Navigating Healthcare Complexity: Harmonizing Stakeholders and Technologies


Healthcare technology must fully support stakeholders to optimize results.

Insights from the symplr Compass Survey and Report, discussed by industry leaders, emphasize the need to address technology overload, nurse burnout, and the disconnect between IT and clinicians.

Solutions lie in integrated systems, effective communication, and leadership focused on digital transformation. 


Host: Mitchell Josephson
CEO Health Data Management

Mary Beth Kingston
EVP & CNO, Advocate Aurora Health

Karlene Kerfoot
CNO, symplr

Related resources

Compass 2023
From Imminent to Urgent: Aligning Clinicians & IT is Critical to Streamlining Healthcare Operations
Compass 2022
From Disparate to Dynamic: Opportunities and Challenges in U.S. Healthcare Operations

Webinar Transcript

Chapter quick links: 


Observations Over the Last Five to Seven Years

Key Stressors in Healthcare

Nursing Supply and Inpatient Turnover

Long-term Impact of the Pandemic

Impact of Multitude of Technologies

Governance and Integration of Technology

Alignment with IT and Digital Transformation

Importance of Decision-Making and Identifying Quick Wins

Shared Governance and Collaborative Decision-Making

Impact on Nurses and Physicians

Challenges of Disparate Systems

Conclusion and Future Research



Well, I am so grateful today to have Mary Beth Kingston and Karlene Kerfoot join us today on this program. Grateful for, what you will all find out very shortly, just their tenure and expertise in this industry. Thank you so much for joining.

Thanks for having us.

This will be great. I did want to kind of put within context. I think that this research now and if you ask the question, why this research now and what is the, you know, importance of this research and the impact it can have, I can't help but think back to maybe five to seven years ago, working in class research, doing a lot of research on the front lines, and we started noticing something that was happening. We not started noticing this, what we call tech bloat. It was just more software entering, you know, not only just the operations, but every single department within the health care institution.

And we kind of sat back and thought, oh, no. Like, this could potentially cause a lot of problems down the road.

I mean, we had back then when we were doing research, we saw systems that had hundreds and hundreds of, you know, of, you know, systems in in their software stack. And we just thought, how are they going to stay on top of this? How are they going to be able to optimize, you know, the one or two applications they sought to purchase when they're being shouted by other solutions they bought? It was just so crazy back then.

And so now to come forward, you know, five to seven years later, the research that you're all doing, it's just it's just interesting to see that it is really starting to impact operations of a hospital. I'm grateful. I'm excited to jump in and kind of get your take on this. And so even before we jump into any questions, what are your thoughts?

Observations Over the Last Five to Seven Years

What have you all been seeing over the last five to seven years in your respective states, you know, inside health systems and outside?

You know, and I you know, you talk to nurses at the point of care.

They are the ones that we should be talking to because they'll be able to tell you how things are working. But, it it's just think about the whole issue that's been framed for a number of years, alarm fatigue. We've put into place a number of different systems saying, oh, gosh. We want to be able to alert people early. And then what happens is they're not integrated. And I think that's the biggest thing that we see with tech load is that it's so important to ensure that we're looking at the work that needs to that needs to be accomplished. And then how does technology enable that rather than just adding technology into an existing workflow, which just creates sometimes it creates, a lot of frustration for the nurses at, that are doing direct patient care.

Yeah. And that's a theme that will follow us through today's discussion. So let's kind of get to maybe the first question and kind of frame that up. It's really this concept around the stretchers that are impacting, you know, you know, clinicians and administrative teams today, specter around the operations of a health system. You know, I think on the back end of COVID nineteen and the pandemic, it's almost feels like the whole world of health care has been turned upside down. And so I'd love for each of you to key you know, in terms of what are the key director that if we really don't stay on top of and get on top of, that are really going to cause some problems here in the near term and long term?

Key Stressors in Healthcare

I can start with that. Mary Beth, you can chip in here and add some, you know, kinds of real examples to it. The research we've done with the Compass survey, looked at what people in IT and CIOs have their perception of what was going on and then then also clinical people. And surprise, surprise, surprise. There's a bit of difference there because people don't necessarily talk to each other effectively within healthcare systems.

So the research said that, you know, last year, financial issues were the biggest threat. This year, it's burnout, turnover, it's the people stuff. Well, in reality, it's the same thing because if you've got the right staff at the right time and the right people, then you've got good finances, good quality, good efficiency and so on like that. But if you don't have that, then that's a problem. So now we're seeing with burnout that a lot of people are leaving because, you know, they don't want to nurse the computers.

Physicians don't want to deal with all their time in the medical record. They want to be out and taking and taking care of patients. So it's a real challenge for us as time goes on. So, obviously, one of the opportunities we have is to look at those silos and see how we can get people talking to each other. As Mary Beth says, you know, you should listen to the users and find out what they need and how they could design products much, much better so they would have less burnout.

Yeah. I'll add to that. You know, there's a number of stressors right now, and finance is still up there even though I know workforce and burnout and turnover are right neck and neck. You know, the financial issues, it's interesting because we've had a lot of focus on contract labor, and the increased cost of staffing.

And, you know, I really challenge people to say, we know that the nursing labor costs have gone up dramatically, and that's put pressure on the system. But that's not really the only cost. And it I think if we start looking at nursing labor alone as a cost and not recognizing the impact and the quality of care that's necessary and the importance of nursing care, we might we might make some wrong decisions. We've got a lot of other things impacting financial performance, reimbursement, for example, supply cost, and contract labor in areas other than nursing.

So that's the one thing I'd like to say for a stressor. We've got to look at the whole picture. We do have, a decreased supply of nursing. We know that, but we are starting to see some positive trends.

Nursing Supply and Inpatient Turnover

So we're starting to see more if we look year over year, we have more nurses in the workforce than we did last year, and that's great. There's one big exception to that, and that is in the area of in inpatient, in the inpatient setting. And so when I think about the stressors in the inpatient setting, I really do think we need to pay attention to that. Why are we seeing more turnover there?

And I believe, and I know this is what we're looking at in in my health care system, is the work environment. So we have our society has become more violent. There's more divisiveness and instability, and this this just comes right into the health care setting as well. And so nurses and others are dealing with a lot of workplace violence.

That is that is not satisfying in the workplace.

Health and well-being, as Karlene mentioned.

We came through the pandemic, and I think we've always known how important health and well-being is. You've got to have healthy and safe people in order to give the best care.

But we're still seeing the effects of the pandemic and just the stress that people felt coming through that and the stresses, you know, that we see obviously in the workplace. And then our staffing. I mean, really paying attention to that staffing and making sure we look at, again, the work that needs to be done and who we need to do that work.

One, when I think of technology, one of the biggest stresses and, you know, I love the idea of looking at technology in the future and what AI can do. But right now, we have a lot of friction points is what we refer to them as. And they're sometimes very simple things. And, you know, one thing we've done is started to look at let's just, again, go back and look at the work that needs to be done.

And what could be automated? Is there is there something that, for example, nurse managers are doing or nurses are doing that could be easily automated, less clicks, for example.

Is there something that someone else should be doing? You know, and we know that we've had some work shifting with remote work and that type of thing to people who are actually on-site. So we've got to take a look at all of that because it creates tremendous stress, and technology can help, but we have to ensure that we're looking at the work and looking at how technology can really minimize those friction points that I mentioned and stress.

Yeah. A couple of things you mentioned there, Mary Beth.

And, certainly, technology can certainly be an enabler.

And we'll dive deeper into how clinicians and IT teams are thinking through how technology can really help to improve efficiencies and optimizations within the operational flow of hospital.

But I wanted to come back to one thing you said. You said that you still believe that there is still and this is exactly what you said, but, like, fallout being felt from the pandemic. And I and I'm curious. You know, I can understand when you talk about, you know, structures of violence, and you see reports in the news that's starting to escalate, and these strange stories of these patients coming into frontal, you know, harming doctors, nurses, etcetera.

Long-term Impact of the Pandemic

And so I can understand that and wrap my head around that. When you say there's still a fallout being felt from the pandemic, are you talking about maybe is it is it still maybe a PTSD type feeling as they walk into that inpatient setting? They remember three or four years ago how intense it was. Help me wrap my head around what is really the psyche and kind of that mental state of these care teams in that inpatient setting years past the pandemic?

Yeah. You know, it's a great question. And I would have to say it's very individual because, you know, we did actually, we did a research study in our Midwest region and, looked at, this was closer to, maybe two years ago or a year ago. And what we found is that even the nurses that weren't working on the COVID units had that had almost the same degree of stress as those who did.

So it it's this it was this global feeling of stress. And, you know, if you if you think about trauma informed care and how we look at what happens to a person informing how they respond in the future to different events, I think that's really a piece of what's happening. And, again, we've got a ton a lot of different programs and supports, but people respond differently to stress. And so we still do have individuals that were deeply affected by that where it it's it they carry that with them, and it impacts their ability to deal with stress in the future.

And, you know, I I think we have to pay attention to that. We shouldn't assume that everybody's feeling that way, but it's definitely an issue.


So let's thanks for diving deep down that rabbit hole for me and just kind of helping me put my hands around that.

And I would just say that that from a patient's perspective, right, I have five children. It seems like we're always in either, you know, an outpatient or inpatient stay. In fact, I will be up, you know, next Tuesday. I'll be up at Primary Children's.

My daughter will be getting a surgery. She's kind of been our problem child with health care. So we know all too well what those very intensive, intimate inpatient settings look like. And I have observed from a knowledgeable patient's perspective, seeing nurses being frustrated with some of the technologies or maybe with some with some of the workflows, you know, that are going on and some of the miscommunications that are happening.

But I would have to say from my perspective, and maybe it's because I spend all my time in technology, is that is that my, you know, observations were that they were frustrated with a lot of the technologies that they were engaging with dealing with. Now in in my in my specific case, it was with the EHR, that they were frustrated with. They were experiencing some downtime that day, very frustrated, impeding their ability to get work done, impeding their ability to really engage face to face with patients. And I can only imagine how that extends now as we talk about, you know, what this research uncovered that there are, hundreds, of systems that are being used in the operational flow of a hospital.

And if and if, one, if they're not connected, two, if they're not working right, I can only imagine just the time suck that it can become.

Impact of Multitude of Technologies

And I'd love to spend some time there in just understanding, you know, Karlene, from your perspective, what is the three search telling us about that, about the burden that the myriad of technologies that sit on the lap of these caregivers? What type of impact it's having?

And maybe I love how you brought in there's a CIO perspective, IT perspective, and then the clinician's perspective. How are they looking at this differently?

Well, they are looking at it differently, but I think it's our job to get them in the same place and be able to talk to each other and set priorities based on that consensus versus what's best for this department or that department or something like that.

I think we have to remember too that, you know, the human brain can only do so much multitasking. And what we've asked people to do is do a whole lot more multitasking than what the human brain is really capable of. And so consequently, people get fatigued and they get burned out and so on like that.

Technology should be an enabler. It shouldn't be a system that that holds you back or makes you frustrated. So, for example, in some of the American organization nurse leader studies, they found that, you know, for a nurse manager to do staffing and scheduling, they have to go through anywhere, from six to eight disparate systems that don't talk to each other. So you gotta go out of one into another.

For example, you do your staffing, but then you have to get your quality data to be able to look at quality outcomes. So you have to go into another system that doesn't automatically communicate. So as you're staffing, you can get that automatically. So there's a lot of, manual processes with technology that if we look at it, we can we can do so much differently.

Some places across the country, unfortunately, are having to put technology people on the unit. Now that's really a good idea. That really helps people a lot because there's a technology person there. It's like having your own IT person.

However, why do we have to do that? Why can't we develop more efficient systems that are intuitive and that people can use and we don't have to get, you know, a technical expert in to take care of them all the time. And I think AONL, and Mary Beth's been very active in AONL. They're they have a whole system going in terms of models of care.

So they're looking at exactly these issues because, you know, COVID is just a symptom of what had been going on for several years.

COVID brought it all to the forefront. And so the models of care that we were using were not all that efficient anyway, but then when COVID came along, my gosh, they really aren't efficient.

So organizations such as AONL is looking at what is the leading practice, what's the best practice, and how can we develop future models that hopefully will have easier to use technology, different ways of taking care of patients on the floor. So that when your child has surgery, you won't feel that frustration that the staff is feeling. You'll feel that, oh, this is really cool. Everything's organized and they have the moments that that they can spend with you to take care of you and to teach and do all that, and they're not distracted. So you have a much better experience with a nurse who's not distracted or a doctor or whoever versus what you have today with people who are multitasking and trying to fix the VCR and everything else at the same time. So there's hope out there and that hopefully this crisis is going to make us think differently and turn things around.

Governance and Integration of Technology

Yeah. Yeah. I agree. I think there's kind of again, there's the short term. What can we do to decrease just those day to day annoyances type of things?

And then there's the whole integration of all the technology we're dealing with. And when you think about it, you know, you didn't no one ever went out and got technology that was fully integrated. So you would you would have an electronic health record and then add pieces on. And so now I think that the goal is to take a step back and say, okay.

How do all these pieces work together? I think one of the most important things that that we can do is have a governance structure that is represented by all types of disciplines and our IT colleagues so that we're in the room together before someone decide, well, we're going to this group feels that this is essential to their business. Okay. But we need to understand what the downstream effect of that is.

So it may work for one group. Mhmm. How does it connect? And then what does it do to the person, again, who's providing direct patient care?

Does it add burden? Does it simplify? Does it connect in? And you really can only do that if you have the right people at the table.

So setting up a really strong governance structure for technology decisions, I think, is critical. And I I've seen that work well, and I've seen times in my past where it hasn't worked as well. So I do think that's critical. The other thing is, Karlene, you mentioned having, IT folks at the bedside.

And we don't really have that, but we do have nurses who are clinical informaticist, and they can really help in the translation.

So they know they you know, I know enough to be dangerous, but I I am not an expert in technology. And I may have great ideas, but I need someone that can help bridge that gap, bridge that clinical gap with me and with IT. And many times, nurses who have those skill sets can do that for us. So that's another great area, I think, in order to close the difference in viewpoint potentially or just the difference in, orientation to solving some of these problems.

And it's really good that they can sit in, in both the ID department and also the nursing department and the respiratory department everywhere because Yeah. This is a team sport. And they're the ones that can go around and be able to talk that talk and connect all those people together, and they can see the big picture.

I think also That is such an important point.

I just I have to highlight that because we can't talk about nursing care models alone, and we can't talk about this type of care model. It's gotta be that that team care model. If we all go off in our own silos and disciplines, we'll never get that integrated approach that we're seeking. I'm sorry to interrupt you, Carly.

No. That's a good point because, you know, health care is a team sport. And if we don't involve all the teams in a synergistic way, we can't get we can't get the right information in, obviously, because we can see the disparity right now between IT and clinical people and everything else. So it's really important for us to be able to think about that.

Alignment with IT and Digital Transformation

And then, also, I think if we were all aligned with, like, the IT department and the admin department and everybody else, we're aligned with the fact that we're trying to simplify this so that people have more time to care, more moments to care than what they've had before. I think that would be good. We have a project going again with AONL. I'm cochairing it, and it's to help chief nursing officers become more technologically savvy because, you know, the whole future is this digital transformation.

So if we don't have leaders who know about the digital transformation and if we don't have leaders who aren't competent to sit at the table with the people making all this kind of decisions, then it's not gonna work because you're gonna have one group making a decision, about somebody else. So it's a continuous learning. Okay. This is this is the new thing.

It's digital transformation. So what kind of what kind of, support do you need? What kind of education do you need? Our challenge is sometimes, you know, that chief nursing officers don't show up for some of our technology demonstrations and so on because they're not interested and they don't have a the ability to do that.

But that's one of the biggest decisions you can make. Because if you let somebody make a decision for you that doesn't really reflect how your people practice, then that's a real disconnect. So if we can have more people who have beginning level of that digital transformation stuff, then we'll have much better outcomes, much better much better dialogue with vendors, and things should work much smoother. If everybody is aligned around, this has got to be simpler.

We have to take work out of the system. There has to be more time for caring. And it doesn't mean that you gotta have more people. In fact, you can have fewer people if we could just move into that efficiency realm of making sure that that's our goal.

Yeah. You have two important things that you that you so you said a lot of things that were important, but two that I I would highlight. The one is the need to develop some capacity, within nursing, particularly about technology. And, yes, the folks coming in are technologically savvy, but, you know, there's the there's the baseline of what we need to know, and then there's learning more about AI and what the future holds so that we can make the right decisions moving forward.

Importance of Decision-Making and Identifying Quick Wins

And the second thing is having the right people. So for example, when we're looking at a lot of our systems, if something is selected, for HR would be a great example because nurse managers use the HR functions all the time in terms of posting positions, you know, all the things that we do with very large spans of control. Many nurse managers have, you know, a large number of nurses that they're working with. And if someone else makes those decisions without incorporating in how that end user is going to function within that, then we'll be making decisions that frustrate everybody.

Mhmm. And so really important points, Karlene.

But my question is here is where do we actually start? Where are some of these quick wins, especially around the technologies, the data management, where within these health systems can we really get some quick wins where these doctors and nurses and care team members can really start to feel the wins. And we feel like there might be a lot of administrative, tasks that are in the background that patients don't see, things like staff scheduling, etcetera. But it sounds like from the research, and just by breaking from what I hear, that maybe, you know, credentialing staff scheduling, a lot of these operational tools that sit in the background aren't as efficient and effective as they could be today.

Is that accurate? I mean, I'm hearing some of that, but I'm not close to that realm of technology deployment to really know. But both of you, I know, are. We'd love to get your perspective of can those things is that the first place to start, you know, in terms of automating those pieces?

Yeah. I think that's a good point. And I think if we had some consensus in terms of what's the most important thing for all these disparate systems to think about, you know, number one would be, how much time can you save by using these disparate systems? Or how much more time how many more people do you have to hire to run them?

So if the answer is we need more people to run them, that's the wrong answer. So we can say one of the principles is to make sure that that we don't need more people to run them and our clinicians don't have to run them, and the clinicians have the time that they need to care for patients. So that would be, you know, a number one outcome. And number two outcome would be, as Marybeth talks about, the integration of all these different disparate departments into one shared governance structure.

So the left can negotiate with the right because, for example, IT might say, this is the most important thing for our budget. And so, therefore, they get whatever they want. And then here's another group over here that says, this is the most important thing for our budget, and they get whatever they want. And then some group at the top negotiates that.

Shared Governance and Collaborative Decision-Making

But is that really the right group? It should be from the ground up that the IT and the clinical people all work together to come together with a proposal that says, this meets the criteria of more time. This meets the criteria of this. This meets the criteria of that.

And as you can see from the from the information, we don't have good enough connections That nursing informatics people are great in terms of translators, but it's not the same thing as a Marybeth sitting down with the CIO, sitting down with the CEO, and all those people saying, we got to talk about this together. And that's some of the new models of care that AONL is looking at. How do we have more synergistic, you know, disciplinary models versus, you know, respiratory's here and nursing's here and physicians are over here. That'll work.

And, Karlene, you mentioned something really important, and that is criteria. So prior to even having a, you know, a decision-making body, the groups need to come together to say, what is what is that criteria? What are our priorities, and how are we going to measure how are we going to match and evaluate where we decide to invest based on our values, our needs, our patient needs, all of those types of things. So developing that criteria for decision making is is a really important step.

Well, I think also there has to be a lot of evidence behind that criteria, and we have plenty of evidence. We know right now that nurse managers are saying they wanna leave because the technology burden is number two. We know the physicians are leaving because of the technology burden.

We know that. So we have to act on the evidence. We have to, you know, bring the evidence up and then do something about it. So simple. Right?


Well, you know what? I think we are making some progress because I the burden, I know that my own organization, we're working on that from all angles right now to say, you know, what are the things that are adding burden? And a lot of it is documentation.

And our partners and are working with this as well to say, okay. Let's see. Even in the short term, what can we do to reduce that burden? Right. So I think there's there is activity in that area. But as you point out, it's gotta be coordinated activity.

Yeah. I think one of the most heartbreaking things is to hear a nurse say that, you know, they're leaving nursing because they can't do what they were born to do. They thought they go into nursing and they'd be able to have significant relationships with patients. And the system doesn't allow them to do that because, like, Michelle, in your situation, you know, if the nurse is frustrated and so on, she's gonna go home and she's gonna say, I didn't I can't do the things I wanted to do.

Impact on Nurses and Physicians

I don't wanna sit here and watch this anymore. It's killing me. It's killing my spirit. So we've gotta pay attention to that, and physicians are saying the same thing.

And, you know, they're leaving health care, especially inpatient as Mary Beth mentioned, because they can't do what they wanted to do, what they were born to do. So, you know, we belong to the DAISY program, and that's a way of honoring extraordinary nurses. But the problem is you can't be an extraordinarily extraordinary nurse if you don't have the moments to do that. So if you're out nursing the technology and the patient is over here having a problem or you can't get to them, there's no way that that patient's gonna nominate you for being an extraordinary nurse.

They might nominate you for being an extraordinary technical nurse who's taking care of the technology. But my whole goal has to be to be able to simplify things so that people do have the time to care so they could do those moments that really matter.

Well said.

Yeah. Very well said. And as we as we wrap up this call, I wanted just to shift just slight focus and have both you help me, put within context and understanding, the current state of operational technologies, in in in health systems today. I in in in the research, it talks about, some reflecting on and putting forth this desire to have, you know, one platform, one source to go to work from to, you know, really, maybe aid in a shared governance environment to help aid in pointing, you know, the group to what's the next thing that needs to be fixed or taken care of.

And I can't help but reflect back to early days of the EHR implementation and deployment where it was let's put the financial side in. Let's put the clinicians you know, the clinical workflow side in there. But then what you started to see with all of these other third party sources, whether it be the EHR or the surgery application or what have you, all started to be more stuck into that respective EHR platform, and kind of becoming one big, you know, multifaceted system. But, yeah, all, you know, interconnected, all integrated, you know, big data all there.

And so I I'm just curious as I watched that unfold over a decade, and we're at we're at a point where, you know, even though that's the case, we are in a stage, and a and a phase of optimization with these EHR platforms. Mhmm. But I almost I'm almost seeing history repeat itself with the operation side of the house. It just feels like there are a myriad of disparate systems, third party solutions, point solutions everywhere, but there's not one single, you know, form or maybe in the Lord of the Rings term, one ring to bind us, kind of kind of a, you know, a an analogy.

Challenges of Disparate Systems

And so I'd love both of you to maybe reflect on, will one work is that really the reality? Is it really just a bunch of disparate systems currently?

Two, if we bring them all together, will that really have an impact? And three, then to reflect on how will it have an impact if we can get all these digital tools altogether, you know, on one platform.

I think that's a good point. And there are disparate systems out there, and it's costing the organization lots of money. You know? When a when a CIO has to think about, you know, a hundred, two hundred, three hundred, four hundred disparate systems, that means four hundred contracts.

That means four that means a whole lot of care and feeding if we can get it down to something more simple. But I think the real key is these systems have gotta talk to each other. You can have disparate systems if they talk to each other. You can have very innovative systems if they talk to each other.

But if they don't talk to each other, then that that's the wrong direction. So I think the first thing is just connectivity, simplifying. You know, where's the duplication and how you can do things. And, you know, as a patient, Mitchell, just keep track of how many times you have to put information in from so many different sources, and then you get there with your child.

And they say, well, what about this? You go, I already told you that. It's in the record. Well, not in this record.

It's in that record. So that's what it's like for people on the front line. It's not here. It's not there.

I gotta have to go. I have to go hunt and peck just like, you know, with patients. So the real key is once you put that in, it goes everywhere, and everybody has that information. So the connection there is super important at first, and then, you know, to get them on, you know, a similar platform is another challenge.

Another level.

Yeah. I think in my own organization, we have really made the move to make decisions based on how things connect together because we've seen the benefit of having, information flow across the entire continuum of care, of connecting now with patients and allowing them to come in. It makes all the difference in the world. And, certainly, we have a lot of work to still do, but we people make decisions.

You know? There might be a best in class. We make decisions based on let's take a look at the at the whole picture. And I think you just have to do that in this day and age.

I agree with you, Mitchell. In the past, that was not always the case, but I think most organizations are really trying to move towards that. And ad, Karlene, I'm sure as you interact with people, they're always asking you about connectivity and that type of thing.

Otherwise, it will just, as you have said, go down the rabbit hole. And it's very hard to simplify if you're not connected. And to have to spend time in and out of different systems, As we said, people get so frustrated that they just say, I I'm not doing what I'm here to do, and they, you know, they'll look elsewhere for roles. So pulling that together, I think, is key. And I do think we are moving in that direction, but there's a long way we have a long way to go because of our history and how things have, you know, have I mean, in the industry in general, but how things have been built and, and executed. So a lot of work to do. Again, engaging those that are doing it and identifying those points of pressure and stress is a really good first step.

Conclusion and Future Research

Well, wonderful. Well, thank you once again, Mary Beth and Karlene, for joining and for just being very open, transparent again. This has been incredible. So looking forward to interviewing on interviewing you on the next round of research that you conduct next year. This this is year two, I believe, of this research study and looking forward to year three next year. So thank you so much.

Thank you. You. Take care.

Bye now.