Supporting the Transformation of the Public Health Digital Ecosystem
I'd also like to introduce, take this time to introduce my colleague who's the next moderator, Dr. Dawn Heisey-Grove. And again, thank you again, Dr. Noseworthy and Woodson. Dr. Dawn Heisey-Grove is a manager for promoting health and disease prevention department within the Health FFRDC operated by MITRE.
Dr. Heisey-Grove has led several projects for the CDC that leverage clinical and community data to support public health surveillance and health services research. She also supported several research and development projects for the Centers for Medicare & Medicaid. Thank you very much for joining us today, Dawn. I'm very excited to see you and looking forward to hearing the next section.
- Thanks, Sybil, and thank you everyone for joining us today. And it is my pleasure to focus on goal five of the national digital strategy today for our panel. This panel focuses on what the U.S. needs to do
to transform its public health digital ecosystem. As we all know, that the health and wellbeing of our country relays not only on the health care delivery system, but public health and other aspects as well. So for today's discussion, we're going to specifically focus on the second objective of that overall goal, which speaks to the need for a governing entity that will help push forward some of the changes that we're gonna talk about. So I'm gonna introduce our panel members so that we can get started. Our first panel member is going to be Dr. Chris Cassel, who is currently a faculty at the University of California at San Francisco School of Medicine, where she's working on projects in aging and longevity, the role of technology in healthcare, biomedical ethics and health policy.
Dr. Cassel, from 2016 to 2018 was the planning dean for the new Kaiser Permanente School of Medicine based in Pasadena, California. And prior to that, she was the president and CEO of the National Quality Forum, and served as president and CEO of the American Board of Internal Medicine, and the ABIM Foundation. Dr. Cassel was one of 20 scientists chosen by President Obama to serve on the president's council of advisors on science and technology, where she served as the co-chair and physician leader of that group for reports on health IT, scientific innovation, and drug development and evaluation, systems engineering in healthcare, technology to foster independence and quality of life in an aging population, and safe drinking water systems.
Dr. Cassel's other board service includes serving on the boards of Kaiser Foundation Health Plan, and hospitals, Premier Inc, and Russell Sage Foundation. She has numerous honorary degrees and is the author of over 200 articles and author or editor of a hundred, or I'm sorry, 11 books. She graduated from University of Chicago and completed her MD at the University of Massachusetts. Next, we'll hear from Vivian Singletary, who is the director of Public Health Informatics Institute, PHII, which is a program of The Task Force for Global Health.
In this role, Vivian guides PHII's work to improve health outcomes worldwide by strengthening health practitioners abilities to use information effectively. Vivian is also the vice chair of the Digital Bridge, which was launched in 2016. The Digital Bridge creates a forum for healthcare experts, public health professionals, and industry partners, to discuss the challenges of information sharing and incubate solutions for a nationally consistent and sustainable approach to using electronic health data.
Vivian's experience combines almost 20 years in systems development and in public health, including improving, and designing, and analyzing business processes, and developing functional requirements for health insurance information systems, establishing PHII's requirements laboratory business unit in 2012, leading the African workforce planning project, which was a tool that helps allocate healthcare practitioners to areas of greatest need in Mozambique and Tanzania, and serving as director of informatics practice for the Child Health and Mortality Prevention Surveillance, or CHAMPS initiative, which addresses the causes of childhood mortality in developing countries. Vivian holds an MBA from Kennesaw State University and a JM with a focus on global health from Emory University School of Law. Finally, last but not least, I'd like to introduce Jim Daniel, who is representing our industry perspective today. Jim is a public health lead for state and local government at Amazon Web Services.
Prior to joining AWS, Jim served for almost a decade with the U.S. Department of Health and Human Services. Most recently, as the director of public health innovation for the Office of the Chief Technology Officer. And prior to that, as the public health coordinator for the Office of the National Coordinator for health IT. Before joining the federal government, Jim was the chief information officer for the Massachusetts Department of Public Health. Jim also holds an adjunct position in drug regulatory affairs with the Massachusetts College of Pharmacy and Health Services, or sciences.
So Chris, I'm gonna turn it over to you to do our opening comments. - Okay, thank you, Dawn. And I think there's one slide that I wanted to show. I hope people can see it.
And it's directly taken from chapter five of the MITRE digital strategy. And I wanna just, I'm not just gonna go slog through all these recommendations as important they are. I wanna sort of frame them and then highlight a few elements here. One is I'm sure some listeners might be wondering after hearing the initial panel and the lofty and really important aspirational comments that they made about why we need a digital health system and what are some of the barriers to it? Why do we then immediately turn to such a wonky topic as governance? And the reason is, because Dr. Noseworthy referred to this briefly in his comparison with other countries and their single patient identifier, because we have a federated system, and that traditionally and some would argue even constitutionally, public health is the responsibility of the state government not of the federal government. And so here we live in a world in which human health and particularly infectious disease doesn't respect national borders.
It certainly doesn't respect state borders. And as we think about a national strategy for public health, it's just gonna be important for us to understand that we're moving from a very fragmented, very not just state-based, but state and regionally local public health department based to try to understand how to understand this as a nation which we absolutely must do if we're gonna get it right and be prepared for whatever the next health emergency is. The second sort of unique thing, I think in our country is that public health and the healthcare delivery system have traditionally been two entirely separate silos, and we see that throughout all kinds of things that lead to the problem about why we can't get unified and frankly, timely accurate data when we need it. So the reason for governance is that we're gonna have to bridge those divides, which is why Vivian will talk to us about the Digital Bridge, and why it has those names. So if you look at the recommendations from our report, the first one is about funding, developing enduring funding strategies that encourage a systems approach to public health. So let's think of it this way that we spend about 3% of the more than $3 trillion that we spend on healthcare, less than 3% is spent on public health.
And with that amount of money, you just can't have the deep infrastructure technologically or in terms of workforce and human capital that we really need to have a state-of-the-art data system. The second part is that the funding that CDC and the state agencies get, which much of the funding the states get is actually from the CDC, but almost all of that is legislated by congress for certain conditions, and certain diseases, and certain programs. And so even the data that's collected is often collected in these. I mean, now we have COVID so we have COVID data, but it's not connected to other kinds of data which as we move ahead is gonna be really important. So the first thing is the funding has to be enough money and it has to be able to support infrastructure, things that it's hard to get the general public really excited about, except now we're talking about it as a nation infrastructure and long-term funding.
So not just this year, not with a pendulum swinging with every change in the political leadership, but some sense that this is beyond politics, and this is really something that needs to be funded for the long haul. The second issue is a national process and entity for governance and public health infrastructure. So this is where the state boards and public health people have to come together, but we also need the private industry which has access to a lot of this data as we're gonna hear. And also the healthcare system has to be connected to this in a much more seamless way than it currently is. I'm gonna say a little bit more about that in a minute. And because this is sensitive information, this is millions of individuals health information, it needs to be very secure and have a lot of transparent governance and public acceptance of how this is being done.
So that's the second recommendation. The third is ensure accessible and equitable availability, and use of modern technology. So part of that was what you just heard Jonathan talking about is the need for first of all, equitable broadband. That's like number one and really the most essential to infrastructure, but there's also a way of looking at existing data platforms and getting our technology, smart technology people to figure out do we need to rebuild a whole new national platform, or can we repurpose existing platforms that are already out there? And so that's part of looking at the nation as a whole and all of the different entities that need to be covered, and importantly as part of that, the workforce. So there are a few exceptions to this, but what we learned in our report is that many, many public health agencies just don't have the resources to hire the people that they need with the technical skills and the understanding of the digital world to have this all come together as a unified whole.
So that's part of that long range funding that we talked about is not only funding for hardware and software, but funding for people and training for the people who are currently in public health to bring them up to the speed so that they can understand working with national groups that set standards, and that have impact on actually making those technical decisions which are gonna get us to the place we wanna be for public health. Now, I mentioned standards. So recommendation number four is to maximize the use of existing standards as much as possible when exchanging public health data, and to integrate public health experts in standards development. So we have in the healthcare world and in the electronic health data world, there are all kinds of national organizations that create standards for how data is exchanged, how it's configured, how it's protected.
And there haven't been many public health people who've been invited into that process. And again, the silos have been kept rather different. And one of the ways I've thought about this is that the Office of the National Coordinator, HIT, which oversees the standards for electronic health records, the nation put billions of dollars into getting the whole country up and running on electronic health records. And even for all of the flaws and challenges we still have, it has really transformed the healthcare data world in a major way, but that data doesn't easily flow to public health and there's no technical or conceptual reason why it couldn't if we had a governance body that would agree upon what the standards would be and then we had the right people in the public health sector to understand those interfaces. There's actually a law that just a new regulation that was just implemented by the Office of the National Coordinator that came out of the 21st Century Cures Act intended to open the interfaces of the EHR and make them more interoperable. And the language of the legislation primarily is oriented towards giving patients more information for their health, their own personal health.
Well, that's all fine and good, but two major points that could be added to that. One is a lot of that data that they may get if they have access to their electronic health record isn't very understandable to them. It isn't very useful for them. And secondly, why not have this same kind of open interface to authorize users that would be immediately available to public health entities throughout the country, so that you could really get real time data and not wait for what we have now by and large, which is that the hospitals have to report to the public health entities, the public health entities report to CDC, and there's just inevitable gaps in that.
And the other reason, the last reason why it would be useful to individual patients as they get their data, if they understood the context of their community and their state. I mean, right now, the guidance on COVID is it depends on what the positivity rate is in your state and ideally what the Delta positivity rate is in your state. Well, how are people supposed to know that? I mean, you can look on CDC, you could read the newspaper, but if you had it from a trusted health entity in your locale in real time, it would create a level of health literacy and public health literacy over time that I think would really benefit us as we face other health emergencies. So I'm gonna stop there, Dawn, and turn this over to Vivian. - Thank you, Dr. Cassel.
Very insightful information that you shared. And thank you for having me here today, Dawn, to talk about Digital Bridge. And I think you touched upon the highlights of Digital Bridge that it was launched in 2016, and it creates a forum for healthcare experts, public health professionals, and industry partners, to discuss the challenges of information sharing and to incubate real solutions for nationally consistent and sustainable approach to using electronic health data. A lot of what you just talked about, Dr. Cassel, very important. One of the unique characteristics of Digital Bridge is the commitment to bi-directional information exchange.
Most people think about public health as the data second engine. We take data in, but don't often times share back out what's going on. And I think you talked about that as your last point about public health knows what's going on, because it's getting all of the reporting. So it has a obligation to report that back out, and we need to have better ways and easier ways to report that back out to healthcare providers as well as the community in general. In terms of Digital Bridge goals, it has three key goals.
One of them is to really ease the burden in costs for the stakeholder groups through this unified approach to exchange information. The second one is to advance greater standards-based information exchange, so there's tons of standards so you can go to any jurisdiction, public health jurisdiction. They may have different standards across different programs. One different set of standards for HIV, different set of standards for collecting other STD data. So even to get something consistent within a jurisdiction let alone nationally would be groundbreaking for public health. And then the third goal finally is to lay that foundation for this greater bi-directional exchange of data like I talked about to clinicians and others.
One of the real proud moments for Digital Bridge and this is a really great win for Digital Bridge, and an example for all of us to look at in terms of how we bring different sectors together to achieve something that one sector could not do alone. And that is the first use case for Digital Bridge, which was electronic case reporting. And the electronic case reporting is really the automated generation and transmission of case reports from the EHR to public health. So reportable conditions and diseases. Most of them are still being manually reported, or reported through electronic laboratory reports which have limited information. So now this new way and approach where there could be very little to no touch necessary from the health providers and these cases just get automatically generated and sent to public health, that is groundbreaking.
And I know it doesn't sound very exciting for some people, but for public health to have that happen is huge, because most of the time the data is lacking, it's not reported on time. And you really can't effectively respond to an outbreak and even a pandemic if you don't have timely information. So in fall of 2019, actually the incubation phase of ECR was completed and then it was transitioned for national scale-up to APHL, which is the Association of Public Health Laboratories, and CSTE, the Council of State and Territorial Epidemiologists along with CDC.
And it was finished just in time, because this transition happened right before the COVID outbreak hit here in the U.S.. And it's really been focused on by these partners and widely scaled up over the last 18 months, primarily to improve the timeliness of reporting of COVID 19 data. So it's come right in time and all of the partners around the table were instrumental in making that happen.
The other thing that I wanna talk about is our collaborative body. So we have representatives from, like we talked about healthcare, public health, industry partners that come together and our collaborative body is growing as Digital Bridge has made a reputation for itself to be able to bring these multi-sector partners together and to actually get things done. And I think some of the core tenets of this governance body has made it successful, including transparency, making sure that all of the partners involved they understand what's going on, everybody around the table has respect for the process. We have outreach to those that may not be around the table.
If we're doing something new and we're like, Hey, we need to bring a new partner in they need to be a part of this. So we do that outreach. We think about standard-based approaches to whatever the solution is that we're trying to put in place.
And we keep representativeness at the forefront, because we wanna make sure that we keep all of the voices balanced around the table that we don't have too much public health, or too little healthcare, or too much from the industry partners. We wanna make sure that we have that balance representativess, and finally trust. We've had to build up trust over the last five years of working together.
And I think Digital Bridge has been extremely successful. We're onto a new use case. And I think it really represents an opportunity for us to look at how we can govern, how we go forward in transforming public health for the future, really modernizing public health information systems, infrastructure, and data sources. PHII, recently we released a report entitled, Build Back Better. This work was funded by the Robert Wood Johnson Foundation. And the report really focuses on providing some recommendations on how we can transform public health information systems, infrastructure, and data sources through the lens of equity.
So we all know that public health really is a information business. And most recently and dramatically evident is how all levels of the public health system require information to understand and respond to a pandemic, COVID 19 at the top of mind. And furthermore, information is central to the fight against other public health threats and emergencies. And we also need this data so that we can improve health equity. So we've seen unfortunately how lack of data did not allow us to be able to respond in a timely fashion and really understand what's going on out in our communities. And without that data, we cannot do justice to taking care of our communities.
And it's clear that public health suffers from this lack of sufficiently coordinated, and funded, and just a very organized approach to the way that we build and maintain the information systems. And every jurisdiction in the past has kind of gone it alone. And so it's now time for us to come together to do this as a coordinated effort. And it doesn't mean that we do every little thing in healthcare and in public health, but it means that we have to focus on those areas that we believe need to be nationally networked and nationally coordinated.
And those around outbreaks and pandemics are ripe for this type of coordination for sure. I want to offer you just a couple of key things from this report that we have to say in terms of recommendations, in terms of what do we need to really do to make a change, a real change in public health? And the first one is leadership. So real change in public health is a group effort just as I described. And it really takes these energetic leaders to lead. Both grass roots efforts can help, and so it has to be bottoms up and tops down. It can't just be one or the other, but the big part to make that happen is these leaders agreeing to governance.
So governance of the change process and it's critically important, because you have many efforts that are going on that are uncoordinated across the nation. And just even having this group pulling them together to make it visible as to what's going on and to get that buy-in early on so that that adoption can happen at the jurisdictional level is critically important. So having those leaders that are willing to submit themselves, I should say, to some type of governance structure is critically important for us to make these sustainable changes. And I would say for public health in general, we have to be open for change.
We can't just keep business as usual. We really have to look at how we leverage other sectors to do things better going forward. Innovation, critically important. There's lots of new technology that can automate many of the things that we do. There's new ways and approaches of doing things, technologies that may have existed for many years, but can be applied to public health in a different way.
So we need to bring innovation to the forefront as well. Also getting into technical expertise and workforce. So our workforce is going to have to be retooled with new technical expertise to be able to transform public health in a way that it's never seen before.
So we have to, and there's lots of funding that's coming in to public health to help strengthen our IT and informatics workforce for public health, but that too has to be long-term sustainable funding so that we can not only educate the students that are coming out of our colleges, but also to retool and retrain our current workforce. So that's gonna be critically important. And last but not least, I wanna point out that we also need to follow data standards. This is incredibly important. I would love to see us one day come together with a common data dictionary that we could use. And again, whatever that scenario is, whether it is outbreaks and pandemics we're focusing on that, that we can have this joint data dictionary so that when we exchange data, we all know that we're exchanging the same types of data so that we can have a national view of what's going on during these critical times.
And in my final closing, I wanna offer you this. It's an old African quote. If you wanna go fast go alone, but if you wanna go far go together. And Digital Bridge is all about going together and this is what's needed to transform digital health, and let's come together to make that happen. And now, I'm gonna turn it over to my colleague, Jim Daniel, to talk more about how we can do that.
Thanks, Jim. - Great, thanks, Vivian, and thank you, Chris, for all those great comments. And from an industry perspective, I think, (indistinct) that I would like to out focus on why I see industry playing a key role. Obviously, we want to help public health really modernize their public health infrastructure and think about both scalability and sustainability. There's a lot of money floating around in public health agencies right now, but we need to make sure that we're building these in a way that they're sustainable as well. But going back to scalability, I think that's one of the major issues that really was brought to light during the initial phases of COVID response.
If you think about the core public health systems that are responsible in the beginning of the pandemic like electronic lab reporting and the disease management systems that would receive the electronic case reports, and be the types of places where people are doing the investigations into clusters, those systems were failing. I mean, we just have to be completely honest. They were not able to withstand the volume that came about with COVID. I heard many stories about electronic laboratory reporting systems simply not being able to keep up with the volume, but the volume was huge. We were receiving over 100 times the normal volume of electronic lab data.
State health departments were receiving within a couple of days, the amount of data that they would have normally received over an entire year. Our systems were not set up to scale. State health departments did not have the capacity to really immediately make these systems more robust and have them able to take more data. We saw the same types of situations happening with just some of the simple, well, not simple, but some of the basic tasks that public health had to do during the response like generating reports for a governor, using the typical programs that epidemiologists like to use like SAS for their analytic environment. And I heard stories about those SAS programs running to create the dashboards for a governor to look at in the morning were running 15 or 20 hours. So they couldn't even do daily updates for their governor, because their compute infrastructure was just not able to keep up with that.
And then as we moved into the stage with mass vaccination campaigns, we certainly saw the challenges there as well with our immunization information systems, which are really key to keeping track of immunizations and part of the requirements of any provider who received COVID vaccination was that they had to report these vaccinations to the state immunization information system. And again, the volume of data coming into these immunization information systems was just logarithmically higher than what they were normally used to. And I heard of states that quadrupled the number of servers that they had up to a hundred servers, but still were not able to keep up with the volume and actually had to put in business rules with their providers about the number of times that they could connect to the Immunization Information System just so that they could make sure that their system didn't go down. And you don't wanna be limiting the clinical guidance that you're getting from these Immunization Information Systems during a time like this.
So it really is I think a critical part of modernizing our public health infrastructure to think about the scalability that we need there. And one of, I think the most important things to do there and that's where I think that partnership with industry comes in is really thinking about how we stop thinking about supporting these systems on-premise, which means that they're running on a server and you're a department of public health and start thinking about moving these to the cloud, because when we're running on these systems on the cloud, scalability comes in automatically. If all of a sudden the volume starts to increase 100 fold, that's not an issue when you're in the cloud. That automatically scales, new servers are spun up virtually, and they can handle that volume. Whereas if you're trying to do this on-premise, you have to start with purchasing those servers to come in and fill it in.
And even just purchasing in the state health department can take months. And then there's the whole process of installing them and them getting them up and running. You avoid all of that, and it's all automatic when things are running on the cloud.
So it seems like a fairly simple thing to think about, but it is a challenge still, I think for many health departments to think about migrating some of these core systems to the cloud. There are concerns about security, concerns about having industry partners have access to your data. That's really not what putting your systems on the cloud is about. The security is always a shared model with the customer where the cloud service provider really provide you with some core security that you're not really even gonna have in the most secure onsite physical server room. And then there's a shared security model as well to really, really control who has access to the data, make sure that all the HIPAA compliance and other public health regulations are in compliance. So it's a shared model as well where you work with your public health partners to do that.
So there are ways to really address all those concerns and help people get through that, but it's something that we really do need to work closely together with our public health partners on even to start with a very simple process that I like to call just lift and shift, where we take some of these older public health applications that have been around for 20 years. The last time, honestly, we had a refresh of our public health systems was with bioterrorism money in the early 2000's, but we can take these older systems and just put them on the cloud and get us through this crunch time that we're still in with COVID response. But while we're doing that, we do really need to start to take a step back and think about how we strategically spend the dollars that we have now. That's really a once in a generation opportunity to make sure that we're spending those dollars in a way that we're going to build sustainable systems that can last for the next 30 years. And we really have to start thinking about looking at more cloud native solutions and how we start to make that migration. And it's a challenge for public health to think like that, because we have our core public health vendors and our core public health systems that are so close to our hearts as an emotional bonds.
And it's hard to think about working with other vendors that might have more cloud native solutions that are gonna offer us that scalability and flexibility that we really need to have. But it's time to break that emotional tie and really start looking at some of these new cloud native technologies. And I think that really is an important part of governance. And I think that's where an industry partnership can really come into play and help public health really start thinking about that, do some of that basic education about what it means to be on the cloud, what it means to do a lift and shift strategy, but also I think more importantly, what it means to think about, I would say both looking at cloud native solutions that are out there, but also doing some of the work that public health is really good at. I mean, Public Health Informatics Institute is amazing at doing collaborative requirements. If we can all come together and put down on paper what we need for these systems to work in a collaborative requirements document, we can then build open source solutions that are cloud native as well that we can then have an emotional attachment with these new systems instead.
So I think there's a lot of work that we can do together and industry is really excited to be a part of that, and I think there's a lot that we can bring to the table. So I'll stop there so we have some time for some questions. - Thank you, Jim, and thank you, Chris, and Vivian for your comments too. I just wanna note one thing throughout all of your comments was we need to come together, we need to work together. And each of you had different perspectives, which I loved.
So we have a couple of questions from the audience. The first one is from Danny McLean and he asks, would like to know how we would leverage digital health by comparing our challenges with other countries who have already accomplished this? And I was thinking maybe Chris, you could try to answer that. - Well, that's a really good question. I don't wanna be too cynical about it, but I would say that we have looked at as somebody who's worked in the health policy arena and particularly around the aging of the population, there are many, many useful things we could learn from other countries and different models of healthcare. It's not all socialized medicine or market-based systems.
There's actually all kinds of different approaches to the way you bring those two things together, but the difference is that there's a lot more of a unified sense in most of the countries that I think that John Noseworthy was talking about of public health and the healthcare system being one thing and sharing a national database. Those two things can just transform everything that we're talking about and many of the things that we struggle here with the kind of technical changes that Jim was describing. So I think the problem is that as a country, we tend to not look to other countries for solutions and whatever the sociologic or sociopolitical dynamic about that makes it actually more difficult, it seems to me to try to learn from other countries, although I think the private sector has a large voice in healthcare and in our world.
And if leaders in the private sector who I know are equally concerned in looking for solutions can bring in some of those insights from other countries, that could lift those insights up and have them be more acceptable in the policy arena. - Jim, I think you wanted to add something there. - Yeah. I can definitely build on that theme.
One of the projects that I was working on actually when I was at the U.S. Department of Health and Human Services was the global digital health partnership, which was really built on the premise, Chris, that you were talking about which is the health IT suppliers that they are not focused on one country. They generally work throughout multiple countries. They would love to work with us on doing things in a similar fashion, doing things in a streamline promoting best practices. So the global digital health partnership was actually all about bringing together countries, bringing together the health IT suppliers and talking about best practices, and how even though there are core differences in our healthcare systems, there are models that we can share and best practices. And one of the really great public health focused activities that came out of that was actually a public health data analyst exchange program with the UK, where we brought about 10 public health analysts over from the UK to spend two weeks here and really understand what happens at the U.S.,
and then we sent 10 local health analysts through a collaboration with (indistinct) who works at the UK as well. We were supposed to have another UK team come over last year. Unfortunately, that got postponed where hopefully, they'll be showing up at APhA in October, if that means (indistinct) That collaboration is still going forward, and I think it's something that would be great to expand both to other countries and across other organizations within the U.S.. - Okay, we have a second question from Ubah in Seattle, and her question is she also shared some links to some of the work that they are doing about connecting rural health public health agencies and getting them access. But her question is around whether there's work to support- And this is for you, Jim.
Whether these work to support high speed internet access to rural health departments in order to take advantage of the cloud? The rural and frontier public health practitioners have noted that they have internet issues. That mean they can't easily use programs or web apps that require fast internet. - Yeah, I mean, that's a really great question.
And I think it's something that is addressed a lot more from the federal policy perspective than on the industry perspective. We certainly stay on top of that and try to make sure that providers who need to use our technologies do have that high-speed internet access and can potentially form those partnerships with the federal government. But we do need those policies as well to get high-speed internet access.
And this has been a challenge that's been going on for years, and back when both Dawn and I were at the ONC, we had projects associated with that through FCC. - All right, and I think we are now at time. So I, again wanna thank all three of you for the great discussion. I apologize that we didn't get to everybody's questions, but we do need to switch it over to Dr. Brian Anderson, who's going to continue the conversation on ways that we can empower individuals to use digital technologies.