Datica Podcast

March 24, 2020

The S Curve, Chaos and the Evolution of Healthcare

In this episode of 4x4 Health, we meet Dr. Joshua T. Honaker, Chief Medical Administrative Officer, for the Norton Medical Group, a part of Norton Healthcare in Louisville, Kentucky. Josh’s responsibilities include serving as the physician leader and co-administration leader for over 1,100+ employed providers. Dr. Honaker shares practical insights on building successful medical practices and leading healthcare organizations. We also discuss his work applying the S-Curve Discontinuity Theory to medicine as a way to explain healthcare’s past and predict its future – particularly timely as the COVID19 pandemic disrupts the established healthcare delivery system.


Dr. Dave Levin: Welcome to 4 x 4 Health sponsored by Datica. Datica, bringing healthcare to the cloud. Check them out at www.datica.com. I'm your host, Dr. Dave Levin. Today I'm talking with Dr. Joshua Honaker, Chief Medical Administrative Officer for the Norton Medical Group, a part of Norton Healthcare in Louisville, Kentucky. Joshua's responsibilities include serving as the physician leader and co administration leader for over 1100 employed providers. Dr. Honaker previously served as Chief of the Division of General Pediatrics at the University of Louisville School of Medicine, and as Chief Clinical Operations Officer for the University's Department of Pediatrics from 2009 to 2012. Dr. Honaker has held numerous leadership roles in the American Academy of Pediatrics, including president of the Kentucky chapter from 2007 to 2009. Dr. Honaker earned his medical degree from the University of Louisville, a master's in business administration from the University of Massachusetts and a bachelor's degree in biology and chemistry from Western Kentucky University in Bowling Green. Welcome to 4 x 4 health, Josh.

Dr. Joshua Honaker: Thank you for having me.

Dr. Dave Levin: Well, let's get right in. I'm going to ask you a series of four questions today, and we'll take about four minutes to discuss each one. To get us started, tell us a bit more about yourself and your organization.

Dr. Joshua Honaker: So myself, I live in Louisville, Kentucky. Born and raised in Kentucky, originated in Bowling Green home of the Corvette where I did my undergrad in Western Kentucky, as you noted and came to University of Louisville in 1994 to get my medical school training. And pediatric training was at Kosair Children's Hospital directly after. Been in Louisville since, and married a Louisville native, my wife, Michelle, and we have two awesome boys. They're 19 and 22 and ironically live together and are both students at the University of Louisville also. So we reside in Kentucky and I’ve been here and had the opportunity to serve as a general pediatrician in the community, starting my own private practice at a residency, and then joined the academic division at the University of Louisville School of Medicine. And then now been in corporate medicine as a healthcare administrator for the last eight years. And having a lot of fun, doing that, continuing to learn about healthcare delivery and leadership.

Dr. Dave Levin: Well, I want to come back to some of your current responsibilities, but one thing that jumps out at me and your story is coming out of residency and deciding to start your own practice rather than joining an existing practice. And one of the themes of this podcast has been innovation and risk taking. And so I'm curious to cast your mind back to that time and tell us a little bit about how you came to that decision to strike out on your own.

Dr. Joshua Honaker: Sure. That was probably the pivotal decision I made in my career and it has truly been the platform that put me where I am today. So I came into college and medicine without any business training, but I grew up in a very entrepreneurial castle. My father was in the oil fields of South-central Kentucky, and I watched him grow his business out in the oil fields. And then my brother is very entrepreneurial start his own aviation business. Actually in high school, he purchased a flight school, his senior year in high school and was flying at the age of 14 and now has a very large aviation behemoth business. And so I watched them enjoy growing their own businesses. When I was in residency, as most of us middle residency started interviewing at places and I was intrigued and had some job offers and I looked at all the practices and I just kept telling myself, I think I could do this on my own. I think I would prefer to be my own boss.

So that middle of residency, I decided to start my own practice, did my research in Oldham County where my wife was from next to Louisville with the highest per capita income. And ironically only had a couple pediatricians and it's the fastest growing County in the state. So I thought no brainer from a business and risk-taking standpoint to start my own practice. So I spent my last year and a half of residency preparing for such, bought a piece of property, renovated a house. And since then the world has grown around that little space commercially and is a thriving space in LaGrange, Kentucky. And we started with zero patients. I started with one partner and the practice grew to nine full time physicians in eight years and we were all busy and it's still thriving today. So one of the most fun experiences and as a result of that, I had to learn business on the way. And the first lesson I learned was to put a good team around me. I just learned as I did and being the only one of a few physicians in the community had started their own practice. And it was seen as a thriving practice. I then quickly got nominated tapped on the shoulder and volunteered to be in different leadership roles in the community, whether it's children's hospital or the Kentucky chapter of the American County Pediatrics or invited to be the first chief medical officer for Baptist Healthcare Northeast. So that kind of was my platform to propel on a lot of different leadership areas.

Dr. Dave Levin: That's really interesting. And tell us a bit more about what you're doing now and how that early experience has contributed to your success in your current role.

Dr. Joshua Honaker: Again, the most influential part of my career was probably starting that practice. After I left the university I came here because I had an invitation joined Norton healthcare back eight years ago, they had a growing medical group. At that time it's called Norton Physician Services, about 350 providers. And they did not have a full-time physician administrator. And I was asked to be that. So I came out of that role and through the years took on some other roles, helped out in operations. And last two years, my title was, I serve as the Chief Medical Administrative officer, which is essentially a hybrid between a CMO and a CAO and work in a dyad with a fellow oncologist who is a CAO of the Norton cancer Institute and the Norton medical group. So together he and I oversee and lead a group of 1200 providers. He is the point person for all things ops and finance, and I'm the point person for all things, clinical and are physician leaders and clinical and quality and recruiting and contract and compensation. You know, when I look back and think about my days when I started that practice, what I learned then was I love seeing patients and I love the business side. I love growth. I loved taking a risk. I loved business, and I love that healthcare is such a complex and innovating and challenging industry and being in my space today. It's super fun to be with a group that has a strong brand, such as Norton Healthcare. And I get to be in a space of growth. We start at 350, now we're at 1200 and we will likely be 1400 plus this year. So I found that I like to grow things.

Dr. Dave Levin: Well, it's a heck of a story. I suspect that you like me believe that having physicians more involved in these kinds of leadership roles, administrative roles, operational roles, is good for healthcare and good for the right kinds of physicians as well. Assuming you agree with that, any advice for physicians that are thinking about dipping their toe into the water, beyond their clinical practice?

Dr. Joshua Honaker: Yeah. So come back, I want to first give a lot of credit to mentors that I’ve had through the years, it's always been a mentor in my most recent one, being Dr. Hester, our CMO of the healthcare system in Norton Healthcare. And to me, if you're going to grow in this space, you have to have someone who does mentor you, prep you, teach you because we don't go to school to become a healthcare administrator. You learn along the way. So I always remind everybody when I'm talking to young physicians who now have an appetite to go down that path, and I'm very thankful Norton Healthcare has been very proactive and having and supporting physician leaders. We have about eight that are full time physician executives at Norton Healthcare. As they recognize the value of the clinician being at the table for business decisions. My advice for young physicians would be this first and foremost, be the best clinician that you can become. That is what gives you the integrity, gravitas, and relationship with your community to sit at the table, to make clinical decisions and lead for other clinicians, and then learn as much as you can be as part of as many projects as you can volunteer and be a part of counsels, committees, task forces, and you truly learn by doing and in any leadership training that you can take is definitely a value. And it's not a must, but it's growing to be a must is being a master in either healthcare administration or a business administration. So those are added credentials that are very helpful moving forward.

Dr. Dave Levin: Boy, that's really sound advice across a number of points. The one I would emphasize is volunteer. It's a really good way to start and find something that you care about. A quality issue, an IT committee, somebody that's working on policy, whatever your other natural interests are and find the opportunity where you can volunteer some time, as you said, you will learn a lot and it allows you to begin to demonstrate your interest in your capabilities and signal that to others as well.

Dr. Joshua Honaker: True, totally agree. And the sad thing, there are a number, I think most physicians have a desire to go down that path end up being successful, but then sometimes there's a number of physicians who they go down the administrative leadership path for the wrong reason, and they simply want to get out of clinical medicine. Most of us that are physician leaders truly miss seeing patients and miss the clinical medicine, but we realized that the calling was to go to work in a space that you could help more patients in a bigger way. And I was still focused. I feel like I'm still practicing medicine, just with my pen and through policy and on a bigger level. And it's my job to support patients and those who take care of the providers. So you had to go into the heart to still serve and take care of patients. It can't be just because you want to go down the business pathway and to get away from clinical medicine.

Dr. Dave Levin: Yeah. I think that's just good advice in general, as you pursue your occupation and other aspects of life, my dad used to say, "be sure you're running to something, not away from something." And I think you described that really well. Josh, you've got your hands in a lot of different things. I'm curious what's the most important or interesting thing that you're working on right now?

Dr. Joshua Honaker: Well, I think the most important work as been tasked with in the medical group is to identify ways to, in two buckets, one constantly improve patient care and number two, and decrease the burden on our providers. As we all know, provider burnout is a hot topic right now, the suicide rate is about 400 providers, doctors, I should say, per year. That's essentially in medical school equivalency being wiped out across our country every year from suicide. So provider burnout and emotional wellbeing of our providers is very important. So anything I can do to decrease their burden, which then in turn improves patient care, I am focused on right now.

So we have multiple niches. My most exciting one I think could have come to fruition and be helpful in the future is that is utilizing virtual scribes. So I think it's the most novel, innovative approach to coming around a physician and providing support at the bedside and having a scribe virtually on a computer who can help assist with the visit and accessing data, but also start building the notes. So the physician can truly practice medicine, eye to eye contact with the patient, work with the patient, serve the patient and listen, and problem solve as they're expected to do while someone else builds the notes, helps prep the note and serves an assistant during the visit. So the day we can get that technology to our providers is, will be an exciting day for me. And I think will enhance patient care and decrease physician burden. So we've got a lot of exciting things we're working on, but that one I'm most excited about.

Dr. Dave Levin: This is a theme that's been coming up frequently on the podcast and this idea of burnout and creating resiliency. And you've touched on an aspect of it that I find particularly appealing, which is letting physicians and others, other members of the care team, get back to what they really got into medicine for in the first place, which is taking care of patients. And when you survey physicians, when you talk with them, they're very consistent that paperwork, the introduction of electronic medical records and awkward workflows and time-consuming documentation these are major factors in their dissatisfaction and work and rising burnout. So it's good to hear that, that this is on your agenda and that you're running right at, in particular, these issues of workflow and things that interfere between the doc and the patient or the nurse or the pharmacist, or as I said, any other member of the care team. The thing I'm also curious about is how are your colleagues responding to this?

Dr. Joshua Honaker: So we did a demo of one of the different solutions and there's multiple solutions, multiple vendors, and we're looking at those right now. And maybe some time to before we finalize that, but the physicians who saw that and have seen the testimonies and talk to other physicians who lived and breathed this, they're excited. They believe there is light at the end of the tunnel. They believe their day can be more about the patient and not having many minutes or even an hour plus at the end of each day, being on the EHR. With that one of the other science things that we've done around burnout is about three years ago, we surveyed our providers, understand why they had burnout. Then we adopted the Mayo clinic wellbeing index as a measurement for burnout each year. Then we created an ethic optimization team to help enhance Ethic, the EHR delivery for providers. Cause that was a big cause. And then we identified a medical director of wellbeing about a year and a half ago. And so I'm hopeful that the scribe piece, the virtual scribes will be something that helps augment that in a big way.

Dr. Dave Levin: Sounds like a multifactorial approach with a number of different interventions. And we'll be interested in get an update from you at some point of how it's proceeding and being received. If you've just joined us, you're listening to 4 x 4 Health, and we're talking with Dr. Joshua Honaker, Chief Medical Administrative Officer for the Norton Medical Group. I want to ask you about some academic work you've done, because in addition to all of your other things you have your hand in you've published some papers and particularly around the idea of applying something called the S-curve, discontinuity theory to medicine to essentially explain our past and predict our future. Take a couple of minutes and tell us about this idea of the S-curve and why you were attracted to this and what you think you've learned through putting these papers together.

Dr. Joshua Honaker: Yeah. So appreciate the question. I have to go back and tell a little bit of a story. Dr. Adler, a pediatrician in Kentucky approached me back when I joined Norton Healthcare about eight years ago. And he came to me cause he'd seen; I'd done some speaking and written some work on obesity in Kentucky. And it was a passion of his, he was in a space many years before back in the eighties that he wrote a paper and initially describing this concept of applying the S-curve and discontinuity of S-curves to healthcare. And it hadn't ever been written in literature before. So he wrote a paper on this and essentially what he highlighted was an observation that, well, first coming back S-curves are used in a lot of areas of science, such as mathematics, chemistry, economics, and sociology and such, but the S-curve is a concept, a scientific concept that when laid on X, Y axis over time that the Y axis in this case reflects progression improvement in healthcare. And there was an S curve that he labeled as the sick S-curve. And that was the period of the 20th century and show progression of us be able to improve and help with sickness. And obviously the 20th century is a big center for that, because of antibiotics, anesthesia surgery, and such.

And then that S-curve plateaued at the top as S-curves do. And he had hypothesized that there would be another S-curve called the wellness S-curve in the early 21st century. And as one S-curve went to another S-curve. There's this continuity. And at that discontinuity space, there's chaos. And I think he predicted well in the eighties, there would be this period of chaos, which was later discussed in the paper by me, an observation that chaos were built itself in the way of implementation of EHR, physicians being employed, payers playing a different role, this transition from volume to value. How do we pay for healthcare? Then we had the onset of affordable care and accountable care conversations and all that I reflected on his paper when I wrote a paper and said, I think a lot what he says, come to fruition. But with that, there's a light in the tunnel because when we get through this chaos, then we're going to go in the wellness curve, where we as a society really focus on healthcare around prevention and wellness. So I wrote a paper just talking about that and talking about that we will have likely a very steep progression in healthcare of improving as we focus on a preventional wellness, then wrote a second paper that is entitled the S-curve, this continuity theory predicts the path towards a well society, increased longevity. So I have fantasized and the journal medical hypothesis that there would be a third S-curve and called it the longevity curve. And after we have helped people live a healthy life, and we focus on provincial wellness and ridding chronic disease, then we can then work on for those folks how to live longer.

So it was a fun academic concept and had some interesting conversations with folks. And I think it truly does reflect what has happened in our past and with that maybe lessons learned for the future.

Dr. Dave Levin: Well, I’ve had the pleasure of looking at a couple of those papers and this really appealed to me, the basic concept, and it was really fascinating the way you've applied it to the earlier history of medicine and predictions about where we're going. The other thing that jumped out at me of course is, it looks like I will have spent most of my career in medicine during the period of chaos. So there's that. That's right. And has this guided some of the practical work that you're doing on the ground day to day? Have you figured out a way to take this very high level, very strategic overview of the broad sweep of medical history and apply it to specific activities in your day to day work?

Dr. Joshua Honaker: Yes, just as I noted that when I started a private practice with a couple of colleagues, how much that impacted my career, probably has nothing has impacted me more than this concept of you and I practicing and being in medicine during this time of chaos. And these papers have really made me think that the current stage is a period of chaos, but we are getting through it. And when we get through it, we'll see the light at the end of the tunnel, be better and healthcare will be great. And I will tell you how it's impacted conversations I’ve had recently and how I do business. I felt like I’ve been more diligent over the last few years to know that we need to put some things in place. We've got to fix some things, put infrastructure, prep for the future. And we got to start building a model based on prevention and wellness. Obviously, it's great our society is thinking that way, but everything in the medical group and around primary care, it's been about chronic disease management. How do we engage the patient? How do we hopefully prevent problems? And when you live in a state like Kentucky, where we're a leader in everything from lung cancer to obesity, to kind of congestive heart failure to diabetes and COPD and asthma, we have to take this as seriously as anybody does. So knowing that we've got to get on top of all this sickness, and we've got to get people living healthier. We also know from a social economic standpoint and fiscal security for the future, we have to work smarter, not harder, as there's not enough money to take care of all of our healthcare woes, given the current state of our country and what we spend on a percent GDP.

And so with that being said, what would be the ideal approach is to keep people from getting sick to begin with. So we'll have to get on this wellness curve and keep people from becoming obese, keep people from doing, getting to chronic disease spaces. There's another paper I recently wrote around that. And actually as a pediatrician, my mindset went as I’ve been this adult space for the last eight years, that so much of the burden of chronic disease and so much of the costs in our society, the burden is because of honestly choices in lifestyle, and a lot of choices in lifestyle for adults at least the chronic disease sadly comes from mental behavioral health issues, events in their lives. There's been papers written around the adverse childhood events and things that happen to the lives of kids that translates into, healthcare choices later that hurts some of them, rest of their lives. So I wrote a paper with that observation and proposing that and hypothesizing that if we, as a society focused on parenting and the family structure more, that is probably the only way we're going to be able to bend that cost curve. And that chronic disease curve is getting back to the early childhood experiences and parenting the family structure.

So with that me transition from being a pediatrician to administration, to administration in a largely adult health care space, a lot of observations and lessons learned. And, but I do think we're in a brighter place now back to the question of how impacts now, I think the future will be brighter and all the more, because I look at these S-curves that it tells me that mathematically, we probably are getting through the chaos here soon.

Dr. Dave Levin: Well that's a ray of hope here. And that's part of what I took from reading these papers as well is, so a really valuable model for thinking about where we are and how we got here and where we might go. And it's also sort of reassuring that there's an end to the chaos and some interesting and exciting opportunities for how we go forward. So like I said, I think it's been a challenging time to live through as I’ve often said the last few years, I think things are finally bad enough that we're really going to do something about it. So that fits with this notion of S-curves and the role of chaos during these transitions. So for my next question, want to remind you that this show is family friendly and please keep it PG 13, but what's your pet peeve or favorite rant these days?

Dr. Joshua Honaker: Oh, I think my biggest pet peeve in an age in society where life is so good and we're so blessed in so many ways is when I hear people complain about first world problems, especially when you're in the healthcare space where you see people in need, going through a lot of tough times and a lot of morbidity and mortality issues in our day to day space and healthcare. You know, when I hear folks in society complaining about things, whether it's about social media or their iPhone, or my golf cart wasn't working right. And it's like that's my biggest pet peeve, complaining first world problems.

Dr. Dave Levin: So what's your remedy for that? What's your counsel to yourself and others on that?

Dr. Joshua Honaker: I think keep it real and constantly remember how great our life is and keep it all in perspective. And remember that other people have truly worthy things to maybe complain about. And often what we have is not worthy to be honest.

Dr. Dave Levin: Yeah, I think travel, volunteering and familiarizing yourself with the basics of history are also really helpful as well. I mean, I think about this, you know, for example we were having an issue in this country right now with people concerned about vaccinations and their value. And I know this is not exactly what you're talking about, but when I hear those conversations, what on my mind goes back to is these folks don't really understand what life was like before vaccines. And that that's really the proper context for this kind of discussion. And it's not to say that vaccines or anything we do in healthcare is 100% safe and effective but compared to what is a really important question. I presume you would agree, but well, I always encourage my guests to call BS on me if they don't so feel free.

Dr. Joshua Honaker: So as a pediatrician, I have to concur. For those providers or anybody in society who's ever seen death and disease, morbidity and mortality from any vaccine preventable illness they're going to be advocates of vaccines. Those who haven't seen those illnesses and seen those deaths, they tend to not be able to, honestly, as you said in context, it's as context for them, they can't appreciate it. But if you live in the times or different spaces of the world where these diseases could have easily been prevented by a vaccine, we know nothing's perfect. That's the world we live in and there are risks and there's not a perfect vaccine and we don't have a perfect antibiotic or medicine of any sort. But it's all a risk and reward calculation. And yes, that's all-in context.

Dr. Dave Levin: So for my last question today, you've offered us a lot of really Sage advice and wisdom, but what do you consider your most Sage advice?

Dr. Joshua Honaker: Boy, that was a hard one, as we've all received a lot of it, a lot of good advice through the years. And we hang our hat on a lot of different things. The one that always comes up to me, the probably the most common theme that I will share with young physicians or folks in the workplace for my two boys. And I'm a broken record in some spaces on this, just cause I believe it's so tried and true. There's a book that was given to me by my mother's first cousin Rita, when I was in medical school. And she gave it to me to read in medical school. I did not read that book until after residency. And I so wish I had read it back then, but it was labeled margin. It's entitled margin. And the author was Richard Swinson. And that book is all about having margins and buffers in your life. And the whole purpose of having margins and buffers is so that when you have crisis, things that don't go right, you actually can handle the crisis.

And the other part that I took away from that book is, it's not just about self-preservation taking care of yourself, but when others have a crisis, if you have margins and buffers in your life, then you can help them. When I say margins of buffers, I mean having in every aspect of your life, such as in your bank account, having a little extra in your bank account, having an extra amount of cash in your billfold. Every day when you get up in the morning, don't just set the alarm clock to be for 30 minutes ahead of time, because that's what you need. Give yourself a buffer of 45 minutes. If it takes 30 minutes to drive somewhere, give yourself 45. I always tell my boys, don't let the gas tank go empty on your car. Always keep at least a quarter of a tank, have buffers. So the more you have buffers in your life, then you can handle life. Cause life just is always going to hand you crisis in the unexpected. And I tend to find this as the older I get, that my happiness, my contentment, my sense of security correlates with how many buffers I have in the various parts of my life. And when I run out of margin, I run out of security and my stress increases. So to me, that kind of keeps me level set and helps, it's just a good bit of what wisdom I give myself every day.

Dr. Dave Levin: Well, that's terrific wisdom. And it resonates really deeply with me at the risk of going on a mild rant. I think this almost reflects an American illness, if you will. In the name of efficiency, I think we often, we don't leave a margin. We don't leave the buffer. We organize and we optimize for the best case in a process or something that we're doing. And we don't build in that extra for the unusual, the unexpected. And I see it in all kinds of things in life around me. I personally believe it's a false economy. Obviously, we don't want to be wasteful. But designing for the optimal best case is often not really that a very practical or efficient way to do things over time. Does that make sense to you or do I stand to correction here?

Dr. Joshua Honaker: No, I, I totally agree. Totally agree.

Dr. Dave Levin: And how does that, how do you reflect that in your work? Cause you're at a position to have a real influence on this.

Dr. Joshua Honaker: Yeah, so in my work I am emphasized and the teams around me to have buffers and margins. So in other words for example, when it comes to our quality goals for the medical group, we have a 12-month period that we have to hit those goals by January 1st of the next year. And I always want our timelines to be to have a couple of months buffer. And I always tell the team, I want to hit this goal by November one or October one, cause I want a buffer. I want a margin. So my team is so used to hearing me talk about buffers and margins. They do the work, plans accordingly now and timelines accordingly. And when I make my schedules, every time I see a space that I can block a little bit of time, prepare for something I do because before I know it, I can turn around and my entire day is eaten up by good things, things I need to do. But if I don't have time to prepare and be thoughtful or reflect or digest previous meetings, every work meeting turns into more work. And I tend to find when my buffers are used up in my daily schedules, I don't do my job as well. I'm not as happy. I'm not as patient. I probably don't extend as much grace and I'm not as good as I need to be. So to me, it's a constant work for me every day in my schedule when applying this concept.

Dr. Dave Levin: Well, I could definitely relate to that and I can see the direct connections to the work your group is doing around creating resilience in your providers as well.

Dr. Joshua Honaker: Yeah, it definitely impacts, and you like to think you are imparting on others to think that way. And of course, I try to get my two boys who are college students to think that way. And I think they probably taken on some of that. But I think it makes such a difference in how you live your life and honestly, how you interact with other people and planning for the future. Everything about planning is putting resources in place and you can't do that at planning. And to me, the biggest lesson is just knowing that life will happen. Things will get in the way that you did not plan on. If life went as you expected, then you probably wouldn't need buffers, but that's the whole point. Crisis come at times when you least expect them.

Dr. Dave Levin: Yeah. Or good things happen, good opportunities as well. You know, your kid wins an award and or they, unexpectedly the team's playing in the championship and you want to be there. You want that to be part of your life as well.

Dr. Joshua Honaker: Oh, exactly. You want to have buffers in your time and have put money in the bank, with your employer or your workplace. So you could leave and enjoy those times and know that you can be rewarded for the extra times you invested to build buffers.

Dr. Dave Levin: Yeah, I think that's right. I've heard some folks refer that to that as their screw you money. They've had enough and they know they need to make a change. They build that buffer in financially as well. Josh, this has been really terrific. Thank you for your time today. We've been talking with Dr. Joshua Honaker, Chief Medical Administrative Officer for the Norton Medical Group.

Dr. Joshua Honaker: Well thank you for having me. I enjoyed the conversation.

Dr. Dave Levin: You've been listening to 4 x 4 Health, sponsored by Datica. Datica, bringing healthcare to the cloud. Check them out at www.datica.com. I hope you'll join us next time for another 4 x 4 discussion with healthcare innovators. Until then I'm your host, Dr. Dave Levin. Thanks for listening.