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June 6, 2024: Dr. Eric Lee, the Medical Director of Clinical Informatics at AltaMed, engages in a deep dive into the integration of technology and healthcare services at one of the nation's largest federally qualified health centers. They explore how AltaMed leverages its position to manage care for a vast and diverse patient base across L.A. and Orange Counties. How does the implementation of technological innovations like EPIC's Chronicles claims loader and digital tools address quality measures and improve patient outcomes? What strategies does AltaMed employ to navigate the challenges of Medi-Cal expansions and the integration of clinical informatics? These questions are explored, shedding light on the practical implications of digital transformation in a healthcare setting focused on underserved communities.

Key Points:

  • Digital Transformation Journey
  • Managed Care Challenges
  • Clinical Informatics Integration
  • Serving Impoverished Communities
  • Adapting EHR Systems

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Transcript

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

    Today on Keynote

  my most important criteria was. based on our patients that we serve. So it had to handle Spanish. That's 40 to 50 percent of our patient population so if half our patients weren't going to work with a solution, it just right there, the cost is just not worth squeeze, right?   My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health, where we are dedicated to transforming healthcare one connection at a time. Our keynote show is designed to share conference level value with you every week.

Today's episode is sponsored by Quantum Health, Gordian, Doctor First, Gozio Health, Artisight, Zscaler, Nuance, CDW, and Airwaves

Now, let's jump right into the episode.  

(Main)   📍 all right. Hey, it's a keynote. And today we're joined by Dr. Eric Lee, medical director of clinical informatics at AltaMed eric, welcome back to the show. Thank you for having me here today. I think it's been a while. you were one of the people I called during the pandemic and I wanted to get an idea of what was going on during the pandemic and that was the pandemic.

That was a long time ago. That was like 2020. some things have changed at AltaMed since that time. Just a few things. Yeah, just a few things. So tell us a little bit about AltaMed, just to get everybody on the same page with what you guys do. I think it's pretty fascinating, pretty amazing.

Okay. All right. So AltaMed so what we're mostly known for across the country is that we're one of the nation's largest federally qualified health centers, or FQHCs. What most people don't know about us is that we also have a for profit managed services organizations in which we delegate our utilizations and referral management to.

And then we also have a Medicaid insurance product known as AltaMed Health Network. And we're responsible altogether in this family of companies where we have maybe about half a million lives that we're responsible for across L. A. and Orange Counties. We're at risk for roughly 260, 000 of those lives right now.

And I think as of August of this year, we'll go over that 300, 000 mark.

Yeah. And you guys serve some obviously what we consider some of the underserved areas when people hear Orange County, I think they think the beach and those kinds of things. But when I lived there, we described it as a donut.

There's a lot of wealth around the outside and then right in the middle there's a lot of not wealth. There's a lot of people really struggling to get by. To housing is scarce just all sorts of challenges. And that's the population that you guys have chosen to serve.

Yes roughly two thirds or 70 percent of our patient mix, or payer mix, is Medi Cal or Medicaid, and then about a quarter is self pay. We do have the rest of the patient population being with Medicare Advantage or commercial plans, and we do have the nation's second largest PACE program, which is over 5, 000 participants, and PACE stands for Program for All Inclusive Care of the Elderly.

You generally have to be or older. You have to have Medi Cal and significant life impairment. And generally our, our sicker patient population that, in which they want to continue living independently for as long as possible and not move into a skilled nursing facility. Those are the folks that we enroll in our PACE program.

We've had tremendous outcomes over the decade that it's been up and running.

Now you guys are moving towards managed care for that population. We've done a lot of interviews. We've talked to a lot of people. How are you able to get in front of the challenges? How are you able to get them, plug them into primary care?

the things that keep people healthy.

Yeah. Well, I don't know if I would say we're in front of it. We're probably running alongside it or trying to keep up with the changes as they're happening. So one of the big things that happened at the beginning of this year was Medi Cal for all.

So redetermination kicked into effect and in 2023, folks that were 50 and over and that did not have insurance. Didn't matter what status you were, if you qualified for Medi Cal, you could sign up. And then that age limit dropped down from 26 to 49 to include that segment of the patient population at the start of this year.

We've been trying to convert a lot of these self paid patients into, enroll them in Medi Cal. There's still fears. And I think that's part of it of they think the government is tracking them or keeping a close eye on how much they're spending and whatnot and are their documentation status.

So there's still some resistance to it, but we've enrolled lots of patients this year as well. But that has been one of the reasons why we continue to grow. Like you said, in terms of managing risk and assuming care for this large patient population and how do we do it, there's lots of building blocks that need to happen.

And what we've been focusing on was from a technology standpoint, we were the first in the country last year to go live with EPIC's Chronicles claims loader, which they now call Dyne. And a few members from the team will be speaking about it at Epic UG on this August. about how our implementation efforts and what we've seen.

But one of the, beautiful outcomes from that was that we had closed another almost seven percent increased quality measures being addressed just from pulling in external claims. Almost two percent of that was just through immunizations that didn't really require that additional validation.

And then, the remainder of that would, you would have these chase lists in which we would, Find that proof or that report that, the mammogram happened outside or the colonoscopy occurred and we would get that into our records to be able to close those quality measures.

but we wouldn't have been tipped off to that if we didn't have the claims being pulled into Epic. So that's one way in which we try to get an overall picture or a better lens of the patients we serve. So

how important is digital? And as you get into that, I'd love to hear more about the digital transformation journey of AltaMed and your role as the medical director in that transformation.

haven't had as big a role as Ray Lowe, our esteemed CIO, right? just tell you this story real quick before I get started. Back in 2018, when I first started working for AltaMed, we didn't have Wi Fi in all our clinics. And, we were just, literally three days after I signed or started here, we signed a contract with Epic and we were off to the races and implemented Epic Foundation a year later, but we had to get Wi Fi in our clinics.

And so That was part of this technology uplift of what needed to happen. It was, Ray has done a fabulous job with the IT leadership team here of getting us up and running. To present day so that we are prepared to be able to do bigger and greater things. My role in this has been, I think it was, we had a clinical informatics team of two, it was myself and a PA who has been with AltaMed for a long time.

And we had to reshape the clinical informatics team after our implementation. And we now have folks on the team with a mix of nursing and pharmacy, dental. multiple physicians, we even have a pediatrician from Children's Hospital Los Angeles as part of our joint partnership with them on the team. And so it's really been more of let's embed ourselves as much as possible into the various departments and with our operational leaders.

And let's understand better what their pain points are. Let's understand when they're requesting something, you have to decrease that distance and of what their understanding or expectation of a final product would be and what our understanding of it is and make sure that we're aligned.

And I think that's been a lot of that, just on a high level of what we've been focused on with any of the various programs that we've rolled out over the last few years.

interesting because I remember talking during the pandemic and think I talked to you and Ray during that time and you were talking about how you guys had to be almost opportunistic.

Like couldn't just, as all these health systems were like, Oh, we need that technology. That they were just starting to throw money at all this different technology. You guys had to to really study it and look at it and make sure. that you are making the right bets. how do you ensure that the things that you're going to do are going to have a positive impact on the clinicians and a positive impact on outcomes for the patients?

It's a lot of careful research conversations, right? It's again, some of these vendor companies would say, Oh yeah, we do integrate with Epic and we're an Epic first shot. If Epic doesn't have a product available or an offering available, We would start looking at other options and figuring out what, what was going to be the best fit.

We often ask for pilots try it out first, see how it works within the workflow. And. Everyone on my team does do some clinical time. For example, I do one to two half days of clinic a week. And I'll go to different clinics throughout our organization just to see how things are working throughout, right?

That's my way of rounding. I'll do some telehealth clinics as well. So yesterday morning I did a telehealth clinic and looking at Ambient AI, right? And what's a good option for AltaMed, right? So I've been trying out a couple of different companies and their products and, even when I'm seeing the same patient or one patient, have both of them running in the background and Compare the documentation and the quality of the notes that they produce.

you've got to have that careful vetting and then figuring out that checklist of questions you're going to ask, making sure you do your due diligence, speak to a reference client. I think it's not unlike what most others do. They're just, I think we don't make the decision as quickly as others do.

Yeah. You guys are almost the equivalent of a startup. It sounds like you guys are very hands on. Everybody's still practicing within your group. I think there's so much value in that. what are some of the biggest challenges that you faced in integrating clinical informatics at AltaMed And how have you addressed, some of those challenges?

It's been a journey, right? I think when we first implemented Epic, folks thought, magically, the technology would fix all, right?

It didn't?

I know, right? With any EHR implementation, in my view EHR implementation exposed All the flaws all the things you swept under the rug and just developed workarounds for with your legacy system.

And it exposes all these deficiencies and flaws and, with a new EHR company that you bring in, they're going to say, well, we can't do it that way. You're going to have to fix this, or you're going to have to, renegotiate these existing vendor contracts and it has to operate better.

And there were a lot of to be gained. Mind you, but at the same time, there are things you have to de scope and tackle that afterward. And the effort of trying to make sure you just implement on time and on schedule. But after implementation folks still have this unrealistic expectation that, Oh, well, Epic can this out, right?

We'll put in a ticket. Hopefully this will get built. And what they didn't realize is we would go back to them and ask them tons of questions, right? And just like that happens everywhere else. But you have to ask a lot of questions, figure out what's the problem you're trying to solve, figure out what's the right scenarios, or maybe what you're asking for isn't the right option, right?

It should be, we would suggest this instead, because we don't want you relying on a manual process. For example, one of the things we have right now is Flags and EPIC, right? On patient chart, there's flags. And one of the things that folks often think is that, oh, I'll update the flag. Don't worry. I'll change the status all the time.

It's well, if it's going to be so manual dependent, why do I see patients enrolled in this program with five different status flags when they should only have one status flag indicating that they're enrolled in a program? It's because you're not keeping up and maintaining it because you're relying on a manual process and it's going to fail inevitably, right?

So how can we help you automate this or figure out a different way? So that we both get what we want.

talked about ambient clinical listening, and I wanted to go down this direction of emerging technologies. Let's focus in on the ambient right now. So when you're evaluating a new technology like this, you describe the process of You're actually using it.

You're using it in a clinical setting. You're evaluating it in the area of ambient. What's the most important thing to you? Is it the ease of use to the clinician obviously there's like a baseline that the note has to be as accurate as it possibly can be. But there's still a human involved in the loop.

is cost a major driver? Is the cost of supporting it long term a major driver? how do you evaluate those new technologies?

my most important criteria was. based on our patients that we serve. So it had to handle Spanish. That's 40 to 50 percent of our patient population whose preferred language is Spanish, right?

There's 40 percent, yeah, but the other 10 percent have preferred languages that are not English. So we would have, you name it whatever your threshold languages are in your state or county we would have it. And so if half our patients weren't going to work with a solution, it just right there, the cost is just not worth squeeze, right?

So that's why we had to sit on the sidelines for so long until, within the last year and a half when things have started exploding on the scene. So that was probably number one. Number two was. Cultural sensitivity we're fortunate here at AltaMed, we have a cultural linguistics department and they're so focused on making sure that we have interpreter services provided for anyone and everyone that needs it, and that is easy to use.

So we have iPads in all the clinics for our telephone visits, we have phone lines in which we can call and request, they join us in under 30 seconds, both in the clinics and for phone visits. We've worked with another vendor just to have a third party interpreter appear for our video visits.

If I'm having a video visit, just like this right now with you, Bill, but yet you speak Spanish and I request a Spanish interpreter, there'd be a third box appearing where our interpreter would serve us as well. I think it's important to have that visual connection with an interpreter, which is why we insist on having that video interpreter join as well.

But it's not only that, right? It's all the patient communication, health literacy It's a real problem in which we talk way over the heads of our patients that we serve and despite our best efforts to try to correct ourselves. We can be guilty of that at times. So what can we do to make sure it's at a fourth grade reading level or lower?

What can we do to make sure that we also have it translated into our major languages that we need, especially in different pockets of Southern California, we make sure we're catering to that segment of the patient population. So in my view, it's also, I would like to look down the line when evaluating an option as well and saying, are you willing to partner with us with integration?

into EPIC. And it's not just the HPI and the assessment and plan, but can you capture what just happened and put it into a robust assessment and plan that meets coding criteria? Can you create a set of patient instructions that would map to the appropriate tab in EPIC, to the patient instructions box?

So I don't have to waste time typing it out. after the visit or at the end of the visit for the patient, it's going to integrate and flow into there, right? Can you create a letter for you so that they can take time off work? so there's so many different things in which you could do this. The other thing we've done is we've taken ExpressLanes, which is a feature of so ExpressLanes is a feature in Epic where You may have it's driven by a reason for visit or a chief complaint, and typically it's been used for really simplistic things like an earache.

I go to urgent care. I have an earache. It'll suggest an express lane to me. I'll open it up and I'll have a very simplistic, maybe antibiotics, ibuprofen. Some codes, right? it allows me to create a template and note really quickly and get through the visit quickly. Most patients aren't like that, right?

And so what we did was took a twist on this and we did this for annual wellness visits for Medicare patients. And made sure we included the appropriate screenings. The nurses knew, okay, this is what we got to do, right? We got to do all these screenings. And after they're completed, it's going to flow over to the node.

We're going to have the right set of codes in there. We're going to make sure we order additional care gaps that haven't been addressed, right? Whether they're labs or immunizations. We offer it in there and we'll pre populate it for you, making it easier for you to do the right thing. So we've done this for Well Child Checks.

We've done this for Medicare Advantage. We're in the process of doing this for all new Medi Cal patients that come to us. as well as annual preventative visits. And this is mandated by health plans and we're getting alignment from our health plan saying, we're going to do this. Do you agree to accept this format?

And they've bought in. So we presented this this year at Epic XGM, a couple of my docs as express lanes for all ages. But to me, again, this is a great way to improve outcomes. example, the improvements that we've seen, right? With our pediatric patient population, I know, We've increased our lead screening in our children, right? I think it was like two or three fold that we increased it. We also had increased pneumococcal immunizations in our adult population.

What we also found was that for hepatitis B and hepatitis C screenings and if we found that they needed the hepatitis B vaccine, for example, we were 10 or 20 times more likely. To order that based off the express lane and going through it all, rather than looking at a breath practice advisor or BPA type of alert, which, was looked at and maybe done 2 percent of the time, we were 20 times more likely to do this.

With an express line. So there's power in being able to make it easy for the clinician to review all that needs to be done, and you're pre populating, suggesting what care gaps remain, and then you're going to help them with the coding. The note template that's then created has the screening results in there, right?

It's already pre populated because it's flowing through from the express lane. You have all the templates, it's going to have all the interventions that you agree to and you're signing off on. And we have the right language in there that you can select from to make sure it's compliant with the health plans.

  📍 📍 📍 📍

All right, it's June and I am wearing my yellow hat. And this June we're championing, uh, A cause close to our hearts, Lemonade Days, supporting Alex's Lemonade Stand Foundation in our fight against childhood cancer. In 2000, a young girl named Alex started a Lemonade Stand to fund cancer research. Her legacy has inspired millions in donations, funding research, and supporting families.

This June, we're inviting you to join us. It's simple. Just visit ThisWeekHealth. com and click on the cancer ribbon to make your donation. Together, we can continue Alex's mission to make a significant impact. Every donation moves us closer to a world where no child has to face cancer. So, take a moment, click on that ribbon, and make your contribution.

Thanks for your support, and let's make this June a month to remember. 📍  

All right, I'm going to go back a little bit and then come forward a little bit. Is there a significant distinction between the ambient solutions being able to handle language at this point?

I think there was. My understanding is it's going to be addressed this summer, right?

So I think all the options out there will be for that. Pretty much on a level playing field from a language perspective. And then I think it's also just, then you're looking at cost, right?

and integration. It sounds like you guys. Really have focused in on making that journey for the clinician, as efficient as possible.

I assume that's so that they can handle the volumes that are in front of them.

just to take you back a little bit too, we've never had any speech to text dictation system. We've never been live with this system. Our prior EHR was a lot heavy on the point and click.

And with our migration into Epic, we figured we would use a lot of the smart phrases, note templates, and lean into that and smart list to help with the documentation. But I still get requests regularly for dictation, right? And again, then what happens is you have to create a whole new set of note templates, For the dictation system, right?

And in case there's downtime with the dictation option, you got to lean back onto the note templates on Epic. so you'd have to maintain two sets of templates, which becomes a bit onerous. So what we've been looking for is an option that will listen, right? ambiently, but not only just create a note, but how can it work within our existing note templates that we've worked so hard to make sure we're always compliant for, and making, and meeting regulations, right?

Meeting requirements. Making sure the quality is there.

You were talking about Fastlane, you were talking about some of that stuff. It sounds like you guys really have leaned in heavily of saying, look federally qualified health clinic, we're investing in Epic. It seems like part of your role is to make sure you get the most out of that tool.

if that tool can solve a problem, you want to make sure that it's solving that problem. Is that an accurate depiction?

Absolutely. We have to, right? Epic is not a cheap product. And so we're going to get the most that we can out of it. And from pushing the team to make sure you're scouring the user web the user forums, you're attending the appropriate webinars, and what are we taking back?

And what are our best practices and how can we imitate that? As Judy says, imitate to innovate. But the other thing is, what you get out of your relationship with Epic. Ray and I, we meet with our BFFs weekly, and it's at least half an hour. So we have touch bases on, here's what's on the docket for future, here's some hot topics for us, here's what's top of mind from just what's going on in the organization.

Just so they're up to speed with us. And it's not like a, one quarter later, it's we might forget some of the stuff we talked about. So we make sure were meeting with them weekly and they're right there with us. So they can help us, right? We'll ask them frequently for help.

Can you help us with this? Can you explore this? Can you tell us what are the options? But it's really that power of that relationship with Epic is what has helped us because we're not richly staffed, right? So we have to then rely on our partners to really help us along.

Yeah, when you were giving me your numbers, I'm not sure.

I know of a system that has numbers that low that is running EPIC. I don't know, we didn't look at your entire organization across the board, but it generally is fairly staff heavy when you implement EPIC. was in a room recently with a couple of the CIOs, that are, part of the most recent large announcements that are moving to Epic.

And we were just talking about, what does it take to be successful? And we had a really good conversation. There was other CIOs there chiming in. you were sitting in front one of those CIOs right now, what would you say how were you able to be successful in the implementation?

What led to success? It sounds like You implemented foundation from the get go.

I think one of the things I learned from the prior role when I had worked for the state of California prison health care system and implemented Cerner Millennium, was known as back then, is you can configure and develop rules and do a lot of, custom configuration builds, but when it comes time for version upgrades, you're going to pay the price.

So in this instance, it's really more of stick to EPIC Foundation as much as possible with subsequent upgrades. And it really has paid off for us because when EPIC started moving to this quarterly or biannual upgrade cadence, it really fit us well, right? So we do it every six months.

Can you imagine if we had a lot of rules and a lot of custom build and development and then you have to go back and test it extensively in each environment and then when you go live with the upgrade, guess what? There's something inevitably is still going to go wrong despite you having tested it in, POC and TST and, so there's something inevitably that will not behave as expected, right?

So you can't capture it all, right? So that's why I think trying to stick to foundation as much as possible is really one of the keys to making it easier for maintenance.

Yeah, getting back to one of the things you said, some people feel like You put the technology in and all of a sudden there's magic and everything works.

Talk a little bit about adoption. is one of the things I think we don't talk enough about in this industry, but it's so critical, right? You're putting these new things in front of people. And for a percentage of the physicians, they see it, they get it and they go, yep, absolutely.

Let's do this. We're off to the races. But for another percentage of the population, it's not. that change is not welcome, and it's hard. How do you help with adoption in your system?

I'm a big believer, and I heard this on your podcast with one of your prior guests, right?

Daniel Barchi, who said any sort of change that you do is 80 percent people, 15 percent process, workflow, and 5 percent technology. And I've really taken that to heart, right? Because when you look at a problem that you're trying to solve, You have to look at, okay, who's going to quickly adopt it, who's not and what's the workflow?

What's the new workflow you want? And you have to work your way backwards, right? For example, like we were talking about this whole annual wellness visit express lane that we introduced, right? there was some resistance at the beginning, and I can't pen the orders, don't want to sign them all at the beginning, or what if I want to add orders later, and there were always folks saying, well, I don't want to create my note yet, because I'm not done asking the questions I want to do yet, right?

I don't want to sign my codes, I don't know what type of visit this is going to be. There was a lot of resistance, right? you can't over communicate, however, we brought this up, we have a monthly webinar for EPIC training for our providers, so fourth Tuesday of every month, 8 a.

m. so we've been doing this for the last few years, and we brought it up four or five different times in the year we introduced it, and said, okay, now you've had this live long enough, chief quality officer, Dr. Bihu Sandhya, she's fabulous. And she was like, this express lane proves Outcomes.

So we're going to make this part of incentives. So it's an incentive for this year, right? If you incentivize it, that if this is 12 percent of your incentive, if you use this 95 percent of the time or more, you're going to qualify for this part of the incentive because we know it's going to improve the outcomes and we know it's going to improve the quality and the care that you deliver.

So it's standardized it, right? So you have to kind of tie it all together and figure out, okay, let's hear the feedback. Let's go back and iterate. Let's go back to EPIC. Again, EPIC, hey, how can you help us with this problem? Okay, what's the development plan for it? And, for example, we just went live in a pilot with EPIC, I believe in April, for the ability to append orders within ExpressLane.

But that was a well over a year after we introduced ExpressLanes for all of these different age groups. So it's been lot of back and forth and again in our partnership and going back and saying we need to be in this pilot group. They signed us up, were live with pending it. So I think that's again part of that partnership and then going back to the business and saying we've got these changes coming.

Just keep hold out, get used to the, develop your muscle memory for this ExpressLane. And go on from there.

I like the fact that you took a fairly long time. I also like reinforcement of saying it, five times. we're coming up to the end here, so this will be sort of the closing.

We had a conversation to start with. You have the five dysfunctions of a team right there back behind you. And you talked about a book club and how, team reads these books together and has discussions and that kind of stuff. Talk a little bit about the leadership team. Talk a little bit about the culture.

and the culture of learning. I know that Sarah Richardson was in there working with you guys as well. You guys are really committed to learning, reading, and advancing with each other. Talk a little bit about that.

Yeah, it's one of those things where you have to be willing to, go outside of your organization and continue to learn and be committed to learning.

So, whether it's listening to your podcast among, several others out there. Thank you, Bill. And again, just making sure you're current as much as possible with the news. Then enriching the team. So the first book that we had read together, at least on the clinical informatics team was the checklist manifesto.

And what, team members may not have understood it back then, right? But that was my purpose. my underhanded purpose was. You always got to have this checklist before you're going to move a change in a production, or you may need a checklist for the types of questions you're going to ask the business who's asking for a product from you, right?

What are those things you need to do? there's lots of checklists that need to be developed. So get in the habit of creating those checklists and refining it over time. And that's what I wanted to instill in our team is that Every time you do validation testing, it shouldn't be that complicated, right?

You're going to have this checklist of these are the different types of patients from the different departments we need to pull from. These are the scenarios we are going to test. see if the outcomes were expected or not expected. But that's what I wanted to get them in the habit of is, apply checklists to your personal life, right?

Figure it out but there's tremendous value in making sure you don't forget things that were easily preventable by going through that. So I always have a purpose in the books that I give my team and try to get them to understand There's a smarter way of working, or it's a different way of working, and let's embrace that, or, you may not necessarily agree with it, but It's all about changing our lens. And then, obviously, Sarah Richardson, right? She came in with a culture of learning and a culture of leadership and improving how we communicate with each other, right? We learn things about each other on the IT leadership team. It was like an extended IT team, and my informatics team was fortunate to be part of this as well.

Just learning things about each other we didn't know before, because we didn't take the time to, I don't know. We didn't have the format or the context of having these forced conversations in which we then talk to each other and are asking each other, or learning or offering up little known facts about ourselves that then become future bridges for.

developing relationships and really like how we elicit feedback, how we ask each other to do things or keep each other updated. I think it's really improved the communication within our IT leadership team.

That's fantastic. Eric, I want to thank you. I want to thank you for coming on the show.

Thank you for your work in Southern California. Hopefully we'll be in the same room at some point throughout the remainder of the year. I look forward to. Seeing you guys maybe up at UGM again. I think we did see each other up there. That was fun.

Yeah, that'd be great. Our CEO is coming, Rocha. He's going to be speaking at the CEO Council this year.

So, maybe you'll get to meet him as well. It'd be fabulous.

Fantastic. Thanks again for your time. Thanks for sharing your experiences. Really appreciate it. Thank you.   Thanks for listening to this week's keynote. If you found value, share it with a peer. It's a great chance to discuss and in some cases start a mentoring relationship. One way you can support the show is to subscribe and leave us a rating. it if you could do that.

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