Kevin Finkenscher (AMIA CEO) speaks on how Informatics will Change Healthcare

this luncheon learns a little out of sequence we usually have about once a month but we had an opportunity today to have Kevin signature who the new CEO and president of the American Medical Informatics Association come to campus and I thought since he was going to be here anyway it might be a nice idea if he could give a talk to the group and so Kevin just joining me in the last two months he hails from furrow systems in CSC and had been a clinician prior to that in North Dakota and had done some early pioneering work in telemedicine he's going to talk to us about where the Healthcare Informatics is going in the next because the next ten years or so and hopefully he'll give us some good insights about that this is indeed Weiner whose rejoiceful inches will Kevin let me hand this off to you and go find our wayward recruit okay okay Oh real pleasure to be here today to have the opportunity to talk with you I have a very deep appreciation for informatics and what it can do but I'm not like many of you so I know how to use these tools to make a difference so what I wanted to do today is to talk with you about what I see happening in the healthcare industry in the United States and specifically where I think things are going because we are experiencing a tremendous amount of change I think we're a very very significant inflection point one that we haven't seen for 40 50 years at the end of the day from my perspective informatics is at the core of how we're going to solve some of these problems so with that wouldn't jump into it this is my metaphor for what's going on in healthcare and as you all probably know this is a very famous Japanese painting of a student anyway now a lot of people didn't know what a tsunami wave was until about I think it's three four years ago Christmas Eve when that massive wave came ashore in Southeast Asia and we turned on CNN and we saw this wave causing destruction of everything in his path well tsunamis are you know they occur and they occur as a result of a disruption that occurs in the surface of the earth what's interesting about a tsunami is that when you're out in the newly ocean it dissipates into the you don't feel it so you don't even know when it goes by it's basically only when it gets to shore where it's a sound wave and it creates a massive wave a massive wave of destruction that cannot be stopped you cannot build brick walls hyah you cannot plant it up trees tsunamis won't wipe everything out into their patch just like we saw in Japan this last year so why is that one metaphor well what's interesting about a tsunami is that the destruction is separated by time and distance from the origination where the somebody came from and I think that's what's going on to healthcare I think we have a bunch of tsunamis born I think there's a bunch of that it started to occur about a decade ago throughout the world that are causing tsunami waves and healthcare is the target for any of these changes that have occurred in society in general so this is the Chinese anagram for the word tsunami and so you'll see this anagram periodically on my slides as we go through it Jonathan Swift is 17:11 said vision is the art of seeing things invisible vision is the art of seeing things uh visible Charles dual 1899 everything that can be invented has been invented vision is never seen things available Harry Warner 1927 what the hell wants to hear actors talk to anyway vision one of my favorites is 640 K ought to be enough for anybody we all know said that vision is the art of seeing things invisible so what I'd like to do today is share some of my vision there's not blue sebaceans about what I think is going to be going on in healthcare one of the fundamental problems that I feel is occurring in the healthcare industry today is that we are we're not looking at the lens with new territory I think that's a real core issue so that we have physicians we are sort of looking at the healthcare world from their perspective we have nurses looking at it from their perspective we have pharmaceutical companies looking at it from their perspective we've got health care systems looking at another perspective we got consumers their perspective and we're all sort of got our blinders on and what's interesting about it is that some of the creativity that's occurring in the industry is where people are taking off their patterns where they're saying hey let's look at this new let's look at this difference so we have a lot of entrance into the healthcare system who are coming at it with a whole new perspective I wanted to ask this question for all of you so which individual in the last decade or the last century the US money actually that's pretty close but it was a lot of people actually think there was this guy because he's the loser Terry's report the surgeon general's report on smoking and he's the one that took the bully pulpit he said let's stop smoking and smoking went from 43% of the population down to roughly 20% today now that's that is a huge impact but it's not him well that's interesting and actually the president talked about sulcus is very close is you know what happened on October the well what happened is that Elvis Presley went on a simulcast on ABC CBS and NBC and he had his immunization done for polio by Jonas Salk the immunization rate in the United States went from 0.6% to 93% in the next year now that's impressive that it went that high but what's even more impressive is that it changed the entire attitude of the American public about immunizations all of a sudden we were getting our measles mumps and rubella vaccinations we were getting flu vaccinations it changed the whole notion of how we treat ourselves as consumers and how we treat our kids so you know should we be looking for Elvis I used to live in Kalamazoo and he's not there but you know I think what's interesting is that we frequently in our industry talk about trying to find you know the icons that can help move the industry so you know there's been a lot of bodies around Jamie Oliver and what he's trying to do around diets and you know get kids giving their weight under control so that's that's good that's that's all good stuff but I think the answer is actually us you know what's fascinating is when I go around and talk to health care people we know what to do we know how to make the health care system better we know how to make it more efficient didn't know what not to make it more effective but we're not doing it over the last couple of decades I've had a lot of interesting experiences and one of the most interesting is when I worked in international I was responsible for international health care for perot systems I lived in London and I basically had the opportunity to travel around the world and then one of the things that really hit me during that two-year stint is that the issues around the world are basically the same as they are here that healthcare focuses on three things it focuses on cost and people like low cost for their healthcare services actually that I could free they can get it but you know low cost is good high cost doesn't work for a lot of people particularly as we are increasingly asking people to reach into their own pockets and come up with their own dollars to pay for their services which is increasingly what we're doing as a society consumers are suddenly getting very interested in the cost of healthcare second thing that they're interested in is they want quality actually they don't want quality they want perfect healthcare does anybody want to volunteer in the admitted to the local hospital here for those local infection in this afternoon so they want perfect health care and we were just talking about that in terms of pharmaceuticals the expectation is that the drugs will be perfect every time there'll be no side effects well that's that's not realistic everything in life is at risk and finally these they want sir and they want it right right now and that's because in the rest of their life they can get those kinds of activities right now so they want better service so those are the three things that I think are really dominating the discussions in healthcare and if we paid attention to those three things we could solve a lot of problems the other issue is that we're moving from information theocracy hi I'm dr. Fisher I went to medical school and very smart well graduates and I went to a nice residency and all that kind of stuff and you know here's my prescription trust me to an information democracy the doctor freaking Gerry look you up on the web last night I discovered that you're in the bottom quartile of the class of 73 at the University of North Dakota you did pretty well in your residency but according to these reports your your standard of care is in the bottom quartile so the juice flame doctor friggin sure why she later touch me okay that's information democracy information democracy is where people come in and they ask their oncologist why aren't you following the protocol that they're using for prostate cancer that they're using at MD Anderson you're not doing that so that is clearly changing the power paradigm of healthcare we are moving from the theocracy to the democracy I think that's a very important shift and that means that the information that we share and how we share the information is becoming increasingly important some of the forces so I'm talking about all these tsunami waves there that are sort of the supply chain on the shore we're also seeing consolidation you have gone through consolidation in the pharmaceutical industry over the last couple of decades it's beginning to affect other parts of the industry as well we're seeing massive consolidation in the hospital sector the number of discussions that are going on between multi-billion dollar health care systems where they're coming together to create even larger buff care systems is really amazing I was just at a meeting with some of my colleagues we've been working together for 20 years many of them are CEOs and CEOs of health care systems and they are involved in any number of merger and acquisition type discussions so consolidation in the hospital sector is occurring it's a Korean in the position sector as a matter of fact physicians are clamoring to try to figure out who they should work with because they recognize that if they don't do that that they may be left out in the cold we're also seeing the breakdown of traditional boundaries did anybody predict that Walmart was going to get into the healthcare business did anybody pick that without before it actually occurred yeah most of us missed that one coming I actually about 15 years ago 20 years ago used to go get up and you have a talk where I introduced myself as the senior vice president of Sears and that we were starting a healthcare you know we're going to take out the carpet section of our Sears stores that we're gonna pretend clinics and we're gonna actually use a nurse practitioners and we're going to give them the consumers beepers and let them go out in the store because we figured out that they would buy $43 and 16 cents worth of goods before they came back to the clinic Lee and we were always going to have them be about 10 15 minutes late now what's interesting is that that's the kind of we've got new entrants we've got cross industry convergence where the hospitals and the physicians are coming together where we've got insurance companies buying up healthcare systems so we're seeing that clearly the rising tide of technology and then finally workforce globalization I got on a plane about two years ago and usually when I get on planes that I travel a lot I usually have this little thing which is I sit on the aisle first of all and then I lean towards the aisle and then I crossed my leg towards the aisle and they give a very clear message on don't talk to me well on this particular day I became dr. Chad young I started the guy my discovery was a physician we were San Francisco flying to Washington DC and they said what are you what do you do no watch me says I'm not going to watch this oh really where you headed he says I'm going to Paris that's a hot Paris I love Paris it's a great place what are you gonna do in Paris he says why weren't there I said well I thought you just told me you worked in San Francisco so do i do what i do is i am a radiologist and I provide radiology services for my partners back in San Francisco for Paris so you know and that that was two years ago that was pretty uncommon but today in fact I you know one Medical School where the radiology department closes down at five o'clock and it's taken over by a radiology organization they have a partnership going for reading standard films laboratory anything this digital can be moved anyplace we all know that there's a change so the forces that we see are the global economy which is a huge factor the fact that the nation's budgets are being stretched you know the big issue in the United States is that we have this budget crisis the biggest part of the budget that is being debated is healthcare because it is such a fast-growing piece of the budget that doesn't seem to be able to be controlled that's the reason it's getting so much attention by we've got the boomers I don't know about you but I'm 62 years old in the last two years I have consumed more healthcare services that I consumed in the previous 60 years of life I'm a fairly typical blur that's what boomers do we consume resources and we want it right now by the way we want it our way so we're pretty demanding and there's a whole bunch of us so not only is the health care system got an issue but a whole cadre of folks that are going to stress the system even more than it's already stressed the other issue that we have is that I don't know if you know this or not but the average age of nurses in the United States is 55 another issue that's important is that physicians are over the next ten years we're going to see upwards of a third of the physician workforce in the United States either become disabled die or retire two years that's a huge number of providers that we have potential for losing my contention is if we think we're going to deliver care with the same old delivery model that we've developed with the years ago I think we're wrong so I think we need to be thinking very clearly about what is our job when I went to medical school genomics we had a a one-week course that's all we had and it was I think only two hours a day so you know and you couldn't get by with ten hours generally in today's world finding the internet and finding the consumer issue one of the things I think that healthcare is beginning to figure out that hasn't really cared about yeah is that there is a big difference between Ruth crystal there is a difference between showing Alexis and consumers understand that and yeah we trying to treat everything the same and that's an issue this is a slide actually that I've been using for 20 years I updated every year and what it shows is the percentage of investment by a country as a percent of GDP health care versus the per capita income for individuals in that country and what you see is it roughly falls along the lines so family income goes up Society spend more and health care there is there are two countries in sort of dramatically increase theirs that's the UK where several years ago when Tony Blair was Prime Minister they increased the payment to primary care physicians and so the cost of that NHS went up pretty dramatically and then we have the United States which is you know way above the curve and going north of 18 percent were actually around nineteen percent now going to 20 the question is if you do that what are we going to take out there's only so much money so we're going to have holes in the road are we gonna get rid of certain programs and schools that's what they did in California they decided to get rid of second languages that's a really smart thing to do in a global economy not teach your kids something besides English regard so you know we've got all these choices that we have to make and so as we consume more resources in health care that that is creating problems for society this is a very interesting slide that I just put together about a month ago and it shows the up and down of the percent of debt to GDP ratio and you can see that after World War two the debt to GDP ratio went up quite high but then over the ensuing decades we paid off the death up until recently in 2010 were cut to 98% is projected to go to 115 percent by 2020 if we don't do something now what's the red line return the red line is Greece and Spain so the question is do we think that we're going to allow the United States the same kind of situation now granted the United States is different than Greece and Spain you do have a lot of resources but I guess I asked the question maybe we should solve this problem maybe we should solve this problem by the way it's interesting I are just having briefing on politicians you know it's really interesting about Washington DC that the two sides really are at a point it used to be they work together I mean I remember working with you know Dave Durenberger who was a Republican from Minnesota and Bob Dole Republican from France's and senator Bernie a Democrat from North Dakota and a bunch of other Democrats and we got into a room and we saw balls around rural health issues and it was really it was good to see that happen today you couldn't get the people in the same room which is really tragic so with the anticipation what I want to do now is sir I think I've made the point that we've got a problem so the issue is okay so how're we gonna solve the problem we're not going to solve the politics but I think we can do things in the field we can make changes we can drive better care delivery I think it's built around these six areas so let me talk about each one first of all it's very clear to me that we do need to think about how we can use a global workforce to help solve some of the problems and healthcare delivery much of the information is digital I know that as a global company that you're working together virtually across all sorts of boundaries and that's good I think that's an example of what we need to be thinking about because there's so much more efficient well and it actually can kind of compound our results this is the slide that I was talking to you about in terms of the shortage of physicians so we're going to be short by 2025 but 70,000 nan primary care physicians shortage of all physicians 130,000 that's that's pretty significant now there's a lot of issues why that superior it's not just a shortage of providers it's also a change in the attitude of physicians don't I mean my era we worked 70 80 hours a week physicians don't like to do that anymore so they they like lifestyle as a matter of fact the interesting thing about the specialties is that the specialties that have no problem in recruiting residents are the lifestyle specialties it's the primary care that have had more difficulty in attracting so I think this is a core issue now its diffusion this is I anybody know Larry gowns he's a economist technology economies UC Berkeley about what he called the technology healthcare or technology customer and I looked at it now this is really health care as well and basically what it says if you have price over here and you have volume over here then if you have a low volume or if you have unique knowledge you can kind of charge anything you want and that's exactly what happens in our healthcare system some of the ultra specialists they can charge anything they want they can charge cash I was talking with a dermatologist they had did with him the other night he was an hair transplant guy and he doesn't see you unless you pay in cash nutnut checks cash he lives in Canada grammars interesting interesting model right now I'm a family physician if patients walk into my office can I demand cash for my services Kevin I'm going to go next so that's because I have general I have knowledge that is held by lots of people as a matter of fact the data shows pretty clearly that a nurse practitioner can do 93% of what I do and so the question becomes you know who should I go see what's interesting about health care is that we tend to treat all problems the same but in fact they're you know if I go bust or if I were to suddenly fall over and have a senior I'd want to go find the glioblastoma specialist I mean because I'm a physician I would probably go out and try to do that versus to find a 32 year old mother of three children and I've had my fourth UTI in the last year am I gonna want to go sit and wait until dr. Fisher's office very 3-4 hours waiting for him to show up so I can get my antibiotics and go home and go back to work I don't think so so the issue here is that these are services and these are products and that's what Walmart has figured out not only Walmart we've got a bunch of other organizations that have figured it out as well and they're beginning to provide product services there this intermedium the healthcare system as we've known it I don't think that's bad necessary I actually think they do really good work they actually have very high quality outcomes and in fact it would not surprise me the other thing that I think is occurring in health care is that the Guild's from my perspective figured that out but they're they're beginning to figure it out I had a really interesting discussion with the CEO of one of the large multi-specialty organizations today the organization's and we were talking about this issue and he agreed that you know what the guild is in trouble they need to think differently about how they're going to work together with other like-minded specialty organizations we are moving from a non integrated artisan type approach to healthcare to much more standardized meaningful reporting and actually systems if you want to be pejorative about it you know the doc say oh you know we're going to be corporatized well I've lived in the corporate world for the last 20 years it's actually not a bad world they can actually do good things in corporations so the question in the new Kaiser interesting organization Kaiser on the west coast attracts the creme de la creme of the residents every single year they get the best resins why because they offer something that you can't get in private practice which is stability you get to practice medicine you have to worry about the business side and you work a regular life and that's what a lot of so Kaiser is exploding it's growing tremendously and Kaiser like organizations I was just with Glenn Steele as a CEO of Geisinger clinic same issue they're getting all the best residents coming into their organization their ability to attract is really quite high diagnostic diffusion is another one so we're starting to implant devices in people and we're pretty sensors into people I'm involved with a very interesting company that started off capturing information from RFID devices so they can track where all the equipment is and all the people are in an institution but they're now taking their platform which is open and they can actually capture the information from any type of RFID provides with their software they're now in the process of capturing all the data from all these devices as well so they're writing their code so that they can be the platform for capturing that information and then attaching it to the electronic health record I think that's a very exciting and interesting idea because that data is going to help determine how we're going to care for people so so let me use the example congestive right there congestive heart failure as we all know people start to go into congestive heart failure about sending two hours before they show up in a year okay how do we know that well they started to accumulate fluid it's very easy to figure out if they're accumulating fluid how do you do that well in the morning when they get up you have them step on a scale you haven't step off the scale the data goes in immediately to a computer the computer does of analysis and says hey this is Jones you've gained 10 pounds overnight your phone call maybe we should start you on the diuretic we keep you out of the hospital you know what that study was actually done it was done at a major institution up in a city in the Northeast the stress with the beat that and they showed very clearly that they can't really go out of the hospital this is now eight years ago what happened to that study well they pulled the plug why because people weren't showing up in the air they were losing revenue now if you're an accountable care organization are you going to implement that kind of a system absolutely it easy to explain what may see a witch this crowd my boy what an ACO is for this phone okay a CEO is an accountable care organization which is a new business model that is being developed I would say it's not absolutely clear exactly how it's gonna be structured but basically what it does is it says that we're going to give funds to an organization and that organization is certain some people like in a decapitation but it's capitation on steroids but we're going to give the funds to an organization and they're going to become accountable for the entire care of that individual and they're going to provide all of the services across the entire spectrum for that individual and in return if they do a good job they get to keep the difference and if they do a bad job they lose money so you become much more cognizant of where your resources are being expended so a lot of you know Kaiser for all intents and purposes is an ACO if you want to look at an organization saying well what do they look like well Kaiser is the example that's thrown out but you get organizations like Geisinger is clearly moving in this direction but it's not just organizations like that they had the nephrologist through de vida are creating a renal accountable care organization so those patients who had renal transplants and have ongoing dialysis have particular problems and they're really cared for by a lot of nephrologist and interests well you can create a system that would care for those kinds of images as well so that's what we mean when we say ACO it's a new business model that was part of the ACA the Accountable Care Act that was passed or what some people call Obamacare so this was the part of the legislation that was created and with the stamp of approval now with the Supreme Court there's going to be an acceleration of organizations developing these types of efforts a matter of fact the number of conversations that are ongoing since it Supreme Court decision so the model is not new it's been there I mean talk about that you mentioned yep so what changed these are there more incentives to drive towards that as a result yeah different what's different is that for example Medicare is gonna be pretty distillates in their day if you take Medicare which represents what thirty eight percent of the entire health care spend in this country some like that yeah you know you all of a sentient the big gorilla is doing something a different way every time Medicare makes a significant change the rest of the industry follows you have the big health insurance members who are recognizing that this is the direction that they're that they're going so they're already getting ready to do this so Ethne Cigna United Humana they're all partnering up with health care systems to try to figure out how to deliver these services on a regional basis most of our being done on a regional basis but once you start to do it on a regional basis I can my projection is that fifteen years down the road that we're going to have some national healthcare delivery systems five I'd be shocked if George Halverson who's the CEO of kinds of Reason thinking about that I mean I'm really shocked because I know he is he has to be because of the amount of money that they're spending on the East Coast building infrastructure capability hiring physicians developing services etc I it's very clear to me that they've made that decision but we can see Mayo go national that'd be interesting guy seniors talking about it the number of partnerships between Cleveland Clinic is you know they're going international why can't they do mention authors my CHF example I'll switch over that Oh another one interesting you guys know my crazy Mike Mike is the chief innovation officer at the Cleveland Clinic he's a physician anesthesiologist but he made into healthy life about 20 years ago and what he has shown is that they have what they call the five normals and the five normals are normal weight no smoking normal glucose and Google and a1c normal cholesterol and keep your vaccinations up-to-date and then this is how they manage them this is how they monitor those five things and what they have shown is that if you manage them those five normals you get your patients gotcha cruisin /center right there so what it shows is that the USA they did this with save a billion dollars per year just just on that one little activity for the Medicare population let alone the rest of the population I mean what's interesting about that is that sometimes in our healthcare of the world we concentrate on the high hanging fruit versus the stuff that's you know sitting right in front of us and in health care I think one of the things that we need to start doing is paying attention that low-hanging fruit because it's right there and you know a trillion dollars over ten years that's that's that's real buddies like to make a difference that could really help and that's focusing on one kind of issue so peripheral intelligence this is where we don't even know how to use analytics in our healthcare system and we don't even know which questions to ask and he's the chief operating officer of the largest not-for-profit health care system in the country twenty five billion dollar enterprise he said that to me that says something that says that in the informatics world where we know how to massage information we know how to analyze it we know how to extract knowledge we know how to create knowledge and intelligence from data that we haven't done a good job of educating the people that run the systems that spend the money and one of the things that I believe is happening in the informatics field is that while we've done a really good job on the biomedical site we have not done as good a job on the applied side and the applied side is where we're going to see the action I think in the coming decade and actually we need to help support that we need to educate people to foster we need to engage in the analytics of this data we're going to all this trouble to spend twenty nine million dollars deploying electronic health records we should surely get something out of it besides storing electronic health records we should be able to create knowledge and I think we have that opportunity we have that opportunity but it's going to rely upon the informatics community from my perspective to step up and say here's how we should do that you know what kinds of standards do we need and we need to be come a little more articulate and a lot more assertive with our perspective on how this should be done and I think it cuts across all the informatics fields it is really industry working with the academics working with the applied side to try to bring this together so then we can help drive value in healthcare so I think we have a very important role as we look to the future necessarily with the new virtuality is so the implications for the healthcare system in general is that we are going to see consolidation effectiveness and efficiency are the watchwords of the day and effectiveness and efficiency will be uncovered by implementations from my perspective we're going to see globalization of care we receive virtualization of care we're going to see accountable care as I described it or in some other fashion but we are going to be we're not going to be passing it to getting a patient in and getting the payment anymore that era is coming to a close the fee-for-service system from my perspective is not going to work except for very specialized very well unique knowledge things productivity is important again how do we manage productivity well again informations are very important looking at the data to figure out what is the most productive approach to delivery care what where is where the problems in the delivery services what are the bottlenecks and then information exchange now I wanted to share with you at least my thoughts as a non pharmaceutical industry person what my perspective was on what this means for pharma so on the train on the way over here I sat down bracer enrolled myself when I talked to Jonathan I said you know here's my thoughts what you think so I want a sermon which is that I think that we are moving towards a period where discovery will include clinical information real-time how we do that well I was fascinated to learn about a project that Steve is working on where you're creating a collaborative knowledge base and I think that has the potential for accomplishing something like this but I think in the next 10 years that's the direction that we're going to be moving in which means that as you think about your research your foundational research and how that extends it's going to become a different kind of approach towards knowledge uncovering clinical decision support clearly is going to be moving from retrospective Techcon current I think that was interesting about the healthcare industry in general is that the life sciences communities have more resources at their disposal in terms of technology and infrastructure to accomplish analytics than the healthcare delivery systems don't care delivery systems are way behind life sciences in terms of capability I could go to ascension and I couldn't get this many people in a room to talk about informatics and there's just they don't exist so they're going to be doing a catch-up to what you are yeah at the same time and I guess what I would suggest is that if you agree with the notion that we're going to be capturing real-time clinical information in the future and that's going to become part of the data pool having those kind of resources out in the systems is going to become an important part of how you do your work so we need to think that through and I think informatics as a profession is moving interest to really a capability we have done that through the fact that the AMIA now we have the subspecialty designation for informatics it's the first time that that has been accomplished we are now the 26th specialty within medicine we are in the process of putting together the board certification process so it'll be a specialty under the American Board of Preventive Medicine and so we're working on that and it's kind of exciting to be a part of that but that means that it's no longer just an interest among clinicians and researchers and the light it is now becoming a capability and we're going to have accreditation standards and so that's really changing the field of Informatics I liken it to you know when I went into family medicine I was at the very first wave of family medicine people that go through residency prior to that it was all on-the-job training again well all of us will be grandfathered in a super magicians in the future and then you know can i you is going to become like a real key criteria for accountable care organizations so they're going to be looking for knowledge that can help drive value and I think they're going to become much more discerning around how they spend their resources so it's going to be interesting to see the interface that they create as these organizations come together and how they're going to interact with the pharmaceutical industry because you're going to have to demonstrate value for the drugs and other medications hidden create and you know bring to and then finally I do believe that we're going to have the capability of creating cross institutionally identified databases for clinical research that's already being discussed the example that I shared with Steve is last Friday I met with the CEO of the American Society of Clinical Colleges and they want to create a database of oncology information that they can share real time with oncologist in the field so that the oncologists can do engage in the right protocol at the right time that's not being done today it's being done locally they think that by doing it nationally that they can actually help accelerate the adoption of certain protocols because quite frankly a lot of oncologists sort of cruise along and they don't use the latest protocols we all know that so that's all my thoughts you know I believe that from my perspective is really important to embrace the future and so my perspective is I keep trying to encourage my colleagues to take their head out of the sand and recognize that we've got a lot of change going on around us rather than resist it try to build brick walls try to plant trees to create tsunamis so they won't affect this rather than that I think we need to learn how to serve tsunamis so I'm in my executive colleagues to get surfboards and you know we can go out and try to find Elvis every morning when I get up I have a little sign actually on my mirror it says what are you going to do to solve problems today because I think it is important for us to look at ourselves we know what to do in health care that we have the answers when I sit down and talk with I can have one-on-one with all of you we could come up with four or five ideas like tomorrow that we could implement that we think healthcare better so I think we need to get the other thing I would say and when I tell my colleagues particularly the healthcare delivery side is that they need to paddle like hell so with that I have we got a little time our QA

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