Please follow the show on Itunes, Google Play and Stitcher
Follow This Week in Health IT on Twitter @ThisWeekinHIT
Take a look at the website www.thisweekinhealthit.com
More videos at www.thisweekinhealthit.com/youtube
Follow Bill Russell on LinkedIn and Twitter
Reach out to [email protected] if you want to discuss your next project.

     

Transcription is done through machine learning and AI algorithms.  We post the transcript as a means to search and index the podcast.  This text includes mistakes, once the algorithm’s are perfect, our text will be perfect as well.

Episode 8

[00:00:00] Welcome to this week in health it. Where we discussed the news, information and emerging thought with leaders from across the healthcare industry. It’s Friday, March, 2nd this week. What is the future of hospitals epic’s new sonnet EHR and what it means for interoperability? We dive deep on the role of technology and physician burnout.

This podcast is brought to you by Health lyrics a leader in digital transformation in healthcare. This is episode number eight. My name is Bill Russell recovering Healthcare CIO writer and consultant with the previously mentioned Health lyrics today. I’m joined by a relatively new friend and first person to appear on two episodes of the show dr.

David Bensema former CIO of Baptist Health and Kentucky who has started his second round of work in his I guess your pre-retirement phase of retirement as. We all know you don’t just go off into the sunset people tend to pull you back into work, so good morning David and welcome back to the show Marvel appreciate the chance to be here again.

I’m looking forward to our conversation a lot of good topics this morning, so this appearance is through a scheduling mistake on my end, and I appreciate you being so gracious to come back on the show so so normally we ask our guests. You know. What are they working on? What are they excited about I guess.

So true the first returning guests will modify it a little bit what have you been working on since last time we spoke and what do you what do you excited about these days? Yeah? Well? I’m actually you stimulated what I’m excited about it at the moment you wrote an article about budgeting in the need to plan to cut today for tomorrow, and it got me thinking about the process that we had put together, so I just submitted a post to HealthSystemcio.com.

On The Daily discipline of budgeting hoping that people can understand that budget Cycles shouldn’t be as traumatic as they’ve been in the past and provide some insight from the three and a half years of stumbling that I had so hopefully some others can find a smoother path to their budgets. Yeah, there’s an

Awful lot of talk going on right now around reducing the budget as more and more pressure comes on the on the hospitals from a budget standpoint. What so did you just recently write an article for health system CIO. Just submitted the final draft yesterday. Rachel can you give us like a preview of what you’re what you discussed in the article.

Yeah, I’m part. Is that your managers have to have a regular Cadence of looking at their human resource spend to be able to track when whether on contracted or employed individuals. They’re getting out of line. Either a positive variance in which case you want to find out how can you perpetuate that positive variance or the negative or harmful variance where you’ve gone over budget and catch it early so you can make course Corrections and make sure you don’t let something balloon because the HR spend is our biggest then the other piece that I think is most relevant is in yours and my role and in other CIOs and Executives roll to set the example.

And so we don’t need the latest bright and shiny you and I answer emails we do some podcasts. We do some webinars, but we don’t need the most powerful lightest laptop in order to do our job, and I think showing that fiscal restraint is a good example for our teams. It says yeah, I used to have a one of my vice presidents used to have the oldest iPhone.

It could possibly have because you wanted to communicate to the organization that you know really the iPhone hasn’t changed much since the you got bigger screens will not but it really hasn’t changed much in terms of its functionality. And he wanted to show them that you know essentially we’re still doing the same things we were doing then and he also wanted.

He was sort of a no, man, Left Behind kind of thing and he said you know I will be the last person to get the newest iPhone so once everyone in the organization has 1 I’ll move up and. And and I think people appreciated that they appreciated the the fiscal restraint and the fact that I T wasn’t the one walking around with all the shiny new objects while the rest of the organization was stumbling along so that was a exactly great move on his part.

So okay. Let’s just a lot of news, so let’s jump into the news as you know first section David, and I have each selected a story to discuss, and I’ll go ahead and kick ass off so. The future of hospitals is an article that appeared in the Wall Street. Journal this past Monday in the health care section is a great section if you if you get that I am a former Paperboy so no matter what I do.

I always have one paper delivered to the house so I can so I can read a newspaper. It’s just old habits die hard but. So we get the Wall Street Journal great article. Let me give a recap real quick the day’s itself first couple paragraphs the days are the hospital as we know it may be numbered in a shift away from their traditional inpatient facilities Healthcare Providers are investing in Outpatient Clinic.

Same-day surgery centers free-standing emergency rooms and micro hospitals, which offers few as eight beds for overnight stays. They are setting out setting up programs that monitor people 24/7 in their homes, and they are turning to digital technology to treat and keep tabs on patients remotely from high-tech hubs, they go on to talk about the economic drivers there has been fewer admissions fewer overnight stays although the patients have gone up.

And essentially what they’re saying is there’s just an awful lot of economic drivers in one of the one of the sections. That’s cut out from the story. They have some statistics of the total savings inpatient versus outpatient for instance hysterectomy there’s a total savings about you know $4,000 per procedure 480 out-of-pocket.

They go on. Cardiovascular angioplasty and they just have these numbers there, and they’re pretty significant numbers having the procedure done in a traditional Hospital gets to be pretty costly so I’ll summarize. Where do they think we’re going they may believe hospitals are going to more helping patients at home, and they saved Mount Sinai Hospital at home program, which is saved Medicare 45 million dollars, they’re talkin about building smaller facilities and I have.

Personal experience with those we’re doing a company students some work for my hometown hospital system, and there’s literally a street corner that has three buildings for st. Luke’s university health network and each of the buildings represent. It almost represents a different department that used to be in the hospital you have you know women’s on one Orthopedic another oncology on the other, but they’re smaller buildings nice big parking lots easy-to-navigate if you’re going there.

They’re finding new uses for old hospitals. I thought the most interesting part of that was a Geisinger setup of a food a fresh food Pharmacy that they are they’re converting so the community that the community actually has a 50% predisposition towards diabetes, and they’re recognizing the whole population Health moves that if we really want to get in front of this.

It’s better to help people with their food and then help from afar. And we’ve talked about this before HCA Inter-Mountain and Mercy Health, and St. Louis all have digital Hospital set up, and they’re providing services to rural facilities. They’re providing services to even some other large Health Systems where they are monitoring certain situations and even.

I some post-op and those kinds of things so they’re they’re providing remote support and some expertise through that so these are some of the things that they highlight in the in the story, so let’s talk about this little bit. I’ll take us off so you know Hospital Stovall who absolutely will make up a significant portion of the the revenue for Health Systems in the foreseeable future.

There’s no doubt about that the big-box hospitals is going. Be that but you know what I want to talk about is. What do we have CIOs and technologists do to prepare for this next wave of change, which is already really upon us, and you know as the phrase goes and we talked about budget already show me your checkbook, and I’ll tell you your priorities the same is true in healthcare.

Show me your budget, and I can tell you an awful lot about what you value and what you’re going to become in the future. Uh future couple of years if I were looking at Health system’s budget right now. There’s a there’s a couple of things I’d look at I’d ask you know how much are you spending on things connected to the hospital versus new models of care.

I see a lot of budgets. Very focused on the EHR, you know how many resources are you putting on the HR, which is predominantly a system to run a hospital or to run a health network and so much money is being still even after the big EMR Implement implementations are still being focused on that and not enough is being focused on the consumer.

You know how much of the analytics budget is being spent on the consumer. How much are the budget is spent on the on the. Changing the way we experienced Healthcare and those questions will lead you in the directions. You need to to look within the houses. I believe you need to look within the houses and find some people that are doing some interesting consumer-based projects and it may not always be in the traditional part of the organization and begin to partner with those guys and look for new initiatives that are going to lead.

And this is one of those areas that we lead to CIOs we identify areas that have promised and utilize some of that margin budget that we have to support those and move them forward so anyway. I thought it was an interesting article, David. You know I guess my question is have you seen this transition away from hospital strategies in the health systems that you work with and where do you think this is going to lie?

And I think we’ve seen it to a large degree in the health system that I was with we started in 2006 already looking to the ambulatory sites decentralizing a lot of the Care Imaging Centers moved off campus infusion centers, so there was that but they were still trying to do it on the hospital-based reimbursement model now with CMS declining to an except to or to approve additional sites that are off campus in terms of.

Hospital-based reimbursement systems are having to figure out how to live on my old Primary Care budget. I’m an internist by training and practice, and you know we learned how to run things tight and I think hospitals are starting to learn that and so we’re certainly seeing that we’re seeing a much more aggressive acquisition or alignment with Home Health to try to reduce the readmission rates to try to.

Move the carrot back into the homes. We saw a significant investment in the system that I was with right as I was leaving and telemedicine both for visits um so communicating as you and I are right now, but also for telemonitoring home blood pressure home weights being fed back in through to the Home Health.

And I think the other thing that has helped is the investment in D. HRS in some systems if they did a good across system integration allow you to decentralize that care and do a better job of making sure that the patients are cared for where it’s most appropriate for them. And then the final was the Ambulatory Surgery centers Association you saw systems that fought that a decade ago, and you saw systems that embraced it in partnered with their Physicians and now if you look at the systems that still have a margin.

I bet they have some relationship with their independent positions in an Ambulatory Surgery Center and in other Investments where they didn’t fight positions, but they joined with them. Yeah, I found it interesting at least for our budget in the previous Health System. I was at the Medical Group.

It budget was was really kind of poultry compared to the hospital and there were many occasions where I sat down because we tightly partnered with them, but it was a separate budget, and there are many times where we had to sit down with them, and they said well. We can’t really afford that analytics package or we can’t afford that pot health package.

And that partnership became really key because the way I first of all I didn’t understand that and because of the way we did budgeting. From the article you talked about we always have some margin dollars to spend and invariably it went to those guys. It was it was an opportunity to really bring that those capabilities forward so that we can do a Clinically Integrated Network better.

We could do the ACL better. We could do analytics on that population. We can keep them out of the hospital’s and for some reason. I don’t know if it’s just history or whatever. Uh, they that side has been starved in the hospital spend been pretty well fed, and you think that’s going to continue to evolve and change or do you think we’re going to do think we’re ever going to get to the other side of that because it really does take money away from the hospital when I know there are incentives, but it takes money away from the hospital when people don’t come in for.

Procedures in those kinds of things, yeah, and and I think we will see that shift over. I think in the system again that I left partially because it when I was CIO, it was as we were transitioning to the integrated EHR we were tearing out our existing systems, and so we did bring the position Enterprise under the same umbrella as the hospitals, and I was able to communicate to the system Executives into the board.

The need to think about them as a Continuum and I think as more and more people think about the care Continuum and drop the walls of the hospital at least figuratively and think about how the patient moves through the system through Care Systems will start to shift their budgets and understand that.

I think it’s still going to come down to you’ve got to have a nice seen a couple of Articles now. That’s so you need about 62 percent of your patients where you are at risk where you are accepting whether it’s capitation or some form of fold the risk in order to pay for these systems in to make that critical mass that tips you over to being able to successfully do that.

Then you benefit from reducing your admissions right now. You know we’re still trying to drive fee-for-service in most sectors of the markets and that stops you or blocks you from shifting money away from the hospital, and I think you should good model that in sharp Healthcare down in San Diego if people want to look into that when they have a pretty high percentage of at-risk patients and they are.

On a managed service contract, so that’s pretty interesting and you brought up. You know talking to the board and educating the board that just reminds me of a that’s probably a good topic for a future episode of the role of the CIO in that but let’s kick to kick to our Second Story epic well actually Jura story.

I’ll let you give it to us and give us a little recap. Yeah, so I saw the article and of course. We’ve heard Judy announced last year that they were going to be introducing new EHR options in Sonnet is going to be introduced at him might take on the article. Is that it’s kind of like Epic light is in the article they talk about you know smaller hospitals get it at a lower price doesn’t have all the functionality doesn’t have all the modules, but then they can add them later which.

You know obviously, I’m an epic fan. I installed epic. I worked well with them. I think there’s a lot of great things going on but in this. I think there’s that blind spot where Judy sometimes thinks that it’s going to be World Domination by epic and so this is declared as they advance of interoperability as they do the care everywhere more robustly for Epic users.

But it doesn’t say anything about how they’re going to communicate with the others and I know there in this quite a project and I you know I think there’s going to be advances out of that, but this article leaves people with that same sense that you’ve seen in the editorials, and you’ve heard in some of the discussions that Judy not really playing with all the other players in the market.

Oh, it’s great if your epic, and I you know I think she is moving to a Comprehensive Health record for patients in making the care everywhere more robust having social determinants follow them wherever they are in this us being able to communicate that so it my snow birds go down to Florida from Kentucky.

They’re going to get the same information shared in their epic everywhere. That part’s good. I think Sonic getting into smaller hospitals good, but I think I personally want to see the whole world moving much more aggressively towards interoperability. I think the o&c missed it originally. I think their idea that you could fix it after you allowed all these disparate ehrs to be built without it they.

We’ve got a mess and I don’t think sonnet solves it, but I think it’s it’s a nice additional solution for epic.  You know this is this is one of those areas that I it’s it’s being from the outside of healthcare seven or eight years ago the first conference. I went to there was. I don’t know that I guess there’s 12 CIO sitting around the table, and they asked us to all do our introductions and went around the table and whoever the first person was they gave their name their system their revenue for whatever reason, and you know what EHR they were on I thought wow that’s interesting ok, so it got to me, and I said, you know here’s my name my system, and you know both are impressive numbers of the numbers are impressive, and then I said my EHR, and it was it was length.

I said I didn’t really graduate from college. I you know I only got an associate’s degree. I mean you could see people look down their nose at me, and I was like. Oh, this is this is fascinating. There’s sort of a culture around what he HR. You’re on and it sort of reminds me of the OS Wards back in the day when people would take size and say you know I’m an OS two guy or I’m a Windows guy or I’m a Novell guy and it.

It really doesn’t help us at all to be honest with you to be so passionate about the HR might my experience. I researchers pretty closely as that the net distinction between these ehrs is. In terms of overall running a hospital and being efficient is not that distinct in fact. We were a meditech shop with 16 Hospital six billion dollars, and it when people would say well.

You know it’s it was that’s an awful system to run that kind of health system on and I’ll just tell you from a number standpoint. It’s highly efficient. It does lag in terms of the user experience, but overall in terms of running the health system. It was effective. It had very good technology and modules.

It didn’t go down. It was a very stable system, and I find people get so passionate about this, and it’s a little off topic. Let’s talk interoperability on this so the interoperability I agree with you. I believe that epic leaves that the path interoperability is if everyone gets on an epic platform, then that we will get to a longitudinal patient record and that’s just.

Never going to happen, and we don’t want it to happen, and we don’t want it to happen for I think the primary reason. We don’t want it to happen is because we saw the same thing in the Erp world and when you get down to very few vendors, and you get down to a certain market share for those vendors The Innovation slows down, and it is not because they don’t have huge staff and huge budget The Innovation slows down because they have to innovate in a way.

That they’re taking into account their their European clients and their Australian clients, and their you know 55 the different clients in the US for large hospitals, and their small hospitals. It just gets too complex to innovate and so we actually slow down Innovation we slow down the market, so I’m not sure we ever want to get to a Epic World Domination anyway, so we should.

Continue to look at things like the square project and the Karen Alliance and it’s some of the other initiatives that are out. There as really the the start of this interoperability Journey. I’m sort of rambled there for a little bit. I’m curious what your thoughts are in terms of what’s next on this and what’s next on interoperability?

Pallid well the next on this is I think you’re going to see Turner and others work towards the Comprehensive Health record more and more so the large players are going to be doing that I agree with your assessment about the need for the competition to create Innovation you and I grew up with the big four and we both drive better Vehicles now because there’s competition from overseas and from all around so the Innovations there.

I think the other. Thing I’m interoperability, I think a high-tech my whole some hope that that group is going to come to an understanding that interoperability is the must-have and we have some legislation that’s driving it. I think you know the physician voice and you’re going to get to that in a moment physician voice more and more is demanding interoperability.

We’re wasting too much of our clinicians times. Positions aprs Pas nurses looking for information that ought to just be there and it ought to be in a usable format when it gets there not in a linear format. They horrible CC CDs that we saw the last several years, it’s got to be better than that.

Yeah, I agree, and I am I’m looking forward to Jumping to the next section talk about physician. / I mean one of what I sat behind a physician at one point and just you know mirrored them for the day. I was shocked to find. You know they were jumping in to all these essentially PDF files, and they you know so they have 15 minutes with a patient and there.

Who think about it like you have this folder full of the 25 pts, and you’re just rifling through them real quick. It’s it really is an impossible job, which gets to you know our role, so you know in our Tech talk leadership. We’re going to talk a little bit about the role of it and physician burnout the reason I just appreciate your physician background.

I’m going to use it here. So the only ncms got an earful on a charge this was a Politico. Article, and I just read you know on CMS officials got an earful for daylong listening session at Health and Human Services on Thursday about reducing provider burden from Health it speaker after speaker said Physicians and nurses are on the edge of a nervous breakdown over the depressing hours.

They spend struggling with bad. HR workflows and government reporting requirements, so. You let me ask you this. Let’s start with the current state. Where do you think we’re at with regard to physician burnout today, and you know what are you hearing out there? Yeah? Um hearing a lot about it the last AMA annual meeting.

I’m a delegate for the state of Kentucky to the AMA the last meeting was dominated by conversations regarding physician burnout it continued at the November interim meeting of the AMA. Uh we a year ago during a half ago almost mouth had they ran study with the AMA that showed that Physicians were spending two times as much time on the ehrs.

They were with patients that the burnout. Level was going up that Physicians a career satisfaction was plummeting. We’ve seen some of this for years. I think you know it for my experience I came into practice in 1990. I think in 95 97 when they came out with the E&M guidelines some of that coding documentation came from outside it had nothing to do with how we really take care of patients or what was relevant to taking care of the patients Physicians felt the pressure of that documentation got more and more copious than you get ehrs, and you get no bloat and you get.

All the meaningless use meaningful use requirements that tell us to pick some boxes that showed functionality of the EHR in terms of it had this code this capability this field was able to be populated, but it didn’t do anything for the patient-physician interaction and for the quality of care. We were delivering patients all of that builds up on the Physicians, and so now we are seeing a critical mass.

We’re seeing that over 50% of positions interviewed and surveyed. Are lamenting armed that they’re losing their satisfaction? They’re losing connectedness depression rates have gone up among Physicians they were high to begin with I mean it’s always been a stressful difficult role, if needed compartmentalization now.

We don’t have time to compartmentalize which we are racing from patient patient and still have the record waiting for us, and we go home and we feed the kids tuck them in and spend another two-and-a-half three hours on the computer and you and over again. The thing that kind of amazes me about HHS and o&c doing this listening session.

You do these listening sessions when you really don’t want to do it something, or you’re not ready or capable of doing something right because they have all this information. I just mentioned a year-and-a-half ago. We had it. I think that’s one of the things that Galls me about this. This was just like Asian and delay.

If they really want to get something done. Yet work, on interoperability reduce some of the cumbersome myths they are at least talkin to us HHS, and I think they mentioned it. They’re talking about reducing some of the myths requirements and easing some of that burden. But they’ve got to quit being in the physician-patient business as much as they are I have a very good friend dr.

Sean Jones former president of the Kentucky Medical Association just published a book Finding part in art. It’s about his journey of burnout. I think it’s an incredibly Brave thing for him to do he’s a prominent ears nose and throat physician in his community and prominent within the medical community at Large.

What it was great gift on his part other Physicians? It’s not every Physicians Journey, but the fact that he would take time out of his life and his wife would allow him. She’s also a physician would allow him to expose himself this way. Tells you how severe this is how critical burnout for Physicians is and I think we as cios have an opportunity to help by really looking at the workflows and demanding of our vendors improved workflow monster.

Do you think there is a?  I mean it is there a risk in speaking out against some of these things. I mean is there a risk right now. Of talkin about you know certain technology is so if I were to sit here and say no epic and Cerner. You know have created way too many clicks and way too much or five sit here and say Health and Human Services Inc macro Mets these things have put way too many birds.

Is there is there a blowback that happens to people that are speaking out about these kinds of things or. Are we passed that down where there’s just so much of it going on that it’s just a matter of getting to the right the right people to get the right things done God. I think the risk is probably perceived to be there more about folks who don’t have a clinical background.

Those of us who have been practicing Physicians, I think we’re past worrying about the risk were desperate to find the right answer, and we feel that for the sake of our patients and for access to characters you burn out Physicians they resign their positions they leave the practice and access goes down, so if we’re going to do that.

I think we get over the fear I think. And I know from conversations with the folks at that pic. I haven’t talked to the folks at the other large ehrs arm but with conversations with Folks at that pic and I watch it you GM and at some of the other conferences folks are getting in their face. Um they’re doing it in a civil way, which we always ought to do it in civil way, but people are being very forthright about what the problems are and they are starting to respond and you’re seeing some of that in the workflow changes.

You’ve seen some responsibility. But I think they built your point these very clicky systems that are incredibly complex coding and to go back and correct that and to streamline workflows is a big lift, and I think it’s just getting a critical mass of all of us saying okay, no more. We’re not going to tolerate this any longer.

You’ve got to do better. And then I think they’ll start moving they also know you know and I know the barrier to change in it health it is huge because the cost is social change Tara Marie implementations. I just went through one. They’re expensive and you do everything you can to not do it again, but I think we’re going to be good partners, and I always talk about good Partnerships our EHR providers.

And we as the users have got to have these hard conversations and be good partners and help each other to improve and get it right. What is the so we’ve talked a little bit about the the it side of it and the EMR providers. What needs to change on the on the on the regulatory side that I mean we talked about in the midst verdens coming down and maybe even some mu things have been eased.

But are there some other things we can look at two. Maybe rollback or some conversations. We should be having that really drive for not just a listening session, but that we as health it leaders or maybe even a couple of people hymns that are listening to this or chime that they could advocate for on Capitol Hill and really move things forward.

Yeah, I think HHS showed us a first step in eliminating the requirement for attending physicians in the academic centers to duplicate. What’s in the student note. We’re starting to recognize that if it’s in the record and it’s available. It’s in the record. It doesn’t have to be duplicated. That’s a great start.

I think they need to look at the 95 97 E&M coding guidelines, and I know they are and say is everything that we’re demanding necessary in the world of an EHR where so much of that social history. You know if I’m simply reviewing and moving on I don’t have to document in every single note. You can follow my clicks if you really want to audit me.

It’s audible, but quit making Physicians be describes responsible for counting the number of boxes checked and trust them that when they say it’s a 991 for visit. It is and if you want to trust and verify because I believe you know Reagan was right trust can verify then go ahead and look at the cliques periodically do some random audits, but don’t make people put all this cumbersome stuff into the note.

It’s time consuming it fills up page after page if you do a printout. It’s just onerous to go through it. I think we can have those conversations. We can make those steps, but this first step by HHS to really eliminate the Redundant documentation for medical students great first step. There’s a lot more steps to be taken absolutely and we talked about that last week with charles’ Boise on the show just how much data is in those EHR logs that you could actually just retroactively go through and create a lot of that stead of putting the burden on.

Session at just probably one of many cases the only other thing. I would we you and I talked about automatics last time, which is one of the ways to ease the burden I saw that UPMC yesterday I saw. A a post by razu on what UPMC is doing with Microsoft in terms of having the machine do the documented do the notes and record the notes while they’re in the room so that was a partnership with UPMC and Microsoft, so hopefully more things will happen in that area.

But as is always the case with you, and I we could we could talk for hours. It’s time to close the show so favorite social media posts that week. I’ll kick ass off, so wow I can’t even read this my eyes are getting so I don’t know what age that happens, but it’s happened to me. So this is a titled how how you treat your low employees determines your future Oleg?

Fish in polsky who I’m sure is an avid listener of the show, but he posted a cartoon. I love these cartoons that says think twice before losing your best employee, and it has the has a like a plank out over the cliff, and the employees walking the plank except their walking to land while the executive who’s losing their best employee is sitting out on the other end of the plank and about to fall into the abyss.

And I think that’s just a great reminder for us so over to you. What what do you have for us? Yeah, I didn’t go for social media post I went for something that was ringing in my ears this week. I’m a comment by my dear friend Steve heck. I don’t know that he originated it, but he was the original person that I heard it from execution Trump’s innovation.

And the reason I’m bringing that up is a lot of our friends are going to be at hymns and chime and particularly at him swords lots of bright and shiny out there. We have all these opportunities to innovate first rule execute get it done right. I’d rather do old school right than new stuff wrong, and I think it pays off you saw this in your work going to the cloud with your system.

I saw it in the work of the team that I got to lead in The implementation epic execution means everything. Yet, so will you be a child RV attempts. I will not be able to I had a family obligation not going to be able to make it out. Yeah, it’s a Well I’m going to I’m going to drive over there and look forward to catching up with some friends, so if you are listener and you’re going to be there.

I would love to catch up with you. I’ll be at the chime event the CIO Forum on Monday, and then hems the rest of the week and stuff sometimes lots of people want to get together at love to update ketchup. So thank you again David for being on the show. That’s all for now please you can. Follow well actually I guess usually I say you can follow us.

Do you have a Twitter handle? I don’t know if you do I do not. Okay, well you have well. It’s let’s just say they can follow you on your articles. You’re writing for health system CIO, diver. Calm and my articles over there as well, so I great publication love those others guys for the service they provide.

You can follow me at the patient CIO on Twitter. Don’t forget to follow the show on Twitter this week in a chai tea and check out our new website this week in health it and don’t forget if you like the show, please take a few seconds and give us a review on iTunes. Reply and don’t forget to come back every Friday for more news commentary from industry in Florida’s next week.

We will be doing our first live show with David Baker from Vegas. I have no idea where we’re going to do do it from probably not the showroom floor the floor of the convention center, but we’ll find somewhere to do it, and hopefully not the casino as well. I know David loves to. To play Blackjack, so I we will not be doing it from I don’t think you’re allowed to anyway, but I can see him trying to push for that so anyway.

Thanks. Thanks again David being on the show and that’s all for now look forward to talk to you next week. Thanks both appreciate it.