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 its 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 whats 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 thats about Mental HealthService Delivery. Im 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 dont 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, im not used to sitting still are standing still when i do this, im 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 highlevel about interoperability and its impact. From my standpoint, i really would like to use the term data liquidity because what were 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. Lets 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 dont have any meaningful information for the patient or for improving their care. Just to give some perspective from a patients 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 dont 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 ElectronicHealth 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 theres directed by the use of what is called direct technology, which is basically a secure, encrypted email 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, im 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 in all their portals, as well as independent practitioners who may be using a variety of other systems, and you have their portal, and their systems are subscribed or have an a. P. I. Enabled, this gets pushed to Apple Health Records and on your phone, on your smart device in an encrypted manner and secure manner, the patient has control over their information. Im spending a lot of time on this, but the reason that this is important is his Large Tech Companies have engaged in the healthcare business or tried to get into the 48 many times over the last 25 years, in particular , with the bend on patient records. The reason they failed is because they say it is the patient record, we will put it in our system, on our servers. This is not on apple servers, this is the patient controlling their own information. I heard a great comment about navigating through kaisers site and going through questionnaire, having to answer your own data, but this does is not unlike if you have had Google Photos or any other app in which you can take the information that is on your device and actually have it interact with an application of your choice. If im tracking, you know, Blood Pressure or heart failure, diabetes or copd or any other myriad of chronic disease conditions, you can control that data, have it interact with an up in a secure and seamless, without special effort on part of the user, who is the patient, direct that through your care settings. I will get into later, just at the very end, some of the legislation that has come down the pipe with this. So the onc, which is the office of National Coordinator for health i. T. , which is part of hhs, ten years ago, in 2015, they set a tenure interoperability roadmap. The first phase was really just the start of exchanging data across domains, having these different systems exchange data, and then the ultimate goal is really improved efficiency, higherquality, lower cost, and improved outcomes, as well as enabling knowledge and Public Health. So there was a comment when i sent the draft out about what we call the Interoperable Health i. T. Ecosystem. It is a biologic term that is making its way into the healthcare space. That is really all the participants, and that is including patients, payers, pharmacies, labs, clinics, physicians, nurses, everybody who is involved in the whole environment of healthcare, and all the technology that comprises of it is what they call so you will hear health ecosystem, or health i. T. Ecosystem. And then, the end goal is nationwide interoperability that is patient centred, and that it is enabled from individual patient scaled up to how we manage and care and improve the health of our communities and populations, and really use that data to go from data to knowledge and knowledge to wisdom, insight insight and real , true predictors. So it is just a map of where we are in terms of nationwide Health Information exchange. In 2004, the onc was formed and set up a National Network, and that was really meant to give people access to the v. A. , and Social Security administration. Over time, is a Technology Got more advanced, and the user became more advance, through standard based exchange, which make it possible for information to really be portable across the continuum electronically, that has morphed into a National Network called the health exchange. At the time that the e. Health exchange was stood up and really what is happening with the majority of Healthcare Organizations across the country , they Exchange Information, care summaries, and other Clinical Data. Some other networks popped up. One is the common well alliance which is a gender participation alliance, which they created their own network to Exchange Information with each other. Then i will get into the care quality which is our network, but also a framework. The sequoia project became is a private Public Partnership that oversees and manages the National Network, it is really important the work that the sequoia project is doing because they are joint hip and hip with o. N. C. Just blowing through some of the data that we have, it really is our current capability from our hospitals, exchanging care summaries at about 80 now. Finding data is about 60 now. The ambulatory providers, sharing data outside of the organizations, is probably at 40 or 50 now. When we talk about the methods of health exchange, theres multiple methods, and i went through that, and this many more , those are the highlevel methods. The mooring more methods of Electronic Health exchange that you use, the more robust your activity in terms of determining how to best care for your patience and population. This is just some data about those who were using multiple methods across the continuum. A breakdown on the hospital side about the availability and use. We have a lot of distance to travel, even though the technology is there. As you see, it is not surprising in the larger urban and suburban areas. It is more widely used in critical acts active hospitals and rural hospitals. When we talk about the domains of the building, that is to find , send, receive, and integrate. The integration is really the end game, and you need to use all four domains. There has been some advancement, but not tremendous. And the ambulatory setting, conducting off for domains is not really improved that much over the last few years. In terms of sharing information outside, and the different settings, it has not advanced that much. When you look at those who are conducting all four domains of interoperability, it is still heartening to see that the response is often the way that they are using the information. If you look at the barriers to adoption, it really has to do with the five rights which are the right information at the right place, at the right time. The integration of this information into intuitive, native workflow, with a platform that the provider is using is key with the Successful Use and integration of this data. So just to point out, i believe at dignity, this is a passion of mine and one of my responsibilities as the system from a clinical and, across Dignity Health, which is now called Spirit HealthSpirit Health, but within our markets that were predominantly california and Southern Nevada and arizona, we have 87,000 users, and Community View is our main platform. We deployed the solution, and i will show you a screenshot of it , of an integrated view of all data sources for the patients that we see and data coming from external Exchange Partners or other system such as centre and kaiser and the v. A. We have 40,000 active users in the system across the system. We are connected to the community, 320 connections. We are doing about a million queries a month. So if a patient, each time a patient has a scheduled appointment and is being seen in any encounter, it triggers a . To go out to our Exchange Partners, and if there is a positive match, then it returns information to the patient. We have 9 million patients, what we call those are 9 million covered lives, basically. This is expanding rapidly. This is primarily through a National Network called the e. Health exchange. This is what it looks like. This screenshot, i know it is very busy, but it gives usm his of, so i am their provider and this is a patient that im looking at within context, and this is a page that i click on that actually brings in data like medications, encounters a bad, notes, diagnostic reports, labs, meds, pathology reports, all the data i would generally be looking for, including and probably most importantly, care summaries and care coordination. And this is a logo of all the different organizations that we are at the care with. When i look at these pages, these are all the organizations that i will be seeing. Some of them are nationwide. The v. A. Is a national connection. Im also proud to say locally that we just connected with the San Francisco department of Public Health, which i will get to in a little bit about why that kind of data is still important. Other efforts that we did the healthcare continuum is really in the community. So there are four walls of our care settings. The clinics, the centres, the diagnostic centres, the procedural centres, and you look at things like e. M. S. Or ambulances. How do we effectively connect what is happening in the field, and the prehospital or precare setting where patients are actually seen a lot, and is the primary mode of transit or entry into our system. So not surprisingly, the ambulances and what we call the e. M. S. Services, they brought their own version of Electronic Health records and they have a whole different electronic standard. We were able to map those standards together so that if a patient is seen by an ambulance in the field, they are able to connect and do the same kind of korey about patient formation and transmit that to the hospital or anywhere they want and pilots that we have done that came out of some initial successful pilots out of southern california, we did one in sacramento with the county fire to reduce unnecessary transfers for high utilizers who generally are not, because they are not connected to community providers, or they have had Behavioral Health needs, and this is where we actually put an advanced practice practitioner in the van or in the ambulance, and it they were to respond to a call and add it and get the patient coordinated right in the field without a transfer to the Emergency Department, saving millions of dollars per year. Another thing that we have activated that i am proud to say really helped with some of the devastating fires that we have had, is an emergency disaster response. Were trying to figure out, is there a way we can effectively connect First Responders in the setting of a Natural Disaster or a major epidemic outbreak, and this is just how it works that if you