The next BriefingsDirect healthcare finance insights discussion explores the rapidly changing ways that caregiver organizations on-board and manage patients.
How patients access their healthcare is transitioning to the digital world — but often in fits and starts. This key process nonetheless plays a major role in how patients perceive their overall experiences and determines how well providers manage both care and finances.
Stay with us to unpack the people, process, and technology elements behind modern patient access best practices. To learn more, we are joined by an expert panel: Jennifer Farmer, Manager of Patient Access and Admissions at Massachusetts Eye and Ear Infirmary in Boston; Sandra Beach, Manager of the Central Registration Office, Patient Access, and Services and Pre-Services at Cooley Dickinson Healthcare in Northampton, Mass., and Julie Gerdeman, CEO of HealthPay24 in Mechanicsburg, Penn. The panel is moderated by Dana Gardner, Principal Analyst at Interarbor Solutions.
Here are some excerpts:
Gardner: Jennifer, for you and your organization, how has the act of bringing a patient into a healthcare environment — into a care situation — changed in the past five years?
Farmer: The technology has exploded and it’s at everyone’s fingertips. So five years ago, patients would come to us, from referrals, and they would use the old-fashioned way of calling to schedule an appointment. Today it is much easier for them. They can simply go online to schedule their appointments.
They can still do walk-ins as they did in the past, but it’s much easier access now because we have the ways and means for the patients to be triaged and given the appropriate information so they can make an appointment right then and there, versus waiting for their provider to call to say, “Hey, we can schedule your appointment.” Patients just have it a lot easier than they did in the past.
Gardner: Is that due to technology? It seems to me that when I used to go to a healthcare organization they would be greeting me by handing me a clipboard, but now they are always sitting at a computer. How has the digital experience changed this?
Farmer: It has changed it drastically. Patients can now complete their accounts online and so the person sitting at the desk already has that patient’s information. So the clipboard is gone. That’s definitely something patients like. We get a lot of compliments on that.
It’s easier to have everything submitted to us electronically, whether it’s medical records or health insurance. It’s also easier for us to communicate with the patient through the electronic health record (EHR). If they have a question for us or we have a question for them, the health record is used to go back and forth.
Gain a Detailed Look at Patient
There are not as many phone calls as there used to be, not as many dropped ends. There is also the advent of telemedicine these days so doctors can have a discussion or a meeting with the patient on their cell phones. Technology has definitely changed how medicine is being distributed as well as improving the patient experience.
Gardner: Sandra, how important is it to get this right? It seems to me that first impressions are important. Is that the case with this first interception between a patient and this larger, complex healthcare organization and even ecosystem?
Beach: Oh, absolutely. I agree with Jennifer that so many things have changed over the last five years. It’s a benefit for patients because they can do a lot more online, they can electronically check-in now, for example, that’s a new function. That’s going to be coming with [our healthcare application] Epicso that patients can do that all online.
The patient portal experience is really important too because patients can go in there and communicate with the providers. It’s really important for our patients as telemedicine has come a huge distance over the years.
Gardner: Julie, we know how important getting that digital trail of a patient from the start can be; the more data the better. How have patient access best practices been helped or hindered by technology? Are the patients perceiving this as a benefit?
Gerdeman: They are. There has been a huge improvement in patient experience from technology and the advent and increase in technology. A patient is also a consumer. We are all just people and in our daily lives we do more research.
So, for patient access, even before they book an appointment, either online or on the phone, they pull out their phones and do a ton of research about the provider institution. That’s just like folks do for anything personal, such as a local service like a dry cleaning or a haircut. For anything in your neighborhood or community, you do the same for your healthcare because you are a consumer.
The same level of consumer support that’s expected in our modern daily lives has now come to be expected with our healthcare experiences. Leveraging technology for access is just beginning and will continue to impact healthcare.
The same level of consumer support that’s expected in our modern daily lives has now come to be expected with our healthcare experiences. Leveraging technology for access, and as Jennifer and Sandra mentioned, the actual clinical experience — via telemedicine and digital transformation — is just getting into and will continue to impact healthcare.
Gardner: We have looked at this through the lens of the experience and initial impressions — but what about economics? When you do this right, is there a benefit to the provider organization? Is there a benefit to the patient in terms of getting all those digital bits and bytes and information in the right place at the right time? What are the economic implications, Jennifer?
Technology saves time and money
Farmer: They are two-fold. One, the economic implication for a patient is tht they don’t necessarily have to take a day off from work or leave work early. They are able to continue via telemedicine, which can be done through the evening. When providers offer evening and weekend appointments, that’s to satisfy the patient so they don’t have to spend as much time trying to rearrange things, get daycare, or pay for parking.
For the provider organization, the economic implications are that we can provide services to more patients, even as we streamline certain services so that it’s all more efficient for the hospital and the various providers. Their time is just as valuable as anyone else’s. They also want to reduce the wait times for someone to see a patient.
The advent of using technology across different avenues of care reduces that wait time for available services. The doctors and technicians are able to see more patients, which obviously is an economic positive for the hospital’s bottom line.
Gardner: Sandra, patients are often not just having one point of intersection, if you will, with these provider organizations. They probably go to a clinic, then a specialist, perhaps rehabilitation, and then use pharmaceutical services. How do we make this more of a common experience for how patients intercept such an ecosystem of healthcare providers?
Beach: I go back to the EHRs that Jennifer talked about. With us being in a partner system, no matter where you go — you could go to a rehab appointment, a specialist, to the cancer center in Boston — all your records are accessible for the physicians, and for the patients. That’s a huge step in the right direction because, no matter where the patient goes, you can access the records, at least within our system.
Gardner: Julie, to your point that the consumer experience is dictating people’s expectations now, this digital trail and having that common view of a patient across all these different parts of the organization is crucial. How far along are we with that? It seems to me that we are not really fully baked across that digital experience.
Gerdeman: You’re right, Dana. I think the partner approach is an amazing exception to the rule because they are able to see and share data across their own network.
Throughout the rest of the country, it’s a bit more fractured and splintered. There remains a lot of friction in accessing records as you move — even in some cases within the same healthcare system — from a clinic or the emergency department (ED) into the facility or to a specialist.
The challenge is one of interoperability of data and integration of that data. Hospitals continue to go through a lot of mergers and acquisitions, and every acquisition creates a new challenge.
From the consumer perspective, they want that to be invisible. It should be invisible, the right data should be on their phones regardless of what the encounter was, what the financial obligation for the encounter was — all of it. So that’s the expectation and what’s still happening. There is a way to go in terms of interoperability and integration from the healthcare side.
Gardner: We have addressed the process and the technology, but the third leg on the stool here is the people. How can the people who interact with patients at the outset foster a better environment? Has the role and importance of who is at that initial intercept with the patient been elevated? So much rides on getting the information up front. Jennifer, what about the people in the role of accessing and on-boarding patients, what’s changed with them?
Get off to a great start
Farmer: That is the crux of the difference between a good patient experience and a terrible patient experience, that first interaction. So folks who are scheduling appointments and maybe doing registration — they may be at the information desk — they are all the drivers to making sure that that patient starts off with a great experience.
Most healthcare organizations are delving into different facets of customer service in order to ensure that the patient feels great and like they belong when they come into an organization. Here at Mass. Eye and Ear, we practice something called Eye Care. Essentially, we think about how you would want yourself and your family members to be treated, to make sure that we all treat patients who walk in the door like they are our family members.
When you lead with such a positive approach it downstreams into that patient’s feelings of, “I am in the right place. I expect my care to be fantastic. I know that I’m going to receive great care.” Their positive initial outlook generally reflects the positive outcome of their overall visit.
Most providers are siloed, with different areas or departments. That means patients would hear, “Oh, sorry, we can’t help you. That’s not our area.” To make it a more inclusive experience, everyone in the organization is a brand ambassador.
This has changed dramatically even within the past two to three years. Most providers are siloed, with different areas or departments. That means patients would hear, “Oh, sorry, we can’t help you. That’s not our area.” To make it a more inclusive experience, everyone in the organization is a brand ambassador.
We have to make sure that people understand that, to make it more inclusive for the patient and less hectic for the patient, no matter where you are within a particular organization. I’m sure Sandra can speak to this as well. We are all important to that patient, so if you don’t know the answer, you don’t have to say, “I don’t know.” You can say, “Let me get someone who can assist you. I’ll find some information for you.”
It shouldn’t be work for them when patients walk in the door. They should be treated as a guest, welcomed and treated as a family member. Three or four years ago, it was definitely the mindset of, “Not my job.” At other organizations that I visit, I do see more of a helpful environment, which has changed the patient perception of hospitals as well.
Beach: I couldn’t agree more, Jennifer. We have the same thing here as with your Eye Care. I ask our staff every day, “How would you feel if you were the patient walking in our door? Are we greeting patients with a nice, warm, friendly smile? Are we asking, ‘How can I help you today?’ Or, ‘Good morning, what can I do for you today?’”
Gain a Detailed Look at Patient
We keep that at the forefront for our staff so they are thinking about this every time that they greet a patient, every day they come to work, because patients have choices, patients can go to other facilities, they can go to other providers.
We want to keep our patients within our healthcare system. So it’s really important that we have a really good patient experience on the front end, because Jennifer is correct, it has a positive outcome on the back end. If they start off in the very beginning with a scheduler or a registrar or an ED check-in person, and they are not greeted in a friendly, warm atmosphere, then typically that’s what sets off their total visit. That seems to be what they remember. That first interaction is really what they remember.
Gardner: Julie, this reflects back on what’s been happening in the consumer world around the user experience. It seems obvious.
So I’m curious about this notion of competition between healthcare providers. That might be something new as well. Why do healthcare provider organizations need to be thinking about this perception issue? Is it because people could pick up and choose to go somewhere else? How has competition changed the landscape when it comes to healthcare?
Competing for consumers’ care
Gerdeman: Patients have choices. Sandra described that well. Patients, particularly in metropolitan or suburban areas, have lots of options for primary care, specialty care, and elective procedures. So healthcare providers are trying to respond to that.
In the last few years you have seen not just consumerism from the patient experience, but consumerism in terms of advertising, marketing, and positioning of healthcare services — like we have never seen before. That competition will continue and become even more fierce over time.
Providers should put the patient at the center of everything that they do. Just as Jennifer and Sandra talked about, putting the patient at the heart and then showing empathy from the very first interaction. The digital interaction needs to show empathy, too. And there are ways to do that with technology and, of course, the human interaction when you are in the facility.
Patients don’t want to be patients most of the time. They want to be humans and live their lives. So, the technology supporting all of that becomes really crucial. It has to become part of that experience. It has to arm the patient access team and put the data and information at their fingertips so they can look away from a computer or a kiosk and interact with that patient on a different level. It should arm them to have better, empathic interactions and build trust with the patient, with the consumer.
Gardner: I have seen that building competition where I live in New Hampshire. We have had two different nationally branded critical-care clinics open up — pop-up like mushrooms in the spring rain — in our neighborhood.
Let’s talk about the experience not just for the patient but for that person who is in the position of managing the patient access. The technology has extended data across the partner organization. But still technology is often not integrated in the back end for the poor people who are jumping between four and five different applications — often multiple systems — to on-board patients.
What’s the challenge from the technology for the health provider organization, Jennifer?
One system, one entry point, it’s Epic
Farmer: That used to be our issue until we gained the Epic system in 2016. People going into multiple applications was part of the issue with having a positive patient experience. Every entry point that someone would go to, they would need to repeat their name and date of birth. It looked one way in one system and it looked another way in a different system. That went away with Epic.
Epic is one system, the registration or the patient access side. It is also the coding side, it’s billing, it’s medical records, it’s clinical care, medications, it’s everything.
So for us here at Mass. Eye and Ear, no matter where you go within the organization, and as Sandra mentioned earlier, we are part of the same Partners HealthCare system. You can actually go to any Partners facility and that person who accesses your account can see everything. From a patient access standpoint, they can see your address and phone number, your insurance information, and who you have as an emergency contact.
There isn’t that anger that patients had been feeling before, because now they are literally giving their name and date of birth only as a verification point. It does make it a lot easier for our patients to come through the door, go to different departments for testing, for their appointment, for whatever reason that they are here, and not have to show their insurance card 10 times.
If they get a bill in the mail and they are calling our billing department, they can see the notes that our financial coordinators, our patient access folks, put on the account when they were here two or three months ago and help explain why they might have gotten a bill. That’s also a verification point, because we document everything.
So, a financial coordinator can tell a patient they will get a bill for a co-pay or for co-insurance and then they get that bill, they call our billing team, they say, “I was never told that,” but we have documentation that they were told. So, it’s really one-stop shopping for the folks who are working within Epic. For the patient, nine times out of 10 they just can go from floor to floor, doctor to doctor, and they don’t have to show ID again, because everything is already stored in Epic.
Beach: I agree because we are on Epic as well. Prior to that, three years ago, it would be nothing for my registrars to have six, seven systems up at the same time and have to toggle back and forth. You run a risk by doing that, because you have so many systems up and you might have different patients in the system, so that was a real concern.
If a patient came in and didn’t have an order from the provider, we would have to call their office. The patient would have to wait. We might call two or three times.
Now we have one system. If the patient doesn’t have the order, it’s in the computer system. We just have to bring it up, validate it, patient gets checked in, patient has their exam, and there is no wait. It’s been a huge win for us and for our patients.
Now, we have one system. If the patient doesn’t have the order, it’s in the computer system. We just have to bring it up, validate it, patient gets checked in, patient has their exam, and there is no wait. It’s been a huge win for us for sure — and for our patients.
Gardner: Privacy and compliance regulations play a more important role in the healthcare industry than perhaps anywhere else. We have to not only be mindful of the patient experience, but also address these very important technical issues around compliance and security. How are you able to both accomplish caring for the patient and addressing these hefty requirements?
It’s healthy to set limits on account access
Farmer: Within Epic, access is granted by your role. Staff that may be working in admitting or the ED or anywhere within patient access, but they don’t have access to someone’s medication list or their orders. However, another role may have access.
Compliance is extremely important. Access is definitely something that is taken very seriously. We want to make sure that staff are accessing accounts appropriately and that there are guardrails built in place to prevent someone from accessing accounts if they should not be.
For instance, within the Partners HealthCare system, we do tend to get people of a certain status; we get politicians, we get celebrities, we get heads of state, public figures that go to various hospitals, even outside of Partners that are receiving care. So we have locks on those particular accounts for employees. Their accounts are locked.
Gain a Detailed Look at Patient
So if you try to access the account, you get a hard stop. You have to complete why you are accessing this account, and then it is reviewed immediately. And if it’s determined that your role has nothing to do with it, you should not be accessing this particular account, then the organization does takes necessary steps to investigate and either say yes, they had a reason to be in this account, or no, they did not, and the potential of termination is there.
But we do take privacy very seriously within the system and then outside of the system. We make sure we are providing a safe space for people to be able to provide us with their information. It is on the forefront, it drives us, and folks definitely are aware because it is part of their training.
Beach: You said it perfectly, Jennifer. Because we do have a lot of people that are high profile and that do come through our healthcare systems the security, I have to say, is extremely tight on records. And so it should be. If you are in a record, and you shouldn’t be there, then there are consequences to that.
Gardner: Julie, in addition to security and privacy we have also had to deal with a significant increase in the complexity around finances and payments given how insurers and the payers work. Now there are more copays, more kinds of deductibles. There are so many different plans: platinum, gold, silver, bronze.
In order to keep the goal of a positive patient experience, how are we addressing this new level of complexity when it comes to the finances and payments? Do they go hand-in-hand, the patient experience, the access, and the economics?
A clean bill of health for payment
Gerdeman: They do, and they should, and they will continue to. There will remain complexity in healthcare. It will improve certainly over time, but with all of the changes we have seen complexity is a given. It will be there. So how to handle the complexity, with technology, with efficient process, and with the right people becomes more and more important.
There are ways to make the complex simple with the right technology. On the back end, behind that amazing patient experience — both the clinical experience and also the financial experience – we try to shield the patient. At HealthPay24 we are focused on financial experience and taking all of the data that’s behind there and presenting it very simply to a patient.
That means one small screen on the phone — with different encounters and different back ends – of being able to present that very simply for our patients to meet their financial obligations. They are not concerned that the ED had one different electronic medical record (EMR) than the specialist. That’s really not the concern of the patient, nor should it be. It’s the concern of how the providers can use technology in the back end to then make it simple and change that experience.
We talked about loyalty, and that’s what drives loyalty. You are going to keep coming back to a great experience, with great care, and ease of use. So for me, that’s all crucial as we go forward with healthcare – the technology and the role it plays.
Gardner: And Jennifer and Sandra, how do you see the relationship between the proper on-boarding, access, and experience and this higher complexity around the economics and finance? Do you see more of the patient experience addressing the economics?
Farmer: We have done an overhaul of our system, where it concerns patients, for paying bills or for not having health insurance. Our financial coordinators are there to assist our patients, whether by phone, email, in person. There are lots of different programs we can introduce patients to.
We are certified counselors for the Commonwealth of Massachusetts. That means we are able to help the patient apply for health insurance through the Health Connector for Massachusetts as well as for the state Medicaid program called MassHealth. And so we are here to help those patients go through that process.
We also have an internal program that can assist patients with paying their bills. We talk to patients about different credit cards that are available for those that may qualify. And essentially, the bottom line too is somebody just once again on a payment plan. So, we take many factors, and we try to make it work as best as we can for the patient.
At the end of the day, it’s about that patient receiving care and making sure that they are feeling good about it. We definitely try to meet their needs and introduce them to different things. We are here to support them, and at the end of the day it’s again about their care. If they can’t pay anything right now, but they obviously need immediate medical services, then we assure them, let’s focus on your care. We can talk about the back end or we can talk about your bills at a different point.
We do provide them with different avenues, and we are pretty proud of that because I like to believe that we are successful with it and so it helps the patient overall.
Gerdeman: It really does go to that patients want to meet their obligations, but they need options to be able to do that. Those options become really important — whether it’s a loan program, a payment plan, applying for financial assistance – and technology can enable all of these things.
For HealthPay24, we enable an eligibility check right in the platform so you don’t have to worry about others knowing. You can literally check for eligibility by clicking a button and entering a few fields to know if you should be talking to financial counseling at a provider.
You can apply for payment plans, if the providers opt for that. It will be proactively offered based on demographic data to a patient through the platform. You can also apply for loans, for revolving credit, through the platform. Much of what patients want and need financially is now available and enabled by technology.
Gardner: Sandra, such unification across the financial, economic, and care giving roles strikes me as something that’s fairly new.
Beach: Yes, absolutely it is. We have a program in our ED, for example, that we instituted a year ago. We offer an ED discharge service so when the patient is discharged, they stop at our desk and we offer these patients a wide variety of payment options. Or maybe they are homeless and they are going through a tough time. We can tell them where they can go to get a free meal or spend the night. There are a whole bunch of programs available.
That’s important because we will never turn a patient away. And when patients come through our ED, they need care. So when they leave, we want to be able to help them as much as we can by supporting them and giving them these options.
That’s important because we will never turn a patient away. And when patients come through our ED, they need care. So when they leave, we want to be able to help them as much as we can by supporting them and giving them these options.
We have also made phone calls for our patients as well. If they need to get someplace just to spend the night, we will call and we will make that arrangement for those patients. So when they leave, they know they have a place to go. That’s really important because people go through hard times.
Gardner: Sandra, do you have any other examples of processes or approaches to people and technology that you have put in place recently? What have been some of the outcomes?
Check-in at home, spend less time waiting
Beach: Well, the ED discharge service has made a huge impact. We saw probably 7,000-8,000 patients through that desk over the last year. We really have helped a lot of patients. But we are also there just to lend an ear. Maybe they have questions about what the doctor just said to them, but they really weren’t sure what he said. So it’s just made a huge impact for our patients here.
Gardner: Jennifer, same question, any processes you have put in place, examples of things that have worked and what are the metrics of success?
Farmer: We just rolled out e-check-in. So I don’t have any metrics on it just yet, but this is a process where the patient can go to their MyChart or their EHR and check in for an appointment prior to the day. They can also pay their copay. They can provide us with updates to their insurance information, address or phone number, so when they actually come to their appointment, they are not stopping at the desk to sign in or do check in.
That seems to be a popular option for the office visitor currently piloting this, and we are hoping for a big success. It will be rolled out to other entities, but right now that is something that we are working on. It’s tying in the technology, the patient care, for the patient access. It’s tying in the ease of the check-in with that patient. And so again, we are hoping that we have some really positive metrics on that.
Gardner: What sort of timeframe are we talking about here in terms of start to finish from getting that patient into their care?
Farmer: So if they are walking in the door because they have already done e-check-in, they are immediately going in for their appointment, because they are showing up on time, they are expected, they are going right in, so the time that the patient is sitting there waiting in line, sitting in the waiting area, that’s being reduced; the time that they have to talk to someone about any changes or confirming everything that we have on their account, that time is being reduced.
And then we are hoping to test this in a pilot program for the next month to six weeks to see what kind of data we can get and hopefully that will — just across the board, just help with that check in process for patients and reduce that time for the folks who are at the desk and they can focus on other tasks as well. So we are giving them back their time.
Gardner: Julie, this strikes me in the parlance of other industries as just-in-time healthcare, and it’s a good move. I know you deal with a national group of providers and payers. Any examples, Julie, that demonstrate and illustrate the positive direction we are going with patient access and why technology is an important part of that?
Gerdeman: I refer to Christopher Penn’s model of People, Process, and Technology here, Dana, because when people touch process, there is scale, and when process and technology intersect, there is automation. But most importantly, when people intersect with technology, there is innovation, and what we are seeing is not just incremental innovation — but huge leaps in innovation.
What Jen just described as that experience of just-in-time healthcare, that is literally a huge need, that’s a leap, right? We have come to expect it when we reserve a table via OpenTable, when we e-check-in for a hair appointment. I go back to that consumer experience, but that innovation, right, that’s happening all across healthcare.
Gain a Detailed Look at Patient
One of the things that we just launched, which we are really excited about, is predictive analytics tied to the payment platform. If you know and can anticipate the behaviors and the patterns of a demographic of patients, financially speaking, then it will help ease the patient experience in what they owe, how they pay, and what’s offered to them. It boosts the bottom line of providers, because they are going to get increased revenue collection.
So where predictive analytics is going in healthcare and tying that to the patient experience and to the financial systems, I think will become more and more important. And that leads to even more — there is so much emerging technology on the clinical side and we will continue to see more emerging technology on the back-end systems and the financial side as well.
Gardner: Before we close out, perhaps a look to the future, and maybe even a wish list. Jennifer, if you had a wish list for how this will improve in the next few years, what’s missing, what’s yet to come, what would you like to see available with people, process, and technology?
Farmer: I go back to just patient care, and while we are in a very good spot right now, it can always improve. We need more providers, we need more technicians, we need more patient access folks, and the sense of being able to take care of people because the population is growing and whether you know it or not, you are going to need a doctor at some point.
So I think continuing on the path that we are on of providing excellent customer service, listening to patients, being empathetic. Also providing them with options; different appointment times, different finance options, different providers, it can only get better.
Beach: I absolutely agree. We have a really good computer system, we have the EMRs, but I would have to agree with Jennifer as well that we really need more providers. We need more nurses to take care of our patients.
Gardner: So it comes down to human resources. How about those front-line people who are doing the patient access intercept? Should they have an elevated status, role, and elevated pay schedule?
Farmer: It’s really tough for the patient access people because on the front line — every minute of every day, eight to 10 hours a day — they are working on that front line, so sometimes that’s tough.
It’s really important that we keep training with them. We give them options of going to customer service classes, because their role has changed from basically checking in a patient to now making sure if their insurance is correct. We have so many different insurance plans these days. To know each of those elevates that registrar to be almost an expert in that field in order to be able to help the patient and get them through that registration process, and the bottom line — to get reimbursed for those services. So it’s really come a long way.
Gardner: Julie, on this future perspective, what do you think will be coming down the pike for provider organizations like Jennifer and Sandra’s in terms of technology and process efficiency? How will the technology become even more beneficial?
Gerdeman: It’s going to be a big balancing act. What I mean by that is we are now officially more of an older country than a younger country in terms of age. People are living longer, they need more care than ever before, and we need the systems to be able to support that. So, everything that was just described is critical to support our aging population.
We have a whole other generation entering into healthcare as patients, as providers, and as technologists. This new generation has a completely different expectation of what that experience should and will be.
But what I mean by the balancing act is we have a whole other generation entering into healthcare as patients, as providers, and as technologists. This new generation has a completely different expectation of what that experience should and will be. They might have an expectation that their wearable device should give all of that data to a provider. That they wouldn’t need to explain it, that it should all be there all day, not just that they walk in and have just-in-time, but all the health data is communicated ahead of time, before they are walking in and then having a meaningful conversation about what to do.
This new generation is going to shift us to wellness care, not just care when we are sick or injured. I think that’s all changing. We are starting to see the beginnings of that focus on wellness. And wearables and devices, and how they are used, the providers are going to have to juggle that with the aging population and traditional services — as well as the new. Technology is going to be a key, core part of that going forward.