Bill Russell on Merger Effectiveness Prescibing Apps and more

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Bill Russell This Week in Health IT

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January 10, 2020: Welcome to this edition of Tuesday Newsday where we look at as many stories that are going to have an impact on health IT as we can in 23 minutes or less! In today’s show, we have eleven exciting stories to cover. We talk telemedicine reaching into space, drones delivering emergency care services, cancer-detecting AI which outperforms humans, and more! Our final talking point is an article about hospital mergers. We cover that piece in some depth because it generated some amazing engagement on LinkedIn. New research has found that the quality of care at hospitals acquired during a recent wave of deal-making in the US either stayed the same and in some instances actually got worse. Get your weekly update of the biggest stories in tech and health today!

Key Points From This Episode:

  • Challenging the idea of ‘magic hands’ with a telemedicine call reaching from earth to space.
  • New trials involving drones transporting supplies between hospitals in the UK.
  • How Partners HealthCare is helping move treatment out of hospitals and into communities.
  • New cancer-detecting AI that raises questions around AI’s role in healthcare.
  • Developments in Germany involving state sponsorship of digital health apps.
  • What Aaron Piercer is doing for EHRs with his new venture, Vital Software.
  • How CVS Health’s Transform Oncology Care is providing cheaper and more accurate care.
  • A plea to prepare homes more adequately to enable the elderly to die in peace at home.
  • Advances in healthcare cost transparency as New York launches a price comparison website.
  • The necessity to start testing AI more rigorously before implementing it.
  • Quality issues arising from hospital mergers and the need for transparency during them.

Bill Russell on Merger Effectiveness, Prescribing Apps, and more.

Episode 174: Transcript – January 10, 2020

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

[0:00:04.5] BR: Welcome to This Week in Health IT news where we look into as many stories as we can in 23 minutes or less that is going to impact health IT. My name is Bill Russell, healthcare CIO Coach and creator of This Week in Health IT, a set of podcasts, videos, and collaboration events, dedicated to developing the next generation of health leaders. 

It’s Tuesday News Day and I am ready to get going. I’ve got a 11 stories. I actually had 20, I had to break it down. 11 stories, that’s why I’m talking so fast. I want to get through as many of them as possible. We have telemedicine reaching into space, we have drones delivering emergency care services.

We have a story which got a lot of buzz on LinkedIn this week with a post which I’m going to go through, a hospital’s merch, the quality didn’t approve. That was a Wall Street Journal article. We have AI ethics washing, we have – New York just launched a healthcare price comparison site and a lot of other things. Exciting week of news, actually, it’s a couple weeks of news since we haven’t covered the news in about three weeks.

This episode is sponsored by Health Lyrics, I coach health leaders on all things health IT. Coaching was instrumental in my success and it is the focus of my work at Health Lyrics. I’ve coached CEOs of health systems, startups, CIOs, CTOs. If you want to elevate your game in 2020, visit healthlyrics.com and schedule a free consultation.

Thanks – special thanks to Drex DeFord for 3x Direct, his service that helps me to do research. What happens is you get three stories texted to you, three days a week and to sign up, it’s pretty easy, just text DREX to 484848, DREX to 484848. 

All right, you ready for the news? As you know, we’re doing things a little different, in November, you gave me some feedback and what I do now is I introduce 10 stories quickly, give you my take and then we circle back and go a little deeper on a few of those stories.

We’ll see if we can do that, we’ve got 23 minutes, clock has started, here we go.

 

[0:01:56.9] BR: Space, the final frontier of tele-medicine. Two months into a six month stint in the International Space Station, one of the astronauts developed a blood clot in one of the large veins in his neck. Nasa reached out to Dr. Steven Moll, professor of medicine at the University of North Carolina who specializes in blood clots and uses various anticoagulant blood thinners, you get the picture.

 

Dr. Moll is also the founder of the Clot Connect Outreach Project, and even though – it says in the article, “Even though he didn’t get to make this trip to the space station, he did provide the longest distance tele-medicine consultation to date, helping to make the decision on how to treat the blood clot.” You know, what’s the ‘so what’ on this story? It is traditional boundaries for tele-health are going to start to fall by the wayside.

 

Dr. Galasso talked about this on the show and he said, he referred to him as ‘magic hands’. That we still have this tradition in the field that there is magic in the hands of the physician, and the reality is that there is a whole bunch of things that can be done remotely and after those traditions sort of fall by the wayside, we start to explore things that can be done remotely that we didn’t think could be.

 

This is so wide, looked beyond the traditional boundaries to unleash the limitations that are currently exist within most health systems around tele-health. 

 

Second story, I started with two fun stories, I don’t know why. NHS could use drones to transport lifesaving blood and chemotherapy kits between hospitals. This is a daily mail story.

 

Here’s what’s going on. The NHS could start delivering these blood samples, chemotherapy kits using drones under a ground breaking new proposal. A partnership of four councils has launched a bid to carry out the first UK trials using unmanned aerial vehicles, UAV’s to transport vital medical equipment between hospitals and GP surgeries. Taking to the sky to deliver the kits would dramatically transform the way emergency services operate.

 

With it, also, hoped drones could be used at serious incidents involving police and fire services. The ‘so what’ on this is, I don’t really know to be honest with you. I just think this is really cool and I would like to work on one of this projects but in all seriousness.

 

[0:04:30.6] My questions is, who is looking at this in the US and is there a possibility? Could this be a major change in the way we imagine emergency services. I think it’s an interesting story. I thought it was cool. Only reason I’m highlighting it is just to expand the thinking of people out there.

 

Again, this is under trial, they’re not doing it yet, maybe we see what the results are of it and fashion something like this in the States, it could be interesting. 

 

All right, let’s get to this a little bit more down to earth, a little bit more practical. Partners Healthcare aims to bring care closure to home, lower costs. This is healthcare financial news. 

 

Here’s the gist of it. Partners Healthcare in Massachusetts is investing 400 million to open up four state of the art outpatient centers that will offer a wide range of new healthcare options to  better meet patients changing needs and, you know, the ‘so what’ on this is, moving care out of the hospital is – into the community is an excellent strategy.

 

We are starting to compete on convenience which is great, this is a win for patients and a strategy that many health systems have started to employ or will employ in the near future so I’m excited that this is happening. I think this is a – let’s just call it an interim step and a good step and then next step obviously is care closure to where people live and where they work so that we’d go to the next level of convenience because quite frankly, if you don’t make care convenient, people aren’t going to take advantage of it and so primary care will still be out of reach for a significant number of people.

 

[0:06:16.3] The fourth story. Google AI beats doctors at breast cancer detections, sometimes. It was interesting to see this article play out on social media. A lot of people posted it to say, “See, AI is beating doctors,” and a lot of doctors actually read the article and said, “See, Google AI isn’t finding everything and is that really acceptable?”

 

It’s, you know – here’s some of the highlights of this. Google health research units said that it developed an artificial intelligence system that can match or outperform radiologists at detecting breast cancer according to new research but doctors still beat the machines in some cases.

 

The model developed by an international team of researchers caught cancers that were originally missed, and reduced false positive cancer flags for patients who didn’t actually have cancer, according to the paper published on Wednesday in the journal, Nature.

 

Data from thousands of mammograms from women in the UK and the US was used to train the AI system. But algorithm isn’t yet ready for clinical use, the researcher said. The model is the latest step in Google’s push into healthcare. The alphabet company has developed similar systems to detect lung cancer, eye disease, and kidney injury.

 

[0:07:29.5] The ‘so what’ on this is, you have to be careful here. Really, what I want to say is that AI is the future. AI may one day beat clinicians on detection at every level, okay? The reality is, we still need clinicians, this is a partnership in the delivery of care. 

 

You know, for the clinicians who are saying, “No, it will never be there,” it probably will get there. We were saying that about an awful lot of things and technology just continues to progress. The reality is if AI reduces the cost of care by reducing the labor needed and improves the quality by detecting previously overlooked cancers, this is what we want, this is the triple aim in putting it out there.

 

You know, the key, I think, is to map out what the future looks like with a partnership between machines and clinicians, and to identify that future, map that future out, and start to talk about it, not push it aside that it will never happen, and act as if it will never happen.

 

And not push it too quickly. We need to put these things through the same kind of trials that we do, drugs and other things to make sure of their efficacy. 

 

Anyway, let’s go on to number five. Germany introduces digital supply act to digitize healthcare. IT news put this out there.

 

[0:08:54.4] There’s a digital supply law, was proposed in Germany and was passed by Parliament in November. Under the new legislation, doctors will be able to prescribe digital health apps to patients which can be reimbursed by the country’s statutory health insurance.

 

App providers will have to prove to the federal institute for drugs and medical devices that their apps can improve patient care. I love that. They will have to prove that but if they prove it, it gets funded which is actually the best of both worlds on both sides. Also, doctors will be able to receive money for providing online consultation to patients with statutory insurance. Doctors will be allowed to provide information about video and online consultations on their websites where as before, they had only been able to discuss this in private conversations.The legislation also aims to phase out the use of paper, promoting e-prescriptions and other things. Germany also plans to bring the EHR for patients with statutory insurance by 2021. 

 

The ‘so what’ is, while we don’t really have a growing listenership overseas, we really do focus on US healthcare so I’m not reporting on that for the German audience, but I am reporting on that because our second highest city for downloads in the past year was in and around the Washington DC area and I cover the story in hopes that regulators are listening and I just wanted to say that these seem like very good ideas. Sound and good ideas, things we should fund within Medicare and things we should figure out how to fund through private insurance as well.

 

[0:10:40.2] Anyway, just a good idea, wanted to amplify great thinking which is the mission statement of the show. 

 

Number six, Mint founder launches EHR solution for hospital emergency departments. Med gadget earlier this year. Mint founder Aaron Piercer’s newest venture, Vital Software came out of stealth mode and raised five million dollars. Talks about who he raised it from. Started in 2017, Vital aims to bring consumer approach to personal finance management, championed by Mint to emergency departments by enhancing the electronic health record. 

 

According to the company’s website, Vital sits on top of the existing EHR for faster, easier view of the ED. We use artificial intelligence to predict admin hours in advance, reduce life to stay and save millions with the improved workflow. Vital solutions consist of both patient and clinician patient interfaces, patients interact with vital web app at intake, to capture necessary medical information and context regarding their visit to the ED.

 

While software does not handle billing, patients can be, can also upload their insurance card. All this information is captured and presented through the clinician portal which includes a risk level and patient color coded in red and green.

 

So what? By the way, this, for all intents and purposes is a press release. I cover it because I use Mint and I like Mint and, you know, the ‘so what’ for this is simplification, automation, AI, experience, improved throughput. Seems like a winning combination if I were sitting in the CIO chair which from time to time I do in an interim capacity. 

 

You know, this is probably worth a look see at him, and if I was in the investment officer for one of these investment alarms within the health systems, might be worth a look in terms of investing as well. Just saying, it seems interesting. Again, simplification, automation, AI, experience, improved throughput, Remains to be seen if they’ll be able to achieve those things but it looks like it works with every major EHR and I’ve looked at some of the screen shots that they were showing. It’s worth looking at. Anyway.

 

[0:12:54.6] Worth a look see as they say. 

 

The next story, CVS Health launches Transform Oncology Care programs to help improve patient outcomes and lower overall cost. This is absolutely a press release, CVS Health, today now, Transform Oncology Care, anchored on first of its kind, precision medicine strategy for pairs. The program uses genomic testing results at the point of prescribing to help patients start on the best treatment faster and in addition, matches elder patients to clinical trials.

 

Transform Oncology Care also uses companies’ local footprint and unique assets to improve patient outcomes and lower overall cost at every point in the cancer care journey. The ‘so what’ of this – first of all, I want to share this because this is an important movement through a potential new competitor for a lot of health systems and CVS is going to do a lot of interesting things, this is one of those things.

 

Precision medicine with local delivery. It’s a great model, probably one you want to keep an eye on, probably one you may want to replicate as you design your programs around precision medicine. I think it’s interesting, worth exploring.

 

Number eight story. More Americans are dying at home than in hospitals, the New York Times article. This article’s worth a read if you get a chance to look it up. More Americans are dying at home than in hospitals. 

 

For the first time in over half century, more people in the United States are dying at home than in hospitals. In Boston in 1912, about two thirds of the residents died at home.

 

[0:14:28.7] By the 1950s the majority of Americans died in hospitals. By the 1970s, at least two thirds did. Americans have long said that they prefer to die at home, not in an institutional setting. You know, this is people’s desire, about 45% of older people have – this is people’s desire, however, the article goes on to talk about, are we really prepared? Have we set up healthcare in that way, have we prepared families in that way and have we done the prepare things to prepare?

 

About 45% of older people have completed advanced directives which often specify that doctors should not take extreme measures to prolong life. If you haven’t done that, you should absolutely do that and figure out ways to encourage people within your health system, to fill out their advanced directives, don’t want to be guessing at those things at the end of life. 

 

You know, the other thing is, they talk about, “We’re sending very sick people and complicated patients home, under the care of their families who are not trained to deliver care and this is a tremendous burden we’re putting on families.”

 

A good article. The ‘so what’ for this is, you know, what are we doing to provide support for those families and a higher level of care in the home?

 

I think this is the year to figure this out. A lot of health systems may choose to partner and that’s great but 2020 is the year to figure this out. How are we going to take home care to the next level? Provide everything, all the way up to an ICU out in the home.

 

[0:16:05.6] That being the extreme and you know, different ways of people supporting the families that are providing the care and supporting the people that are receiving care in the home towards their end of life. Something – that’s the ‘so what’ for that story. 

 

Let’s go to story number nine. New York to launch healthcare price comparison site, Becker’s healthcare. New York plans to develop a consumer friendly healthcare price comparison website in 2020. It’s nyhealthcarecompare.com. Will provide cost, quality, and volume data, broken down by hospital. It will provide info about financial assistance options, for surprise billing, and will be developed by the Department of Health and Financial Services.

 

So what? Transparency is correct. We should be doing transparency. Finding transparency is a losing move. We have talked about that before. From a health IT standpoint, you know, you are going to have to be able to provide this type of information. You are either going to provide it through the state or you are going to provide it through your own website. I prefer to use it as a competitive advantage in the marketplace that you serve and start to provide some of this information.

 

New York is the second state, first state being Vermont that has provided this kind of thing. I think you are going to see this proliferate a pretty quickly across the states. It is not a bad idea, it is a good idea. You know, my coaching to Health IT is to get this work done and really as you are doing the work, do it from a patient perspective. Think about it from a patient, “What would you like to have?” and not from a business preservation perspective. 

 

How little do we have to provide and to continue to provide opaque pricing and to obfuscate really the intention of what the ONC is trying to do with regard to transparency. Again, transparency is good. We want transparency in every other aspect of our lives. We should be providing it within health care especially around cost that are so great to a lot of families. 

 

[0:18:18.5] All right, 10th story, and then I am going into – the 11th story I am going to go into a little bit more detail. In 2020 let’s stop AI ethics watching and actually do something. This is MIT technology review and here’s what they have to say: 2018 saw major advancements in AI. It also saw high profile illustrations of what can go wrong and you know all of these illustrations. Tesla crashed in autopilot killing the driver. A self-driving Uber crashed killing a pedestrian, that was in Phoenix. 

 

Commercial face recognition that performed terribly in audits on dark skinned people but the tech giants continue to peddle it anyway to customers including law enforcement. So Karen Hao, the author, wrote a resolution to stop treating AI like magic, and take responsibility for creating, applying it, and regulating it ethically and the good news is in 2019 that actually happened in a big way and lots of organization set up AI ethics guidelines. 

 

AI conferences had sessions around ethics and there was a lot of talk about this subject. Karen came back this year to write this article and to say, “Now is the time to move beyond talk and get to implementable, less vague AI guidelines, and she talks about we have fallen into this trap of AI ethics watching and the best example is Google formed an AI ethics board with no actual veto power over questionable projects and with controversial members. 

 

And once they backlashed and sued based on those controversial members, it led to immediate dissolution of the ethics board without a replacement presumably. You know, she did go on to note that there’s been great progress at the grassroots level from the community groups, policy makers, and tech employees themselves. Why do I highlight this? Well, AI is all the rage in health care and, you know, AI is not magic. 

 

[0:20:22.1] We need to put it through the paces. We need to treat it like the clinical device that it is. It is providing input to the care of a patient, and we need to understand how making those conclusions – is there a data bias in it? Remember that we put EHR’s in place to improve workflows and to capture data for government regulations, for billing. A lot of the data in the EHR has a billing bias and things to that effect. We have to identify the bias. 

 

We have to know how AI is making decisions and we have to put it through its paces before we see it in the clinical setting. It is one of the reasons why I have been saying on the show that the implementation of AI in clinical settings will take some time. We are going to see AI in a lot of other settings within the healthcare and it could bring great efficiencies and we should be playing with it and advancing it but in the clinical setting, we should be treating it almost like a drug. How are we putting it through that level or rigor and testing. 

 

[SPONSOR MESSAGE] 

 

[0:21:26.8] BR: We’ll get back to our show in just a minute. As you know Health Catalyst is a new sponsor for our show and a company I am really excited to talk about. In the digital age, cloud computing is an essential part of an effective healthcare and precision medicine strategy and we’ve talked about it many times on the podcast but healthcare organizations themselves are still facing huge challenges in migrating to the cloud. 

 

Currently, only 8% of AHR data needed for precision medicine and population health is being effectively captured and used. That is 8%. One of the things I like about Health Catalyst is that they are committed to making health care more effective through freely sharing what they have learned over the years. They published a free eBook on how to accelerate the use of data in the delivery of healthcare and precision medicine. 

 

You can get that eBook by visiting thisweekhealth.com/healthcatalyst and you know, this is a great opportunity to learn how a data platform brings health care organizations the benefits of a more flexible computing infrastructure in the cloud. I want to give a special thanks to Health Catalyst for investing in our show and more specifically, for investing and developing the next generation of health leaders. Now back to our show.

 

[DISCUSSION CONTINUED]

 

[0:22:40.8] BR: All right, so the last story is – we are going to try to do something a little new this year, that we use the turn of the year to try new things on the show, and one of the things we are doing is we are going to start to post these stories during the week on LinkedIn, Twitter, get the conversation started out there, pull that information in, and then include it as a part of our conversation on the air. I am not going to quote anybody unless I know it is okay to quote them. 

 

But you know, so I posted a couple of our stories this week to get started and this story got the most interaction and it is a Wall Street Journal story. It is “Hospitals merge but quality didn’t improve.” I think the title says it all but here is essentially what happened. New research published by the New England Journal of Medicine looked for evidence of quality gains using four widely used measures of performance at nearly 250 hospitals acquired in deals between 2009 and 2013. 

 

The analysis did not find an improvement and quality said this study’s authors and so I pushed, I put a story or I put this out there on LinkedIn and here is what I said, “A merger brings cultural disruption, personal uncertainty, and technology change. Are we surprised by this finding?” It was really fascinating to me to see the comments. You know, at the ground level, you could see the confusion. 

 

There is individuals talking about going through a merger, who have been through a merger, hard to figure out who to talk to, how to get support. Don’t really know where we are going as a whole and this is not like weeks after a merger. This is years after the merger. It is still confusing for people to find basic things like support on the EHR. Very interesting to me. You know, a person said successful mergers are cultural matches. I believe that’s true. I believe they are cultural matches but I also believe that that simplifies it a little too much. 

 

[0:24:46.6] I mean there’s an awful lot of complexity in bringing these things together as we have seen. Some other comments, “FTC wants to hear that mergers will reduce cost and improve quality, so it is no surprise they often hear that.” Prior research has shown a consistent association between merger events and resulting reductions in cost, improvements and quality. You know, again, I hope that is the case and one of the articles that was written recently. 

 

Rod Hackman wrote a piece worth reading and he notes that he believes this year we will start to see the fruits of those mergers and acquisitions that really have come down over the last couple of years, and he believes we will start to see those quality improvements and access to care start to increase and, you know, that’s really exciting. 

 

You know another person writes: “Any of these feel compelled to merge when they fall short on quality and financial positive bottom lines instead of self-reflection for needed and improvements. Merging is thought to consolidate resources in hopes in providing synergies but missed the major first step, looking for the weak links. So many mergers fail for one reason, junk in junk out. The mantra we use for data relevance in HIT.” 

 

And the argument could be made that when you take two organizations that are not financially viable or that are producing poor quality results, I am not sure why anyone would think that bringing those two together would produce positive results but that is the case that’s made and a lot of times these mergers go through, even when the two entities don’t have a really good plan for improving quality or profitability within their own system and now we are expecting them to do it across the board. You know a couple of other interesting comments. 

 

[0:26:48.1] You know, “Many hospitals being acquired are not in a financially sustainable position. One argument is that this is better to maintain some surfaces at a location than to have a hospital go under completely. Service rationalization is happening across the board not just in struggling hospitals being acquired. It is the new norm. The scale at which some systems are taking this on is absolutely daunting.” I think that is true. 

 

You know we have seen some systems take on an awful lot of acquisitions, which is an awful lot of EHR consolidation to do and just in and of itself and then you have others that need to be in there. You know Drex DeFord mentioned earlier on the show, chimed in and just talked about how there is a lane grab going on and there is a fear of missing out mentality and there is a reasonable belief that if we centralize HR and IT and the rest of these things that there will be efficiencies. 

 

But he goes on to say that every MNA is complicated. This is a great discussion that goes on here, worth taking a look at, out on LinkedIn on my personal LinkedIn account. If we are not connected, feel free to send me a LinkedIn request and you can start following some of these things. You could also follow the show at This Week in Health IT on LinkedIn as well. I will be posting them there.

 

Here is one of the things I will say about mergers and acquisitions. I have been through both sides. I have been the larger entity and acquiring. I have been the smaller entity that got acquired and had to put together – spent nine months putting together a plan of bringing two fairly large organizations together before leaving with a severance. So I have been on both sides of this and we discuss this in detail. There is an episode probably about a year and a half ago with Sue Schade where we sort of role played what we would do as two CIO’s in this endeavor. 

 

[0:28:46.8] I will say this, I have seen this done really well. One of the ones I am really looking forward to I hope we hear again from JP Morgan was Mercy and Bon Secours and the CEO got up there and he just – first of all, he was transparent and he was honest. When you talk about this and you go into an organizations and you say, “No one is going to lose their job” they know you are lying. So you just don’t do it. Just stop doing it, it’s disingenuous. 

 

One of the things I liked about the CEO who got up at Mercy and Bon Secours, when he was talking about their merger, he says, “You know, we spent months trying to come up with an EHR decision.” He goes, “It’s obvious to everyone in the organization, when we spend six to nine months involving everyone in a decision that is already a foregone conclusion and we lose credibility right out of the shoot” and he said:

 

“You know we went in there and we said in one month we are going to make a decision on the EHR. We are going to make a decision on the ERP solution. We are going to make a decision on…” fill in the blank, whatever the other ones were and he goes, “Everyone knew we were going to Epic. We are going to Epic.” There is no reason to – now there is nuances to that, you know, which building you are going to go to, all of that stuff. Do you do a new build or whatnot but I liked his approach. 

Because you can lose credibility right out of the shoot in how you handle this and you can lose credibility by not being transparent, by telling people things they know are not true. “We’re a merger of equals.” Please stop saying that. No one believes it. No one from the hourly employee to part time employee to your executives. No one believes ‘a merger of equals.’ So I think transparency, honesty – I think understanding the complexity that you are stepping into. 

[0:30:41.6] When you take an organization that has 1,800 applications and then another one that has 2,000 applications, there is – the amount of tech debt that exists within those two organizations alone that they would have to deal with if they didn’t merge is significant, is a three to five year project. You take the two and move them together, you are now talking about a significant amount of tech debt. I think boards need to be educated on tech debt and understand it. 

And I think, not only boards but also leadership needs to understand that, because a lot of times, IT is the – brought in after the fact we have decided to merge. We make sure there is nothing in the closet that will make this merger not worthwhile and if you sit there and start talking about tech debt they will say, “Nah that is not a reason for not bringing these two things together,” but the reality is, you could be talking about millions, hundreds of millions of dollars. 

 

You could be talking about complexity outages, security breaches and, you know, again, fear of missing out. We’ve got to push through these things. Interesting article, interesting conversation. I really enjoyed doing this. I hope that you’ll start to participate in these conversations. I have started posting stories and we’ll continue to post stories because I really want to get the conversation going back and forth between us. 

That is all for this week. Special thanks to our channel sponsors, VMware and Health Lyrics for choosing to invest in developing the next generation of health leaders. This show is a production of This Week in Health IT. For more great content, you can check out the website at thisweekhealth.com or the YouTube channel. If you want to support the show, the best way you can do that is to share it with a peer. Send an email and let them know that you value the show and you get a lot out of the show and that they should take a listen. That helps immensely. 

We will be back again on Friday with another interview with an industry influencer. Thanks for listening. That is all for now.

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