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November 3rd, 2023: Alistair Erskine, Chief Information and Digital Officer / VP for Digital Health at Emory, delves into the transformative impact of large language models and ambient listening technologies. As healthcare professionals increasingly adopt AI tools for note-taking and summarizing patient interactions, what are the implications for efficiency and patient understanding of medical information? The conversation explores how these technologies not only cut down the time spent on documentation but also hold the promise of making medical notes more accessible to patients by converting them to a fifth-grade reading level. What qualities and shared visions set apart a productive partnership, and how does this relationship contribute to advancing healthcare’s mission of saving lives and providing equitable care?

Key Points:

  • AI in Healthcare Documentation
  • AI Recorded Medical Notes
  • Innovative staff engagement
  • Vendor and Partner Relationships
  • Navigating remote work

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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 This Week Health.

(Intro)   to be able to make that data flow better to the people is critically important and kind of the duty of a health system to make sure that we're discovering the next best care item for a patient.  

📍 Thanks for joining us on this keynote episode, a this week health conference show. My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of this week Health, A set of channels dedicated to keeping health IT staff current and engaged. For five years, we've been making podcasts that amplify great thinking to propel healthcare forward. Special thanks to our keynote show. CDW, Rubrik, Sectra and Trellix for choosing to invest in our mission to develop the next generation of health leaders. Now onto our show.

(Main)   All right. Here we are for this week health. This is a keynote episode and we're joined by Alistair Erskine, the CIO, CDO for Emory Healthcare. Alistair, welcome. to the show.

Hi, Bill. How are you doing?

Good, I'm looking forward to this conversation. We got to meet at one of the 229 roundtables and we had such a great discussion while we were there and I'm glad you took the time to come on the show and share some of the stuff that's going on. to start with the question that my, my users, the listeners have asked me to start every show with is tell me about Emory Healthcare.

Tell us about your system and a little bit of the detail around it.

Yeah. So Emory Healthcare is an academic medical center in the capital of Georgia, in Atlanta, Georgia. It's becoming more and more unusual compared to other academic medical centers in the sense that it truly is integrated in the university.

The healthcare science center and the hospital systems together. So other organizations used to be that way and for one reason or another decided to split healthcare from the university. But Emory has retained that, believing that it can reap the benefits of each other to make a stronger system.

And otherwise, from a healthcare delivery perspective, It's about a 6. 5 billion, 11 hospital, you know, 250 clinics system that serves about 6 million patients in the greater Atlanta region.

So is it primarily urban then? Do you reach, I mean, cause I know that Atlanta becomes rural very quickly as soon as you get outside of the multiple beltways that are there.

that is exactly right. And I haven't only been here five months. have been taught that it's called the periphery, not the beltway and that we definitely draw from patients from hours and hours away, sometimes from other states to Emory. So it's definitely drawing from a rural population as well as obviously an urban population.

So with what you described, the CIOCDO role, at a lot of academic medical centers, you would have a person who's over the university, a person who's over the healthcare organization, and potentially some other roles as well. Is that integrated then? The role is essentially over multiple aspects?

It is over multiple aspects, although it's not over the entire university. So there is an interim university CIO, and he and his team are responsible for the network, cybersecurity, and some of the software, like PeopleSoft and Microsoft and those kinds of applications. I have responsibility over anything that touches health.

So that's the healthcare delivery side and the Woodruff Health Science Center, which encompasses a school of medicine, nursing, and public health, and some research lab, like the Primate Lab, the Goizueta Institute for brain health and so forth.

Fantastic. So CIO, CDO role. Talk, talk a little bit about what does that role look like at Emory?

a traditional CIO in the roles that I've been exposed to have a focus on the infrastructure of the organization making sure that the technology is optimized making sure that there's a strategy that ensures that we're taking maximal use of that technology.

I think the chief digital officer aspect of the role is more of a looking forward. So if one had to force the the concept that the CIO is the accountant, the digital officer is the finance person. So always a look ahead. Understanding where healthcare is going from a digital patient experience perspective, a value based care population health experience perspective, what's going on with AI, machine learning, large language models those aspects of technology.

Well, that's a fun area to hang out in So what is coming next? I mean, putting on that hat of what's coming next, normally I would talk about, what's going on now. And we will come back to that because I want to hear some of the things of coming through the pandemic, some of the challenges, how you guys at Emory really address some of those things.

And I realize some of that's before you. It was one of the reasons I'm starting off looking forward. What is coming to healthcare? What's coming specifically to Emory in in Atlanta?

we really divided the body of work to be done into six key domains, three of which are experience domains, and three of which are kind of support domains.

The three experience domains are patient, care team, and researcher. And so the kinds of things that we're thinking about from a patient experience are the things that you would expect. A personalized website that takes advantage of propensity models of a patient. For example, having a greater propensity for a colonoscopy as opposed to, an asthma visit.

The ability to have a modern way of Looking up provider search where you can use layman's terms to find your doctor, and you can use an Amazon like shopping cart to pick the right kind of doctor for you. we have put all of our inventory of available appointments online. So you can book online, and that number has gone up by 400% over the past several months.

And, of course, like many systems we have a portal that's associated with Electronic Health Record. We have virtual services so, you know, virtual visits as well as virtual nurse in, virtual tele sitter services. And we plan to offer, we don't offer it today, but we do plan to offer a large language model chatbot.

So people can ask. Plain English questions and get answers 24 7 even if the contact center is closed. We will be implementing an omni channel consumer relationship management tool which will help make sure we have wraparound services so the patient isn't lost as soon as they leave the clinic.

Because we have a population that is very diverse, including language diverse. We want to offer our services in Korean, Russian, Spanish, and other languages, so we have to figure out ways to medically interpret and translate some of the artifacts that we give our patients into the right language. And then we want to move some of the care to the home you know, to, to the extent possible, remote patient monitoring, hospital at home.

So that... If thinking about it from an experience standpoint, not so much the technology, but what is really the experience we're trying to offer the patient, and I guess wayfinding is the other one I should toss in there, is the ability to get a patient from their couch to care, either in as simple a way as possible through virtual means where they can remain on their couch or through as aided an opportunity as possible where they know exactly where they're going, they know the, pick that provider.

They've been able to bundle visits together when they have multiple visits. You know, we want to offer everything that we can to just make the experience of getting care at Emory as ideal as it can be.

as you mentioned earlier, you're fairly new to Emory.

What's the beliefs that sort of support the initiatives that are going on? there's a strategy that's underneath all this, but underneath the strategy is a set of beliefs. And I heard a lot of things around the consumer. So there must be a belief that Hey, we need to start making this more accessible to the community.

I heard some things around virtual nursing, so there's a need for efficiency, maybe a better care experience. I'm curious what beliefs underlie the strategy at Emory?

First and foremost, the most important belief is trust. So, we really have to do everything we can to earn the patient's trust.

We do a good job when it comes to the quality of the care that we deliver. And patients do trust that Emory is going to give them the best care in Atlanta. But we erode some of that trust when we make ourselves inconvenient to work with or hard to find an appointment or difficult to navigate around our facilities that sometimes, didn't have the end in mind in terms of how they were built up over the years.

And so to the extent that we can make things as convenient as possible and remain as relevant as possible to our to our patients and their family members and ourselves since we take care of ourselves too that becomes really a North Star and of course everything else around it that will help support that trust.

let's talk about that trust. how does Emory determine What is important to the consumer? It was interesting when I was CIO we were building out our portal. This was not a decade ago, but maybe seven or eight years ago. And we had a list of like the top eight things we were going to put into our portal.

And when I got ahold of the project, I looked at it. I'm like, have we validated this against the consumers? And so we brought the consumers in and we asked them to stack rank the things. And there was like three things that weren't even on our list that they wanted. And then we had to flip the list almost upside down and then it actually met with the consumers.

How do you get the voice of the consumer? How do you get the voice of the patient?

I don't think we do that well enough today, to be honest. And it's definitely something I'm highly motivated and we have some new leaders. that have just been hired, a chief transformational officer her name is Amaka Inanye, and she is responsible for that patient experience and the consumerism, you know, from a programmatic perspective.

But of course, we use Press Ganey today as a means to be able to collect patient satisfaction information. I don't know that it's granular enough, and I think there's enough of a time delay between the time you receive care and the time you get the survey, and also you're not sure whether you're getting a survey for that visit two weeks ago or for that, MRI last week or, and so forth.

So I think there's an opportunity to bring the experience and the response that I experienced closer together. And we do have PFACs or patient family advisory committees where we can. Propose a change that we're making to the portal and see what patients think. The challenge with that, of course, is You tend to get some dedicated patients, but they don't always represent all the patients that you are trying to reach.

I've seen some other solutions. Vision Critical is an example of a company that allows you to have 5, 000 patients that agree to sign up and provide feedback on different aspects of the portal. And then the other dimension, which is always. Top of mind is how to avoid widening the digital divide as we offer a lot of things on smartphones and technologies that require smartphones, you know, for the patients that have a flip phone or aren't endowed with those kinds of technologies.

We also want to have Solutions for them. You know, those could be solutions in a different language using, you know, using SMS instead of smartphone apps and so forth. But that's the other group that we're always looking

for. So let's explore the clinician experience a little bit. You're a doctor, a physician by training.

And, you know, one of the things that we know is that there's a significant number of doctors now stepping into these roles and the chief digital roles and the chief information officer roles. And I think that represents somewhat what's happened over the years, which is this feeling of disconnect between.

The technology that was thrust upon them and wanting to have somebody in the technology role that would appreciate how this technology gets used. Talk about how you get the voice of that group. How do you get the voice of the clinician?

And how is technology being applied to to making the lives of the clinicians better? So,

It, trust is the word to use for patient experience. Hope is a word to use for care team experience. And what I mean by that is, I was lucky. I arrived at Emory five months ago. And it was about six months after they had implemented EPIC.

And so we were right at that period of time where all the hope that EPIC was going to solve all problems within the health system had since evaporated and people were faced with a system that they had to learn how to use, that they had learn how to adapt to the various different clinical workflows.

Step one was clearly build a team of informaticians that could optimize EPIC. And then also build a digital academy that could house all the, not only just training, but other non EPIC training tools like how to write a... robotic process automation, how to build a Tableau dashboard, how to program in Python, how to use Microsoft to the maximum of its ability.

We wanted to make sure that there's a place for people to go where they could learn anything they felt was necessary to learn and make that easy. The informatics team was very small when I arrived and, that was probably causal to. A lot of distress. People were failing, especially on the subspecialty side of the equation, where Epic really wasn't fit in their workflows.

And so, I've been recruited up to 18 physicians, mathematicians that have 40% of the time protected in order to be able to meet that need. But what's different about what we've actually hired. The scope of the role will be physician informatician for epic configuration and also for revenue cycle adaptation.

And that revenue cycle piece is new in terms of the kind of typical role of an informatician. And the idea being that, 20 years ago, we figured out that clinicians need to be involved an IT configuration of electronic health records. Now we're figuring out that clinicians need to be involved in the revenue cycle world in order to be able to better understand clinical documentation improvement, E& M coding, ICD 9 coding, CPT coding, the various different workflows when it comes to billing, and so forth.

And so we're actually going to use those same physicians and nurses. to do what what they're doing for the electronic health record to what they're doing for revenue cycle.

Yeah, so are they physician builders then as well? They are,

they are the physician builders, but instead of just doing the physician build piece, some of them are going to have additional skills in Resolute or the Revenue Cycle tools as well.

I thought it was interesting at the roundtable, the CIO roundtable that that we were a part of. You talked about addressing one of the challenges we have is most of our teams have gone remote. And so we have lost a little bit of that elbow to elbow daily interaction with the various groups, which is so valuable.

And you shared I thought something that was really interesting and innovative. I'd love for you to share some of that with us. How you take your remote staff on rounds

with you? absolutely. And you described it perfectly that the problem I'm trying to solve is mitigate the fact that my staff is remote.

And you know, initially I was under the impression that I was going to be able to just. dictate that people come back to the office three days a week. And very quickly, I got some feedback that may not be as easy as I had anticipated. And so the question is, all right, well, what are we really trying to accomplish by having people be on site?

Well, we want them to have that water cooler conversation. We want to have that sort of whiteboard experience. But the other piece that's really missing is how they experience the front line for us to reduce the voltage gap that exists between those who configure the system and the front line, the best thing to do is just to walk around.

So what I was able to do is negotiate with a compliance officer and our legal officer to find the right way. To bring my team along when I went to visit. So every Monday morning, every Friday morning, I go to some part of the hospital or clinic. It could be the basement of the hospital for the pharmacy department.

It could be the ICU. It could be the warehouse where we, you know, house all the equipment, whatever it may be. And I sit down with the leadership for an hour and talk to them about how they organize and what the issues are and what the technology needs are. And then I round, meaning walk around whether it's the unit or the warehouse or the pharmacy, whatever it may be.

But I bring my assistant with me and she is carrying around an iPhone. And the iPhone is streaming the experience. It's not recording anything. It's streaming the experience. Only to those that are invited, and they invite my entire Emory Digital team with me. The people know that they can't watch the streaming experience in a public area.

They have to be in a private area because we don't want to... Expose any PHI, and only those invited can come to the meeting. So we have some way of containing that. By virtue of the fact that I'm not recording anything means that I don't have to keep track of where it's stored and who can subsequently see it.

And I also give early warning to the area I'm going to a few days before that I'm going to be coming, and anybody who doesn't want to be part of this can opt out and not be involved in the streaming experience. I have no one who said they're not interested. And in fact, what's happened when I'm on site and I'm asking questions is sometimes one of my team members, and I have somewhere around 200 folks that join me, that's about half of my team, and they will answer a question that is asked by one of the frontline doctors or nurses, or jump in and talk about the fact that they're working on that, or sometimes even fix something on the fly.

So not only am I bringing the team so they can experience and empathize with the front line and appreciate the importance of doing one thing over another. But on top of it, I'm bringing my entire team to do a quick fix if necessary. And it ends up what's happening now is the team is growing. More and more people are wanting to join these sessions.

Even other members of my leadership team at my level and other parts of the organization that wouldn't have expected. are wanting to, , sort of be part, because they know every Monday, every Friday, I'll be out there rounding on the front line.

And that is so powerful. And it was interesting at the roundtable, because you were sharing that, and you would think that's something that everybody has figured out.

But your peers were all sitting there going, how did you do that? How did you get by the compliance? How did you, and you really do have to think through it. There's a lot of ways that you can get stuck with this and just say, well, it's not possible, but you guys were able to push through and give me an idea of the value that your team derives.

I've heard from what you were saying, heard a lot of the value that. The people you're rounding with derive because they're actually getting their problems heard, not only by the CIO, CDO, but also by a fair number of the team, which I think is powerful, but talk about your team. What is, what has this done for them in terms of their.

Ability to solve problems and stay

connected. Just one point of clarification one of the things I figured out also is if you have a streaming camera and you happen to be in a clinical area and any patients are in view, all you do is Point the camera to the floor so you can still hear the conversation as we're rounding, but you can't see, and that's fine because in the few times that we'll have patients kind of around, you know, that's why I have somebody actually holding the iPhone as opposed to it being on some strap device that's being pushed around because I want somebody to be able to point to the floor.

on a moment's notice, if necessary. But in terms of answering your question of what is the team that's actually participating, how are they benefiting? There's a couple of things that I think is advantageous. Number one, you know, you typically folks don't necessarily become analysts because they like to be in the clinical environment, but this is the best of both worlds where they can actually experience what it's like and see without necessarily having to be in a As clinicians, hospitals, nurses, so forth.

We're just, we'll walk into a ward like there's nothing because we're so used to it. It makes sense. It's a very comfortable place. But it can be intimidating to people who are not , clinically inclined. So, this gives them the opportunity to do that reaping the benefit and understanding sort of the relative priorities that are coming from the people that are being interviewed.

You know, we have in our minds what we imagine the clinical workflow to be because you design it a certain way and you think people are going to do that. It's a very different reality, boots on the ground, where things aren't as, Even as they appear to be. The other thing is, I think, people are interested in seeing what is interesting and what the boss is paying attention to.

So I think that's another reason that it's useful to come. They want to know what's on my mind. What am I interested in? What am I paying attention to? Cause in some cases they want to try and meet that need. So I think it probably has a dual purpose.

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You talked about generative AI a little bit, talked about a chat GPT.

I'm curious as we are looking at and expanding, and this week I'll have a conversation with Chris Longhurst Mike Pfeffer and Brett Lamb from UNC. And we're going to talk essentially about, Our AI journey thus far. it still feels to me like we're at our infancy, even though I know that, gosh, six, six to eight years ago when I was a CIO, we were using AI back then, but it feels like to everybody else, this is.

, we are starting to see it really expand from what we were experimenting with all those eight years ago. And now it feels like everyone's seeing possibilities all over the place. How is Emory managing that conversation and , what possibilities are you exploring at Emory?

you're right, for a technology that really became generally available last fall, it's quite extraordinary to see the speed with which it's been adopted when technology, especially in healthcare, typically takes a long time to adopt. And I think the reason it did is because people immediately saw the opportunity for it to cut down administrative work, frankly.

That was probably the most obvious. So writing a letter to the insurance company for denial of, you know, levofloxacin suddenly becomes a lot faster if you can use HIPAA compatible GPT technology. So we don't use ChatGPT, we use Doximity. com, which has a HIPAA compliant version of ChatGPT, which allows us to use patient information without worrying about it leaking.

And then I would say that even In basket messages, the way that they're handled we're using some large language models there as well for the categorization of those messages, for the automatic response of those messages, and even for the routing of those messages to the right in basket by identifying based on what's being written, does it belong as a medication refill?

Does it belong as a scheduled appointment? Is it a general care question? Even though the patient has the opportunity to ask that, In some cases, it may be more two or three things in a particular message. It needs to go three different ways. I think probably the way that we're using it the most by far is what we're doing with ambient listening, which kind of really goes into the care team experience piece.

We have 23 doctors now across 15 specialties that are trying out. Ambient listening technology, and I would say the performance so far is excellent across specialties we're getting some data back that you have about two thirds that use it either all the time or use it more than 50% of the time, and you have about one third that is using it, a very small amount.

So, across a diverse set of providers, early on, I can tell it's not going to be something for everyone, but it's going to be something for the majority of people, and to those that are using it there's an immediate worry is, will patients be okay with me recording their conversation?

And, depending upon how you open, by saying, listen, is it okay if I just record this? It's just to help me write my note. Or, I'm using some AI to help me write. The patient's response is usually, that's really cool. Interesting. Okay. Yeah, sure. No problem. Like, we have not been receiving any patient that's kind of saying, Oh, I don't want to be recorded.

This is not for me. Please don't do that. So hopefully all those patients are feeling comfortable with saying it's okay. And then we're seeing people who would struggle finishing their note at the end of the day, being able to close those a lot sooner, spending about half the time they normally do on documentation, which has been cooperated by other folks that are doing this in a very early fashion.

So I guess my point is... large language model application in that case is listening to the conversation, using large language model to create a summary, and the plan, not yet, but the plan feature that's going to become available soon, is to convert that note into something that is the fifth grade reading level, so that patients can understand all that medical jargon that we typically use in a note in case the health literacy is not there.

that's the amazing thing about these large language models. Even the ones that aren't trained clinically are, I was just reading an article where it had the level of a recent medical school graduate. And I thought, well, that's pretty high for a large language model that wasn't specifically trained on healthcare to, to be.

And I think that's what's happening to us. We're all seeing these things. We're, A lot of us are using it personally for things now and we're sitting there going, Hey, I wonder if this could be applied here or this could be applied here. And the nice thing about the the ambient listening and some of those other recording things that are going on is they're already turning things into a transcript.

Once it's into a transcript, you have the words and now it can be bounced against. These different models you chose to go in the Doximity route, and that was primarily around compliance privacy and security, I would assume.

Yes, definitely went on the Doximity route for the HIPAA compliant chat GPT page.

And then we went the abridged route for the ambient listening technology and the reason, to me it was a bit of a Goldilocks scenario. I wanted some, a company that wasn't so small that it was at risk of not growing to capacity and I didn't want it so big that it would take a long time to get enhancements in place.

And would use older technology that required me upgrading Citrix boxes and so forth. So I wanted to find the Goldilocks size company that I could talk with the development team on a daily basis and get new features added while at the same time being robust enough. And this company happened to have be part of EPIC's new PALS, Partners and PALS list of companies, which just means.

A deeper commitment by EPIC to integrate a bridge into the workflow so in the future. You have the sort of mobile version of EPIC called Haiku, and you initiate your ambient listening directly from Haiku, and that will make its way back into the EPIC chart.

Yeah, I did. I've had several conversations with the abridged CEO, and it's exciting.

It's exciting where this whole technology is going. And I think this is a market that we're going to want to keep an eye on because there are some really interesting things happening almost on a monthly basis. You have to keep an eye on this landscape. It just keeps morphing. I do want to ask you about use of data at Emory, your academic medical center.

You have a lot of research going on. Give us an idea of how you're pushing the envelope with regard to the use of data in the delivery

of care. Yeah, so every transactional system, you know, has its currency data that flows from it. And, very much like I would imagine many other healthcare system that daily can get siloed in that transactional system or even can get siloed In a enterprise data warehouse dependent upon whomever is consuming that data.

really when you think about it, in the most extreme example, health systems are data producing environments. You know, people go in and data comes out and hopefully the patient gets better. But the point is that you don't need five or six data environments to deal with healthcare data.

Whether it's data rolling off a, electrophysiology machine, or coming from an assay in a clinical lab, or coming out of the electronic health record, all that can sit on the same data platform. Whether it's for research purposes, financial purposes, clinical purposes, clinical operations purposes, it can all sit on one data platform.

Most of the platforms in the cloud, whether it's Amazon or Azure or Google Cloud Platform or others, they can accommodate this data, ingest it for very little effort into kind of the raw zone. And then the different hyperscalers have different capabilities in terms of augmenting that data, you know, modeling it, mastering it, cleansing it defining it and so forth into the right.

Set of data sets that can be where you can visualize and manipulate that data. I think the, frankly, the mistake, an expensive mistake that's made is the fact that you end up cutting it up based on how the organization is structured. Instead of actually taking advantage of the fact that data actually is in one bucket.

And use access control as a mean to be able to keep people looking at the right set of data. But I, you know, time and time again, I get, well, I know we have all this mountain of data, but I can't, it's like Hotel California, the data checks in and never can check out. And so having some ability to be able to make that data flow better to the people who have a right to see it.

is really critically important and the duty of a health system to make sure that we're discovering the next best care item for a patient. And as Epic has something called Cosmos and Cosmos has a number of different clients contribute every night, a DNN ified set of data, now it's up to something like 210 million unique patients, but in that signal of , normalized data from all these different patients across the U.

S. are a set of rare diseases that now I can go off and find other doctors taking care of that patient that's got that rare illness because all that data is being pulled together. So... I think each health system has a duty and a responsibility and would benefit greatly from trying to unify their data and use intelligent constructs to try to derive some insight.

Yeah, that was interesting at UGM to see the ability to look at those symptoms, find other patients around the country and realize that wasn't possible just even a couple of years ago, that would have been extremely difficult to find. and to connect with those physicians and to make those connections.

was a really powerful presentation, I thought.

And it all comes down to the fact that Epic is using one data model, proprietary data model, to organize that data. If, in the U. S., we had decided years ago for the National Library of Medicine to create one data model that would make it easy to represent a patient, then, and the electronic health record vendors, Just like the ONCs asking for certain APIs were to use that data model, we would be able to do this in a much easier way.

However, it's just not the way that we chose to do it. So every organization has to invent their own way of organizing the data, which not only is expensive, it makes it difficult to interoperate that data with other organizations. Without losing a lot of fidelity.

Well, Hauser, you've given us a bunch of time.

I'm going to give you the closing question for the interview. And I go back and forth with these. Let me ask you this. You talked a little bit about a bridge. imagine a great partner, a partner. And, you know, it's interesting people make a distinction between vendor partner, but I want you to imagine a really good vendor partner, somebody who's supplying a solution to Emory, somebody you would consider a partner.

What is that organization like? What is that partner like? And what makes them a partner versus somebody, because you probably have a million vendors. What makes somebody a partner?

I think there is you know, I go back to trust I think is an important element in any partnership, but I think a shared vision is really important.

So, you know, we're in the business of saving lives. We're in the business of providing equitable healthcare. And so where are there solutions that help me advance that mission? I think you know, that makes a more natural partnership, but I don't think it's only that. I also think there's a certain amount of agility and nimbleness that is required.

If we're going to innovate in a certain space, it's more. Interesting to me to partner with an organization and co develop so that we can bring the frontline insight and knowledge and needs and so forth, and the partner can bring the expertise in the software development aspect. I mean, we're not software developers at the end of the day.

We take care of patients and so having a partner that can complete us by bringing that aspect is really important. I think making sure that the partner understands the healthcare business model. We are at risk for a lot of the care that we deliver. I've seen some partners go at risk with the healthcare system, in other words, no upfront cost and we'll only charge you if you make money and we can agree on how you make money and so forth.

think that's a useful way of thinking about things as opposed to extract your consumer surplus and we don't really care what happens to the customer. So, I think those are all characteristics of what makes a great partner. Obviously, you want to have, you know, a tool which is effective, scalable, cloud based, AI first, cloud first.

I don't want to have to put a whole bunch of You know, tech in a data center just to be able to make it work.

Yeah. You don't want to build any more data centers?

No. We're trying to get out of the data center business.

Absolutely. Alistair, I want to thank you for your time. Really appreciate you sharing your wisdom with the community.

Yeah. My pleasure. Thanks so much, Bill.

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