Eric Fishman, MD speaks with Andrew Carricarte, President and CEO of IOS Health Systems about his electronic health record system Medios EHR. Carricarte discusses how Medios EHR is different from other solutions. In addition, he speaks about roadblocks that physicians face while implementing an EHR and how they can overcome these issues.
Category: EHR Press
Date: January 26, 2010
Dr. Eric Fishman: Hello. This is Dr. Eric Fishman for EHRtv and today we'll be speaking with a fascinating gentleman, Andrew Carricarte. He's President and CEO of IOS Health Systems and they have a product, Medios, which is a web-based electronic health record. Andrew, if I can ask about the name to start with, where did IOS and Medios get their name from?
Andrew Carricarte: Actually, the product name, Medios, comes from just adding the "ios" at the end of the medical. The name IOS actually stands for Innovation, Opportunity and Service. So for our employees and the people we take of. We have a model in the company that's called Taking Care of Those Who Give Care.
Dr. Eric Fishman: What do you see the effect of the federal government initiatives are likely to be on the industry in general?
Andrew Carricarte: You know, I think right now there's a lot of confusion with physicians. Number one because there's incentives that you have the interim final rule which you mentioned but also because you have health care reform taking place at the same time. So there's a lot of uncertainty right now and the one thing that's certain is change.
What I think will happen is that it's interesting the director of the ONC, David Blumenthal, was quoted as saying the incentives are a designed to be a sweetener and I think the industry will suffer from a sugar high once these incentives go out. I think at the end of the day, it's a good thing because we have to spur this adoption.
Dr. Eric Fishman: Do you believe that most of your users are even interested in the $44,000 if you will?
Andrew Carricarte: I think they are but if you're selling on the incentives alone, I think it will be a failed implementation. When you look at the industry, it's about a 30 percent de-installation rate and that's conservative. So why are they de-installing? What is going on in the industry? Why are physicians not taking it so much that the government's got to pay them to do this?
When you look at the real obstacles price is important so we've solved that affordability obstacle. But really, it's about showing them value and it's about supporting them and backing up with the service component that helps them to the transformation. So I think the industry is going to shift to more taking the suffer mentality out and putting the service mentality in.
What we do is we have a before, during and after concept whereas most companies would drop off after the point of implementation. For us, that's the most critical point of the transformation of the office is after implementation. So it's a living piece of software, it's a living support cycle that supports it before, during and after.
When you look at the industry as a whole, I think it's going to bring to light a lot of the issues facing the industry. If you looked at the adoption rate over the last couple years, it's poor. So from an adoption standpoint, we can say that we've been somewhat ineffective. Part of the reason is because the usability is not good, the affordability is not good and at the end of the day, it's not working for the practice because there's no support cycle to support them after the point of implementation.
Dr. Eric Fishman: All true points. You mentioned 30 percent de-implentation rate and I'd certainly heard higher numbers than that. Without going into details, including which products may have been de-installed, have you installed your software in any offices that de-installed a previous EHR and if so, can you give us any information that you've gleaned from that about what could have prevented the failed implementation in the first place?
Andrew Carricarte: When it comes down, I think at the end of the day what will win this market, what will win over physicians is their service component. I think if you're trying to go forward with a software mentality of -- I cookie cut, I put it out there, I sell it, I sell as many as possible and I distribute as quickly as possible -- it's not about a fast implementation or a rapid implementation, it's about an effective implementation. So when you look at the de-installation rate, what we've seen on our end is the usability. You're going to see a big focus on usability coming down the next couple years. The players in the industry today have pretty much been there for the last several years. There's no big players that have emerged that have come up with a different delivery model. So I think you're going to see more emphasis on usability.
Dr. Eric Fishman: Let me stop right there and drill down on this. When you talk about usability, is it your opinion that other EHR products have software that is inherently usable -
Andrew Carricarte: Right.
Dr. Eric Fishman: - but is not implemented properly because of lack of service or do you think that the larger problem is that the software is inherently not usable?
Andrew Carricarte: It's two-fold. It's usability and then it's the service that supports it after implementation. Aside from that, what we like to do, we're blaming the physicians for that. And while you do see some resistance to change, they're not responsible for what the adoption rate is today. A lot of the vendors are using outdated technology. We have tools today that we know that have developed over the last couple of years that we have to provide for them.
The younger generation doesn't have a tolerance for technology that takes too long or takes too many clicks or looks outdated. Physicians shouldn't either. So the feedback we get is the physician tells us, I don't understand it and when I tried to use it, it took me too long and it was impractical and I couldn't use it. So it's about practicality, it's about getting something very complex - the technology component - and making it very easy for the doctor to use.
Dr. Eric Fishman: And in those situations, is it your opinion that the EHR vendor in general, the generic EHR vendor, has done everything in its power with their human resources to try to get a successful implementation or do you believe that they, in many instances, sold the product and then went on to their next sale and never fixed the problem that was in fact fixable?
Andrew Carricarte: I think in many of the cases it wasn't fixable.
Dr. Eric Fishman: By that do you mean that there are products being sold in the marketplace that are inherently not likely to be usable by the physicians that are acquired.
Andrew Carricarte: By the average physician, no. It may work in some settings, but generally speaking, like we said, if I go from three to five minutes to 18 to 20 minutes, it's not going to work for anybody.
Dr. Eric Fishman: Do you think CCHIT or any other certification entities has worsened that process and more importantly, with the possible loosening of the certification criteria going forward, do you think that issue will become less of a problem in the future?
Andrew Carricarte: I think that if I'm a vendor and I get 90 percent of my revenue up front from the physician, my incentive to service after that point is very little regardless of what we advertise or what it is. If my revenue model, my company is built to collect most of my revenue up front, you follow the money. What we've done is we've spread that out. We continue to support you or we don't get paid. So our whole mentality, our culture is built around supporting the physician.
From a CCHIT standpoint, I think overall it's good in a sense that we've needed standards. We needed something to say, you know, in 2004 with the State of the Union address, everybody will have an electronic record by 2014. So everybody started developing things and you had all these things pop up out of nowhere and nobody really knew what an EMR really was or what does that mean. Is it the patient thing, is it the doctor thing? So they've done a good job as far as standardizing. I think the government's taken the next step as far as creating this criteria which is to say, look, we're all going to talk in this language. If we're all speaking English, then we can talk to each other. If we're speaking 24 different dialects, we can't talk to each other. So from that standpoint, it's good. I think there's a challenge there in they're saying we have to leave other companies to be creative to develop these new technologies for some of the stuff that we want to get out there and just kind of innovate with. And we shouldn't be restrained to developing along these certain lines. Yes, the standardization for how we speak to each other, how we interoperate, that should be controlled, that should be standardized, but how we develop and how we deliver our product to the physician, part of that needs to change and part of that needs to be innovated. So as long as it doesn't restrict it, I see it as an overall good thing, Eric.
Dr. Eric Fishman: What does your company do and more generically, what do you think should be done to determine whether or not a medical practice is even ready to put their toe in the water or jump head long into the water of electronic health records?
Andrew Carricarte: Part of what we do is a work flow analysis. So when we first walk in whenever we can, we link up with different entities such as EHR Scope, entities that can help provide and kind of guide the physician towards the right solution …
Dr. Eric Fishman: Thank you for that.
Andrew Carricarte: Of course. No really, I mean there needs to be an education in the market because we can't possibly educate all of the physicians out there. So whenever there's entities out there who are neutral and say look, this is what we think is best for you, it helps us with our process when we walk in. And it's about sitting there with a physician and showing him the value of the things that are going to be impacted to when he actually implements this thing. I believe that just about every physician can benefit from this type of use because the one thing that's certain in this industry right now at least is change. And if we're not proactive from the physician's standpoint of how they engage that change and how they get ready for that change coming, it's going to be very difficult to manage their practice and provide the same level of care that they want to provide onto their patients.
So part of that is getting the tools - the practical tools, the affordable tools, the adaptive tools - that help enhance the way they take care of their patients and the revenue portion will take care of itself.
Dr. Eric Fishman: So talk to me a little bit more about work flow. There's dozens of different specialties, physicians work in small practices, large practices. They work in one physical location where they go down the block and see patients in a lot of different areas, some of them are used to using pen and paper, some of them dictate, et cetera, et cetera. You say you do the work flow analysis.
Andrew Carricarte: Right.
Dr. Eric Fishman: Describe in a little bit more detail because I think one of the main reasons that physicians don't buy software of this nature and utilize it is they don't know what they're up against. They don't know what they're walking into. So give us a day in the life if you will of a physician who is going to have a work flow analysis done.
Andrew Carricarte: One thing I want to address, and you hit a key point there, Eric, is physicians are moving around. Physicians are mobile so the tools that they use should be mobile. Mobility, it's one of the big trends in the industry. Why can't they access from their phones? Why shouldn't they access from their Blackberry or I-Phone from the hospital, from wherever they're at? This is about making this kind of ubuituous. They can access this from anywhere, they can interact from anywhere. So it's about creating that mobility with the application. I think that has to be there. I think physicians demand that. The days of carrying your crate of medical records to the hospital because you're going to perform a surgery or what have you, it's crazy. It's crazy. So from a work flow standpoint, the first thing we do is you have the office manager, you have the physician.
We have to understand the objectives and the pain points of why they want to do this in the first place. They have to be willing. So when you go in there and you talk to the doctor there's usually something that is a pain point for him. Everyday, whether it's, you know, quality of life that he works 25 hours a day, there's always something that we can identify from when we walk in there that they will tell you. They're very familiar with it, it's their practice. So we identify their pain point, we identify some of their obstacles, some of the issues that the practice is facing. And that's when we go in and we adapt and we enhance what they're currently doing and we show them how the software can actually solve some of those problems.
The implementers are trained when they walk in there. We do not walk in there with a step by step process where we go, Okay, doctor, here's a round peg with a square hole, let me show you how to use it and give you a high five and we're out of there. We understand what the physician is doing first. Where are their pain points?
Dr. Eric Fishman: Let's go back a little bit before the implementation, go back to the analysis. Even with a laundry list of specifics, what type of work flow questions do you ask to get a physician to be introspective enough to understand what it is that they're currently doing and what type of changes are likely to occur in their lifestyle and their activities once they implement an electronic health record.
Andrew Carricarte: So it starts from very basic things, patient volumes et cetera. The implementer is trained to see how the physician is actually interacting with the computer. First of all, access their level of capacity to use technology.
Dr. Eric Fishman: What if you find somebody who is unable to turn the computer on and off? That was me at one point and time.
Andrew Carricarte: We go back to the seven different preferences of documentation. We have a Bluetooth pen. Say you have a group of five physicians and one of them says I just don't want to use computers because I'm retiring in two years or what have you. "Fantastic, Doctor. Don't change the way you work, just change your pen." It's a Bluetooth pen that actually records the handwriting of the physician. They sink it back to the system and the data pulls in the physician so that the practice can still leverage the power of the technology and still not affect the cash flow et cetera in the process of trying to implement.
But some of the basic questions we ask, going back to your question Eric, is that we have to walk in there and there's certain things that a physician's performing. So when the implementer goes in there, they're trained to access billing habits and how they operate on a daily basis. They're pain point objectives and then also to identify is there a potential of cash flow loss. So you see, as a physician going to the hospital performing procedures, are they doing services out of a hospital, how are they recording that. Chances are, it's a little piece of paper that gets put on the office manager's desk.
Dr. Eric Fishman: I've lost some of them.
Andrew Carricarte: Right. So there's a lot of lost revenue that we find out but the first thing is we operate under the premise that you can't manage what you can't measure. So when the EMR get implemented, the EHR gets implemented, a lot of this comes to light and it's part of the support process. I have to say Okay doctor, this is what it is .And then we work with the physician to see how we can analyze the practice to address the work flow issues. So for instance, they can now see all their patients and where the bottlenecks are in their practice, cash flow issues, so where are they using revenue. Those things will come to light as well. Then, different preferences with the staff, things that just don't make sense with the front desk or what have you.
Dr. Eric Fishman: When I was actively practicing, I had a large staff and some of them were in their 70s. If I were to have implemented an electronic health record in the mid 90s, I have people who I'm positive would have been completely unwilling to touch a computer. What do the staff who fit into that category do after an EHR has been implemented? You know, I had a woman, she was the representative of a beautiful Worth Avenue hair salon and she was a greeter. And she was wonderful at greeting people but she wasn't going to touch a computer. That was my office and I'm sure they're in all offices. What do those people do after an implementation?
Andrew Carricarte: There's two issues there. So when we first walk in, you will have unwilling staff members, you'll have unwilling physicians. The burden should be, again, on the software provider to show the value in what they're doing. "Doctor, if you can do this everyday" or a front desk clerk, "If you can do this everyday, this is the result. It makes your life easier." So I think from a staff member's position, it's always, what's in it for me. They don't like change, right? They're used to doing the sticky note. So it's about showing them this is how this reduces your work, this is how this makes your life easier. And then afterwards, what we've always seen is our strongest resistance that comes from staff members or physicians they're usually your biggest advocates after the implementation because they see the impact that it has on their daily lives.
Dr. Eric Fishman: I've heard that before. Tell us if you will a little bit about your company in general, how many employees there are, where you do the programming, some of the strong points of the software.
Andrew Carricarte: It's almost a campaign we're on. The software is made in the USA. We don't outsource.
Dr. Eric Fishman: I think being in the military for four and a half years, I guess I can understand that.
Andrew Carricarte: Listen, we live in the greatest country in the world with some of the greatest providers in the world. I'm not sending those jobs offshore.
Dr. Eric Fishman: And so the support also is done --
Andrew Carricarte: The support is 100 percent stateside, the development is 100 percent stateside. Our software is made in America, right? We do all that for two reasons. Number one for us, we believe culturally it's the right thing to do. But number two is when you separate the development process from the clients, you always see there's a disconnect. A result of what we see with a lot of products out on the market today is that that process of development was very much separated.
We have the programmer who interacts directly with the physician and we have a company policy that programmers have to go out and do implementations. They have to actually sit and parallel the implementer and see the pain points of the physician's experiences.
Dr. Eric Fishman: You must have a different class of programmers than I do.
Andrew Carricarte: Don't get me wrong. We don't have them talk to the physicians sometimes. The implementer is doing the implementation but the programmers actually go onsite. They will sit there and watch the implementation.
Dr. Eric Fishman: The programmers actually go on site and watch what's going on. That's a great idea. And tell me about the implementation process. There's the big bang, there's the incremental. Do you have a philosophy? Do you do it the way the client wants it?
Andrew Carricarte: Yes. A lot of that's driven through the physician. This is where we give a lot of feedback on what we see and we give a recommendation. But as far as the speed, it's not about a rapid implementation, it's about an effective implementation. I mentioned that before. Our process is first understanding the work flow analysis, understanding how these physicians work. Secondly, it's understanding their preferences and their outcomes that they're trying to achieve from a care perspective and from a financial perspective. Once we understand those, then we develop an implementation plan for them.
After the implementation is the go live. We do not leave the customer. We sit there. That's the most important time because that's the transformation. We sit there and guide and continue to steer the practice towards what's best for them.
Dr. Eric Fishman: And how long a time period is it do you think between signing a document and the majority of your staff who have been living at the office, having them leave and the doctor's reasonably self sufficient?
Andrew Carricarte: We have the unique advantage where, because of our technology, we can deploy very quickly. It's 100 percent web-based. We don't have to install anything. A lot of times we don't ask them to buy extra hardware because it's an added cost for them. So we can deploy very quickly.
Dr. Eric Fishman: Most of your offices already have wireless connections to it?
Andrew Carricarte: Right. So we deploy as quickly as a day. Some have taken longer. The industry standard is three to six months. We're usually well under three months because what we focus on, as I said in the beginning, is the user ability standpoint. You should be able to pick up an EHR and just figure out how to use the system through clicking a couple buttons and walking through. The actual IPhone does not come with an instruction booklet but you figure out how to use it.
Dr. Eric Fishman: And certainly one of the characteristics of your software is you've got big, colorful, pretty buttons that tells you what it is that you're supposed to do when you click it.
Andrew Carricarte: Right. Listen, running a practice is hard enough as it is. The EHR shouldn't be. It should be something that enhances the way they do it.
Dr. Eric Fishman: And were you personally involved in the design of the graphics?
Andrew Carricarte: I'm the dummy. I did the dummy testing. If it works for me, then it works. No, but we invested a lot of time and energy and money into the usability studies behind it. So we had physicians from different age groups, different types of specialties. We have over 30 specialties that we serve. I actually used the application and watched the interaction and developed accordingly.
Dr. Eric Fishman: Nothing is perfect for all people. Which specialties is your software most appropriate for? And not to say it isn't appropriate for others but it's probably not appropriate for anesthesiologists would be a guess of mine, maybe oncologists but where is your strongest point?
Andrew Carricarte: Our strongest point, a lot of primary care but we've done just about every type of setting from large to small. Like I said, we actually developed for 30 different specialties because they are different but primary care is typically our stronger.
Dr. Eric Fishman: And if you're in primary care, primary care providers are 240,000 that the HITRECs are going to be addressing. Are you making any plans as it relates to the HITRECs, the Health Information Technology Regional Extension Centers?
Andrew Carricarte: Sure, we are. We have good relationships with the people who are trying to do it in South Florida and at last count was anywhere from 40 to 60. I think there's a slot for 60 to be actually funded through the incentive.
Dr. Eric Fishman: Maybe 70 at the end of the day.
Andrew Carricarte: Right. So I know everybody's submitting applications now. They haven't approved it yet but it's to be --
Dr. Eric Fishman: Coming soon?
Andrew Carricarte: It's coming soon. Yes, hopefully, hopefully. To be very much tight end. It's a fair process. At the end of the day, our philosophy is we don't want to sell you a product if it doesn't work for you. We don't want to sell it to you because three weeks later, you'll be unhappy with it. It's a neutral process that says here's the education, let's educate the physicians. Most of the physicians we talk to and most of the office staff have no idea what the EHR/EMR can do for them. The concept is foreign. So most of the sale that we do is an education process. If we can have that happening before, it's going to help the increasing adoption within those areas.
Dr. Eric Fishman: And so here's a bit of a tougher question. This is phenomenally complicated technology. Physicians go to medical school, they do a residency and for the most part, they're not techno geeks. What types of problems do you see surfacing most frequently? Not to say that you can't solve them, but what types of issues do physicians have shortly after implementing the software?
Andrew Carricarte: Shortly after implementing the software, just industry wide speaking in general terms, I think it's support. When a physician runs their practice, the staff revolves around what they're doing which is giving care. So now when they're operating off the system, they expect the same response but it doesn't exist for most of these companies. So they become frustrated and they just stop using it. And what you see is these partial implementations. I think if it's a partial implementation, it's a failed implementation.
But our approach is this, "Doctor, what do you feel comfortable with?" We use a progressive implementation style when we go to actually get the office up and running where we refer to when somebody's first trying to swim, you don't just throw them in the deep end and say, "All right, well, if you start drowning, I'll throw you a life preserver." We start them off in the wading pool in the shallow end and teach them how to swim. So it's a slow progression. It's a progressive implementation where they're at their comfort level. If you take them out of their comfort level, which naturally they will be, and you try to just kind of put an end to the regular two, three days that we're in there - we're out, big high five - it's just not going to succeed in the long term.
Dr. Eric Fishman: Let's go to a couple of weeks after the implementation has been successful and now let's look at it from the patient's perspective.
The patient walks into the waiting room and I understand that you have the opportunity to use a kiosk for instance. Tell me first about, if you're willing to, what percentage of your physicians are actually using a kiosk and what functionality are they using. Are patients actually entering their financial information, are they paying their bills at the kiosk, are they putting in their confidential personal, private health information there?
Andrew Carricarte: Actually, from the kiosk standpoint, it's mostly pre-registration. From the patient portal standpoint or the PHR standpoint, we have payments that get processed to the physician offices. We have different records that are pulled from different sources. The reason why it's important to keep the PHR private is because they simply don't trust the Microsoft's, the Google's out there because they think they want that information for something. Ours is completely neutral and independent of the physician office. The physician initiates a record, now all the patients that have gone to that office have a PHR free of cost. So you see pre-registration, you see different exchanges of information. A physician can actually communicate with the patient via the portal. They can make payments. So for the physician, it's a cash flow advantage and they can actually schedule appointments from there as well. So you have both the capacity from the kiosk standpoint and the front desk has to do a lot of different things when the patients are checking in.
Dr. Eric Fishman: From my perspective I'm just still shocked - and I ask a lot of people the same question - and they all say kiosks are not widely used. I had 50 staff in my medical office and I paid every single one of them. I would have loved to have had my patients doing the work that my paid staff were doing. And yet, kiosks are not as prevalent as I would have expected. I'm just wondering if you have any insight as to why it is because for me to pay a medical assistant or a registered nurse to sit and talk with a patient and find out what their history is, is extraordinarily expensive and to have the opportunity for a patient to sit in a waiting room at a kiosk and do it --
Andrew Carricarte: Less errors. Right.
Dr. Eric Fishman: -- fewer errors, the authenticity is there and the efficiency. It just seems to be a phenomenal cost savings and yet, I've not heard anybody tell me that's it's occurring pervasively in their practice and their company and I'm just wondering if you have any insight into that.
Andrew Carricarte: Yes, it is a smaller percentage. What we've seen is that people who are using it like it. When you have patient entering information for instance, it depends on the type. I think some of the obstacles are if you treat a lot of older patients then you might have some more difficulties having them go to the kiosk and put all their information in.
Dr. Eric Fishman: I'm not sure you'll see an office that mandates the use of the kiosk.
Andrew Carricarte: That would be interesting.
Dr. Eric Fishman: Certainly if it can take care of the requirements of 50 percent of the patients that come in, it pays for itself. I don't know what the kiosk costs but it pays for itself.
Andrew Carricarte: As far as from our software perspective, the kiosk is included with the system. It depends how they want to set it up.
Dr. Eric Fishman: So a physician's group can acquire licenses to your software, pay a fee, and then for no additional cost they can either have or not have a kiosk. And most of them don't have a kiosk.
Andrew Carricarte: Most of them don't have a kiosk, right.
Dr. Eric Fishman: Shocking.
Andrew Carricarte: Yes, and I think the ones that have been successful, Eric, are the ones that use kind of a hybrid. So you're not going to have every patient always use it and I think that's kind of the de-motivation that I think the mentality is. Well, I'll just enter everything and it reduces all the work flow issues, et cetera. You're always going to have somewhat of a hybrid. So you have an elderly woman walk in the office, you're still going to have to help her acquire that information. So we always see kind of a hybrid. Most of them use it, some of them don't.
Dr. Eric Fishman: And let me ask you about the whole industry of telemedicine or telehealth. You've mentioned that your connectivity is very successful with your technology. I have a particular interest in promoting the concept of telemedicine and having patients get treated when they're not in the physician's office.
Andrew Carricarte: Absolutely.
Dr. Eric Fishman: Tell me what your take on that industry is.
Andrew Carricarte: I think if I'm a physician, it's the easiest way to document, right? I think part of the things holding it back are they're not being fully reimbursed.
Dr. Eric Fishman: (inaudible).
Andrew Carricarte: It makes a lot of sense. I think Hawaii was the only state that ran a pilot where they were doing some reimbursements behind it. Some insurers are starting to pick up on it. They do have pilot programs where they're starting to incentivize physicians to do this. I can imagine the day.
Dr. Eric Fishman: How long do you think it'll be?
Andrew Carricarte: My call is three years where you start seeing some of this come out via these portable devices. I imagine the day where a physician's watching television, a call comes in, they move the television to the side, the patient appears on the screen and they conduct their visit from there. Again, EHR is not just something that should run an office or the documentation for the physician. It should be something that is ubiquitous. So it permeates what the physician does as far as taking care of their patients and an operating system so to speak for the physician beyond just his practice. That's kind of the approach we've taken
We have a video conferencing capability that helps record video interactions among physicians and patients in our system and it stores with the patient record. I think it's coming. I think the big driver there is when insurance companies start paying for it. No doubt.
Dr. Eric Fishman: Well, Andrew, it's been fascinating. I thank you for your time. Is there anything else that you'd want to tell us about what you're expecting to see in the next few years in this industry?
Andrew Carricarte: You know, I think you saw recently the incentives that created this proliferation in the industry, so a lot of new companies have come about. I think you're still going to see some consolidation among the single solution providers. I think the big consolidation is going to come in year two, year three after this when we really start figuring out the industry.
Dr. Eric Fishman: The requirements are a little bit tougher.
Andrew Carricarte: Overall, very positive things that are coming I think it's long overdue in the health care industry and this is just going to be something that brings the issues to light and helps us solve them and help physicians take care of their patients and move forward into the future.
Dr. Eric Fishman: I thank you for joining us.
Andrew Carricarte: Thanks for having me, Eric.
Dr. Eric Fishman: This has been Dr. Eric Fishman for EHRtv. We've been speaking with Andrew Carricarte, the President and CEO of IOS Health Systems. Thank you.