step up on 

[00:59:33] Dr. Bravo: next, on the next election or to remain governor.

[00:59:37] Dr. Bravo: And that's the problem. That is a big problem. That is, but 

[00:59:40] Dr. Taraman: that's why we did the health economics researcher to, to show in the near term right now, and the things that the insurance plan actually cares about, right? Like I don't need to prove the long-term cost savings. That's. It's two and a half million per child and everybody else did that research.

[00:59:55] Dr. Taraman: I was like, let me show you that just right now you're gonna [01:00:00] Save about 2, 500 just in the time the kid's waiting. Forget about the diagnostic fee. And like the health economics are very compelling for this device that we've created in the near term. And what's 

[01:00:14] Dr. Braham: interesting is that I just looked up the child core set, which are the quality metrics that Medicaid plans have to meet basically to, to, achieve quality standards and what it's the early intervention or diagnosis is not on there, but screening is, which is interesting, which 

[01:00:32] Dr. Bravo: means that there are no two.

[01:00:33] Dr. Taraman: But you screen and, so this is I fundamentally am like, okay, great, we've screened for something, but why would you screen if you can just jump straight into actually diagnosing and intervening? Screening only makes sense if you can't diagnose in the setting that you're in. I don't know.

[01:00:48] Dr. Taraman: Or if 

[01:00:48] Dr. Braham: the resources required for diagnosis are too much, right? If we can't support the resources. But if you have an affordable, scalable solution, then I think it makes sense. 

[01:00:57] Dr. Bravo: Yeah. And how do you, I'm [01:01:00] sure you've put a lot of thought into this. How do you, what leverage, what levers do you pull on to get the Medicaid programs to understand how important this is?

[01:01:11] Dr. Taraman: I thought that you were going to do that on this show for me. I've 

[01:01:15] Dr. Bravo: been trying to get people to pay pediatricians what they're worth and stop with you're just an advocate. You need to do it for free. Which is I think where it has to start. And but the reality of it is that we are competing for dollars.

[01:01:34] Dr. Bravo: And, and we're very lucky, but we are not neurosurgeons making a million and a half a year where we can pull our money together and get to people that have the power to change it. It's a money power, a money problem. You know what would 

[01:01:53] Dr. Rogu: be cool, Herb? That grant that we're working on for our clinically integrated network, one of the medical projects is [01:02:00] behavioral health.

[01:02:01] Dr. Rogu: And, everybody thinks anxiety, depression, but and developmental stuff. This might be a cool thing to try to get New York State to 

[01:02:08] Dr. Bravo: like. But I don't understand, I don't understand why, is it, you guys have decided that you won't charge Medicaid patients for it, or is it because you intend to participate with Medicaid and you cannot?

[01:02:21] Dr. Bravo: By federal law, charge take money from Medicaid patient. You can't take money from getting medical money from Medicaid patients. So 

[01:02:27] Dr. Taraman: we, so for example, we are working with Wyoming Medicaid. We are working with Arizona Medicaid. I have a managed Medicaid in California. That we're working with to give this to patients in those areas.

[01:02:41] Dr. Taraman: All I need in New York or Virginia or wherever anyone's listening is give me the state Medicaid director and tell him like, Hey, this sounds really interesting. Can we do something, even if it's not for medical policy, which obviously would be ideal saying, Hey, look, can we try this in a couple hundred patients or whatever?

[01:02:58] Dr. Taraman: Let me show you that it works. Let me show [01:03:00] you the pediatricians want to use it. Let me show you that parents how it helps them and their kids actually do better, right? I know these are all true statements because we've demonstrated that in several test markets. Right now it's just about, can I get this to the rest of the country?

[01:03:15] Dr. Taraman: Because guess what? 2030 is coming around the corner. I'm looking at my watch. It's like almost there. And again we're failing as a nation. And the health, we hit the quintuple aim, right? What are you trying to do? Make the parents more satisfied and the patients were satisfied. Take away the documentation burden from the clinicians.

[01:03:32] Dr. Taraman: I had a psychologist who was like, yeah, if I'm working my butt off, I can do maybe five evaluations a week. But because of your tool, I'm able to do eight evaluations a day. So even if you don't adopt it in primary care, which is honestly I think the best place for it to be, give it at least to the specialist to make them more efficient.

[01:03:51] Dr. Bravo: But I'm still trying to struggle. If you don't participate with Virginia Medicaid, why can't you, why can't a parent say, I'll pay for [01:04:00] out of pocket? You don't participate. 

[01:04:02] Dr. Taraman: We're actively talking to all the medicaids, sir. 

[01:04:04] Dr. Bravo: So is that why you don't want to, you don't want to ruin that bridge? Yes, 

[01:04:09] Dr. Taraman: I would rather just help that patient if I can in the near term as much as I possibly can in terms of, as we negotiate with the medicaids.

[01:04:19] Dr. Bravo: Because it's the same challenge that you alluded to before, right? If you only wait to do what's evidence based and proven three times over a lot of kids get left out 

[01:04:31] Dr. Taraman: And we've done that three times over already So it's just a matter of getting it paid for so there's 

[01:04:36] Dr. Bravo: cms cpt code for this test 

[01:04:39] Dr. Taraman: So cms did not give us our own unique code the code that's being used within highmark is One called a like apple nine two nine one, which is a course of digital therapeutic Ah, so 

[01:04:51] Dr. Bravo: it's a generic code, it's a HCPCS code.

[01:04:54] Dr. Braham: So they can't use the same code that's used for diagnosis of autism? Why are they using a different [01:05:00] code? Is it because it's digital? 

[01:05:01] Dr. Taraman: Yeah. I see. That's what HIMAR wanted to do, and I think, and that's what we've been hearing from other plans that's their intention is to use that code. Cause CMS did not assign a unique code to Canvas DX.

[01:05:14] Dr. Bravo: So that's really complicated, cause it's not CMS, it's AMA, that this, that owns a CPT codebook. And it's, I think, very well. 

[01:05:23] Dr. Taraman: There's E and M coding and physician billing. And then there's device. Yeah. So it's pixie. Exactly. Yeah. Don't you guys fall 

[01:05:31] Dr. Rogu: under remote monitoring or therapeutics? No. 

[01:05:35] Dr. Braham: Yeah. I'm just wondering how much school districts and maybe that the payment that you could get from school districts is lower.

[01:05:44] Dr. Braham: But. From where I'm sitting in my FQHC, this is such an essential health equity issue, because what I see over and over again are kids who are not getting adequately diagnosed, either because there are not, there isn't the workforce to do the work, or the school district [01:06:00] doesn't think they meet criteria.

[01:06:01] Dr. Braham: And so essentially what's happening is you have a generation of kids that are being denied access to education and equal opportunity because they're not getting early intervention. So it feels like that's where the incentive is. really is because they are held to the standard of meeting the early intervention needs in the state.

[01:06:19] Dr. Taraman: We've had some conversations at the school district level and departments of education level, because obviously they start at three and above, and our device is labeled from 18 months to 72 months, so that three to six group definitely could apply in the educational space. It's just, like anything, if you're a startup, you've got to be super focused on like kind of one thing.

[01:06:42] Dr. Taraman: Otherwise you lose the ability to survive. So we've been just really hyper focused on the medical side of the house. Again, I think if there are listeners that have influence within the educational health system and the educational health system can come and talk to us, like happy to, Do it.

[01:06:57] Dr. Taraman: I just I don't have the time, energy and resources to go chase [01:07:00] down. I hate to say it right. Chase down the educational thing. I think my primary focus is get the medicaid's and other commercial plans to cover this and then help the pediatricians understand how to apply it and get the specialist to start using it so that they can be more efficient.

[01:07:15] Dr. Taraman: And then everybody hopefully wins in that situation. And what you're 

[01:07:19] Dr. Braham: articulating is true across the board for any digital health company that's trying to serve this population, is that the friction involved in getting to the people who can pay for this, for vulnerable populations, is so great that it can be existential for these digital health companies that are on lean budgets. So I hear you. 

[01:07:38] Dr. Rogu: When you have a new company that comes out with a product, they'll go to the commercial carriers because they'll convince them to pay for it. And nobody ever goes to the Medicaid. You should go to the Medicaid, get them to pay for it. Then you can shame the commercial companies into paying and saying, Hey, Medicaid's paying for this. You guys should also, 

[01:07:56] Dr. Taraman: we're doing both. So again, we've had, we got Highmark [01:08:00] first, but it's not that we've just started talking to Highmark first. I have been talking to them, the medicaids or we have been talking to the medicaids and we have, there are innovative medicaids again, wyoming, I think is showing that they're innovative. We've been working with them. Arizona has shown that they're innovative. We've been working with them. Other Medicaid's are currently evaluating us, but again, like any process, I think they don't understand the sense of urgency. So there are millions of kids in the United States waiting for a developmental evaluation.

[01:08:29] Dr. Taraman: And if we don't want to be like our friends in the United Kingdom or Canada, where they've actually declared a state, like almost a state of national emergency. Because the wait lists have gotten so out of hand that, honestly, and if the parents listen to this, you should revolve because we wouldn't accept this for any other condition.

[01:08:44] Dr. Taraman: We don't really accept this. If a kid has epilepsy or a kid has a brain tumor, a kid has any other neurodevelopmental or neuro thing. It's you got to get them in right away. Even migraines get in faster than a kid with a neurodevelopment. But it's the reality [01:09:00] is when we do that, we're missing that neurodevelopmental critical window.

[01:09:03] Dr. Taraman: Yeah. of opportunity and you don't get it back. But 

[01:09:06] Dr. Bravo: Canada has universal health care. But this is a greater problem than just your, what you're doing for autism, which I think is great. Yeah. But it's a problem of all chronic disease and early intervention in pediatrics. There are not enough pediatric cardiologists to treat every kid that I find in the clinic now that's hypertensive.

[01:09:29] Dr. Bravo: There's not going to 

[01:09:29] Dr. Taraman: be enough pediatricians too. Do you see what happened in the last match? Yeah. Pediatrics didn't match as many spots as there's 

[01:09:35] Dr. Bravo: a ton of open spots. But it's exactly the same problem. Like I don't treat hypertension. What, where do I start with a diuretic?

[01:09:42] Dr. Bravo: Obesity is the same problem. Diabetes is the same problem. Metabolic syndrome is the same problem. These are all chronic diseases that if you intervene early, you can make a huge difference. 

[01:09:58] Dr. Braham: But I think Cognoa [01:10:00] or Canvas DX is a really excellent example of how technology is going to help us solve that problem by empowering primary care.

[01:10:07] Dr. Braham: At least that's my dream of what that looks like is in all of these cases we can harness some combination of decision support some sort of an AI based algorithm that that assists with diagnosis so that we can deliver it in a family centered environment, which is which is primary care.

[01:10:25] Dr. Braham: That's at least 

[01:10:26] Dr. Taraman: my hope. Absolutely. The way that this should work, Herb, is you go, Oh, you know what? I've just diagnosed you with, because I think most pediatricians can diagnose, hypertension. I feel like that should be a thing you can do. And then even if you're not an expert, right? You should, the AI, right?

[01:10:41] Dr. Taraman: The health support tools should be like, Hey, by the way, patients like this who have hypertension, the best treatment is going to be X, Y, or Z and lead you so that you're not thinking like, Oh, do I need an ACE inhibitor or a diuretic or a beta block. What do I put in this specific patient?

[01:10:57] Dr. Taraman: But it's going to know, Hey, that's asthma. Don't play with the [01:11:00] beta blocker. It's going to make their asthma worse. And yes, a pediatric neurologist remembers that from their training. Way back. I know I look young, but I'm old. I'm telling you. 

[01:11:11] Dr. Bravo: Must be the good weather out in San Francisco. 

[01:11:15] Dr. Taraman: Sharif. It's 

[01:11:16] Dr. Braham: been so great to talk to you today.

[01:11:18] Dr. Taraman: Yeah very much. I love the country and view. Herb didn't hold back. 

[01:11:24] Dr. Bravo: I just have to push on you because I hear it all the time of how do you implement this? When? Where? How? There's no money. There's no time. There's not enough pediatricians. There's not enough pediatrics specialists.

[01:11:37] Dr. Bravo: There's not enough money. And these are all huge problems that just one single person can't solve. 

[01:11:45] Dr. Taraman: I'm like Atlas with the world on my shoulders. I will not rest until there are no more wait lists. I am a fierce advocate for both patients and their families, especially kids with neurodevelopmental disorders and neurodevelopmental [01:12:00] concern.

[01:12:00] Dr. Taraman: But I'm also a fierce advocate for every pediatrician, every pediatric specialist out there. And I think collectively and together, when we come together and we do the right thing for patients. Ultimately doing the right thing is also financially rewarding. And I'm not blind to the challenges, Herb. I really am focused on when I negotiate with the payers.

[01:12:20] Dr. Taraman: Not only am I working to try and get Canvas DX covered, but make sure that the reimbursement to the clinician at the primary care level is appropriate for the work that's being done, so that it's a win for everybody involved. The, us as a device manufacturer or creator, you as the primary care doctor using it or the specialist, and then the families.

[01:12:42] Dr. Taraman: Yeah, and the insurance company. Everybody can win. Even the insurance companies can win in our 

[01:12:46] Dr. Bravo: situation. You're 

[01:12:48] Dr. Taraman: absolutely right because that's what i'm trying to do and I think we've set up set ourselves up to Do it in the right way, but it's going to take a little bit of time To really get it out there and get it everywhere where we want to have it So i'm looking [01:13:00] forward to the day where virginia medicaid and some other virginia plans come around and you can play with it and george hopefully in In new york and sabrina in california You If I didn't mention your state and you're listening, just call your Medicaid director and be like, Hey, there's this guy named Sharif. He's really nice. He's not feisty at all. And he wants to talk to you about your car insurance or your car warranty, whatever.