Episode 2: From Good to Great #Behavioral Health

Today, we get to hear from our very first guest on the show ever and to do that, we have taken the team on the road, San Diego, California to be exact. During this episode, we get to talk with Dr. Dan Gizzo, one of the true leaders and practitioners in the area of Feedback Informed Care within the domain of behavioral health psychotherapy. In this episode, Dan takes us through the art of digitally enabled clinical review, feedback informed care, optimizing therapeutic effectiveness, and gives us his take on the prospective role of artificial intelligence in behavioral health. Daniel Gizzo, Ph.D. is a clinical psychologist specializing in working with children and adolescents. He is a graduate of the California School of Professional Psychology and is licensed as a psychologist in California and New York. He is the Training Director for the APA-accredited Kaiser Permanente Medical Care Program doctoral internship in clinical psychology located in San Diego. Dr. Gizzo also provides a variety of clinical services in an HMO setting, including pediatric neuropsychological assessment, autism/developmental assessment, and assessment of ADHD. Dr. Gizzo is the chair of the Kaiser Permanente Southern California Regional Psychologists workgroup and oversees their continuing education program for psychologists. Dr. Gizzo’s clinical interests include clinical research, evidence based treatment for children, treatment of Tourette’s Syndrome, and Feedback Informed Care in psychotherapy.

Transcript

Mark Redlus [00:00:06] Welcome to episode two of the 10x Total Health Podcast hosted by Dr. Gabriel Eichler and me, Mark Redlus. The purpose of this podcast is to uncover and highlight breakthrough work that is being done in and around the healthcare arena, in an effort to 10x the level and quality of patient care, leading to better outcomes and hopefully overall healthier people.

Today we are going to get to hear from our very first guest on the show ever, and to do that we’ve taken the team and the show on the road, literally to San Diego, California. During this episode we get to talk with Dr. Dan Gizzo one of the true leaders and practitioners in the arena of feedback-informed care within the domain of behavioral health psychotherapy. Dan Gizzo, PhD, is a clinical psychologist specializing in working with children and adolescents. He is a graduate of the California School of Professional Psychology and is licensed as a psychologist in California and New York. He is the training director for the APA-accredited Kaiser Permanente Medical Care Program’s doctoral internship in clinical psychology, located in San Diego. Dr. Gizzo also provides a variety of clinical services in an HMO setting, including pediatric neuropsychological assessment, autism developmental assessment, and assessment of ADHD. Dr. Gizzo is the chair of the Kaiser Permanente Southern California regional psychologists work group and oversees their continuing education program for psychologists. Dr. Gizzo’s clinical interests include clinical research, evidence-based treatment for children, treatment of Tourette’s Syndrome, and feedback-informed care and psychotherapy. Finally, one more important note, Dr. Gizzo’s views are his own today. The opinions and views expressed during this episode are not those of Kaiser Permanente or Kaiser Southern California Permanente Medical Group. Now without further ado, please enjoy this very informative and interesting conversation with Dr. Dan Gizzo.

Mark Redlus [00:02:17] Welcome to the podcast. We’re here in beautiful San Diego California. We’ve taken the podcast on the road. Gabriel Eichler and I are here with our first guest on the podcast. We’re very excited about this. We have Dr. Dan Gizzo with us. Welcome, Dan.

Dan Gizzo [2:34] Thanks for having me. Awesome.

Gabriel Eichler [2:36] Great to have you, Dan.

Mark Redlus [2:38] Gabriel just spoke.

Gabriel Eichler [2:40] You leave that part in.

Mark Redlus [2:43] This is so much more fun. It’s a fun podcast, right? So, we’re going to talk about …

Gabriel Eichler [2:48] At least we’re enjoying it.

Mark Redlus [2:50] Now it’s very exciting. So today we’re going to spend some time talking a little bit about the domain and area of behavioral health and some tremendous innovations that Dan is involved in, but through a process of leveraging technology into the practice of behavioral medicine. And so, we’re excited to do that. Gabriel, you want to add anything else thematically?

Gabriel Eichler [00:03:13] I think it’s helpful to set some context here about why the hell behavioral health even matters. Right? I mean there is just so much research that I think is coming full circle now about how important behavioral health is to overall health. And you know as we look at the out of control costs of healthcare, it’s really critical to understand why we would have such a focus on the behavioral health aspects because it doesn’t feel like physical health. It doesn’t feel like diabetes or causing early death, but it clearly is that they are associated. So, Dan, as a practitioner and, I know you’re speaking for yourself here, but it will be great to get that perspective as well.

Dan Gizzo [00:03:54] Absolutely. You know and as stigmas decrease, we see more demand for behavioral health nationwide, but still there’s a fair amount of stigma that exists. This conversation really does need to happen in this country.

Gabriel Eichler [4:08] Because now more people are getting care, but it’s still not enough.

Dan Gizzo [00:04:10] Exactly right. And you know probably not enough people have access to very good care, in terms of mental health, depending on where they might happen to live.

Gabriel Eichler [00:04:19] Yeah. So maybe can you start and just tell us what is this interplay between behavioral health and overall health, and how should we just understand the importance of behavioral health from that interplay?

Dan Gizzo [00:04:34] You know working in a system where we have behavioral health services tied into a large medical setting, there’s a lot of overlap. We know that a lot of individuals with mental-health illness or are carrying a diagnosis of mental health when they have physical conditions, it takes longer to treat them. They cost more to treat. They have more complications along the way. Their outcomes aren’t as good. So even aside from the value that comes in treating people’s mental illness, which has its own value for each person and for our society, there’s good value in terms of overall health outcomes.

Dan Gizzo [00:05:12] I think a lot of us in the end would like to think of it all as just healthcare. I think Patrick Kennedy said that he looks forward to the day that it’s, you know, that we just talk about ‘it’s not mental health or physical health,’ that ‘it’s just health.’ and this is just a part of it. Just like any other type of healthcare that we would provide.

Gabriel Eichler [00:05:32] Yeah absolutely. We don’t have to distinguish between behavioral or mental health.

Dan Gizzo [00:05:35] Mental health is just as an equal part of your health picture, just like seeing any other type of specialty care. It’s all part of the total healthy outcome for an individual, and that you know there’s good services available to treat a mental health condition, just like there is to treat a physical health condition.

Gabriel Eichler [00:06:02] Yeah that makes a lot of sense.

Mark Redlus [00:06:04] Now we’ve been seeing this kind of phrasing going on because everyone’s been struggling for: Is it integrated health? Is it total health? Total health is something that you know we’ve been locking on a lot. Talking about total health, and kind of to your point, it’s like ‘just stop talking about this,’ like it’s almost stigmatic.

Dan Gizzo [00:06:23] And it can kind of get perpetuated in some way. And mental health, we know a lot about what types of illnesses there are and what the prevalence is. And it’s out there, and it’s out there quite a bit. And so, people are suffering, and you know we want people to come forward and get the care that they need. And they’re going to have better outcomes in their lives, but they’re also going to have better physical health outcomes. And so that’s good systemically for the entire medical system in our country.

Gabriel Eichler [00:06:57] Have there been links between behavioral health status and productivity at work and in the economy?

Dan Gizzo [00:07:06] Not my area of expertise. I would Imagine so. I know that when we did some study of looking at programs designed to get people back to work, you know there’s significant costs economically to companies when a person is out of work. But also, there’s a cost to the individual/individuals who have unaddressed mental health concerns and then who end up out of work. You know their lifetime earnings drop, and you know they suffer economically as well. So, there’s probably a cost to the economy in terms of business and company loss, for personal economy, too, and people aren’t getting care for these conditions.

Gabriel Eichler [00:07:53] Yeah. Very interesting. So maybe we can get to one of our first topics which is: we’re interested to understand some of your work and these innovations you’ve been bringing to your work around this feedback-informed care idea. And what is it, and how do you use it to advance your treatment of patients.

Dan Gizzo [00:08:18] Absolutely. I think this is what we’re probably most excited about right now, where you know in the areas of outpatient mental health that I work in. And I’ll speak to this really from an outpatient perspective and thinking about the individuals who are coming for care for a mental health condition and who are really good candidates for some type of therapy intervention, like a psychotherapy intervention and individual psychotherapy.

And so, when we think about that, it’s: How do we deliver this care in the most effective way? We want good outcomes. We want it to be an efficient system. We want to be able meet people’s needs. We want to be able to reduce their symptoms. And so, we’re constantly looking at how do you deliver care in the best way possible? And so, you know in psychology, look at evidence-based treatments and what works and what has research support for an intervention. But we’ve learned over time that even when you put aside a lot of these variables, in terms of the intervention or the provider, that there are some variables that really relate to outcomes that matter that are part of that therapeutic relationship.

And so, we’re really interested in feedback-informed care because it’s an evidence-based practice, and it involves, and you can deliver actually, any evidence-based treatment from a feedback-informed care method. So, once you put this modality into place you can kind of insert the treatment that’s most appropriate for any given patient, but the feedback-informed care gives us a focus on measurement. And the measurements – not just like final outcome-based measurement – but ongoing measurement at the point of every contact. And that’s where the feedback-comes in because we’ll have information for the provider about where their patient is at and where the symptoms are at, but also, what’s happening in that relationship between the provider and the patient. And we call that the therapeutic alliance. And so, we know that the therapeutic alliance is the single best predictor of outcome for this group of patients that’s in individual psychotherapy. And feedback-informed care allows us to put the therapeutic alliance front and center in the care that the patient receives. It gives the patient a voice in their treatment in a way that that other therapies might not.

Mark Redlus [00:10:37] Along those lines, do you have a patient’s success story or something that really has kind of blew you away in using feedback-informed care…?

Dan Gizzo [00:10:51] Yeah, I do actually. Thinking about it, so you know one of the things about feedback-informed care is that we do a kind of a supervision process, really look at what’s happening at points in time. We make decisions kind of like a clinical team making decisions about making sure that the patient’s on track, making progress. And that’s one of the things that’s different about collecting data at every point of encounter and having that in real time is you catch people who are maybe slipping or deteriorating or at risk of dropping out or who just are not making progress. And so, you then become obligated to think about what do we do if we’re not making progress? And we make decisions as a group on, what do we do for that patient if the progress isn’t there? And we’re always looking to change something. Now we know research has shown us that about four to seven sessions in, we know if a patient’s going to make progress with that therapist and that therapy that’s occurring. And so, we’re monitoring that in that timeframe. And if that’s not happening, we’re going to change something to make sure that progress occurs. And if that continues to not generate results, we really need to come up with what do we need to do.

So, we had a patient who was receiving care and was not making progress and then actually was deteriorating. And the therapist was working really hard to really change the goals, change the treatment, and find a way to make this work. And it just was not happening. And we’re maybe 15 sessions in. And so, we’re well past the mark where we would know if it’s working. We’ve tried multiple interventions. And so, looking at the data and looking at all of that information, we made a really tough decision when we said we’re going to transfer the patient to somebody else. And that’s hard to do, especially with the younger patient. You’re worried about, you make sure your patient doesn’t feel rejected. You want to make sure that the provider doesn’t feel like they’re ineffective in some way. We want to make sure that we handle this carefully. But it’s also a hard thing to do because a patient typically doesn’t want to do that, even when the therapy is not going well. A lot of times people will stay with the therapy. So, we made the tough decision. And we transfer that patient to somebody else and you know they weren’t happy about it…

Gabriel Eichler [00:13:18] Who was that? The patient?

Dan Gizzo [00:13:18] The patient was not. But we said, ‘This really, we’re not helping you.’ And what happened is with a new provider, that patient started making progress three sessions in. And they end up completing their treatment episode by the time they hit session eight with that new provider. And they were able to discharge. And it really taught us, it was really was an a-ha moment. Mark, you bring that up… because it really allowed us to have faith in the data that we’re using to make decisions because it really played out. The research told us this is the way that we should go. The data was showing it. But it’s also it’s hard to know, in terms of the culture of what psychotherapy is, it’s hard to make a decision like that. But by doing it, we really help somebody. And got them back to their life. Right? And so that has stood out. I’ve heard that story told on our clinical team multiple times, where we’ve been hesitant to make a difficult decision before. Like, don’t forget this really works, you know. And so that comes to mind.

Mark Redlus [00:14:28] Just jumping off that idea from a systems approach, like thinking about it as a system — meaning in your clinic with your teams — does that serve as almost like a touchstone for everybody? That story where, ‘I’m going to embrace the system of feedback-informed care as a practice.’ You talked about deliberate practice, off air. We talked about how important that is.

Dan Gizzo [00:14:52] Yeah like a performance improvement.

Mark Redlus [00:14:54] Making it happen.

Dan Gizzo [00:14:54] Absolutely. I mean I think that becomes a touchstone. You know one of the other things we do is we often try to celebrate successes. So will providers will tell about you know patients that have had successful graduations from care. And that also becomes reinforcing of buying into the system. It is a different way of practicing. I mean a lot of us trained a long time ago. I trained some time ago. There wasn’t methods of having instant information from the patient. You could certainly solicit feedback at any point, but there wasn’t that instant data that helps to quantify it and helps you to really synthesize it quickly and make clinical decisions in real time. And so, we’re kind of relearning, a lot of us, how to be therapists with this.

Gabriel Eichler [00:15:51] Who’s harder to convince, the patient or the clinician, that this is worth investing in?

Dan Gizzo [00:16:00] When you describe a treatment to a patient, with a sense of credibility and a sense of optimism and hope, patients buy into the treatment. Providers have to be convinced.

Gabriel Eichler [00:16:14] Right.

Dan Gizzo [00:16:15] Providers have to undo old habits. Providers have to be willing to to approach things differently even just the concept of soliciting feedback. I mean some people may have been trained in a model that’s more reserved in terms of what the therapist puts into the session and elicits in the session. And so, I think that there’s a culture change that has to occur, and that’s at the provider level.

Gabriel Eichler [00:16:43] Yeah.

Dan Gizzo [00:16:44] That that’s the harder part.

Gabriel Eichler [00:16:46] It’s really a cultural thing. I mean could you imagine being a chiropractor and you just go in session after session they never ask how you’re doing. They just go and adjust you and you walk out.

Mark Redlus [00:16:56] That’s not something you’ve experienced? I mean I had two three chiropractors that do that.

Gabriel Eichler [00:17:00] They don’t even speak…

Mark Redlus [00:17:01] Nothing they just adjust, they just kind of shoot your, the Atlas vertebrae with that little high-pressure gun or whatever and then they crack your back, and you’re off to the races. I’m not saying it’s good, but it can happen.

Gabriel Eichler [00:17:14] I’ve never had a chiropractor but always imagined it was much more interactive.

Dan Gizzo [00:17:18] Well imagine other areas of medicine, even outside of something like physical therapy or chiropractic. Probably, would we not assess along the way that the medication is working. Curing an infection, four days in, the antibiotic’s not working. I mean that’s a data point that we always collect. Right?

Gabriel Eichler [00:17:36] Yeah, sure.

Dan Gizzo [00:17:38] We never ignore that and say, ‘Well just keep taking the antibiotic for another four or six months.’

Gabriel Eichler [00:17:43] Right. Right. Well but in many ways, part of the advent in the innovation here is the ability to even quantify the behavioral health status of a patient. Because if you can’t measure it, then you can’t … the old saying is ‘what’s measured is managed.’

Dan Gizzo [00:18:01] That’s true. Right. And that’s not always been the history in this aspect of behavioral health, in terms of therapy measurements have not always been a part of that. And a lot of the ways people are trained, and providers have different levels of comfort in dealing with data and dealing with measures. I mean that’s a conversation I have with my teammates frequently. And you know that’s part of the culture change.

It’s really getting comfortable with the concept of measurement, using measures. I have some advantages in that area coming from my background. I do a psychological, neuropsychological assessments and so constantly using measures to determine what the answer is, what the outcome is. And so, I have a comfort level with it. But I recognize that most people that are working in mental health don’t have that background. So, if we have to change the culture around just being comfortable with using measures and having data.

Gabriel Eichler [00:19:02] Yeah.

Mark Redlus [00:19:02] Well can we dig in on that a little bit? On that acculturation part of that? Because that’s actually how behavioral health will kind of evolve over the next half a decade on a national level as far as delivery goes. How do you scale feedback-informed care, and maybe starting with, how do you just get adherence up with your clinical team members? And what are techniques that you’ve seen work?

Dan Gizzo [00:19:29] Yeah. One of the things is you have to have a process by which everyone feels that they’re a part of it and doing it in the same way. And so, you know having a you know having a model where cases are reviewed systematically in a data-based way and everyone participates in that process. Because then you kind of have to have adherence. The way we do it is we put the data up on a big screen in a room and then there’s no hiding from it. Right? The first time it’s like, ‘Oh that’s my note on the wall really large. If I haven’t developed appropriate goals that are measurable for my patient, that’s there, and I’m going to get feedback from my peers.’ Right? The feedback is not all just between the therapist is getting feedback from the patient. All right? There’s feedback for the provider as well. And so, you know I’ve got to be on my game if I’m going to participate in that process. The other piece of it is, I always talk about it, you have to kind of check your ego at the door.

Mark Redlus [00:20:39] Yeah, it’s hard.

Dan Gizzo [00:20:40] What works for us is we keep a really flat hierarchy. And so it’s everybody on the team participates in the same way. And you know it doesn’t matter if you’ve been practicing 30 years, if you’ve been practicing two years. If you’re a manager, part time, or you’re a new therapist, you’re a psychologist, if you’re an LCSW, we do this together. Our MDs participate. We do it on the multidisciplinary team and we just we keep a flat hierarchy. We’re all kind of doing this and conforming to this process. And so that helps with the adherence. I think people feel accountable to it, but they also feel that they’re a part of it. You have to support people, provide training. You have to have opportunities to help people, when they’re stumped and stuck. We encourage our providers to help one another.

Gabriel Eichler [00:21:36] Is this sort of physician- or clinician-to-clinician coaching in review used anywhere else in healthcare? I mean I’m thinking about Atul Gawande who has published his checklist work, about how surgeons could use best practice checklists to ensure that they’re following the proper procedures, that they actually have better outcomes when they have those. And culturally it was really hard. He actually had one of his own teachers shadow him in the surgical suite for a few months. And watch everything he was doing and talk about the places where he saw room for error, room for improvement. And Gawande speaks about this being actually quite hard on his ego to hear regularly how he was not doing stuff as well as he thought he had, right? I mean most doctors most physicians clinicians think of themselves as being better than average. Right?

Dan Gizzo [00:22:27] Right.

Gabriel Eichler [00:22:27] Anyway so where else in medicine though do we help clinicians critique and manage and measure or compare each other’s performance on the delivery of care?

Dan Gizzo [00:22:39] I’m not sure to be honest.

Mark Redlus [00:22:42] Doesn’t it feel like behavioral health really lends itself really well to that kind of team-based support? Because you are wading into a lot of subjective and kind of qualitative elements, and we’re talking about quantitative a lot with feedback-informed care, measurement-based care.

Gabriel Eichler [00:22:57] Endocrinologists could compare the HbA1C of their patients and talk about how you know you’re not controlling the HbA1C well of the population that you serve.

Mark Redlus [00:23:06] That’s fair.

Gabriel Eichler [00:23:07] There’s other really quantitative ways: the rates of heart attacks for cardiologists. Right. I mean there’s all sorts of ways you’d imagine this could have happened easier and faster, but in many ways, this FIC [feedback-informed care] stuff has enabled you guys to have really cool dialogues about it.

Mark Redlus [00:23:20] What do you think, obviously everybody’s in the early stages and starting to see results from FIC in population levels and things like that. But what’s your hope, I guess, with proving out? What’s the top on this thing, like could it really change availability, and would we even wade into access here? But that’s a big area, which is, it’s tough to see a provider right now because they’re overloaded with folks they just can’t seem to graduate out. Right? So that was like a three-part question.

Dan Gizzo [00:23:57] Yes. I think what happens with you when you practice, are practicing measurement-based care and you’re taking data along the way and having outcome data allows you to monitor what’s happening in real time and see if we can prevent the bad outcomes. But it also increases efficiency for the treatment. And you know we’re learning, evolving a definition of what a treatment episode is and how treatment episodes occur in different patient populations. The concept is if we can get good care to the person in a highly effective way, they’re going to get better faster. Most of the time it’s going to average somewhere around seven/eight sessions. And you can get people to really a good functional level and then they can graduate. And they might have future episodes of care, but as you keep the system moving, you create space for other patients to come in. I think that’s a critical piece: You’ve got a finite quantity of service you can provide. You want to provide the right service to the right patient at the right time in an efficient way so that you can reach as many of those patients as possible as quickly as possible. And so, I see feedback-informed care as really helping in that kind of broader, systemic goal.

Mark Redlus [00:25:14] You just kind of talked about the right thing at the right time, or the right approach at the right time. You know as we see this evolution towards ‘tele,’ which we were kind of just riffing on before the podcast a bit in various ways, but feedback-informed care’s role in that, is there even a bigger opportunity to kind of supercharge you know what you’re capturing from the patient?  And can you get at more attributes of what’s going on, characteristics, data points, that would even enhance how your approach is? Is the promise of tele actually even maybe more than we thought it could be for behavioral health, if it was done right?

Dan Gizzo [00:25:54] It may be all right, because it eliminates some barriers to treatment. And you know I think that patients want options for how they get their care, right? You know that the patient’s a consumer, and they want options. It would be crazy to think that there’s only one way to do it. All right, there’s only one way that everything has to be just face-to-face in an office? Because that’s way too limiting and so the telehealth opportunities are boundless. Feedback-informed care may help telehealth to really evolve in terms of an evidence-based practice and having that ongoing measurement. I think you know we need to see. We were talking about you know telephone visits and video visits earlier before the podcast, talking about digital therapeutics, like there’s different levels of care, we need to figure out how to get the right ones for the right patient and then have a way of monitoring what’s happening once we provide it. And so, when we get into some of these non-traditional methods of providing care, that monitoring and that database monitoring probably becomes even more important.

Gabriel Eichler [00:27:18] You have the confounders of the modality in addition to the quality of the intervention itself. Right. So, you have digital modalities, therapeutic psychopharmacology. You have talk therapy and everything else in between. And if you don’t have a common framework for evaluating what’s working for a given patient then how do you know whether you’re really deploying those effectively?

Dan Gizzo [00:27:41] That’s true.

Mark Redlus [00:27:44] I always get nervous when Gabriel starts to talk softer. Because I feel like there’s something coming that’s going to be ominous. I’m so nervous when you do that.

Dan Gizzo [00:27:55] Now we’re waiting.

Mark Redlus [00:27:57] What’s going to happen? Do you have anything?

Gabriel Eichler [00:27:58] I’ve got nothing else to say. No.

Mark Redlus [00:28:01] So candidly, Gabriel has nothing.

Dan Gizzo [00:28:04] But in behavioral health, we can do a common … we can create that common framework. Feedback-informed care is, I mean there’s others probably out there, but it is a method that we could apply to multiple types of treatment.

Gabriel Eichler [00:28:22] Is it ever used in places where medication is being used?

Dan Gizzo [00:28:27] So we have our physicians using measurement at each point of contact, just like our therapist do. And one of the things that we assess for is medication compliance in terms of our assessment at each follow up visit. And that would be for any patient that’s taking medication. The therapist in providing the therapy is indirectly supporting the physician’s treatment and compliance simultaneously because we’re getting that information at each point of contact.

Gabriel Eichler [00:29:08] Right. Right. Very interesting. Yeah.

Mark Redlus [00:29:14] So one of the things that we kind of started down this path about tools and techniques for getting adherence. You’ve been able to do some pretty amazing things at scale. You work in a scaled environment in what you’re doing. Could you share a couple of tools and techniques that you’ve learned in operationalizing FIC? Maybe even more specifically, what are one or two things that other folks listening to this that are trying to stand up FIC in their behavioral health areas, that you’d say these would have an outsize effect on you getting this going, or scaling it, or you know any number of things like that?

Dan Gizzo [00:29:57] So I think to scale it, you have to provide training and mentoring, but then you have to put in a common system that everybody uses and participates in. So, I really think the supervision process, what we call our care review process, has been the best vehicle for scaling and spread that we’ve developed. And that involves really changing a culture around how we discuss and how we conceptualize the patient’s care.

Traditionally in psychotherapy, case consultation is kind of like, well it’s like, a grand rounds derivative. It’s this in-depth dive into the patient’s issue, the diagnosis, how we arrive at it, what all the factors are. And there’s a lot of detail and a lot of theoretical discussion. That doesn’t prove to be as useful in terms of what relates to outcome. And so, what we’ve done is we’ve changed the supervision model to fit better with the concept of data collection and feedback. And so, the supervision of what’s happening in therapy is data based at the beginning. We look at variables around what kind of goals have been created for the treatment. And so, you get a lot out of training providers on how to do goal setting in therapy. We focus a lot on the therapeutic alliance. And so when we think about having an outcome measure that tells us where the patient’s functioning at and having data points for that at every point of visit, tracking that over time, paying attention to the therapeutic alliance, and having a feedback-loop that the patient has a voice in therapy and can really have their needs get met, having the measurable outcome goals, and the goal setting is part of the treatment, and then structuring that where we make decisions by looking at those three things in terms of: Is someone making progress? Are they not making progress or are we just unsure? And having a decision tree there that’s fast and efficient and focuses on changing something for the patients that are not doing well.

So that’s what we’ve been able to kind of scale I think is a system for analyzing and integrating all the data we have to make good clinical decisions in real time, in the very core, at the right time moments in the episode of care. We know four sessions in, we typically know if treatment is going to work with that patient and that provider. So, if we’re assessing and doing this at session 5 or session 10, we’re at good time points in the course of care. I think that’s what we’ve really developed is a system that providers can learn and can practice. We’ve timed this, and you can do some of these in two minutes, you can do some of them in five minutes. So it doesn’t have to be a half an hour to discuss a patient, which then allows you to better supervise – ‘supervise’ is kind of a tough word to use — but you kind of monitor what’s happening with a larger number of patients on a weekly basis in a busy outpatient clinic setting. I think that that’s been critical for scaling and for spreading.

Mark Redlus [00:33:19] And that real-time nature sounds really important too. I mean you’re basically functioning in real time all the time.

Dan Gizzo [00:33:24] Right. Yeah if you only look at outcome at the end of treatment, and the success or failure, you kind of missed the boat on quite a few patients. Right. So being able to catch deterioration or lack of progress early gives you an opportunity to intervene and really change things meaningfully.

Gabriel Eichler [00:33:45] Yeah.

Mark Redlus [00:33:47] You know the data science aspect to this — we have our very own Gabriel Eichler here, who is a data superstar. When he’s not on his Peloton, he’s doing data stuff. I had to fit it in.

Gabriel Eichler [00:34:03] Actually, my Peloton has tons of data on it.

Mark Redlus [00:34:06] I know, your measurement-based exercise.

Gabriel Eichler [00:34:09] It’s pretty impressive what you can do.

Mark Redlus [00:34:11] It’s amazing. Candidly my friend, on the data science side you know one of the things that we were kind of kicking around before this conversation with Dan was getting his take maybe on the role of A.I. and machine learning and feedback-informed care or just in behavioral health in general. Do you have any thoughts on how algorithms can help you as it goes forward, beyond just that measurement?

Dan Gizzo [00:34:44] I’m intrigued by what the two of you were talking about in terms of how algorithms that help get the right patient to the right provider. Get the right patient into the right treatment. I mean I think that when you make that happen, change happens faster, and you really accelerate the whole process, and you make the system more efficient. I think when we get into looking at options for treatment and getting away from the idea of the one size fits all and having lots of options, I think that it’s going to be pretty critical to make sure the right patient gets into the right one of those options. And so, I don’t know how to do that stuff like that. Right.

Gabriel Eichler [00:35:30] We’re scratching the surface, but we’ve contemplated that modality could be optimized, intensity, number of visits per frequency of time. Right. Whether medicine is needed. I mean with enough data one could start to mine a lot of these different things and start to build out optimal care pathways. Right.

Dan Gizzo [00:35:50] Right. So, if you’re able to do that, that could really fit into this feedback-informed care model very well. It also could help us make sure that we have the right set of options for the patients most likely to show up for treatment. Because there’s always going to be rare and unusual presentation. Yeah. Like there is with any type of medicine.

Gabriel Eichler [00:36:16] Right.

Dan Gizzo [00:36:16] Right. But you know I would imagine that your data would be more profound and impactful where there’s high prevalence conditions, high prevalence patterns.

Gabriel Eichler [00:36:26] Lots of observations. Absolutely right. For sure.

Mark Redlus [00:36:31] You talked about that on our intro podcast: about radiology being kind of that; this is getting better than people. But it’s kind of like that screening identifier, like that first stage step which is easier in radiology than behavioral health, because you’re in an ongoing kind of intervention, going on an episode of care. But you could reduce the noise — well not the noise but the complexities — that when you get that patient, it’s really a good match for you and good match for the patient too.

Gabriel Eichler [00:37:00] Yeah, we’ve seen the initial data suggests we can get a clinically significant improvement on the course of care that that patient and clinician engage on when they’re properly matched with each other. So that’s something we hope to validate prospectively in the near future.

Mark Redlus [00:37:15] Yeah that’s really cool stuff.

Gabriel Eichler [00:37:17] Yeah. Which is exciting because if patients can get more bang for the buck in that therapy time they invest and the money invested in the system, then that benefits everybody. Yeah. Yes.

Dan Gizzo [00:37:27] Yeah right. Absolutely.

Mark Redlus [00:37:29] Dan, as we wind down, we’re trying to make these episodes consumable on a drive. So I think we’re in good shape there, but a question, I don’t know if Gabriel really agrees with this question, but I’d love to ask this question of every guest because, especially around healthcare, which is — you can take this down any road you want — but you know when it comes to healthcare, what do you think we will collectively look back on five years from now, and go, ‘I can’t believe we used to do it that way’? And it would be maybe an order of magnitude but a significant improvement in something. It can be with what you’re doing or just something you observe.

Dan Gizzo [00:38:13] For me it would be the paper and pencil measures. In behavioral health, we use a lot of paper and pencil measures even in psychological testing and assessment. Still using a lot of paper and pencil measures. And the time that that takes and how much more efficient it would be to have technology providing any kind of real-time feedback. There’s just so many areas of improvement for that. So, I still have a pencil sharpener in my office and pile of number two pencils. Yeah like I go through a lot of pencils.

Mark Redlus [00:38:50] That’s pretty interesting. I would never have pictured you doing that, by the way. That’s crazy.

Gabriel Eichler [00:38:56] But you know EMRs made that nearly obsolete in most clinical environments now.

Dan Gizzo [00:39:02] But there’s more room for that to advance and in a lot of areas of mental health.

Gabriel Eichler [00:39:07] So EMRs have largely left behind mental health in terms of support and catering to their needs.

Dan Gizzo [00:39:12] It’s getting there but EMRs tend to be built based on you know the medical model that doesn’t match up as well to what happens in behavioral health.

Gabriel Eichler [00:39:23] Interesting. Yeah. So, you know I guess also the only person inputting stuff into the EMR is the physician, whereas in this feedback-informed care environment…

Dan Gizzo [00:39:32] I mean, our providers are inputting…

Gabriel Eichler [00:39:36] …in the EMR still?

Dan Gizzo [00:39:38] Right yeah, they are. Yes. So, we’re paperless in terms of progress notes and you know so we’re not sitting with the pads for that. But in terms of measurement, there’s still a lot of measurement that goes on paper/pencil. In five years, I think we’re going to not see much of that. I hope.

Gabriel Eichler [00:39:57] Yeah. It started to have, I think it’s ready. You know it’s already well on its way.

Mark Redlus [00:40:02] You know things move slowly. Things in healthcare, five years feels… it seems really far away, but in healthcare, that’s kind of like the next innovation cycle.

Dan Gizzo [00:40:15] Absolutely.

Gabriel Eichler [00:40:17] If you’re lucky.

Mark Redlus [00:40:18] If you’re lucky.

Dan Gizzo [00:40:19] Neuroscience will give us a lot of opportunities. The overlay of neuroscience with mental health will maybe be a fruitful area. That could be another podcast.

Mark Redlus [00:40:29] Yeah we’ll have a part 2. We’ll come back to San Diego to do this. It sounds like a really good plan.

Gabriel Eichler [00:40:35] Thank you, Dan. This has been just phenomenal to hear your viewpoints on these and these topics.

Mark Redlus [00:40:41] It was really fun to do it.

Dan Gizzo [00:40:43] A lot of fun. Thank you. I appreciate the opportunity.

Mark Redlus [00:40:45] Thanks for doing it. And thanks, San Diego, for having us. So, it’s been good. Bye.

Gabriel Eichler [00:40:51] Bye.

Gabriel Eichler [00:40:56] So thank you so much to our guests for joining us today for this conversation with Dan Gizzo. Really hope you enjoyed it and loved learning a little bit about this feedback-informed care model and what he’s doing that space. Thanks again and tune in for the next episode.

Mark Redlus [00:41:20] Thanks again to everyone who just sat through episode two of the 10x Total Health podcast. If you enjoyed the episode, please feel free to drop us a line via our Web site 10xtotalpodcast.com or e-mail either of us at Gabriel@10xtotalpodcast.com or Mark@10xtotalpodcast.com. We’d love to hear your feedback. Without our listeners, we’re just two guys having an interesting conversation, which is how this whole thing got started anyway. As always, the show notes will be up on our website under Episode 2. Please stay tuned for upcoming guests across the healthcare delivery product and investing spectrum. This should be a great ride. We hope you enjoyed it and we hope that you continue to join us. Thanks.