This Week Health

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Aug 1, 2022: Mari Savickis, Vice President, Public Policy at CHIME joins Bill for the news. What’s happening on the Hill? The October 6 interoperability deadline is looming. Information blocking. 21st Century Cures. Where are we at? What is CHIME doing to help prepare its members for this deadline? How much of this is falling on the EHR providers and how much is falling on the systems themselves? Navigating the compliance landscape is challenging. Even for larger health systems who are more well equipped. And what about the problem of the haves and the have nots? Does big tech have too much access to healthcare data? What’s being talked about in regards to privacy? What's going on in the telehealth world?


Key Points:

  • A downturn in an economy is not a bad thing. It’s an opportunity.
  • Do we need this much labor to provide a level of care that we've provided before? 
  • The Medicare Payment Advisory Commission is conducting a study on the expansions of telehealth services
  • We have a demoralized and depleted workforce, and yet we have amazing technology
  • Consolidated Appropriations Act, 2022 -

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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.

This issue of workforce and depletion of clinicians and maybe even non-clinicians is like, how can technology best be leveraged to minimize the burden on the clinician? How do we continue to do that? Because we have fewer clinicians. We have a demoralized and depleted workforce, and yet we have amazing technology. What else can we do? How do we leverage that and smartly. So it's not just by a thousand clicks.

It's Newsday. My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health, a channel dedicated to keeping health IT staff current and engaged. Special thanks to CrowdStrike, Proofpoint, Clearsense, MEDITECH, Cedars-Sinai Accelerator, Talkdesk and DrFirst who are our Newsday show sponsors for investing in our mission to develop the next generation of health 📍 leaders.

All right. It's news day. And today we are joined by Mari Savickis with all things, federal the hill what's going on and whatnot. And we're gonna do a little back and you're are you just back from, by the way, welcome back to the show, ma

thank you. I always loved joining your belt.

So are you you're just back from.

If you wanna call it that yes. .

If you wanna get we're, we're not gonna go into your vacation on the show itself, but it's interesting. I've been talking to people and there are different kinds of vacations. There's vacations that feel like work. And then there's vacations that feel like vacations.

So I remember one time we took our kids to Disney world and when I came back, I felt like I needed to take a week off from work just to relax after that. After that event, but alright, today we're gonna jump into a bunch of things. Questions can go in either direction. We're not covering any story specifically, but there is a lot of stuff going on in the world right now.

I wanna start with this October 6th interoperability deadline, that's looming out there information blocking 21st century cures. So where are we at? First of all, talk to me about the things that chime is doing to help prepare the membership for this October 6th deadline. What have you guys been doing?

A lot a lot of listening to start, but for the past several years, we've actually been in education mode and I think we continue to be in education mode. I think the challenge though, is that those two extra years that the government afforded our members to prepare and for the vendors. Has been gobbled up by in many cases of pandemic, not to completely use that as an excuse, they've been working towards this, but it certainly has added a layer of complexity to the situation.

And I know that before we started recording, you were mentioning workforce. There's a lot of pieces that go into this and then last but not leave. So just be like a lot of uncertainty around how you comply that. I dunno if you're hearing that from some of the folks that you already talking to.

That has been more than bubbling up to the surface is just uncertainty around the, how do you, how do you meet these deadlines? There's a paramedic complexity. There's some remaining answers that people are seeking from ONC. So just put like a cloud over how compliance is gonna be met for one of the definitional requirements, October 6th, the definition of, eh, I expands, how do you move from that subset of data, which was U S D D I to a more complete set of data. How do you push data out of systems that are not EHR on and on we go. So that's what we've been hearing as of late

it's interesting. How much of that is falling on the EHR providers and how much of that is falling on the systems themselves? Do you think.

Well, I'll say this. One of the things that we've been hearing is that there's a misalignment between what the dates that the vendors have to meet things and the dates that the providers have to meet things. And so there's a level of complexity to this situation where you have Medicare, which is the only lever in terms of like the levers, the government pulls in terms of compliance.

It's really just those who are in the pool of meaningful use. Now promoting interoperability, you don't have to use their certified EHR until like the last quarter of 20, 23 yet. Technically they're supposed to deliver it right. Starting January 1st of next year. But there's a whole other subset of providers that don't, that never had a meet high tech and didn't get the money before that.

So there's like that challenge. How do you execute on that? They're gonna have to claim exceptions and then there's this whole subset of data for those that have been meeting. Is promoting interoperability that are not house EHRs. And so, I mean, I think everyone's feeling it, the vendors are feeling it. I think the providers are failing it.

There's a level of feeling of not readiness that we're, we're we're hearing about. And so that is a challenge. And we've been talking to the federal government about these issues. It's people are trying, they're absolutely trying, but I, I think that there's a lot of people who are not ready and that that'll those two alignment issues between the vendors and providers is one big issue.

Yeah. gosh, at every given phase, you can hear the things and you can almost predict where this is gonna go. So we're getting very close to the deadline where we July, towards the end of July, The deadline will be right around the corner. But when we were first talking about this, there was there's questions that needed to be answered, but there was an awful lot of talk amongst the ranks of, well, a majority of this is gonna fall on the HR providers. They're just going to blah, blah, blah, do their thing, and we'll be able to create the mechanisms for.

Secure sharing and to protect the privacy and do all that stuff. And we seem to have buy-in from the EHR providers that they were they were gonna do that. And a lot of the systems don't have the wherewithal to do some of the things I'm gonna say in a minute. So they almost have to rely on their vendors to come up with a solution to do this.

They just don't have. A massive staff to do it. And a lot of their investments are already going towards the EHR. If the EHR doesn't do it and do it effectively, they're not gonna be able to do it. Some of the larger players though realized that they needed data liquidity and a data. Framework for what was coming next, not only with regard to interoperability, but they needed it for research and data sharing across the whole litany of things that they do, especially if they're an academic medical center.

And so they started to create this repository of data. That was mallable that could. That could be used. So when you talk about getting data from these other entities, they're already doing that and they're doing that for research purposes. They're doing that for any number of things. And plugging interoperability or 21st century cures into that is not all that hard.

It sounds like in healthcare, we still have this problem of the haves and the have nots, right? So the haves are gonna be able to meet this pretty easily. You're probably not hearing from the academic medical center saying, Hey, you need to let the federal government know that we're not gonna be able to do this.

You're hearing probably my guess is from the smaller health systems or even even really small. Hospital systems saying, I don't even know how we're gonna do this.

I think there's a lot to be said to what you just articulated though. I will say that I've heard from some of the more sophisticated systems that they still have a lot of outstanding questions. And while I think that they're far more. Equipped to navigate the compliance landscape. I think it still is challenging.

And some of that just comes back to some uncertainty with how ONC will interpret things. What are the compliance levers that have not been articulated? So I mean, overall, I think that applies to a lot of things with public policy. Like they're just better equipped because they have more resources.

That's not like always the case, but I mean, again, I have talked to some of the bigger systems and. They'll be able to spread the needle, but they also they've also talked about some of the challenges that they're having. So, but if they're having challenges and that's how that goes.

Really. Like if a slow down, if that, if the top folks are articulating issues, then we're gonna have a lot of challenges with those who are like say community based hospitals and small providers. Absolutely.

So the October 6th deadline, is this when they're actually going to start imposing penalties or is this just the date for compliance?

It's just a D compliance because there are no penalties yet for providers. There's the only, and in fact, there's no penalties yet in place for the other three actors, which are the vendors. The HIE is H IEN. Those three were actually named in the statute and they have penalties up to a million dollars for information blocking.

However, the OIG rule is not final for them, so that hasn't been cut free yet. So there's really like, it's a little bit of you. Uncertainty. Well, there's a lot of uncertainty about compliance, so it's just a, but, but I mean, you could say like we've having worked in the government for a long time or with the government that they could be retrospective.

So hopefully that will be the case, but there could be some retrospective odds, like we're you in compliance by October 6th, right? Plus make it all file a complaint, right. To ONC someone could file a complaint and then they could start investigating, even though there's technically no enforcement mechanism.

Yeah. So what kind of resource? I assume you've done some webinars, there's probably OnDemand webinars for chime members for this, and there's probably some cheat sheets and other things that you guys have developed for this as well.

Yeah. We actually have an entire website to go to this for one stop shopping for providers. It's not even limited to the chime membership in Bo blocking And I'll give you that website, bill that, I mean, it's, there's a lot of stuff in here. PowerPoint implementation guides, fact sheets recorded webinars. I mean, you name it. So we just did a webinar with it's a little bit beyond information blocking, but TECA, but we've done.

We've done a series of webinars. We have a series of web a fact sheets on our website, which I can share with you. And we'll probably do I imagine we'll be doing more. The closer we get to this, we're probably also gonna be issuing a survey to our members shortly, just to gauge readiness, cuz we're hearing a lot of challenges around that.

Yeah. So, so gimme the, the URL one more time.

Info blocking

Great info blocking All right. So people can check that out. Lot of stuff to download there and take a look at.

📍 📍 We'll get back to our show in just a minute, we have a couple of webinars coming up and I don't like webinars. I think they are oversaturated at this point. And I think a lot of them are not all that good. And so that's why I think I'm the perfect person to put together webinars for you. I make sure that we have great topics.

I validate them with CIOs. I make sure we have great guests and I make sure. We actually plan ahead and we actually spend time together before the actual webinar. So it's not just spur of the moment stuff, but we make sure we identify the things that we should talk about in those webinars. And we even collect questions from you ahead of the webinar so that we can make sure to talk about the things that you want to talk about.

So let me tell you a little bit about the two webinars we have coming up. There's a global survey. That we talked about on the today show a thousand cybersecurity professionals found that 30% plan to change professions within two or more years, and cybersecurity threats are growing. And, you know, quite frankly, we need to make sure that we recruit, retain and optimize our staff so that they can be our frontline.

And so the first webinar we're doing is how's your frontline recruit. Retain and optimize your cybersecurity team. And we're gonna talk to experts from Christiana care and Seattle children's and Seuss about their thoughts on this exit of security professionals and what you can do to stay ahead of that.

You can join us August 11th. At, 1:00 PM Eastern time and you can register right on our homepage this week, on the top right hand side, you're gonna have the two upcoming webinars. You go ahead and click on those again. That is August 11th at 1:00 PM Eastern time. The next one, we're going to talk about ransomware, but I've seen a lot of different ransomware, webinars.

I love this one. The topic we came up with is Don. Pay the ransom and rubric is bringing together some great leaders from Thomas Jefferson university in St. Luke's university health system and and rubric themselves. And we're gonna discuss solutions around protecting all of your healthcare data, especially as you're moving to the cloud.

And specifically, we're also gonna talk about epic. Backup in Azure. And what rubric gets doing around that, that webinar is going to be on Thursday, August 18th at 1:00 PM. You can register for both of them. Just go to our homepage this week, upper right hand corner. You're gonna see both of the graphics for those click on the one you wanna attend, fill out the form. And we will see you then now back to our show. 📍


what direction to go with you? We have so many interesting conversations. So we can go privacy, cyber telehealth. Let's go with privacy. we seeing anything in the capital right now around privacy, what's being talked about.

Yes. And it's been bubbling up to the surface. It seems to have these like, and starts, but it is a topic Toure and increasingly as we try to navigate increasingly complex landscape around data, and I would argue. The landscape where you have the HIPAA providers, right? So those who have to comply with HEPA that ecosystem as contrasted with the one that doesn't have to comply with HIPAA, maybe governed by the FTC, the data that is held by those non HIPAA covered entities, I think may even surpassed like say hospitals and health systems is getting so large. They have access to so much data. And so there's an increased amount of attention on them in big. With something to do, how do we protect consumer rights? There was gonna be a hearing this week. It's sliding, they're arguing still over trying to iron at some of the differences like around private rate of action, things like along those lines where there isn't a complete amount of consensus, but hearing on that, coming up with energy and commerce.

So they have a bill out there it's by caramel bipartisan. that's a piece. So I heard that, and I think this has been in the media that the California delegation has some challenges that they're trying to iron out with respect to the California law, which really kind of set a high bar for privacy and making sure that there aren't significant complex, but with whatever moves forward on the national level, There is, there is a tension being placed on this and lawmakers are are paying attention. So people who wanna tune into this should be looking for, again, that NC hearing hopefully will be next week was supposed to be this week. So the.

The answer is yes. And short. So privacy. So we're talking about healthcare privacy at this point. So we're talking about that healthcare data, and they're worried about big tech having access to that data.

You may not know the specifics and I'm just sort of grasping here a little bit, cuz I'm wondering what are we worried about for big tech? Cause we don't have any big tech data breaches, so we're not worried about data breaches. For the most part we have. Every day, we have a breach of a health system.

So we're not worried from that perspective. Are we worried that they're literally going to be able to access this information and then utilize it in ways like potentially resell it or potentially utilize it in ways to market to these to individuals usually they're using their private information to I don't know, to essentially be more effective in the businesses that they are running.

There's a lot to that question or statement. Let me just say, I'm sure that big tech is not completely inoculated from breach as number one. I think a lot of people would've disagreed with that. And number two is not just big tech it's little tech also. So you have, I mean, if you and I, I challenge anyone listening to your podcast and to you is to go pop up in any privacy terms and conditions for an app that you're downloading or on a website.

And you'll find nothing about like huge snooze Fest and like practically like four point font. That doesn't make any sense to anyone it's not written in plain English. So no one would really even understand what they're agreeing to, to begin with. So it's trying to pull that apart. Like one thing you should look for example, and a notice is the term third party, third party is like the slash bucket term for like other people organizations beyond us.

That kind of thing. Where's your data going? So you're asking like the data can be hoovered up, right? It's aggregated, which becomes an issue. They put a number on your head in terms of like, oh, you're worthy of this kind of credit bill Russell. They have lots of data points on you. It it's a far larger issue actually, because they have so much. More data and the access now. And whereas healthcare providers and other HIPAA covered needs, they don't, their purview is not like hoovering up data and using it in a way to completely like commoditize it. That is not the primary interest of a healthcare provider. I mean, certainly there's a lot of integration with technology, but they have to meet the HIPAA requirements.

And so it's a lot more data that can be used. And a lot of consumers either. Aren't really sure what they're giving away or they're agreeing to things or it's done in a way that's so nebulous and no one would even know that they're giving it away or it's been taken. So there's, it's bringing a lot of transparency to the entire sector of healthcare data, not just to like the HIPAA area. Cause the HIPAA area is already covered. And hopefully again, for those CIOs and other providers listening, there'll be some sort of card out for the HIPAA covered any. So there's that duplicity, right? We already have to meet privacy and security requirements. We don't wanna see like duplicate require. So it's, it's bringing more oversight to the areas that do not have oversight today.

Yeah. And by the way, I, I agree with you and I, I'm just, I'm gonna play devil's advocate a little bit here, but I agree with you that that no entity is completely immune to to a breach. I will say that defining big tech is also an interesting thing, too.

When I say big tech, it's sort of synonymous with five or six companies, but it also does take into account all these other startups that are bubbling up around there as well. So I, and, and clearly not all of 'em have the same kind of security architecture and framework in place, but I'm just saying we, we don't see. Amazon getting hacked, Google getting hacked and whatever, but we just saw 600 tele systems get hacked through a business associate. So that's one aspect of it. That's the only reason I bring that up. But the other thing is it's, there's sort of a when we talk about HIPAA, it's interesting because we talk about privacy, but it's not my data.

The health systems, it's their data. And they will say the words that it's the patient's data, but they don't act that way. it's not easy to get all my data. It's not easy to aggregate all my data. And so from that standpoint, I almost have a more complete record from apple and apple health today than I do the providers I've seen.

and proof of that is you you have new companies coming out there from health system providers that are treating my data. Like it's not my data anyway. So you wanna talk about privacy. I mean, you have companies like true Veta that are essentially aggregating millions of records and forming a billion dollar company around research and other things.

Now they will say for the good of mankind and for research and that kind of stuff, but at the end of the day, There was no regard for my privacy or my data. Nobody asked me I didn't get to review the security measures that they're putting around this or anything to that effect. And to be honest with you, it was a.

Probably a, a checkbox along a very long set of forms that I filled out from the health system that said, can we put your data into an HIE or can we share your data, whatever. And it was amongst a million things when I was in the, in need of care that I just checked the box. Not too much better than the innocuous privacy or consent forms we've signed from big tech there's problems on both sides is essentially what I'm saying. it's not as clear, clear, cut as it's big tech.

I don't necessarily disagree with what you're saying. However, I just like talk, when I talk to memories, I like to remind them that the days of your hin department being open from eight to four, like Monday through Thursday are over like over.

So I think we're moving the train is moving forward, not backwards. So we absolutely have some work to do. I will say though, that is having been in healthcare for a really long time. And I won't say how long, but a long time. But the early days of hip of which I was a part of it was Don share.

And so you're basically eras. Decades of muscle memory, where it was brow beaten into providers, like thou shall not share, except for like these limited situations and the fear too, when you have again, I think we've all experienced it too. Sometimes. I don't think it's so much nefarious or like ill intended as you've got someone at the registration desk.

What do you think that they're a HIPAA expert? Oh my gosh. No, they're not. And you're trying to ask them to do something subtle. Like, I'll give you a personal example. I don't want this record going to this provider. They can't figure how to do this in the EHR. They're just like the front office person.

They try for like 15 minutes and then they give up and then you give up. So is that nefarious? No, it's not nefarious. Just that. Trying to navigate how you do that inside of an HR may not be as straightforward and I'm sure we can see and pick apart like a few providers to do the wrong thing.

But it's, there's, we're erasing muscle memory for years of like thou shall not share. And so we need to change that to like if the patient asks for their data by God, you better give them that data. And it's trying to figure out, so I don't, I haven't met anyone recently. Who's like, I'm not doing that but it's more like, how do I get to where we.

So I think it's generally well intended, but that doesn't mean that we don't have work to do. We absolutely do. And I agree with the transparency piece that you mentioned, like I'm just checking a bunch of forms. Where's everything going. We can certainly make that better.

Yeah. And I love this conversation and you know what Murray, I'm not. I'm not afraid of the people who are struggling, who can't figure out how to share this thing. That's not the people I'm afraid of the brilliant people. That's who I'm afraid of. I'm afraid of the people who are really smart, who are writing these things and saying, oh, I know what we'll do. We'll put this phraseology in there.

Or or we'll, we'll aggregate the data in this way. Therefore we don't have to ask the patient for anything. I am worried about the brilliant people more than I am. The people who are struggling.

I don't really experience that.

let's so We've cut these shows down to about 30 minutes and there's always a lot to talk about with you. But I do wanna hit telehealth in cyber. What's going on in the telehealth world. Have we gotten more data? Are we starting to identify areas that are going to be funded moving forward? How's the discussion going?

Okay. Telehealth feels like tick, tick, boom. Like, alright. It's what is July 13th, July 15th. The PhD ends. So it's like tick, tick, tick. We're waiting for H to announce the. Repping, right. The renewal of the PhD for everyone. That's a public health emergency that continues the pandemic authorities in place to allow for Medicare billing of telehealth, so on and so forth.

So that ends on Friday, this Friday. So we expect, oh, everyone keep everything is under control over here. I think we expect the government to reissue that. I mean, we're probably looking right now and maybe you're hearing something, bill, you can comment on this one in a second is the uptake in hospitalization, like what is it?

BA five variant. I don't, we don't foresee the administration ending the PhD just as we head into the fall that plus they're gonna give 60 days notice they, they promise. Pinky promise that we're not gonna like pull off the rug underneath you. Also the physician's fee schedule, which just came out in draft form talks about we are not gonna do anything for like 151 days, because that was what was in the statute or from earlier this year.

There's a lot, there's a lot here to track and it's very complicated. There's a lot of moving pieces. and so it's hard to always keep everyone like trying to figure out like what's going on. So the telehealth thing is a lot of moving pieces, but first thing is get PhD extended. And then continue to fight for a lengthier extension of the congressional authorities, which were very, very short.

They gave like five months or something like that. Earlier this year after the PhD ended, which again, it hasn't ended yet. So, but should it end? The government has about 151 days to wind it up or wind it down. Does that make sense?

No, it makes perfect sense. The PhD will not end on Friday. It won't end in the next six months.

If it ends at the end of the year, I would still be surprised. I mean, this is a yeah, we have an uptick. But to be honest with you, I get on planes. I fly around, I'm doing stuff. No, one's living as if we're still in the middle of a public health emergency. Yeah, the hospitalizations are going up, but the critical NA I'm sure there still deaths from COVID.

Don't hear me saying that. I'm sure there still is. And there has been an uptick, but it's not. Anywhere near where it was before. We're not seeing spikes where hospitals are struggling to maintain the type of care. Now, some are struggling to maintain the type of care, mostly out of staffing shortages, but that's again, another, a different conversation.

I would love to know if the capital is taking that up that the clinical staffing shortage would be an interesting conversation. And I I'm shocked. There aren't more conversations like that happening on the hill, but I know that sometimes this stuff takes time to bubble up there and have the hearings there's already a docket on there and things going on, but yeah, no, it'll continue for a little, it definitely won't end by Friday.

And I don't think there's an appetite to have it end anytime this, this year, quite frankly, cuz we're but here's the thing I would like to have. And you tell me if something like this does happen. They have all this data from CMS all the telehealth data from CMS. I, and they've started to look at it and my guess is they've had more and more opportunity to look at it and to see where telehealth has been effective.

in the, at least the Medicare population. Right. and probably they have data from the commercial side and Medicaid side too, if it's reported on correctly, but at least on the Medicare side, they can look at it and say, you know what? This is actually more effective for us. We're seeing progress.

Now we, we saw them. Create some codes around mental health for for telehealth. So there was reimbursement for mental health. Across telehealth because the code that they said, you know what we're gonna, we are going to create some new codes that are available through through CMS, but I would think there's gonna be more of those codes.

I would think there's more of that data being looked at and saying, okay, this is effective. This isn't effective, which will give us a, I think a much more robust conversation when the time comes. It won't just be, Hey, telehealth is good. No telehealth is bad. It'll be. Well, let's break this down into a conversation.

Telehealth helped us here. It helped us here. It helped us here. We need more data here and here, and quite frankly, it didn't impact a thing on these areas. So we're gonna fund this. We're not gonna fund this. That's what, that's, what I would hope would happen. do you think that process or a process like that we'll see that anytime.

Yes, I think that's underway right now. There's different entities you've been studying. This is probably, you've seen like a bunch of peer articles on analysis of data. I think there was one like that came out of Michigan recently. I don't know. I think that's the one. But in that funding bill that funded the government for fiscal year 22, which was passed on March to this year there, I believe there was a report on telehealth that has to be issued.

So I actually look, we could find that for you and send it to you, but there, there is an analysis you like, it's interesting. At the beginning of the pandemic, we actually, even before the pandemic, we were thinking there should be like some sort of a national office. Withins I should be looking at data across multiple, not just like HSS, but like there's other places where telehealth is impact like a department of agriculture, like take a ecosystem, look at this.

And then the pandemic happened shortly after, like that bill was introduced. And again, it would've created this office, but the point is like, it should have been studying all along and we thought Initially approached lawmakers who said like, Hey, why don't you, why don't you put in place like a two year funding so that we can study this and that.

And they never did that. They lived it along right now. We got like a five month thing. So part of this is totally rooted in data, right. And I'm sure the Medicare actuary is gonna continue to study this. And it's your point about mental health? I think there's widespread consensus around mental health.

That is like one of the strongest use cases. But I think that there's a sufficient amount of uncertainty. Around the data and around program integrity, the AKA fraud Nevius by Medicare and some lawmakers that, that is held something back that combined with the price tag is just it's holding us back and, but the providers aren't most folks get I think they think it's probably gonna work out in their favor initially, but like that level of uncertainty, how do you plan and you bringing it back to workforce you need someone to operate all this stuff.

One question I have for you, bill. this issue of workforce and depletion of clinicians and maybe even non-clinicians is like, how can technology best be leveraged to minimize the burden on the clinician? How do we continue to do that? Because we have fewer clinicians. We have a demoralized and depleted workforce, and yet we have amazing technology.

What else can we do? That's something we're gonna be looking at more closely. Like, how do we leverage that and smartly. So it's not just by a thousand clicks. Like, what is, what do you see as like the foremost technology that just say like the middle middle of the road do hospital system. It doesn't have to be the most advanced one could put in a place to make it easier for our clinicians.

Yeah. I, I think the conversation that needs to happen there is what level of care can be provided at what level? Right. So what can only a specialist provide? What can a doctor provide? What can a of a RN provide? What can a nurse practitioner provide and whatnot? So I, I think we need to determine that because there's an awful lot of.

Telehealth calls that could be handled by potentially a little lower level of practitioner that currently is. So if we have a deficit of primary care physicians, it'd be nice. If some RNs could jump in there, it'd be nice. If some other nurses could, could jump in there. And quite frankly, some of the nurses we let go because they would not get vaccinated would be fine in a.

Facility doing telehealth calls and that kind of stuff. I think we need to revisit that conversation and look at increasing the number of workers and deploying them in ways that is still safe for the community and safe for for for the for the provider. So that's one area.

The second is we're having this conversation around automation all the time and the level of automation that's gonna be required over the next couple of years, cuz it's not just, it's not just this problem that, that you're discussing here of lack of workers. We also now have financial challenge that's hitting health systems and so more and more pressures gonna be put cuz labor is the biggest component of delivering care and more and more pressures gonna be putting there. To a certain extent. We have to look at automation. We have to look at new ways of delivering care. I don't, I don't fear a downturn in the economy. I never have feared a downturn in the economy. Cuz what I found is new things happen during a downturn in the economy. People are forced to rethink the way they've done things.

And if things just continue to go the way they. They normally go, you have a muscle memory, as we talked about before of, oh yeah, this is how we deliver care. And it's big buildings and it's we just keep doing it this way. I think this is an opportunity, a downturn in, economy's not a bad thing.

It's an opportunity to sit back and go Are we doing things to the way that we should, could we be doing things in a different way? And do we need this much labor to provide a level of care that we've provided before? And perhaps it is partnerships between big tech and healthcare, and I know.

Healthcare kind of rolls their eyes cuz every time Oracle, I can't believe Oracle came into the industry and made the announcements the way they did. They essentially said we're gonna save healthcare. And I, I just I'm like, I wish they would stop doing that once they stopped doing that though. I hear a lot of health systems that are partnering with Google partnering with Microsoft, partnering with apple.

I mean, I just talked to the CIO. A couple weeks ago who went out and visited apple and, and she was extremely excited about the things that they're doing. And I know people who've talked to Amazon and they're partnering with them. There's partnerships because of we're gonna be, need to look for different models and there's not gonna be, there's gonna be.

Capabilities. We're not gonna be able to build ourselves in the health system. A lot of partnerships happen in downturns in the economy. When you realize we just can't keep trying to build everything ourselves, which is we fall into that trap after 15 years of a boom. Essentially. So it it'll be interesting.

I wanted to talk to you about cyber, but we are at the end of the show and you know what cyber will always be with us the next time you're on the show. I'm sure there will be stuff to talk about around cyber. So Mari, welcome back for vacation and thank you for taking time to spend with me. I appreciate it.

That's pleasure. Thanks so much.

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