Selected Podcast
Reducing Clinician Burden and Alert Fatigue
Clinical decision support (CDS) alerts hold promise to improve patient safety but may also endanger it. Finding the balance between effectiveness, efficiency, safety, burden, and clinician concerns such as loss of autonomy will remain a challenge. With appropriate governance, monitoring, and analysis it will be possible to optimize alerting within clinical workflows and share knowledge and strategies across organizations to improve safety by effective use of CDS without contributing to alert fatigue and burden for clinicians.
Featuring:
Christina Michalek, BS, RPh, FASHP is a Medication Safety Specialist and Administrative Coordinator for the Medication Safety Officers Society at the Institute for Safe Medication Practices. She began working with ISMP as an external consultant and advisor in 2001 and later joined the ISMP staff in 2010. At ISMP, Chris works collaboratively with health-system leaders and clinical staff in order to define, design, and improve medication safety initiatives. She has a passion for empowering others to enhance medication safety efforts and enjoys collaborating with healthcare practitioners and sharing best practices through educational programing at national, international, state, and local-level professional conferences. Chris also manages the update and analysis of ISMP’s Targeted Medication Safety Best Practices for Hospitals and is the ISMP lead for medication-related technology issues. Additionally, she has been serving as a Patient Safety Analyst to ECRI Patient Safety Organization since 2013.
Chris is the Chair of Leapfrog’s Barcode Medication Administration Expert Panel, she Co-Chaired ECRI’s Partnership for Patient Safety Health IT Clinical Decision Support for Drug-Allergy Interactions workgroup, she co-leads ECRI’s Partnership for Patient Safety Health IT Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis and Optimization workgroup, and she represents ISMP on the Centers for Disease Control and Prevention Safe Injection Practices Coalition. Chris has had clinical instructor and adjunct faculty appointments at University of the Sciences in Philadelphia, Temple University School of Pharmacy, Wilkes University School of Pharmacy, and is a lecturer at Jefferson College of Pharmacy. She has more than 20 years of acute care hospital pharmacy experience during which time she provided care to a variety of different patient populations before advancing into management and ultimately department leadership roles.
Robert Giannini, NHA, CHTS | Christina Michalek, BS, RPh, FASHP
Mr. Giannini has over 30 years of experience in health care. He joined the ECRI Patient Safety Organization team in April 2012. Prior to joining ECRI, he has held roles as a Patient Safety Officer and Nursing Home Administrator at a variety of facilities. He is a certified healthcare technology specialist (CHTS) as an implementation manager and clinician/practitioner consultant. He has had responsibility for providing patient safety and quality improvement leadership for medication safety initiatives and conducting proactive and reactive risk analysis. He has also provided consultative services to the departments of pharmacy, emergency medicine, geriatric and neurosciences service lines. Mr. Giannini has lectured for professional organizations and alliances, as well as manufacturers.Christina Michalek, BS, RPh, FASHP is a Medication Safety Specialist and Administrative Coordinator for the Medication Safety Officers Society at the Institute for Safe Medication Practices. She began working with ISMP as an external consultant and advisor in 2001 and later joined the ISMP staff in 2010. At ISMP, Chris works collaboratively with health-system leaders and clinical staff in order to define, design, and improve medication safety initiatives. She has a passion for empowering others to enhance medication safety efforts and enjoys collaborating with healthcare practitioners and sharing best practices through educational programing at national, international, state, and local-level professional conferences. Chris also manages the update and analysis of ISMP’s Targeted Medication Safety Best Practices for Hospitals and is the ISMP lead for medication-related technology issues. Additionally, she has been serving as a Patient Safety Analyst to ECRI Patient Safety Organization since 2013.
Chris is the Chair of Leapfrog’s Barcode Medication Administration Expert Panel, she Co-Chaired ECRI’s Partnership for Patient Safety Health IT Clinical Decision Support for Drug-Allergy Interactions workgroup, she co-leads ECRI’s Partnership for Patient Safety Health IT Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis and Optimization workgroup, and she represents ISMP on the Centers for Disease Control and Prevention Safe Injection Practices Coalition. Chris has had clinical instructor and adjunct faculty appointments at University of the Sciences in Philadelphia, Temple University School of Pharmacy, Wilkes University School of Pharmacy, and is a lecturer at Jefferson College of Pharmacy. She has more than 20 years of acute care hospital pharmacy experience during which time she provided care to a variety of different patient populations before advancing into management and ultimately department leadership roles.
Transcription:
Prakash Chandran: Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran.
The growth of health IT resources, specifically clinical decision support, has greatly helped simplify the process of providing patient care, especially in the hospital environment. Many of the sounds and alerts that you hear in a hospital setting are from the system and let care providers know that a patient needs attention. But could all of that beeping and buzzing also have its drawbacks for clinicians?
Here to tell us more is Robert Giannini, Patient Safety Analyst at ECRI and Christina Michalek, pharmacists and medication safety specialist at the Institute for Safe Medication Practices. Chris and Rob, really great to have you here today. Thank you so much for joining me. Rob, I would love to start with you. I wanted to start by asking what exactly are the issues with clinical decision support?
Robert Giannini, NHA, CHTS: Thanks. So although it was designed to help clinicians with information and relevant decision-making, these tools have been found to be relatively ineffective. So we see issues such as overrides, misnotifications, so you did return to uninterrupted tasks and also a lack of relation action.
Prakash Chandran: Okay, understood. And just more specifically, can you go into like the nuances of exactly what CDS is?
Robert Giannini, NHA, CHTS: Yes. So CDS is really a group of tools designed to promote patient safety by providing the information at the right time to the person who is making the decision. CDS functionalities typically include things such as order sets, care plans and protocols, smart documentation forms, data summaries, monitors and dashboards, and protective analytics and reference information. These tools are sometimes informed by patient-specific information, knowledge-based information and quality measures and clinical guidelines. These tools are designed to enhance clinical decision-making at the needed point of care.
Prakash Chandran: And I know this is something that you have written pretty extensively about and you kind of touched upon, but what exactly is alert fatigue?
Robert Giannini, NHA, CHTS: So as Peterson and Bates have defined this, they are researchers in the field, they refer to it as a condition in which too many of us consume time and mental energy to the point that those important warnings and clinically unimportant ones can be ignored.
Prakash Chandran: And when we talk about clinician burden, what exactly does that mean?
Robert Giannini, NHA, CHTS: So burden is the time that providers are spending. And it's often too burdensome and they're often mindless administrative tasks that they're focusing on and their focus should be on the delivery of care to patients.
Prakash Chandran: Chris, Rob obviously just touched on this, but I'm curious as to why you think reducing clinician burden and alert fatigue is so important?
Christina Michalek, BS, RPh, FASHP: Yeah, good question, Prakash. I think first we have to acknowledge that there's a lot of data in the electronic systems that we utilize when we're caring for patients and that data, it's there and it could help clinicians. There's a lot of patient-specific information that could help clinicians make more informed decisions.
But you know, as Rob alluded to, the basic tenet among decision support is that we're providing information to help people do the right thing and make it harder for them to do the wrong thing. And decision support can be really valuable. It could help us ensure that we have the right drug, the right dose, the right patient, that we're providing it at the right time. It could also help us become aware of, you know, significant either real or potential interactions between drugs or with patient-reported allergies.
But in order for this to work and for us to really see the value in it, we have to be able to recognize the message. It needs to be meaningful to us. We don't want practitioners to become desensitized and, you know, that's the fatigue that Rob was talking about. You know, when people become desensitized, then we risk that they might not respond or they might have a decrease in their responsiveness to those warnings, which really can result in messages being ignored. And that's what we don't want. We don't want these important messages being ignored.
So to get back to your question, why is it important? It's important because we want to avoid that fatigue and burnout and frustration that can result when clinicians start to overlook these important messages.
Prakash Chandran: Yeah, that makes so much sense. And yeah, one of the things that you're, you know, focusing on is just how people become desensitized with things that they're exposed to over and over, which is really true of any system that humans are exposed to over time. So I guess the question becomes how we can actually make improvements here? And Rob, I guess I'll direct that question to you.
Robert Giannini, NHA, CHTS: Thanks, Prakash.. And ECRI, as part of it being a patient safety organization, we convened a partnership through the partnership for health IT patient safety, and we gathered relative subject matter experts to actually develop recommendations for this, which included health IT governance, monitoring, analysis and optimization.
So governance includes the ability to identify, develop and execute a clinical decision support and knowledge-based governance. Monitoring gives the ability to gather data and information using clinical decision support specific metrics and other tools to identify real-time or near real-time CDS alert functioning, and the impact that it has on clinicians.
Analysis includes the ability to regularly assess, evaluate, and interpret metrics, functionalities, usability, and impact to determine how effective it is, and is there a value while balancing and minimizing burden.
The last is optimization, and this is where organizations can maximize the use of technology and various tools to create and promote effective, targeted, relevant, and routinely updated alerts.
Prakash Chandran: You know, you've kind of laid out this framework here of governance monitoring and analysis and optimization, but how do you know when those improvements are starting to work?
Robert Giannini, NHA, CHTS: So really, you need to involve senior leadership and the subject matter experts. So that's the clinicians that are using these systems to determine whether they're effective or not. It allows us for them to not only have input in the systems that guide us, but also in providing safe and effective care to our patients.
Prakash Chandran: So Chris, we're talking about this more comprehensive framework to get on the road to making improvements, but what can really be done today?
Christina Michalek, BS, RPh, FASHP: Yeah, great question. I mean, the reality is every organization is at a different point and where you are today is going to guide what you can do today. So if you haven't touched anything, if you haven't addressed anything, you should start. But don't get overwhelmed. Start small. Because as I said before, there's a lot of data out there.
If you're just starting in that data collection phase, you're just starting to look at information, maybe you're even just trying to gather feedback from practitioners, you know, providers or pharmacists. I mean, it would be great if you could set a system up so that practitioners could respond, give you some feedback on decision support that's presented to them, whether it has value.
You could also look at data, picking like just a focused target, maybe it's how many alerts are firing and who's receiving those alerts. Maybe it's number of alerts per order. You know, with a higher number of less significant alerts per order being maybe a trigger that you could be feeding into alert fatigue. It could be at like a firing rate by either a department or an individual. And are alerts specific and sensitive? Were the alerts that fired or were presented to the practitioner appropriate? And what are people doing with alerts? You know, are they overriding? And what's that rate? And this is data that you should be able to pull out from your electronic medical record. Are people accepting the warnings and heeding the warnings? And if they're not, are they providing a reason and what are those reasons?
I mean, it's really good if you can capture some clinician comments in order to really make changes to make alerting more appropriate and reduce that risk for fatigue. And you really want to get at the impact on the recipients because again, there's a lot of really good information there, but we want to make sure that what we're presenting is appropriate and it's meaningful to the person who's receiving it. You know, it might take a little bit more digging, but certainly it's really an important piece to understand in order to reducing clinician burden. Are those alerts effective? Did they provide efficiencies? And then take action on your data. Once you have the data, take action on that. You know, what's effective? What has impact? Push those. And don't forget about the EHR vendors. They may very well be happy, certainly likely, to be able to help you with all of these steps, monitoring, analyzing, and optimizing your electronic health record to really produce the best outcome.
You know, really you have to recognize the work does take resources. So, for sure, start small because even small can affect great change and keep in mind that evaluating alerting really requires regular work. So it's not something we're going to just touch and walk away from. It's going to be something that we stay engaged with.
Prakash Chandran: Yes. You know, Chris, one of the things that you mentioned was that this initiative or making these improvements require resources. So Rob, I was hoping that you might share what resources are currently available to anyone considering making these improvements.
Robert Giannini, NHA, CHTS: Yes. So the partnership has developed a toolkit which includes additional resources as well as strategies and action plans to implement the safe practice recommendations. Some of the resources that are available are things such as the tracking log, what you should be looking from a dashboard perspective, the algorithm and other additional resources and assessment tools. It also provides specific strategies to implement for each of the four recommendations that I spoke of earlier. So things such as engaging leadership and identifying a multi-stakeholder oversight team and assign ongoing accountability.
Then as Chris had said, you need to use technology to sample that information that's needed to monitor alerts. So one is incorporating collaboration with your EHR vendor, but it's also looking at other types of information such as patient safety events, help desk tickets and conducting things such as walk arounds, and just looking at trends and report. Then from an analysis perspective, we need to be able to look at the function and impact and value that these alerts have on. So really that's going out and getting information from the users in order to optimize, which is the next goal.
So ways in which you can optimize are considering ways or types of clinical decision support. There are invasive and non-interruptive alerts that are available. So there are many different ways in which you can alert providers to a function. So make sure you're selecting the right one and to determine the appropriate tool or intervention that's needed to convey that intent and information while always considering patient safety and burden on the clinicians.
Prakash Chandran: So Rob, Chris, this has really been a really fascinating conversation. Just before we close here today, Chris, I guess I'll start with you. Is there anything else that you wanted to share just regarding reducing clinician burden and alert fatigue?
Christina Michalek, BS, RPh, FASHP: Yes. I really would like the audience to not be afraid to tackle this issue. It does seem like a monster when you think about all the information that's available, but really if you take it one step at a time making improvements towards reducing alert fatigue and burden is really going to better empower practitioners to make more informed choices by providing them with information that's relevant to the care that they're providing to their patients at the time. So definitely, don't be afraid to get your toe wet and dive in and really try and start to make improvements in this area.
Prakash Chandran: And Rob, I'll leave you with the last word.
Robert Giannini, NHA, CHTS: Chris is right. It's all about taking small steps. So when CDS was initiated, really was incorporated to improve patient safety. But after looking at it for so many years, it also created a process in which it could endanger patient safety. So it's really finding the delicate balance between safety and burden. And if you take it step by step and include all the appropriate stakeholders, you should be able to optimize and benefit from this great information technology support work.
Prakash Chandran: Well, Chris, Rob, I really appreciate your time today. Thank you so much for joining us.
Christina Michalek, BS, RPh, FASHP: Pleasure to be here. Thanks, Prakash.
Robert Giannini, NHA, CHTS: Thank you, Prakash.
Prakash Chandran: That was Robert Giannini, patient safety analyst at ECRI and Christina Michalek, pharmacist and medication safety specialist at the Institute for Safe Medication Practices.
The ASHRM podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran. Thank you again for listening and we'll talk next time.
Prakash Chandran: Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran.
The growth of health IT resources, specifically clinical decision support, has greatly helped simplify the process of providing patient care, especially in the hospital environment. Many of the sounds and alerts that you hear in a hospital setting are from the system and let care providers know that a patient needs attention. But could all of that beeping and buzzing also have its drawbacks for clinicians?
Here to tell us more is Robert Giannini, Patient Safety Analyst at ECRI and Christina Michalek, pharmacists and medication safety specialist at the Institute for Safe Medication Practices. Chris and Rob, really great to have you here today. Thank you so much for joining me. Rob, I would love to start with you. I wanted to start by asking what exactly are the issues with clinical decision support?
Robert Giannini, NHA, CHTS: Thanks. So although it was designed to help clinicians with information and relevant decision-making, these tools have been found to be relatively ineffective. So we see issues such as overrides, misnotifications, so you did return to uninterrupted tasks and also a lack of relation action.
Prakash Chandran: Okay, understood. And just more specifically, can you go into like the nuances of exactly what CDS is?
Robert Giannini, NHA, CHTS: Yes. So CDS is really a group of tools designed to promote patient safety by providing the information at the right time to the person who is making the decision. CDS functionalities typically include things such as order sets, care plans and protocols, smart documentation forms, data summaries, monitors and dashboards, and protective analytics and reference information. These tools are sometimes informed by patient-specific information, knowledge-based information and quality measures and clinical guidelines. These tools are designed to enhance clinical decision-making at the needed point of care.
Prakash Chandran: And I know this is something that you have written pretty extensively about and you kind of touched upon, but what exactly is alert fatigue?
Robert Giannini, NHA, CHTS: So as Peterson and Bates have defined this, they are researchers in the field, they refer to it as a condition in which too many of us consume time and mental energy to the point that those important warnings and clinically unimportant ones can be ignored.
Prakash Chandran: And when we talk about clinician burden, what exactly does that mean?
Robert Giannini, NHA, CHTS: So burden is the time that providers are spending. And it's often too burdensome and they're often mindless administrative tasks that they're focusing on and their focus should be on the delivery of care to patients.
Prakash Chandran: Chris, Rob obviously just touched on this, but I'm curious as to why you think reducing clinician burden and alert fatigue is so important?
Christina Michalek, BS, RPh, FASHP: Yeah, good question, Prakash. I think first we have to acknowledge that there's a lot of data in the electronic systems that we utilize when we're caring for patients and that data, it's there and it could help clinicians. There's a lot of patient-specific information that could help clinicians make more informed decisions.
But you know, as Rob alluded to, the basic tenet among decision support is that we're providing information to help people do the right thing and make it harder for them to do the wrong thing. And decision support can be really valuable. It could help us ensure that we have the right drug, the right dose, the right patient, that we're providing it at the right time. It could also help us become aware of, you know, significant either real or potential interactions between drugs or with patient-reported allergies.
But in order for this to work and for us to really see the value in it, we have to be able to recognize the message. It needs to be meaningful to us. We don't want practitioners to become desensitized and, you know, that's the fatigue that Rob was talking about. You know, when people become desensitized, then we risk that they might not respond or they might have a decrease in their responsiveness to those warnings, which really can result in messages being ignored. And that's what we don't want. We don't want these important messages being ignored.
So to get back to your question, why is it important? It's important because we want to avoid that fatigue and burnout and frustration that can result when clinicians start to overlook these important messages.
Prakash Chandran: Yeah, that makes so much sense. And yeah, one of the things that you're, you know, focusing on is just how people become desensitized with things that they're exposed to over and over, which is really true of any system that humans are exposed to over time. So I guess the question becomes how we can actually make improvements here? And Rob, I guess I'll direct that question to you.
Robert Giannini, NHA, CHTS: Thanks, Prakash.. And ECRI, as part of it being a patient safety organization, we convened a partnership through the partnership for health IT patient safety, and we gathered relative subject matter experts to actually develop recommendations for this, which included health IT governance, monitoring, analysis and optimization.
So governance includes the ability to identify, develop and execute a clinical decision support and knowledge-based governance. Monitoring gives the ability to gather data and information using clinical decision support specific metrics and other tools to identify real-time or near real-time CDS alert functioning, and the impact that it has on clinicians.
Analysis includes the ability to regularly assess, evaluate, and interpret metrics, functionalities, usability, and impact to determine how effective it is, and is there a value while balancing and minimizing burden.
The last is optimization, and this is where organizations can maximize the use of technology and various tools to create and promote effective, targeted, relevant, and routinely updated alerts.
Prakash Chandran: You know, you've kind of laid out this framework here of governance monitoring and analysis and optimization, but how do you know when those improvements are starting to work?
Robert Giannini, NHA, CHTS: So really, you need to involve senior leadership and the subject matter experts. So that's the clinicians that are using these systems to determine whether they're effective or not. It allows us for them to not only have input in the systems that guide us, but also in providing safe and effective care to our patients.
Prakash Chandran: So Chris, we're talking about this more comprehensive framework to get on the road to making improvements, but what can really be done today?
Christina Michalek, BS, RPh, FASHP: Yeah, great question. I mean, the reality is every organization is at a different point and where you are today is going to guide what you can do today. So if you haven't touched anything, if you haven't addressed anything, you should start. But don't get overwhelmed. Start small. Because as I said before, there's a lot of data out there.
If you're just starting in that data collection phase, you're just starting to look at information, maybe you're even just trying to gather feedback from practitioners, you know, providers or pharmacists. I mean, it would be great if you could set a system up so that practitioners could respond, give you some feedback on decision support that's presented to them, whether it has value.
You could also look at data, picking like just a focused target, maybe it's how many alerts are firing and who's receiving those alerts. Maybe it's number of alerts per order. You know, with a higher number of less significant alerts per order being maybe a trigger that you could be feeding into alert fatigue. It could be at like a firing rate by either a department or an individual. And are alerts specific and sensitive? Were the alerts that fired or were presented to the practitioner appropriate? And what are people doing with alerts? You know, are they overriding? And what's that rate? And this is data that you should be able to pull out from your electronic medical record. Are people accepting the warnings and heeding the warnings? And if they're not, are they providing a reason and what are those reasons?
I mean, it's really good if you can capture some clinician comments in order to really make changes to make alerting more appropriate and reduce that risk for fatigue. And you really want to get at the impact on the recipients because again, there's a lot of really good information there, but we want to make sure that what we're presenting is appropriate and it's meaningful to the person who's receiving it. You know, it might take a little bit more digging, but certainly it's really an important piece to understand in order to reducing clinician burden. Are those alerts effective? Did they provide efficiencies? And then take action on your data. Once you have the data, take action on that. You know, what's effective? What has impact? Push those. And don't forget about the EHR vendors. They may very well be happy, certainly likely, to be able to help you with all of these steps, monitoring, analyzing, and optimizing your electronic health record to really produce the best outcome.
You know, really you have to recognize the work does take resources. So, for sure, start small because even small can affect great change and keep in mind that evaluating alerting really requires regular work. So it's not something we're going to just touch and walk away from. It's going to be something that we stay engaged with.
Prakash Chandran: Yes. You know, Chris, one of the things that you mentioned was that this initiative or making these improvements require resources. So Rob, I was hoping that you might share what resources are currently available to anyone considering making these improvements.
Robert Giannini, NHA, CHTS: Yes. So the partnership has developed a toolkit which includes additional resources as well as strategies and action plans to implement the safe practice recommendations. Some of the resources that are available are things such as the tracking log, what you should be looking from a dashboard perspective, the algorithm and other additional resources and assessment tools. It also provides specific strategies to implement for each of the four recommendations that I spoke of earlier. So things such as engaging leadership and identifying a multi-stakeholder oversight team and assign ongoing accountability.
Then as Chris had said, you need to use technology to sample that information that's needed to monitor alerts. So one is incorporating collaboration with your EHR vendor, but it's also looking at other types of information such as patient safety events, help desk tickets and conducting things such as walk arounds, and just looking at trends and report. Then from an analysis perspective, we need to be able to look at the function and impact and value that these alerts have on. So really that's going out and getting information from the users in order to optimize, which is the next goal.
So ways in which you can optimize are considering ways or types of clinical decision support. There are invasive and non-interruptive alerts that are available. So there are many different ways in which you can alert providers to a function. So make sure you're selecting the right one and to determine the appropriate tool or intervention that's needed to convey that intent and information while always considering patient safety and burden on the clinicians.
Prakash Chandran: So Rob, Chris, this has really been a really fascinating conversation. Just before we close here today, Chris, I guess I'll start with you. Is there anything else that you wanted to share just regarding reducing clinician burden and alert fatigue?
Christina Michalek, BS, RPh, FASHP: Yes. I really would like the audience to not be afraid to tackle this issue. It does seem like a monster when you think about all the information that's available, but really if you take it one step at a time making improvements towards reducing alert fatigue and burden is really going to better empower practitioners to make more informed choices by providing them with information that's relevant to the care that they're providing to their patients at the time. So definitely, don't be afraid to get your toe wet and dive in and really try and start to make improvements in this area.
Prakash Chandran: And Rob, I'll leave you with the last word.
Robert Giannini, NHA, CHTS: Chris is right. It's all about taking small steps. So when CDS was initiated, really was incorporated to improve patient safety. But after looking at it for so many years, it also created a process in which it could endanger patient safety. So it's really finding the delicate balance between safety and burden. And if you take it step by step and include all the appropriate stakeholders, you should be able to optimize and benefit from this great information technology support work.
Prakash Chandran: Well, Chris, Rob, I really appreciate your time today. Thank you so much for joining us.
Christina Michalek, BS, RPh, FASHP: Pleasure to be here. Thanks, Prakash.
Robert Giannini, NHA, CHTS: Thank you, Prakash.
Prakash Chandran: That was Robert Giannini, patient safety analyst at ECRI and Christina Michalek, pharmacist and medication safety specialist at the Institute for Safe Medication Practices.
The ASHRM podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran. Thank you again for listening and we'll talk next time.