inclusive program for trio. it is a white glove service. we have specialized and specially trained member service -- [please stand by]

mentality. it's all on us, not the member to get the care they need, or talk to somebody about their current health care crisis or that of a family member. so identification for shield

concierge -- some of the -- what is the word i'm looking for -- if you have cancer, catastrophic injuries, diabetes, lgbtq health, opioid use, pain management, all of those things are triggers for us to outreach to a member. and then on july 1st of this year, we also launched an enhanced program that is a digital experience for members. it is individualized based on their health care needs. i didn't put that information on here, but thought i would offer it up. and that is designed to treat the whole member and give them an individualized health and wellness pass. it's based on, if i log into the program or access it from my phone, and i put in my scores and my blood pressure and things like that, it will help and then

any other identifying factors for a health care condition, it will create an individualized health care and wellness path for that member and give them access to several different applications that are housed on our app, so they can be successful in their wellness journey. that's it. any questions? >> i guess -- in both populations you identify a pretty low percent. and so i'm assuming there is some -- you have quite a laundry list. it's identical for both groups. the percentage differs a little bit, but are they stratified, so if you have cancer you move to the top of the list? you know, anticipating a certain percentage in that you're going to support in this. certain things like behavioral health, unless you've already killed yourself, may not be at

the top. >> right. no. we look -- if we look at the medical and pharmacy claims and all of those indicators, we are going to do outreach. we try to have -- we have reps trained to identify needs. we do outreach on how to best identify those in the population that need our help and they can self-refer. at the found it is applicable to 1% to 2%. those individuals that really need that care support. however, it's available to everyone. so you know, we don't -- you know, i have to check and see if they make -- i don't believe they make a list and, you know, say okay these people first. i believe what it is, they get the indicators in and either --

a lot of times they're referrals from nurses, physicians. our utilization management teams. since they're all housed in one area, it's easier for the member to get answers to their questions, to be directed to the right course of care, given care options. so -- but they do use the indicators that i mentioned to outreach to those members. and i can get you that information to see if they strat phi it. >> i guess the question is, we have an all-claims database. my suspicion is if we look at blue shield members both in trio and not, if you add up all the people with behavioral health issues, cancer, diabetes, opioid use and all that, it's greater than 1.5, 2.5%, so there has got to be some -- to come up with this you know guess. >> this is a list of the conditions that rise to the top. and you know, it's well

understood the top 5% are 50% of the cost. many of these persons have multiple chronic conditions so there is various ways to cut the data. we're just giving you a sample listing of the conditions that do rise to the top. and eventually, everybody with those conditions gets some type of care coordination, but to get with the program, you start with the highest risk. >> commissioner follansbee: so there is stratification. that's what i'm trying to get at. how this is being implemented. because i suspect that we have more than 1% of our blue members are diabetic. they can't be targeting all diabetics. >> right, but diabetics with depression -- >> got to be multi-conditions, that's what i'm trying to get

at. how this list is being weighted. >> and how we perform our outreach based on that? i can get back to you with our detail around that. that's an important indicator for our program is how we look at these people and how we outreach and decide who goes first when it comes to outreach. >> so any member is eligible to this, they don't have to have these particular problems? maybe have one problem, but they don't have to have three or four? >> right, if they're in access, plus or trio they can go into shield support and shield concierge. >> how long has been this going on? >> we launched it 1-20-19. >> it was new this year. we re desidesigned the whole pr.

we have an all inclusive care program. so instead of disease management on one side, cure management on the other, this is wholistic approach and integrated for the member. >> so they can just pick up the phone and say i'm interested in the program? >> absolutely. >> and are you providing any kind of report? you said you had performance guarantees, so i'm assuming there is reporting? >> yep. we provide reporting on the success of the program, how many members are engaged and we have a guarantee around how many individuals we engage and keep on the program. we have reporting on it. >> president breslin: so you will be reporting on that annually? >> yes, absolutely. after the end of the year, we certainly will.

>> i'm wondering if you provide any sort of -- >> any cultural sensitivity training to your representatives, because i can just imagine that people of different cultures may have different levels of comfort. >> yes, we absolutely do. that's a large piece of our training. not only do we train our reps to ask the probing questions, but they're trained to be culturally compassionate and have access to language lines and other means to communicate with individuals. >> any other questions? thank you so much for your time. good afternoon. i'm with kaiser permanente. i would like to outline our

integrated care coordination, walking you through our navigation and advocacy support resources and examples how this comes together. at kaiser permanente we take a team-based approach to care coordination where we're able to provide the right care at the right time. this helps to reduce unnecessary treatment and better population health outcomes. clinical care is coordinated with the member at the center of our team-based care model. every doctor, nurse or other health professionals have a total picture of the member's health through our single electronic health record allowing for realtime information about the member to be seen. this leads to more coordinated approach.

when a member is diagnosed, their primary care physician works with a care team and member to create a tailored treatment plan. the care teams help the member to navigate from one appointment to the next across the locations and specialties to deliver seamless and effective care. kaiser permanente members are well supported should they need help navigating through the system. member services is the primary hub for help with any type of support from benefit questions to finding a doctor, helping with care navigation, assistance with getting a second opinion, claim support, interpreting or paying bills, or with filing a grievance. they are member advocates and members may choose to either call or meet with them in person. we make it easy for our members to navigate their care by providing them with a variety of tools and resources. through our website, members can, for example, e-mail their

doctor, make appointments online, find a class, look up the cost of services with our cost estimator tools, which can also help with plan selection during open enrollment, or order prescriptions online. they also have apps. we have apps for their mobile devices, allowing similar access to functions on the go. in addition, members have access 24-7 to clinical support through our appointment and advice nurse line where they can have access to either a nurse or doctor if needed. other examples of clinical support are having embedded mental health clinicians at our medical facilities for emotional support, proactive outreach by our clinical care team for members with chronic conditions and help for primary care physicians connecting members to specialists or helping with second opinions. these are just a few examples

how we can help members navigate their care. let's look at the next couple of slides here where we provide examples of how our integrated care model works. the first example here to better illustrate our approach to care, i'm going to walk you through the example of sidney who has been diagnosed with high blood pressure. she scheduled a routine checkup with her primary care physician. at the visit, the intake nurse updates sidney's electronic medical record with her basic health information, height, weight, blood pressure, smoking, alcohol and exercise habits. her results reveal high blood pressure so her doctor schedules a follow-up appointment to monitor her situation more closely. at her follow-up visit, sidney gets a tailored plan to includes regular blood pressure screenings, a new prescription,

healthy eating classes at our medical centre, and recommendations to use the website. so sidney goes and registers online and starts using the online features to save time and monitor her health. she can now e-mail her doctor's office with nonurgent medical questions, schedule appointments, view lab results and more. automatic emr prompt informs sidney's care team she's due for her next blood pressure screening. the care team sends phone and mail reminders and sidney receives them and makes her next appointment. after weeks of monitoring sidney's blood pressure lowers. during the visit, the doctor updates her prescription and electronically sends it to a pharmacy. she stops by the pharmacy to get her refill prescription filled and then sidney has been

exercise class at the kaiser permanente facility near her home the next day. two months later, she orders refill through kp.org to have them delivered to her home. with the support of the care team, her hypertension is under control, she successfully reduces blood pressure, lost 20 pounds and built a sustainable healthy lifestyle. our second example here to understand how our disease management program works, we're going to follow this example of carla. she's a 50-year-old kaiser member, bothered by foot pain. she visits her primary care doctor for exam. based on the visit, her medical history and lab results, carla's diagnose is type 2 diabetes. kaiser electronic medical record system called help connect enrolls carla into our diabetes management program. she doesn't have to opt in. she is automatically enrolled

into the program. carla and her doctor make a care plan that includes depression and vision screening, new prescriptions and healthy eating classes at local medical center and then she learns how to test her blood sugar at home. after a few weeks, carla's daily testing shows a spike in her blood sugar. once she is registered on kp.org, she can e-mail her doctor who sends her prescription to the pharmacy. carla stops by the pharmacy to fill her prescription after a yoga class at our center and also uses her kaiser app to order refills and sent to her home at no additional charge. the new prescription works and carla's blood sugar levels are stable. a month later, she has an eye appointment, although it's not relative to her diabetes vision, an automatic prompt in the

system lets the receptionist know that carla is due for a mammogram. so he schedules her. now that carla's diabetes is under control, her foot pain is gone, up to date on preventative care, and feeling more engaged at work. this team-based coordination approach to care helps members navigate to have a more seamless experience and optimal outcomes. any questions? >> commissioner follansbee: we heard from the previous presentation white glove coordination. having been a kaiser doc for 16 years, i don't see this is any different from what i was involved with over my 16 years at kaiser. the programs get better, the prompts get better, but i don't see actually any proactive interventions here, where people are automatically getting follow-up. they may get into a diabetes

program, but the follow-up, the white glove, the sort of the personalized, this is the situation where it looks like a member may actually want more personalized care with someone they can call to help coordinate all this. and i don't hear this, other than e-mailing your doctor, that there is any way for a member to get personalized care. >> right. so you're right, there is not one single point of contact for the individual. if anything i would say, there is kind of a multi-pronged approach or the team approach, so either working through your physician to kind of help get the coordinated care experience where they would refer you onto specialists. or if you're not getting what you need, reaching out to member services and having them sort of help with that care coordination or any sort of problem solving.

>> i just wanted to add a little bit there. kate from kaiser permanente. there actually is a lot of proactive outreach where we're tracking with care management and the major disease states and making sure we're ensuring these members get in for their checkups. so while there is examples, it sounds like there is a lot that you can do on your phone and you can reach out to the physician and that is absolutely true, we're monitoring that as well. it's actually a tremendous amount of outreach that is going on. and a couple of things, doctor, i think about for example, mental health professionals for example being embedded in or primary care departments as well. it's taking this so it goes beyond just what they're in for,

for that particular visit. we're really trying to treat the whole person. and this gets into, you know, a number of things we talked about, social determinates of health and all those things. so i actually believe that we're extremely proactive from each of the care teams in making sure we're managing those conditions. >> do you have a program for complex care coordination? >> we have case managers, absolutely, that will work with -- and each of the facilities can be slightly different, so we can get you the details on each of the facilities, but absolutely. if there is a complex case, we have case managers that help to work through those situations. >> yeah, because we heard both from aon and blue shield, identifying the more complex cases proactively. >> yeah, which is something that we talked about. >> the person has multiple specialists, how that is coordinated and followed through on. yeah, it would be good to have an understanding how that is

available to the members. but i think the members, you know, there is -- the outreach of the care coordination and then the understand offing the member and -- understanding of their member and the family how to reach out to kaiser when things are getting too complicated. >> absolutely and maybe even a deeper dive. we talk about electronic medical record a lot, but really talking about how that works within our system. i know the doctor practiced with the electronic medical record, but having the specialists that are connected when there is multiple specialties working on these cases and how all that information is connected. >> commissioner follansbee: i don't think it's my role to critique what is going on. i would just say that, yes, i played a doctor for 33 years, but i'm also patient with a complex medical condition and i don't get that outreach. so i'm the one who has to call and remind that i'm due for this

task or due for that or for this follow-up. and so i'm certainly not getting white glove, but i can put on white gloves. i don't know that all the members can. so this is what i still think is missing. this model of adult primary care was rolled out when i joined kaiser in 98 and the roles have actually changed. the behavioral on each team, the nurse, their roles have changed considerably. i'm not sure that the model is being followed. it probably does varies from meds center to medical center, but on departments and the personnel. it's concerning to me when we're talking about the future, that i'm hearing the past. but again, i'm only speaking as someone who has been through this. >> i appreciate the feedback. and we need to hear these examples, absolutely. and i think better than me

answering some of this, i would love to have the opportunity for one of our physicians to talk about what they do. absolutely, if there is variability between medical facilities talking about the reasons for that and if there are changes that are coming, but appreciate the feedback there. >> so this isn't anything. you've been doing this for a few years, this is not a new process for you? >> no, this is -- what i would say, it's the basis for what we do as an organization. now, do we try to get better all the time? absolutely. and i will say that as we look at these emerging companies that are out there, it prompts us -- i mean it continues to challenge us to be better at what we're doing, so there is great ideas that are out there. but you're absolutely right, this is not a new model for our organization, but to the doctor's suggestions, we need to continue to improve upon those

as well. >> president breslin: thank you. any other comments? thank you. >> good afternoon. heather, united health care. we're going to have two components -- >> president breslin: excuse me. we'll have public comment once the presentations get through for all three plans. thank you. >> thank you. so first we'll talk about the city plan. so this is our ppo plan for active and early retiree members. and to go along with all the presentations, this is something that has always been a part of the plan. there is additional enhancement, so i'm going to talk about the main product in general and then toward the end of the deck, we'll get into detail. >> president breslin: this has always -- >> always, as long as you've had united health care, the care

management model. 2.0, the first slide just kind of reiterates what everyone said, left to ourselves as the consumer we make less than optimal decisions half the time, because we don't know what to do, where to go, and who to support us. so engaging members can help them proactively address and reduce health care costs, so the personal health support program, very similar to what was talked about for blue shield is the program that takes 50 chronic conditions. i don't have a list here, but they're similar. people with heart disease, cancer, musculoskeletal, diabetes, those kind of conditions. >> pardon me, but maybe you could point out what is new. >> oh, yeah, when we get to the end, i'll talk about advocate for me which is a customer

service model. these are the disease management components. they look at medical claims, lab results, pharmacy data. we do have some members that do biometric screenings and we have their information and health assessments. and essentially people that full into the 50+ category, there is 100% outreach made in one way or another to look at the members closing gaps in care that are identified or risks. different components of supporting those members across the continuum, one of the things that is used is a designated nurse team. those nurses that get the information on the members that are identified will understand those needs. there are clinical things going on and education. so the members can opt in like she said, anybody can call in and access the nurse advocates, or again, the outreach is done. so they and the recovery family members can help them with the

chronic conditions. additionally, we have a decision support tool that will guide members to choosing appropriate care. so one of the main things that you'll find here, for example, somebody has back pain and they've been using chiropractic. they get to the point where they're talking to a surgeon and using the decision support tool, it's helpful for them to determine the right route of care and what the outcomes will be and navigate through that decision support process. case management is using disease management for those conditions, so again, outreach tools and those nurse managers. and then for members themselves through our website, there is a lot of online tools, rally health and wellness. keeps employees motivated. they can do their own check ins and assessments and coaching and information.

part of the process of reaching out in many different ways, one of the things that are used are healthy notes. these probably wouldn't be used for somebody with cancer, but healthy notes, you have a person with asthma, we see they're only using emergency inhalers and not taking preventative medication. a note not only to the member, but the member's provider would be done to try to engage the member. clinical programs that we have for our maternity, transplant, many others that are part of the program, but for example somebody newly found out they're expecting. the maternity program makes an outreach call to the member, tell them about the program, engage them if they'd like to enroll. they get the what to expect when you're expecting, coupons and baby items. that's an example of how the program works. but using the clinical, network and behavioral health offerings, these are a lot of the different

ways they'll reach out for support. and so essentially, by screening 100% of those members that are in the risk categories, they're able to engage them, improve their health outcome and reduce overall health costs. any one of those categories where they're assisting a member, they're going to have the resources, the nurse advocate to help them make the best decisions for savings and outcomes. and then additionally, yeah, just talks about the different support, both nurse advocates using line which is the toll free number they can call 24-7 for support on issues and then the condition management programs.

okay. the healthy notes and reminders. i gave you an example, but this is where we talked about the gaps in care. [please stand by] [please stand by]

>> they can get with that expert right away, a nurse expert. i believe these calls averaged eight to nine minutes. they're taking a lot of time helping the member, maybe getting them a new diagnosis so they will find solutions that are working with them. they will then engage and call that nurse back. they will be able to have a one-on-one relationship with that person to help them make those decisions when they're dealing with those kinds of conditions. for many different areas, emotional, clinical, it is not listed here, but we also have the virtual visits for medical fin it -- visits, as well as

virtual behavioral health visits there has been an issue with trying to get access to behavioral health providers, those are also components. questions? >> i was a member of the city plan for years and i don't recall anything going on like this. >> yeah, and i think as we all talk about some of the programs that are always embedded, you are right. if you are not necessarily needing the services, or if you are not showing up in one of those top chronic conditions, you may not have received an outreach, with those models are just a component of the program and how it works. one member -- when members either called in, or self identify, or an outreach is done to them. >> i apologize for this question because i probably should have formulated and asked each one of you the same question, but let's say a woman is diagnosed with breast cancer, and the question is, does a breast cancer diagnosis trigger a response

from united healthcare to offer the kinds of options, the second opinions, education, and all of that, and this question should have been asked for blue shield and for kaiser in terms of, yes, i know members can access information, they all have lots of information, and they are providers can provide all this information, and by law, they have to provide certain kinds of information anyway. the question is whether the health plan response to a diagnosis such as breast cancer with this kind of advocate for me program, were any program to verify that the member gets all the information and he or she hears all the options. i apologize for singling you out i should have asked it for everyone. >> probably the answer would be similar, i would imagine. especially cancer, pregnancy, others as i have mentioned will be on that 50 list of conditions , but they will make a

nurse outreach to those members. i think the challenging part for all of us is a lot of times when we call, we can't reach them because we may not have a valid phone number, we don't always get that information. often when we reach them, they will enrolled, with so many of our provider groups are providing support for them. for example, some of these don't -- someone is diagnosed with cancer, they'll be told about the soaker -- support groups in their area and they enrolled. that is okay. at least the outreach is made, but absolutely, those top 50 plus. i apologize they don't have a list, but it is very similar to what blue shield was shown. our labs claim to show that they are in that category and would receive an outreach. >> my question is, in part, given by the fact that if we have a vendor offering second opinions, and reviewing the summary of all of those cases, it was quite clear that majority of cases, members did not feel that they had access, or maybe

they just didn't want to use it, but they have access to other opinions or more information, so they were calling the vendor to get that information, and so, i think the health plan -- the health system is trying to address how to encourage members to use this, and so how are they being outraged? if the medical group is providing that, as well, they need to make sure the information is not falling through the cracks in the information is consistent for every member. >> yes. i agree. i think, also, the second opinion process, as we learn from what we shared is different our plan happens to be a plan where you can choose to see any provider in and out of networks. benefit levels will be different you are right. they can get a second or third or fourth or a fifth opinion if they wanted. >> questions?

thank you. >> thank you. >> shannon hobbs, united healthcare, representing the medicare advantage p.p.o. plan. the first slide is showing our medicare advantage continuum. it has the member at the centre, and i were two cornerstones are holistic case management as well as our house calls program. our house calls program is geared towards making sure that the members can -- their health conditions are known, which will generate referrals into some of our clinical programs. let's go to the next slide. we have clinical programs and services that meet the member at every stage of their healthcare journey. staying healthy, again, we have our health to house program, solutions for the caregiver, we

also use our advocate for me program, like heather explained, so as members are calling in, we know if they have a health condition. we know if they haven't gotten their healthcare screening. we can contact their primary care physician, make an appointment for them. with people who are hospitalized , we have case managers on site, our own nurses will be assigned to those members to help them through their hospital visit as well as their transition into a skilled nursing facility or return to home. we also have programs for people who are living with illness or are at the end of their life. we have those programs that are geared towards improving their quality of life. we are committed to providing the right level of care at any stage that the member is in.

my final slide is just some of the ways we engage. this particular example is on our healthy membership. whether we are doing mail ins or doing outreach to members, members calling in, we do education via open enrolment events, or brain sharks. we have several educational apps our fitness programs, and we do member incentives. we do mail ins all the time targeting our healthy population as well as our sick population to get them engaged in the programs that would be appropriate at their level of care. >> any comments? thank you.

all right, now we will have public comment on this item. this is under all the care management that was represented. >> my name is dianne and i represent the retired division. i would like to comment on kaiser because that is what i am a member of. my husband and i have been members for over 50 years and we have been very happy with kaiser , with some exceptions, but my husband now has a lot of chronic medical conditions, and i have never found, except for one department at kaiser, that anyone has reached out to me. anything i've gotten from them is because i have reached out to them. it was last spring, he was in and out of the hospital in the emergency room maybe four times. kaiser used to have a program where you were in the hospital

and you went home and they called to see how you were doing it doesn't happen anymore. maybe they are so busy and so big now that they can't do that. i thank you can get good service from kaiser, what you have to be able to advocate for yourself and know, to a degree, what you need and want. i have never found anyone reaching out to me or to him. with one exception, and that is the hematology department. >> thank you. >> i'm a retired teacher. i had the opportunity of clicking on the kaiser website. i thought i would like to know about my general well-being, physically. so i clicked and i clicked and i said, yeah, i work so many hours , i exercise, and then it

got to, enter your blood pressure. so i had to get out of that path or find that information and enter this, as i go along, it is like i had to do all the information, and it was not a seamless thing where i or i could click on to kaiser, and at the end, i found out that it was johnson & johnson. sure, i got reminders every day for about a week to finish it, but i just didn't have the heart to have to enter all this information. another thing i clicked on was clinical trials, and i'm wondering if it has to do with my entries on facebook now of clinical trials, so i am wondering how this information, what happens to the information.

the other example i have is working -- going to a dignity health cancer survivor opportunity, and it was one of these special concierge events, and believe it or not, it was at the hospital, and it was a gong event. these people came from all around california. they set up these gongs, cancer survivors all laid down, covered in blank kicks, et cetera et cetera, and they gong for 40 minutes and it was amazing. so that was a really wonderful thing, but it took me 20 phone calls and just actually showing up to get through so that it's not a seamless kind of thing. when i went through it, it was

dark, and i was -- take off your shoes, and i was afraid i was going to trip myself finding my way through. thank you. >> thank you. anybody else? thank you for that feedback. i think it is very helpful to see what's really happening. you can see a lot on paper, but when people actually experience it, it is more important. thank you. anybody else for this item? seen none -- seeing none -- come forward. >> i do have one question to ask , and that's about mental health service delivery. i'm wondering if a major of psychotherapy is basically based around cognitive behavioral therapy, because i think psychodynamic psychotherapy is also very important. cognitive behavioral therapy is

good for treating symptoms and good for resolving problems, but there may be underlying personality patterns behind these symptoms, and psychodynamic therapy addresses this very well. so i would hope that with the service delivery with all these systems would include psychodynamic psychotherapy as well as cognitive behavioral because sometimes treating the symptom you develop other symptoms, and sometimes you address a system and you don't address the cause. these are my concerns. thank you. >> thank you. at this time, we will have a break. maybe a ten minute maximum break

>> i moved item number 12 up to the number 11 spot and the fertility benefit after that. >> item 12 is a presentation of intraoperative ability presented by dr. david kaneda. dignity health. >> thank you. i apologize, i'm not used to sitting still are standing still when i do this, i'm used to roaming or pacing, excuse if i have any lack of coordination. i will truncate my mega deck because i could talk for this -- talk about this for hours and hours. it is a huge passion of mine.

i am a system leader at spirit spirit health for medical informatics and health informatics. i have been doing informatics for 15 years, being in healthcare for over 25 years. i was asked to speak high-level about interoperability and its impact. from my standpoint, i really would like to use the term data liquidity because what we're really talking about with an operability is data liquidity so we can really keep the patient at the centre of all of the care throughout the continuum. with that, i will focus on having the patient at the centre , and we will focus the conversation around this perspective, and a really common scenario that unfortunately is happening today. the patient is at home, doing well, winds up in facility a, in a health system, gets discharged

, and winds up in the community, seeing some specialists, or getting some rehab, getting some imaging done , getting procedures done, p.c.p., back and forth with a specialist, more testing, and then eventually winds up in another facility and system be. let's say that, in the community , it would not be uncommon for all of these care settings and systems to be disparate. all of them to be using some form of health i.t., and none of them to be connected. in my practice, this would not be uncommon that my patient would wind up in my office as a double book, and then in a complete double booked day, added on with a stack or several stacks of paper that they were given on discharge that basically had, you have been diagnosed with this, or you have been treated with this, the don't have any meaningful

information for the patient or for improving their care. just to give some perspective from a patient's perspective and the healthcare setting, one in three patients are still burdened with furnishing their own healthcare information when they are seeking care in a healthcare setting. i can attest that i have actually had this myself as a patient. i am just pointing out that there is a lack of reality to this and i don't know if everyone remembers these guys. the average p.c.p. interacts with 229 specialist through 117 settings over the course of the year. i would also say it looks less like this and more like this, and then with the use of healthcare information technology, if you ask the general provider, that is the perspective they get. again, the patient is being

circumvented to access the technology. if anybody wants any great satirical commentary on the state of healthcare, this is the dog who is a hospitalist who came out of harvard. i am going to use interoperability not by the engineering term, but by what is actually called out by the onc, and the tests. that is the ability of the system to exchange electronic health information from other systems without special effort on the part of the user. this is baked into, if anybody is aware of in 2016, the 21st century -- and his focus on interoperability healthcare i.t. to engage the patient in their own care. the focus on this last part, without special effort on the user, is really not just focused on the healthcare providers, but

the patients being at the centre and they further go on and say that it really is, it is a meaningful use of that information, searching for, finding, receiving, and integrating it in a contextually meaningful and valued manner. just an overview, there is some key types of what we call health information exchange, and the message. so there's directed by the use of what is called direct technology, which is basically a secure, encrypted e-mail that is compliant. that is generally between care providers, although patients do have the ability to leverage direct technology, and that is mediated through what we call the health information service providers. there is? -based, which is basically a? out and find and request, and it is a whole, and that can be mediated to local, regional, or state hio or h.i.v., and

national networks, which will really speak to largely, is that is the paradigm where we are now that it will give us the scalability of really transforming care. and then there is consumer mediated. that is where patients, you know , a common example is through a portal, they can aggregate and assemble their own information and direct it. i do want to call out, i'm not being an apple fan here, but apple kicked the door open in terms of patient engagement and patient control of their own information with the apple health records. what they did, by using -- emerging and new standards, they made it so that the patient has control of all their information that they get through the portals, which is independent or agnostic of the platform, it is being used in the care setting, so if you are being seen at dignity at ucsf and stanford and sutter and kaiser and you are enrolled