medically assisted treatment. we have a great toolbox of medications now available to treat substance use disorders, particularly opiate disorders and alcohol disorders. the bill creates a pilot program and provide state funding for this type of work. so obviously the san francisco department of public health is supporting 1557 and it's going to be heard in assembly health committee in april. second item is i'm very pleased, and probably already heard, that mayor london breed appointed bland to serve as mental health reform. in this new role, which was created by the mayor, dr. bland will be responsible for reviewing how san francisco provides mental health and substance use services to homeless individuals, people at risk for ending up on the street and other vulnerable populations. this will help us not to improve our system that already serves

tens of thousands of people in our behavioral health system, but as you know, there's an ongoing question of how do we do better, how does the system adjust to meet the needs of homeless individuals and those most at risk for becoming homeless. dr. brand is a psychiatrist, he has firsthand experience in clinical care and in services in our system, being -- running the psyche emergency services at zuckerberg hospital. and he'll report to me and i'm really looking forward to working with him over the next period of time, to figure out how do we really strengthen our system. in terms of the balance balancing issue at zuckerberg hospital, this has gotten a lot of attention. and we are working diligently across the network and with the hospital to improve our billing practices. and just to remind you, the recommendations will be brought to you on april 16th for your consideration. but i'm going to give you a little more detail on, at the

request of the commission. so we're focusing on our efforts on patient protections and creating new policies that present patients from being caught in the middle of disputes between the hospital and the insurance industries -- and the insurance industry, when insurance companies do not pay adequately for the care that we provide their customers. patient protections will fall into three main categories. first, you'll recall that we have halted the practice of patient balance billing and collections during the development of these new policies. second, we will present a plan to make discounts and bill reductions for patients available to more people by increasing the eligibility for charity care and sliding scale programs, based on income. third, we will propose to set an out-of-pocket maximum for patients at all income levels. meanwhile, our patient financial services team continues to resolve bills for patients and pursue insurance payments for services.

above all i want to emphasize that we care about people. and the department's mission and the hospital's mission is to provide the highest quality care and trauma services with compassion and respect and that we care for our patients and always and continue to be proud of the critical role as the city's only trauma center and safety net hospital. i note that the hospital provided $61 million in charity care in 2017 alone. and i look forward to bringing our recommendations to the commission on the 16th, to align our hospital billing practices with the department's values. so every member of the public feels welcome and cared for at zuckerberg san francisco general. and in closing, i will just note that this week is national public health week. and we are going to be telling stories on social media, focusing on some of the themes of the week, including healthy communities, violent prevention,

urban health, technology and climate change. and for those of us who are social media mavens, we can be followed on facebook and on twitter. and i'm asked to remind you to please like, tweet and share our postings. thank you. >> thank you. commissioners, questions of the director at this point. >> i did have one on the dental transformation. >> yeah. >> program. and while noting that in 2018, you cite the improvement in a number of areas, i think when the report was made here, we had a major deficit in chinatown. but i didn't see that it was noted to have any improvement. and my hope is that there would be outreach programs to really target that, because that was a

very major area of concern. >> yeah. i can just -- i believe that effort is under way. but i can certainly confirm with staff to make sure that that is noted. and that work will be done. >> okay. thank you. i think the other is that the tuberculosis statistics in san francisco still are not good. i know that in the past, we have made sure that we were at least back filling a minimum that the feds were de-commissioning, so to speak. i'm hoping that you would make sure that they have adequate resources, because it sounds like there is now an increasing number of cases within the city. >> yeah. so in some ways we are seeing some slight increases right now. i will say that compared to say ten years ago or 15 years ago, we have certainly improved the

t.b. -- the dynamics of t.b. among homeless population. so that has vastly improved, compared to where we were 10 to 15 years ago. you are right, particularly in populations that are new to san francisco, we're seeing increase -- some increase in t.b. diagnosis. we're also improving our diagnostic capabilities. i was just up at our lab upstairs two days ago. it's pretty amazing in terms of the diagnostics we bring to the t.b. work. but certainly with a back fill from the commission and the increased attention on screening people, i'm hoping that we'll be able to see these numbers go down over the next few years. so thank you for calling attention to that. that's one of the -- you're referring to the world tuberculosis day, that's occurring. and i think the point is to bring attention to the issues. so thank you for calling that out. >> yes. thank you. >> commissioners, any other questions of the director? seeing none, we will move on to the next item, please. >> sure.

no public comment on that item. item 51 general public comment. i have not received any requests. we can move on to item 6, which is report back from today's finance and planning committee meeting. >> good afternoon, commissioners. the finance and planning committee met today, right before this commission meeting. and we went over the contracts reports and a few new contracts, which are all on the consent calendars. we originally had another presentations for the charity care report, that unfortunately we have to reschedule that, due to some unforeseeable situations. the presenter had to go home because they didn't feel well. thank you. >> commissioners, any questions? the consent on the items of the

consent calendar, otherwise we will go on to the items of the consent calendar for approval. yes? >> you have a public comment? >> i believe commissioner loyce has something to say? >> okay. >> california contract severed. independent vote. i have to recuse myself. i'd like to be able to do that, in separate of -- >> oh, okay. so you're working on the consent calendar at this point and asking for the extraction of the memorandum of understanding, so the commission could agree and accept your recusal. >> yes. >> on that vote. are there any other potential extractions from the consent calendar? seeing none, is that not correct? >> item 6 is. >> it's before us for vote.

and we have extracted the memorandum of understanding. all those in favor of the concept calendar, otherwise please say aye. >> aye. >> all those opposed? we'll now go back to the memorandum of understanding. understanding there's a potential conflict of interest. the commission must accept that. we will then, without objection accept that. commissioner loyce will not be voting. all in favor of the memorandum of understanding, please say aye. >> aye. >> all those opposed? the memorandum of understanding is accepted. and noted that commissioner loyce has recused himself. >> all right. thank you, commissioners. i also note the charity care report will be presented at the next finance and planning committee meeting. >> okay. thank you. >> item 8 is the resolution of commitment to trauma care.

>> good afternoon again, commissioners. susan ehrlich, c.e.o. at zuckerberg san francisco general hospital. you have in front of you a resolution of your commitment to trauma care. this is very similar, if not exactly the same to resolutions that you approved in 2016 and in 2013. this resolution simply states that you support us, the s.f.g. as a regional one level trauma center and maintains your commitment to providing services in accordance with the rules. this comes in advance of an american college of surgeons' validation survey that we have every three years. this is a voluntary certification process that we go through. we are, of course, also approved by the e.m.s. agency and through cdph and title 22. what the a.c.s. survey does is it holds us to the highest

standards of quality, around providing trauma services. so we do go through that every three years and this is upcoming in the next couple of months. this resolution is part of what they expect to see in that survey. >> and commissioners, the j.c.c. reviewed this and recommended this for approval at its march 26th meeting. >> yes. thank you. so the resolution is before us, commissioners. it was brought by the j.c.c. it does not require a second. are there questions at this point, either to dr. ehrlich or in regards to the resolution? seeing none, we're preparing for the vote. all in favor of the resolution? >> aye. >> resolution is therefore adopted. thank you very much. >> thank you very much. >> item 10. i'm sorry. item 9 is the san francisco health network updates.

>> i'm sorry, everyone.

>> good afternoon, commissioners. roland pickens, director of the san francisco health network. it's my privilege to bring you this semiannual update of the network. i was last here in october of 2018. so i'm back now in six months just to give you an update on where we are. so just an overview of today's presentation. i'm going to start off by reviewing our strategic priorities for the network. then i'll be joined by my colleague, dr. alice chin, who is deputy director and chief medical officer for the network. and she'll review true north and where we are with our true north metrics and our journey looking at our true north experience over the last few years. and then, as always, whenever we come, we always highlight one

section of the network. and today we'll be highlighting telehealth and language services. and it's really appropriate, because i remember when i first came to the department almost 20 years ago, i was at san francisco general and dr. sanchez was very interested in our language access services and making sure we had -- we maintained a connection with the mission language school, which we have always done. and really they've been a major referral source for the interpreters we use within the network. it's amazing how things come full circle, so i'd like to point that out. we always show the department organizational chart. again today we'll be talking about the network, which you'll see on the left-hand side of this chart. and getting a little bit in more detail, this is the network

organizational chart. in addition to the major divisions that you're most familiar with, laguna honda zuckerberg, ambulatory care, including jail health, primary care, maternal health and adolescent health, and behavioral health. there are also other nut units within the network. part of our journey was to centralize key aspects of our operations. so, for example, on the far left, at the bottom of the chart, you'll see a couple of areas that are part of the network. and those are -- >> mr. pickens, you can use the point -- you can use the thing to point to it. >> there we go. thank you. so in addition to our clinical services, the network also oversees supply chain operations for the department. that's purchasing of materials and supplies.

and then also we have our rehabilitation services, including occupational therapy, physical therapy, speech therapy and our health-at-home program. then when you come over to the far other side, you'll see two other programs that are affiliated and part of a network, whole person care, which we have talked about before, which is part of the 1115 medicaid waiver. and then our telehealth and language services, which you'll be hearing more about later on in the preparation. -- in the presentation. so just to refresh your memory and where we are in terms of our strategic priorities, this is what's called our x matrix. it represents the result of our strategic planning process. as you know, we utilize the lean

process. and in lean of strategic planning, it's referred to as ocean condrey. it really means a compass or a direction in terms of where the organization is going and interpreter condrey represents a method by which you deploy that. this x matrix is meant to represent kind of a one-stop shopping in terms of a balanced score card, at a high level for the organization. by no means does this depict all that we're doing within the network. but it's really meant to show where is our major focus, both in the short-term, over the next year, and in more long-term, three to five years. so to react on that, there's what we call the north box, the east box, the south box and the west box. so the north box, up here,

represents the strategic initiative, that the leadership decided upon for the network. and we've got three covering this year. e.h.r. readiness, develop our people through lean, and value-based care. when you move over to the east box, so each of those strategic initiatives has what we call an a3, which is a document that really goes into detail describing what that initiative is about, what's the current state, what problems or areas of concern that we're addressing. and so each of those a3s has counter measures and those counter measures are listed here in this section. so, for example, e.h.r. readiness, some of the count measures for e.h.r. readiness are listed here. then as you go to the bottom, it

shows which members of the team are responsible, are either as owners of that particular metric or as members of that a3 team. so those performance metrics really were meant to show how are we doing in terms of the progress of those strategic initiatives and their a3s. then we move to the south box. and here we have our true north outcomes. and you'll remember the true north is really metropolitan to be a-- really meant to be a concise set of ideals that the organization holds it to be, continuously improving in its performance to meet. true north outcomes are meant to not change significantly in the short-term. they're meant to be more three- to five-year horizons.

dr. chin will give you the specifics in terms of where we are in meeting those true north outcomes, when she gives her report. so we shared this slide last time we were here. and i'm actually going to go in reverse chronological order. so in the current fiscal year, fis -- rather preparing for the next fiscal year '19-'20, we have the three strategic initiatives i just mentioned. the e.h.r., which we called reata, standing for right information every time anyway where. developing our people through lean, which is really deploying what we call d.m.s., the daily management system for lean, which is how we bring it down to the unit level in terms of reinforcing our true north and a3 counter measures.

value-based payments, really represents our journey in terms of moving from fee-for-service to fee-for-value, based upon having reimbursement based on actual outcomes. it's good to show this, because it really shows the evolution of our thinking and our ability to prioritize and focus. when we first started our planning process, you'll see we started with nine strategic initiatives. and quickly found that that was just too much, to realistically do given our bandwidth. we sent then -- we went back to the drawing board and we began to align both with the d.p.h. in fiscal year '17-'18 and you'll see now, preparing for next fiscal year, we are in lock-step with the strategic priorities of the department, which are a data science, developing our people and homelessness and then for the network the three initiatives we just went over.

so again the three initiatives, each of them has an a3. this is just a quick snapshot of the a3. it describes a problem statement. the fact that we have i believe 67 plus electronic health systems within the department. and we are moving to one integrated platform across our delivery system and that's epic. and this also then shows what some of the counter measures are in terms of achieving our implementation of epic. for example, setting up a governance structure and tracking milestones for epic go-live for august 3rd. a3 has to do with developing our people. as part of the process for trying to prioritize and really bring focus to our process, we

decided that we needed to have our -- develop our people, lean work really focuses around the e.h.r. the countermeasures involved here involve rolling out daily management system to units that are going to be implementing epic. sorry. >> not sure what happened there. >> i don't know. oh! >> okay. okay. and the third a3 is value-based care. again this is outlining our path to move more from a fee-for-service to fee-for-value. it talks about the problem

statement that we need to have better data and use of that data, in order to measure our outcomes and performances. again this is just a brief overview of what we're doing at the strategic level. and for each of these, there are true north metrics associated with each of the a3s. and i'll go back to this. our goal, if you look at our x matrix in the south box, is that we've set the target of having achieved 70% of the true north outcome measures across aldi -- across all dimensions and review the true north score card, so you can see where our metrics are. okay.

>> i'm going to try to do a little tech fix here. see if that works. good afternoon, commissioners. so in the same way that director pickens showed you the evolution of our strategic thinking, this slide is really meant to show how our approach to true north has evolved over the years. remember we had the six colors. those are unchanging and that's the point of the true north pillars. but what you can't see is over the last four years, we have really narrowed our focus and created more alignment. so you can see we went from 49 metrics to 47 metrics to 33 metrics and next year likely 25.

importantly what we decided for next year, is we're actually going to take the same metric for financial stewardship, that's going to be not increase reliance on the general fund. and lastly, everything will be still working on own quality and care experience measures. you see that again the narrowing and focus and alignment going on. [ please stand by ]

>> you can see at a glance if we're at goal and the blue line, our target, and how we're doing over time. this is a lot of information at a glance. this is what we're pushing out to divisions and sections. because i know tables and graphs can be overwhelming, i wanted to give you a peek behind the dashboard. the equity measure is around decreasing disparities and african american blood pressure control. what's amazing about the work in primary care is how they're able to use the data to push out to the leadership teams to the clinics and engage frontline

staff. when you look at the piece of paper you'll see who, when, where, what, why. so the bottom always round the patient data in the vignette. this is not a real patient but mr. lee is always the grounding patient paradigm for primary care. it talks about partly sunny lee, that's the -- mrs. lee, that's the who and controlling blood pressure in african american patients by this much. this is the who, what, when, where. where, you can see the clinics is displayed. each round bubble is a clinic. the reason some don't have a heart is they don't do adult hypertension and the ones that are purple are at goal.

then why is at the top. particularly for frontline staff whether you're a medical assistant or pharmacist, it's important to know why we're doing this and why are we going out of our way to do this extra work flow in order to move the metric. what's amazing about the team is they've gone beyond the who, what, when, where and why to how. the kind of work flows is they have them come back and use team-based care and make sure the people at home have blood pressure monitors. if your insurance doesn't cover it we have a supply and we're targeting african american patients for that clinic-based supply. the quality improvement is never a one and done. we would love for all of our

clinics to be part of the mission but improvement is ongoing work and you can put a lot of work into it and a staff member leaves or there's a competing priority and you get the ups and downs. this slide was supposed to be up front to show you the standardization across the measures. in the last bit i wanted to give you a sense how it fits in. dr. pickens told you about our matrix and it's now part of the larger cas case of the departmental strategic planning and divisional and sectional division plan. i give credit to our team we established a cadence so the planning happens at this level first and we have months to

digest that and incorporate that at the ph.d. level and there's a gap where people have a chance to digest and how to apply it to the it to facilities and the smaller ambulatory care divisions haven't decided to do a formal x matrix or not. if you haven't had a chance to go out, the tenet is around visual management. you can see our priorities. or staff work by the boards all the time because they're right in the hallway. what are our priority and how we're doing. for any organization to consistently communicate that is powerful. this is the one at primary care around the corner at van ness and this is at laguna honda and there's been cross-learning and

learning from best practices and quality improvement and we say steal shamelessly because it's all fair game. lastly, i want to say this is truly a team effort. we have amazing k.p.o. staff at the levels and the laguna honda primary care and have great q.i. leads and the one who pulled this data together is on vacation and she deserve as a big thank you. with that i'll turn it over to bruce ocenya. our director of interpretive services. >> good afternoon, commissioners. i'm pleased to talk to you about interpreter service and telehealth services today.

both of which are very crucial service utilities and like all utilities they're supposed to operate in the background silently and they're not supposed to be noticed until they're not working. so that's basically both telehealth and interpretive services are crucial service utilities for our core patients. it's really nice to have an opportunity to highlight them since we're usually working in the background. i'll start with telehealth services. the goal is to provide technology-enhanced care to increase specialty access, improve care quality and enhance patient experience. i wanted to add a little thing about our approach to telehealth

which i'm pretty proud of which is telehealth gets a lot of buzz these days. it's been marketed a lot the last few years. but right from the beginning we took a systemic approach to telehealth. in other words, our concern was to make sure our approach to telehealth was systemic. meaning we paid attention to scali scaling we tried to avoid telehealth initiate were boutique driven by a provider who's tech know savvy and has good gadgets and research money and you do something that's very effective and then basically three years later the paper's written and the innovation is set aside. so we really have intentionally

not taken that approach to telehealth. so we've taken everything we look at we figure out how it will scale across our whole network. given that, i'll first and highlight two of the main projects we've been working with for years and two of the more recent ones just to give you a flavor. we use sophisticated cameras that able to take images of the back of the retina and in terms of efficiency they can be operate technicians at the level of medical assistants and prior to that the effort was done by

ophthalmologist and optometrists. not surprisingly, we didn't have the funds to put one of these specialized cameras in every clinic. we put them with clinics with a major volume and then in a van. the vendor assured us we couldn't put it in a van and we said thank you and we did and it's been operating successfully the last two years. so if your clinic does not have a camera we send the van to your clinic every month. currently the ophthalmology clinic is three days and opt tom

-- on tom try is one day. the metrics were counted and this is the average now in both the clinics. you can't separate that from the utilization of these sophisticated retinal cameras. right now we're targeting a screening rate of diabetics were 65% and our screening was at 20% and 30%. this is again substantial

practice improvement and very substantial efficiency boost. moving to jail health, this is a new nshtd we started month -- initiate we started months initiative we started months ago. i'm having a hard time talking. in terms of the ivan, we started two months ago to send this to the jail and now it's visiting san bruno. thank you so much. the challenge is there's a lot of inmates who get custodial

sheriff and ophthalmology was at the to the list and it was puzzling why ophthalmology in terms of jail visits. it turns out the reason for that was more for vision screening. that was opposed to a more serious eye disease. we took the ivan and put in an optometrist on the ivan -- eye van and gone to the jails. the significant thing is we've screened 25 inmate. that's 25 inmates that don't have to come to the hospital. we address their eye needs on the van at the jail.

we take photographs and the reports go back to the primary care docs and only the most severe cases are then made an appointment to see the dermatology clinic. the net effect in terms of efficiency is the third next available appointment for dermatology is five days. for lump and pump four days and for procedure clinic four days. determine dermatology was count

in months. in a bad year the months look like eight or nine months to get into dermatology. again this is a very dramatic practice improvement. then the last thing is palliative care. we just begun this recently. we're trying to slowly understand the potential of home video visits. we started a small pilot with palliative care and you'll see on the right-hand side some of the materials explaining how we're trying to integrate this into palliative care. as people get registered into palliative care, they're being encouraged in their third visit to try their third visit through video. we're essentially trying to expand the menu of options so

for palliative care we don't want to require home visits but that way if they're feeling ill they can opt to keep their visit so it also helps us manage no-shows and be able to transition and say today, i will not come in but i'm available through video. the initial expansion of that has been very encouraging. those are the highlights of what we've been trying to do. in terms of the challenges looking forward, one of the main ones is we're attempting to reengineer teledermatology and

teler teleretinopathy is we don't want to lows the gains from the last few years and now have to shift to a new medical record and we're figuring out how to do that and in so doing doing the quality improvements we've done so far. and the other is to steadily build telehealth applications over the next few years and this is an important challenge because it's within the constraints of trying to do the epic build. so the cornerstone for any system of telehealth would be a universal health record. so we know that's the priority. on the other hand, we can't sit on our hands for the next three years and so we're trying to figure out given the constraint how we step by step continue to mof forward in tele -- move

forward in telehealth, one epic is up and tested and the tires are kicked. the next big efficiency leap will be tied closely to telehealth. we want to make sure that we're keeping that focus in light of the constraints with the epic build. moving on to interpretive service. the mission of interpretive service is to provide trained medical interpreters to ensure service between the patients and the san francisco health network providers. our overall need is the most recent report from the data center is 36.7% but over 35% of our patients require some level

of language assistance. so again, i just want to place this in context. this is extraordinary. medical systems our size are nowhere near this rate. so said another way, it's safe to say as a network we couldn't practice medicine without interpreters. that's the importance of this utility. over the past year, we've done just to give a sense of volume, over a 250,000 interpretations. the top three languages remain stable. for years they've been spanish, the main chinese dialects and a series of second-tier languages we use vet nam -- vietnamese and

the metrics have remained stable the last few years. we spent a lot of time this last year trying to get policy clarifications on all the bilingual language and there was confusion on what is the difference between an interpreter or bilingual staff or provider and we spent time trying to it's out the different resources and determined what's the appropriate use of each of those. the most important challenge we had was to move away as a system

to move away from self-report. for years we basically if you told us you were bilingual in a language we said boy, we're glad. but that doesn't fly so we have to know can we validate that's true and we're working with other national agencies. now providers and bilingual staff all have to be tested to validate that they have a functional level of fluency. i want to stress at this point our achievement is basically written policies. it's going to take us probably a couple years to actually do the implementation so that becomes a consistent practice in that work. the other thing i want to

highlight is we expanded a new level of management. we have now a lead interpreter. we added three lead interpreters and this is day to day work. to stress we do over 500 interpretations a day. you can just imagine what it take to manage that every day and where we were very vulnerable for years is the day to day work rested on the shoulders of one manage. we were in an extremely vulnerable position and we're now able to handle the administrative and training needs of the interpreters and things like that.

we have a video phone ambition in every exam room. we started to implement this at the hospital and there's four and we're starting to see the practice improvement is extraordinary. san francisco was a pioneer in introducing video interpretation but we basically abandoned it because the technology was clunky and we had to put it on carts and we had to find the cart and drag the cart into the room. it was kind of cute but basically it didn't work. gradually people abandoned it and degraded it down to phone.

now the technology exists and it's reasonable and you can put a video in every room. so we're trying to eliminate the search and fetch function so that providers can have easy access within arm's reach. the other thing we're challenged with is we have a pretty integrated service through the two hospitals and the health centers. but behavioral health still functions in a semi-autonomous way and we're trying to take the first steps into behavioral health for the whole network. lastly, our goal would be to establish an interpreter servie group and we need some way to

have consistency in policy and practice and standards when it comes to interpreter service. thank you. >> i have not received any public comment requests. >> thank you, bruce and dr. chen. commissioners, we're happy to take questions an hopefully provide answers for you. >> commissioners, questions? commissioner guillermo. >> first of all, i just want to congratulate you on this report. it's a lot and it's hard to know where to start questions.

it looks like everything's moving up and there'll a lot of green and that's our hope. i wanted to acknowledge bruce's work as i've known him 40 years. i'm glad to know he's making contributions in the same direction that i find myself in now. i had a question about the interpreter services. one, the two-minute i guess average time from point of request to getting an interpreter, is that system wide? is that a system wide metric? >> yes, by and large it's system wide. by the time you pick up the phone and ask for an interpreter

it's about the minutes before you get one. >> that's in all languages? >> good question. basically it's in the common imagines and a rare -- common lack -- languages and maybe five minutes for rare languages. >> they're telephonic. >> as i was watching bruce present i've been in the system 15 years, when i first started you had to wait a long time for an in-person interpreter and the fact that you can get one within 30 seconds or two minutes and we're impatient , we have to step back. like i have a yemeni arabic speaking patient and if it's not straight-up arabic and a

variation, it take longer. i've had one instance where we couldn't find somebody. >> so different from where things were from what i remember and advocating for language accessible services 30 years ago. now i wanted to ask a question about the telehealth services. the ones you described in the report, is that the extent of the telehealth or are there other telehealth services beyond the ones you exemplified here? >> those the main things we're working on. the challenge in front of us is how to continue to make steady progress in this next three years when we're trying to get epic in place. so all these are special additions but we're constrained now by resources. that's our main constraint.

>> we also have a huge e-concert and a patient portal we've had in various languages and proxies because people aren't able to manure it on their own and limited texting. it's not just these but we are holding off. >> i just want to agree or commend your strategy and not waiting for the full epic implementation to continue with the telehealth program and expansions and such. i would just say the technology is such or the state of the art is such that at some point when we'll be able to have the resources to bring the data in that's actually not going to be as heavy of a lift at some point

in the future. >> we'll go to commissioner chung. >> it's good to see my former job presenting. in terms of telehealth we often talk about digital divide in talking about the communities and who may not have the access to the same kind of hardware in order to do that. so are there any support given to those patients or they're just out of luck? like telehealth efforts for some but not all? >> so if you look at the

palliative care, that issue comes right to the forefront. one of the requirements is you need digital service. that's where the digital divide comes in. the over arching issue is it's not as pronounced and how ubiquitous people's access to the internet and their ability to use a number of handheld instruments and tablets. that's resolving itself but it's there and came up in the project with palliative care. >> and another question about the telehealth component is does that have barriers and for

instance elderly may not hear as well if it's not a person or not speaking in the good year, for instance. >> with the home visits that's a major factor you come up against is who will facilitate and who will still have barriers because even with the technology, the ability to hear and see, i have to say at this stage we're trying to get the projects and systems up. we event really gotten into the margins of that. what about the people now that it's functioning have additional handicaps we have to figure out how to address? >> i'm excited about the technology itself. i think in another 20 years we

would be doing it with a different generation of patients who would be more trained or skilled in accessing these kinds of technologies. i think the transition is this is where the transition is wlt with the older baby boomers not part of the technology era and how do we mitigate some of those barriers. we'd be interested to continue to find out. >> i'm one of those baby boomers. one thing that's been interesting is there was a sense the younger people would have a facility around technology the older folks might have a time