"The Rapid Autopsy Program" and "Ambulatory Oncology Transformation: Care Delivery Workflow"

May 13, 2022

Information

Yale Cancer Center Grand Round | May 10, 2022

Presentations by: Harry Sanchez, MD and Marcello DiStasio, MD, PhD and Monica Fradkin, BSN, MPH, OCN, CNML, Christina Matousek, MSN, RN, OCN, and Mandeep Smith, BSN, OCN

ID7825

To CiteDCA Citation Guide

00:00Welcome everyone to grand Rams.
00:06We have two sets of speakers today
00:09with two quite different topics,
00:13so our first presentation is going to
00:17be focused on tissue donation and the
00:21rapid autopsy program that's developing
00:24and and we welcome Harry Sanchez,
00:27who's an assistant professor of pathology.
00:31And and as well as Marcella Destasio,
00:35who is an instructor in pathology.
00:39Doctor Sanchez is currently
00:41developing the Yale or Doctor Sanchez
00:45and and doctor this size there.
00:47Currently developing the Yale
00:49Tissue Donation Program,
00:50which we hope will enhance.
00:53Both basic and translational research
00:56at at the school.
00:57When fully launched,
00:59the program will enable patients
01:01with late stage cancer to consent
01:03to donate tissue for research,
01:05as well as the component that
01:09is about rather rapid autopsy,
01:11where patients will be will be able
01:14to donate tissue in the context
01:17of a rapid autopsy program or a
01:20warm autopsy program so the tissue
01:24can be can can be taken and used
01:27for a variety of different.
01:29Purposes in.
01:30In my experience,
01:32many,
01:33many different labs and it's one
01:36of the big advantages of this this
01:40somewhat difficult to approach.
01:42So without further ado,
01:44I'm gonna ask Harry this morning
01:46and we'll go from there.
01:49OK, I'm gonna share my screen.
01:52And hopefully you can see that OK.
01:56Yeah, you just need to
01:57be in presentation mode
01:58that you go.
01:59OK, well thank you. Thank you very much.
02:01Doctor Weiner for the introduction
02:03and thank you very much for having us.
02:05As you said, we'd like to talk to
02:07you about the rapid autopsy program,
02:09which is really, there's nothing
02:11technologically new about the approach,
02:13but it is a it's a way to get patients
02:16I think involved in the basic
02:18science aspect of clinical research,
02:20and it's way to coordinate our existing
02:23resources of so that we can get.
02:26You know, sort of address the
02:28problem of getting high quality and
02:31and sufficient quantity of tissue.
02:33And so our objective said today are
02:34to talk to you a little bit about
02:36this approach and its advantages for
02:38patients and and clinical researchers.
02:40And we do feel they were advantages for both.
02:42To talk to you a little bit about rapid
02:46autopsy programs that already exist.
02:48And finally,
02:49to ask for your input and to
02:51and your participation,
02:53so that we're still putting this together.
02:55Those of you with thoughts on
02:56how we could do this better.
02:57We'd love to hear them,
03:00and so sorry to do that.
03:02And we'll just. We'll go with that.
03:04The outline I'd like to put
03:06the problem sort of in context,
03:09and talk about the problem of sort
03:11of human tissue for research from the
03:14patient and research scientist perspective,
03:17and then talk to a little bit about
03:19how I think the rapid autopsy approach
03:21addresses some of those things.
03:23It's it's not a solution for everything,
03:24but I think it is a very useful
03:27addition to to what's already in place.
03:32So problems for patients in the
03:35general public or, you know,
03:36sort of the subheading why you might
03:38not want if you are a patient to
03:40participate in clinical research.
03:42And I think this goes back
03:44to the problem that has been
03:46since the beginning of sort of.
03:48Sort of formal medical research
03:50once people realized physicians in
03:52the 1300s that it was hard to study
03:56function without understanding form,
03:58people started studying anatomy,
03:59and at the very beginning it was a
04:02small enough enterprise that only
04:04the most marginal people executed.
04:06Criminals were what was needed
04:08and that was enough,
04:09but as interest spread success became,
04:12you know,
04:13sort of more universal and the
04:15approach became adopted.
04:17The supply of of bodies for a study
04:22was far short of the legitimate demand,
04:25and so it created this sort of
04:28underground network of supply and
04:29people resorted to grave robbery,
04:32and when that wasn't enough,
04:33eventually in in Edinburgh murder to
04:37come by tissue and that led to the
04:39Anatomy Act of 1832 and the reason
04:41that I include this is that I think
04:44the Anatomy Act which addressed this
04:46problem beautifully states the problem.
04:47Basically,
04:48you can't know the causes and nature
04:51of disease without studying tissue,
04:53but the supply of tissue is
04:55insufficient and that can drive
04:57people to do very ill advised things,
05:00and that's not a problem that
05:02went away in the 1800s.
05:04So on the left here you can see
05:06this is an image from the Tuskegee
05:08syphilis experiments,
05:08which are rather the study that started
05:11in 1932 and went on for the next 40 years,
05:15400 unwitting.
05:17Volunteers for this program and on
05:21the right is the front cover from
05:23the immortal life of Henrietta, Lex.
05:26She was a woman in her early 30s
05:28who developed cervical cancer,
05:31went to Johns Hopkins for treatment
05:33and tissue from her cervical cancer,
05:36was used to create a very successful
05:39cell line.
05:39The heel of cells,
05:41but that was done completely without
05:43her knowledge or her consent.
05:45And so while all of these things
05:47may have had.
05:48Good intentions behind them
05:50and developed some results.
05:52The result is that human.
05:56Sort of tissue for use of medical
05:58research has this sort of checkered
06:00and sort of fraud.
06:01Past that,
06:02I think generates the sort of
06:04suspicion that still with us today.
06:05Even when we try to do things as a as
06:07a profession that are for the public good.
06:11No, there are still
06:13plenty of people who want to participate
06:15in research and and and do and and and.
06:17I'd like to say that I'm going to talk
06:19mostly about participating in the earliest
06:21phases of sort of basic science research,
06:24and that is something that's very
06:27difficult to do as as a patient or
06:29just a member of the general public.
06:32Research is extraordinarily expensive.
06:35I think you know the average NIH award is
06:38something on the order of half $1,000,000.
06:40And it's not the sort of thing that most
06:43of us can put a dent in individually,
06:45and you can do work that helps you know
06:48with sort of organizations and things,
06:50but you can't really foster.
06:52You can't advance basic science
06:54work as an untrained person.
06:55You can, however, donate tissue.
06:58The problem with tissue donation
07:00as it currently exists is one of
07:02coordination so that people do
07:04occasionally come to us and say that
07:06their next of kin would like to donate
07:09their body to the medical school.
07:11Or for research,
07:12and the problem is that it's
07:14sometimes hard on short notice to
07:16put together somebody who will
07:17receive that really generous gift.
07:21And I'm going to turn this over here
07:24to Marco, or, rather to Marcello.
07:26So yeah, I'm I'm just going to point out
07:29a couple of issues for researchers when
07:31it comes to performing effective research
07:33into the pathobiology of human disease.
07:36We can do next slide.
07:39So you know if you wanna study human disease,
07:42you have a few few options.
07:44You need cells of some kind and you need
07:47tools to study them with and so there
07:50there are a few model systems out there.
07:53Actually, I shouldn't say a few.
07:54There are many many model systems out there,
07:56including cell culture and models,
07:59surgical specimens and
08:00standard hospital autopsies,
08:01all of which are are fairly readily
08:04available but have their own
08:06limitations next slide so you know with.
08:10Certain tissue sources,
08:11like cell culture, you know cell
08:12culture is an incomplete system.
08:13The tissue is not intact and the
08:17cells are grown in media that may.
08:20Have, you know,
08:21may have a lot of factors in it,
08:23but they are not embedded in
08:26their natural environment,
08:28so it makes it difficult to model.
08:29You know non solar cell autonomous functions.
08:32Animal models of course have have contributed
08:36tremendously to our understanding of biology,
08:38but there are cross species.
08:40Differences and I'll just
08:41highlight a couple of them here.
08:42RB Newton Mice developed pituitary
08:45adenomas as opposed to retinoblastoma.
08:48P53, essentially a lead from any
08:51type of mutation in a mouse,
08:53produces sarcomas as opposed
08:54to the the often you know,
08:56mucosal carcinoma is typical of,
08:59you know, the human patient would leave
09:01from any and in terms of metastasis,
09:04you know there are models that
09:07that do you know,
09:09produce metastases?
09:10In in miles,
09:13but spontaneous metastases are much more
09:16rare in mice than they are in human.
09:19So if you want to study human,
09:21it's best to actually look at human tissue.
09:24Ohh yeah, next slide.
09:25So with human tissue we have a few options.
09:28There are surgical specimens,
09:29but there is limited availability
09:32of certain tissues,
09:33and the tissue that is available
09:36must be retained and examined by a
09:39pathologist for diagnostic purposes
09:41before it can be released for research.
09:46I'm a neuropathologist my my research
09:48interested is in central nervous system
09:51diseases and of course brain tissue
09:54is extremely precious and surgically.
09:56Surgical removal is is minimal as
09:59possible to minimize morbidity.
10:01So we have very limited access
10:03to that kind of tissue.
10:05And then there are standard
10:07hospital autopsies which,
10:08while there is ample tissue
10:11available and often,
10:13you know,
10:13consent is given the the.
10:16Status of the tissue is
10:19often the problem here,
10:21so with longer postmortem intervals
10:24there's degradation that occurs and
10:26also you know the the standard autopsy
10:29service on the hospital you know accepts.
10:33Patients from a wide variety of sources,
10:35some of which are better
10:37documented than others,
10:38and so you know one thing that the rapid
10:41autopsy program aims to do is to recruit.
10:44You know donors who are well known to
10:48clinical services and their you know,
10:51clinical researchers here at Yale.
10:54So just to quickly highlight a couple
10:57of effects of postmortem interval,
10:59if you look at these Histology
11:00images here on the right side,
11:02this was a nice study where they they
11:04used surgical specimens and then
11:06basically just let them sit around
11:08for a few hours and see what happened
11:10to the tissue and you can see that
11:13as the postmortem interval changes.
11:16I just I really,
11:17I just want you to appreciate that
11:19there are changes from a an immediately
11:22resected specimen on the far left to the.
11:2424 hour interval on the on the far right
11:28and and essentially what's happening there.
11:29There's breakdown of membrane integrity.
11:32Proteins are denaturing, and you're.
11:35You're basically losing the
11:38the histologic structure.
11:40The histone morphology of the tissue
11:43which which can be limiting for for our
11:46understanding of of microscopic anatomy.
11:48In that case there's also
11:50molecular changes that occur.
11:52There's a lot of rhetoric around RNA.
11:56And post mortem interval is related to RNA.
11:58I can attest to the fact that grant reviewers
12:01get very very touchy when it comes to RNA.
12:04I think it's actually a little bit overblown.
12:06The total quantity of RNA actually
12:08doesn't decrease that much,
12:10but there's actually more insidious
12:12problem when it comes to setting
12:13RNA and postmortem tissue,
12:15which is that certain RNA's
12:17actually decrease or increase right?
12:20Because transcription,
12:21you know your your tissues don't necessarily
12:23know that your brain is stopped function.
12:25Functioning or that your heart
12:27has stopped beating immediately,
12:29so certain transcripts
12:31actually increase after death,
12:34and certain transcripts decrease after death,
12:36and so that can lead to substantial
12:39unquantifiable bias in your study,
12:41which I think is actually a more significant
12:44problem than total RNA integrity.
12:46And then for the next slide there
12:48are also effects on proteins.
12:49This was a nice study that was done
12:52on cerebral spinal fluid and looking
12:55at the effect of protein aggregation.
12:58Actually in the CSF.
13:01Overtime after death.
13:02And so again,
13:04these are basically deviations
13:06from the normal Physiology of life
13:08that are occurring and therefore
13:11less representative of the state
13:13of your system during life.
13:15So these are all effects that
13:16we would like to minimize.
13:17With the rapid autopsy program.
13:20Another limitation.
13:24With currently available tissue is
13:26just in sampling surgical specimens.
13:28For example, you know we have to.
13:30As I mentioned,
13:30we have to minimize morbidity.
13:32So in the central nervous system,
13:33you know that you you can only take so much.
13:35So this picture just shows a composite
13:38fMRI image of eloquent cortex.
13:40In other words,
13:41brain that you still need in your head,
13:44and so therefore is inaccessible
13:47to interested researchers, and so.
13:50Of course this stuff is
13:52is is extremely valuable.
13:54For understanding the tumor environment,
13:57but we are unable to study it
13:59using standard surgical specimens.
14:03And that's important.
14:05It's important to have a wide breadth of of
14:09tissue to study both in space and in time,
14:12because we need to understand tumor
14:15tumors both in space and time, we need to
14:19understand heterogeneity within the tumor.
14:21There are multiple clones within a tumor,
14:23some of which give rise to metastasis.
14:25There's evolution we see molecular evolution.
14:27We see phenotypic evolution in tumors.
14:30Within the primary tumor and
14:33we also see a selection for for
14:37certain features in metastasis,
14:39so access to all of this
14:41tissue from multiple sites.
14:43Multiple regions of the tumors.
14:46Is all essential for understanding
14:48the the complete,
14:49you know pathobiology of tumor
14:52Genesis and metastasis formation.
14:56So so thank you. So what
14:58I'd like to talk to you
15:00about next is just some of the mechanics
15:02of of what rapid autopsies actually are.
15:05And how they differ from a standard autopsy
15:08and then the short answer is that rapid
15:11autopsies are not technically autopsies.
15:13They are anatomic gifts,
15:15so an autopsy is a diagnostic
15:18procedure performed on the remains of,
15:21you know, a decedent and and.
15:23Permission can only be
15:25given by the next of kin.
15:26The legal next of kin.
15:28I cannot legally give permission
15:29in life for my own autopsy.
15:32That permission doesn't survive my death,
15:34however.
15:35I can give and this is by virtue of
15:39some universal anatomic gift act
15:42legislation that's been adopted
15:43by most states in this country.
15:46I can in life give permission for an
15:49anatomical gift of part or all of my
15:51body for the purposes of transplantation,
15:53therapy or research,
15:54and this is from the Connecticut statute
15:57and the important thing about this
16:00statute which governs organ donation,
16:02is that this permission survives my death.
16:06And cannot be.
16:09Sort of rescinded or modified
16:10by my next of Kent,
16:12so it's it's a durable gift and it
16:14can be made not only for as I said,
16:17transplantation,
16:17but to a hospital or a medical school
16:20dental school or university specifically
16:23for research and education purposes.
16:25So this is what covers these things.
16:27As Marcelo pointed out,
16:29the delay in standard autopsies
16:31is the thing that you know,
16:33renders the tissue less useful.
16:35And we've looked at our own
16:38postmortem intervals over.
16:392/3 of our cases are longer than
16:4324 hours between time of death
16:44and start of what typsy and most
16:47of that delay is due to consent
16:49delays and and family discussions,
16:51which are important but take place after
16:54death and and sort of slow things down.
16:57So how does the actual process work?
17:01So what we propose is that research
17:05investigators contact us when
17:07they have sort of Yale approved
17:10Yale IRB approved protocols,
17:13file them with us and and talk
17:15to us about the requirements for
17:18tissue collection and storage.
17:19The clinicians and researchers are identify
17:22patients and you already have research,
17:25you know,
17:25sort of relationships with them,
17:26so that makes that easier
17:28that might be interested,
17:29and if they are interested,
17:32walk through this very transparent
17:35and very thorough consent process.
17:38If the consent is is given,
17:40we retain a copy of that at our program and
17:44provide contact information with the family.
17:48When the donor dies,
17:50we were contacted either by
17:52the family or the facility.
17:55The permission you know we contact next
17:57of kin and then we assemble our staff
17:59as quickly as possible within an hour,
18:02certainly.
18:03And and we hope that we'll be able
18:06to get to the actual you know,
18:08process within a few hours,
18:11hopefully no more than six
18:12and and hopefully less.
18:14The idea is that we collect
18:16this according to protocol,
18:17save it in the appropriate way,
18:19and then hand it off at the
18:22first possible chance to the
18:24research lab who recruited.
18:25This patient, and so we're not a tissue bank.
18:28We are just sort of there to
18:30you know, smooth things over.
18:32I'll turn this back over to Marcella.
18:34Yeah, I won't be labor this but
18:36actually go right to the next slide.
18:39There are a whole host of
18:43modern technologies that have
18:45really come into their own.
18:46A lot of them driven by
18:49next generation sequencing,
18:50but also by new techniques and
18:53microfluidics and other other.
18:56High throughput.
18:59Platforms that allow us to just
19:01gather a huge amount of data from,
19:04you know, relatively small but
19:06high quality fragments of tissue,
19:09and so all of these highlighted
19:12here are certainly on the table
19:15they've been performed in human
19:18tissue and and validated there are.
19:21Yeah there. There are too many
19:23technologies to sort of enumerate,
19:25but a large number of them.
19:28Really yield the highest quality of data.
19:34And and by by quality I mean high
19:38reliability information which which is
19:41basically it's important to combat these
19:44issues of of bias and and and being
19:48misled by artifactual changes in the tissue,
19:51which with with these huge data sets is
19:53very easy to get sort of LED down the
19:56garden path by those kinds of artifacts.
19:58And so the quality of what you put in
20:01are really influences the value of the
20:04information that you get out of these these.
20:06High throughput, big data, new technologies,
20:10and so the rapid autopsy, again, will we?
20:12We aim for that to be sort of the input
20:16to many different types of experiments.
20:18My ability, yes.
20:19So these are the limitations.
20:20Again, the things that we talked
20:21about you know post mortem,
20:22interval, time, temperature,
20:24all these things can affect
20:26quality of tissue.
20:27And of course clinical factors.
20:29Again just contribute to the value
20:32in that the information about the
20:35patient having having a basically a
20:38pipeline in good communication between
20:41the the sort of basic science labs,
20:45the clinical researchers and the
20:48clinical teams treating the patients.
20:50You know closing that loop,
20:52ideally through the rapid autopsy program,
20:54where we can disseminate all this
20:56information, will will again,
20:57you get the most out of the out
21:01of the the the these precious
21:03gifts that the patients donate.
21:06So just very very quickly
21:07a couple of results.
21:09A couple of results from similar
21:11programs around the country.
21:13Johns Hopkins has a pretty mature program.
21:15They've had a a segment of it,
21:17very much focused on prostate cancer,
21:19and they've shown a lot of
21:21really interesting things about,
21:22you know,
21:23clonal evolution and prostate cancer,
21:25and how that contributes to metastasis
21:27in in different forms and the androgen
21:30insensitive and the androgen sensitive forms.
21:33Dana Farber has a very.
21:36It advanced program.
21:38This is just one example of of a breast.
21:43First carcinoma study that showed
21:47you know the the amount of diversity
21:49in breast tumor metastasis.
21:52But there's there's a lot of other
21:53research that's come out of that program.
21:55If we go to the next slide just a
21:58couple more of the NIH actually runs a
22:00program out of their clinical center.
22:03And this you know again they have.
22:05They had excellent records.
22:07This was a really exceptional case study
22:10and that they had tissue collected
22:12surgically during the patient's life,
22:15both of primary tumor and
22:17of lymph node metastasis.
22:18But also then they had the rapid autopsy
22:20at the end of the patient's life,
22:23which you know together comprise
22:25just a tremendously valuable data
22:27set. And finally the the
22:28live on New York. That's it.
22:30That's actually a a transplant.
22:33Service and Columbia has partnered
22:35with the transplant service to sort
22:38of simultaneously perform warm
22:40autopsy on consented patients,
22:42and that's enabled them to do all kinds
22:44of really innovative immunological studies.
22:46And this is just one example,
22:48looking at natural killer
22:50cell interactions and in their
22:52development in different tissues.
22:56So just quickly to go through
22:58some of the programs that exist.
23:00There's this is not a complete list,
23:02but there's somewhere I
23:03think between you know,
23:04a dozen and 15 of these programs,
23:06and I list them here in sort
23:08of order of proximity to us.
23:10And and I point out that what these
23:13programs all have in common is that
23:14they are in areas that are metropolitan,
23:16have large patient populations,
23:18and they're all based at academic
23:20hospitals with national reputations,
23:22and they all have a critical mass of NIH
23:24funded clinical research scientists.
23:26And I think we have all of those.
23:29All of those factors in place.
23:30And I think we are in a position to
23:32set up a successful program here.
23:35And I'll just turn that over
23:36to Marcelo to finish up.
23:38So finally, yeah, just just to summarize,
23:40you know the the the patients are offered an
23:44opportunity to to make a very meaningful.
23:48Contribution to medical research that really
23:51could not be replaced by anything else.
23:54This kind of program promotes transparency
23:57and preserves autonomy of the donor and
24:00really puts the the the donor at the
24:04center of of a very important line of
24:08research into their into their disease.
24:11Researchers I, you know,
24:12I spent a bunch of time on telling you
24:15about different factors and tissue quality.
24:17Essentially, that's the core good quality,
24:19good quality tissue that's well documented
24:23and and part of a sort of coordinated
24:28research team that includes the clinicians,
24:32the patient, the researcher and and the.
24:35The rapid autopsy program.
24:40So we I don't know Harry.
24:42Do you want to maybe take this one
24:44so so in trying to put this together, we've?
24:47We've looked for input from a bunch of
24:49different sources and we've had long
24:51talks with the the folks at MSK and
24:54Johns Hopkins about their program,
24:55and we've had some really great
24:58conversations with the Yale Cancer
25:00Centers patient and Family Advocacy
25:02council and Community Advisory Board.
25:05So we've had, you know,
25:06patient input and sort of existing.
25:10RAP input what we're looking for.
25:12Hopefully today is the input of some of
25:14our own clinical research community.
25:19And you know, we'd like to invite
25:21you to weigh in and ask questions
25:23and and hopefully participate.
25:24And and this is, you know,
25:26where we can reach where you can reach us.
25:28We have the beginnings of a website
25:31and and here our emails and be happy
25:33to take any questions you might have.
25:38That's great, thank you very much.
25:41Let's just see if there in the chat.
25:45So a question that was asked how do you
25:49recruit connect with patients and families?
25:52I know that body donation is a
25:54very meaningful gift and legacy for
25:56many patients and their families.
25:58How can frontline clinical
25:59colleagues help support your work?
26:01And I'll I'll just add to
26:03that a bit which is, you know,
26:05you talked about the fact that there
26:07was not a bank but that you would be
26:10essentially delivering tissue to a lab.
26:11I think it's often going to be a program.
26:14Or an individual clinician who
26:17can do the recruiting,
26:19and I don't think it's going to be
26:22a lab per se that that does that.
26:26Maybe your issues?
26:28Yeah, no, you're absolutely right.
26:30So the different hospitals
26:32use different models.
26:33So MSK, I think their program takes consent.
26:36Johns Hopkins, the clinicians take consent
26:39and the ideal situation is to have a
26:41clinician who is also doing research.
26:43But you're absolutely right.
26:44I think it's really the clinical
26:46the clinical carotene that has
26:48to approach the the patient,
26:49and they have a you know and and they
26:51have to identify people who they
26:53think you know might be interested
26:54and and might be willing to.
26:56To broach the subject.
27:01If a second question, if a patient
27:04dies at home, how is it that the
27:07the patients body reaches Yale?
27:11What in those cases what we have are?
27:14We have a contract with an area
27:17Funeral Home that has agreed,
27:20obviously for a fee, you know to
27:22make you know that transport to you.
27:27And finally, would you prioritize
27:29certain disease areas for for
27:32patient recruitment in the initial
27:34rollout or would be up to each and
27:37every clinical research group?
27:39And again, I'll add to that and say I
27:42think it would be really helpful if
27:45we could pilot this in a few areas.
27:48Getting those that you know,
27:50the clinic clinical people in
27:52those areas interested in invested.
27:54Do you have thoughts about that though?
27:56Yeah, more chill. Do you want to take that?
27:58Sure, so I think we have a lot
28:01of interest from neurology.
28:03Obviously, you know this is one
28:05of the main avenues for for
28:07central nervous system tissue,
28:09and so we we have a number of
28:12clinicians and research labs,
28:14sort of already sort of preparing,
28:18particularly in neurodegeneration,
28:21but also stroke.
28:22And I think we you know. Again,
28:25part of our purpose talking to to this group.
28:28Is we, you know,
28:29we think that the Cancer Center you
28:32know would be would be an excellent.
28:35Basically plays for us to connect,
28:37you know,
28:38with all the the the the research
28:40that's happening in the labs you know,
28:42run by Cancer Center,
28:43Pi and and the clinical teams here.
28:46So I I think essentially these two areas
28:48are probably our first two rollouts.
28:52I can tell you that our lead neuro
28:55oncologist has already jumped in
28:58to say that he is happy to pilot.
29:01Right, that's wonderful.
29:03Thank you, thank you Antonia.
29:06So with that I'll thank you and we'll
29:10move on to something entirely different.
29:14Monica, do you have a presentation yourself
29:16or you're going to use other people?
29:17You do OK, so we're going to hear 3
29:22presentations from Monica Fredkin
29:25and from Christina Matusek and from
29:29Mandeep Smith that will be presented
29:33at the Oncology Nursing Society and.
29:38With that I welcome them all.
29:41Thank you Doctor Weiner.
29:43I'm Monica Fredkin and I'm here
29:45sharing a presentation that we did
29:48in oncology Nursing Society Congress
29:50last week and I'm going to spend
29:52a few minutes talking about the
29:56ambulatory oncology transformation,
29:59specifically around one
30:00working group and I'm here.
30:02There were multiple people that were involved
30:04in this work and Chang Jeremy Corbyn,
30:07Mansky and Connie Angle King is a
30:10consultant and then I will hand.
30:11Give a high level of the work
30:13that we've done, and then I'll.
30:16Handed over to Christina Matusik
30:18and Mandeep Smith were the leads of
30:20one of the work groups that have
30:22patient visit readiness to kind of
30:24show how we took this ambulatory work
30:26and and put it into real practice.
30:29So with that,
30:30how did we get started at all this work and.
30:35Back in March of 2020 and April of 2020,
30:38we really had to.
30:42Change everything we did about
30:44how we provided ambulatory care.
30:46We consolidated clinics.
30:47We moved all of the New Haven teams
30:51and clinics out to the network
30:54to different sites.
30:55To provide additional capacity for inpatient,
30:58and with that what we learned is that.
31:01While we had, we were forced to do this.
31:03There was an opportunity to relook
31:05at how we provided ambulatory care,
31:08and so we Kim's luster,
31:10Lori Pickens, Kevin Billingsley.
31:15At the time said,
31:16how can we create a new normal and make
31:19one smile and really make this a two point?
31:22You know,
31:23version 2.0,
31:23so there was an ambulatory
31:25transformation steering group that
31:27was started and it really looked at
31:29the ambulatory flows from before the
31:31patient arrived all the way through.
31:33So when they left and there was
31:34a steering committee and within
31:36that steering committee there
31:38were six different subgroups.
31:40The subgroups were around facility and
31:44environment patient access technology.
31:46Staff and staffing and then communication
31:48and the final one in Orange is really
31:51the care delivery workflow subgroup
31:52that we're going to talk a little bit
31:54about today to share what we've done,
31:56but each one of these groups are,
31:58as you know,
31:59we're all interconnected.
32:00So how we do this really had to be done,
32:06thoughtful and coordinated.
32:08So the approach to this is that we had
32:10to do have a multiple steps in order
32:13to even understand where we were,
32:16and I'm going to go into the
32:17detail of the elements on this
32:18slide into future slides,
32:19but we had a a five step process
32:22on what how we approached this work
32:24and the first thing that we had to
32:26do is we had to kind of understand
32:28we had to understand where we were,
32:30what was our current state,
32:31and in order to do this and we wanted
32:34to make sure that we represented
32:35all the areas across the ambulatory.
32:38Enterprise, so a key survey was created.
32:41We obtained information around
32:43role where people worked as well
32:46as what team they were.
32:47They were aligned with and
32:49there was a structured and
32:51unstructured questions we we wanted
32:54to know open comments which provided
32:56a significant amount of information
32:59and when you think about analyzing and
33:01aggregating the data we had, you know,
33:04open-ended questions can provide,
33:06you know a whole level.
33:08Of analysis that was created.
33:10The workflows that were not included
33:13because they were part of other working
33:16groups was the supportive care services
33:18and the access Access call management and
33:21intake was all part of other working groups.
33:25So we really focused on the
33:28clinical flow of patients.
33:31The survey had was open for eight days.
33:34We had almost 200 people respond,
33:37which shows that there was a
33:40real opportunity and engagement.
33:41From all different roles and disciplines.
33:45So we had a nice mix of responses,
33:5126% from physicians,
33:5232% from nursing, but we had pharmacy.
33:55We had lab.
33:56We had access staff research, everyone.
33:59We had multiple people that you know roles
34:02that completed this as well as modalities.
34:04So 2/3 were medical oncology,
34:06but we had a nice representation of radiation
34:09oncology as well as surgical oncology.
34:12And what's not on here is that we
34:14had a 5050 split of new like the
34:17New Haven teams and the network.
34:19So we really did get a great
34:23representation of the information
34:24that we were looking for.
34:26So once we took that,
34:27we spent a tremendous amount of time
34:29aggregating and analyzing the data.
34:31But there were ten common.
34:34Workflows that came up as the
34:37opportunities for improvement and
34:38what a group of us did is there we
34:41priority ranked them and there were
34:43about 70 plus people that that were
34:46involved in this and the priority
34:49rank also needed to intersect
34:51with the different working groups
34:53that were also functioning so.
34:56Well,
34:56this is a high level of the 10 different
34:59groups we we had to create different
35:02subgroups within that within those teams.
35:04So there were three different
35:07COVID related projects and we we
35:09deployed them to the COVID team.
35:12There was a working group already that
35:14was in place that could handle and
35:17manage those those groups but the non
35:20COVID related really fell into four
35:23different buckets that you can see here.
35:24We had more than 70.
35:27Participants,
35:27physicians,
35:28and staff of all different roles,
35:30as well as sites that were represented in
35:33these different groups and for clinic flow.
35:37We had three different working groups
35:40that are still actively working and
35:43meeting and right now visit type
35:45criteria was a proactive approach on
35:48how we could identify patients that
35:51would be televisit appropriate that
35:54would help minimize switching visits.
35:57Last minute and being able to
35:59designate those visit types.
36:01The patient visit readiness which
36:04Mandeep and Christina will talk
36:07about is really also about the
36:09patient and physician having the
36:12optimal visit and what can be done
36:15beforehand and after to ensure that
36:17those patients experience that visit
36:19and the checkout process is also an
36:23active working group around that
36:25communication of what needs to be
36:27done following the visit to ensure
36:29that things are communicated.
36:31And followed through on
36:33whether it's referrals,
36:35orders and imaging that have
36:36to be done or next visits.
36:38Infusion flow was really around labs
36:41and advanced release of chemotherapy,
36:43but at the same time there has been
36:46an initiative that we're implementing
36:48lean toss across the the ambulatory
36:51areas where infusion is done.
36:53So we are working on lean
36:55tasks right now and then.
36:56Patient education was really around.
36:59How can we utilize and leverage technology
37:02to provide patient and family education,
37:05especially when there's limited patients and
37:07family members that are allowed in clinic?
37:10That there's a way to do this
37:12in this more of a a video,
37:13you know telehealth forum
37:15and then imaging is really.
37:17We've heard a lot about access challenges
37:20for scheduling and how can we work
37:22together across the discipline with
37:24imaging to get patients scheduled,
37:26timely and appropriately at
37:28the right location.
37:32So while there are a lot of moving parts
37:34at all, these different working teams,
37:36we had a a template of how we
37:39would move forward with this work.
37:41First we needed to understand workflows
37:44we needed to do observations and did
37:47process mapping and really identifying
37:50barriers that could impact the flow.
37:52And then we had to just test it.
37:54And so we piloted we're
37:57piloting different initiatives.
37:58We had to be really selective.
38:00And how we determine the site, what teams?
38:03How are we going to measure this?
38:05Because the goal ultimately is that this is
38:08sustainable as we continue to move forward,
38:10and what adjustments we had to make.
38:13You know, using rapid change cycles
38:16and finally the goal is that once these
38:18pilots are really done, is that this?
38:20We get this out everywhere we
38:22want to be able to utilize our.
38:24You know, these efficiencies and
38:26opportunities to really go across
38:29which will enhance the smilow. 2.0.
38:33And so this is just to understand
38:35there were multiple tools.
38:36As I said,
38:37we want to be able to sustain this work.
38:39So we created within EPIC.
38:41There are tools we created
38:44standard operating procedures.
38:46We looked at the literature of what is
38:48said that on the work that we're doing
38:51to validate that what we are doing
38:53makes you know is is aligned with what
38:55else is happening out around the country.
38:58We graded metric based reports so we could
39:01share data so that people understand.
39:04How they're doing and where
39:06their opportunities are and
39:07to celebrate the successes,
39:09and finally,
39:10tell ASCO came out with some telehealth
39:12standards at the same time we were
39:14doing this work to ensure that we
39:16were doing the work that aligned
39:18with the with the ASCO standards.
39:21So these are the high level work that
39:23was happening and now what I'd like
39:25to do is switch it over to Christina
39:27and Mandeep to share how the work of
39:30the patient Visit Readiness project
39:33you know has taken the the framework
39:36of what I have shared into a pilot.
39:39Christina and Mandeep.
39:42Thanks Monica. So as Monica alluded to,
39:45our project was really on
39:47patient visit readiness long.
39:49The next five years,
39:50which has been showing that
39:52in this really patient visit,
39:54readiness is essential and it's
39:56an essential component of patient
39:58safety as well as clinic flow.
40:00In our ambulatory setting.
40:02So this included basically just making
40:05sure that your patients that were coming
40:08in were completed all the prep that
40:10was done ahead of time was completed.
40:12The next appointment you know
40:14disposition was actually completed
40:17prior to the the current visit.
40:19That's coming up and making
40:22sure that any consults lab,
40:24any imaging or studying and studies
40:26or any prior authorizations
40:28that were required are being
40:29done ahead of time as well.
40:31So what we realized is that without the
40:35adequate preparation that was going on,
40:38there were significant delays
40:40within the clinic errors.
40:42Sometimes last minute cancellations
40:43for patients and an overall patient or
40:47provider satisfaction had decreased.
40:53And as Monica had mentioned,
40:55there was multiple surveys.
40:56There was survey questions that
40:58were congregated and reviewed,
41:00and within those visits,
41:03what we realized is that there was.
41:06Practices carried concerning Preclinic
41:08prep and post clinic wrap up found.
41:11There was multiple variations
41:12within our House system.
41:14As you can see in this slide,
41:17you see that about 80% of the team
41:20did some sort of prep before about.
41:24But only about half of them really had
41:27some form of guidelines to follow or
41:30best practices within the clinic prep.
41:34In addition,
41:34a vascular majority of teams were
41:36also not doing any sort of post clinic
41:38huddle and most patients patients were
41:40leaving without any follow up appointment.
41:43Uh.
41:45Which again brought concerns to the team.
41:50We also surveyed uh clinic prep
41:52activities and found that the
41:53majority of respondents 84% do
41:55review the schedule ahead of time.
41:57But again,
41:58half did not use any standardized criteria,
42:01and.
42:01In addition,
42:02about a third do not review test results.
42:07Of course,
42:08do not communicate or review missing orders.
42:10And lastly,
42:11less than half did not evaluate
42:13ahead of time which patients could
42:16benefit from a nursing visit.
42:18McLeod.
42:23So when doing a literature review,
42:26as Mike had mentioned,
42:27there was reviews being done and
42:29in it what we realized was that
42:31we're starting to work on this
42:33initiative and needed to really look
42:34at the ambulatory areas and see.
42:38You know what was happening in other areas,
42:41so a major article that we
42:43reviewed was published in 2021,
42:45which found that researchers were
42:47performing a systemic review about
42:50of 49 studies that ranged around
42:5210 countries and highlighted about
42:548 previsit planning techniques
42:55that could be used.
42:56And with this review,
42:58it really suggested that prepare
43:01preparing for clinic can enhance the
43:03quality of patient care as well as
43:07patient to provider communication.
43:09And 84% of the authors reported
43:12that proactive visit.
43:14Patient preparedness was a
43:17really effective way to improve
43:19patient centered care.
43:24So when looking at what we've talked about,
43:27which is patient visit readiness,
43:30what does this actually mean
43:31and how do we achieve it?
43:33We needed to define this,
43:34so visit readiness really begins.
43:37Your post clinic wrap up from the
43:40prior visit as that will be outlined.
43:43You know, with an RN or a scheduler,
43:46at which time then you are looking at
43:48your next visit and really reviewing
43:50what what is required for those people.
43:52Preclinic prep sounds obvious.
43:54This is a proactive approach of
43:56reviewing what the practice nurse
43:59is looking at and all the elements
44:00that need to be completed before
44:02the patient comes in for the visit.
44:04And how do we achieve all that?
44:07It's through completion of your provider
44:10disposition to guide the Previsit
44:13prep as well as the the defined team
44:16huddles to improve communication
44:18for all the teams and then this can
44:20all be done virtually or in person.
44:22Weekly, daily or really,
44:24whatever works for your team,
44:26but it allowed you to have the what,
44:28how and when of what patient was it?
44:30Readiness looks like.
44:33Next slide.
44:36So I have seen really just to fix the team.
44:38This is Doctor Kirkman's team and the post
44:41clinic cuddle that they run is usually
44:44done weekly on Friday and as you can
44:47see he did it in person with his team.
44:51This also act as a wrap up for
44:53the general elements that are
44:55being done within the clinic.
44:57What we found is that it engaged
44:59the staff and increased efficiency,
45:02communication and collaboration,
45:03and these huddles can really be customized
45:07to each team and what exactly you are
45:10requiring for your team. However,
45:12we did outline key players for each channel,
45:15meaning the practice nurse,
45:17the provider and the scheduler.
45:20And I'm going to hand it
45:22over to Christina now.
45:23Casino.
45:27Thanks Randy. So when we began
45:30our process a long time ago,
45:32we developed this Visio map which
45:35really outlined every element from
45:37check out from the previous visit
45:39to the next visit that they were
45:41being seen to really understand
45:43this process and how we can improve
45:46this across the health system.
45:48We further broke this down and to the
45:50left hand side where you can see the
45:52different swim lanes that looked at
45:54the responsibilities of the provider
45:56versus the practice nurse versus the
45:58schedule as well as we incorporated.
46:01Via medical assistance or the ACA's.
46:04It was a lot of work to do it in this way,
46:06but it really helped to be.
46:09It really helped us to understand
46:11where we needed to improve our process.
46:14Next slide.
46:17So since we discussed
46:19the different elements that we focused on,
46:20we actually did develop some tools that
46:23were meant to be helpful for preclinic
46:26prep purposes and to lessen the
46:28workload of the practice nurse who is
46:31performing the preclinic prep elements.
46:33So the first is what's called
46:35the UNC Summary Nurse tab.
46:37It's actually located in the
46:39multi provider schedule.
46:40It allows the practice nurse who is
46:44performing the Preclinic prep one click area.
46:48To go through the different elements
46:50that she may find helpful to the
46:52Preclinic prep prep process.
46:55So this was developed to hopefully reduce
46:57the amount of time that the practice
46:59nurse has to spend doing preclinic prep.
47:01It involves many elements
47:02and components to the report,
47:04including treatment plan,
47:05the actual follow up disposition from
47:08the previous visit will be there so
47:10that they can actually understand
47:12what is needed for the next visit.
47:15To help streamline this process.
47:18So you can go the next slide.
47:20The other feature that we developed
47:22is what's called the Visit Ready
47:24feature on the multi provider schedule.
47:26This is a column that anyone can add
47:29to their provider schedule and it for
47:32those that are currently in the pilot phase.
47:35The physicians will actually see
47:36this being done in their areas,
47:38but you can see that once the
47:41patient is deemed visit ready,
47:42the practice nurse will actually
47:44go in and make the patient a green.
47:48Check for yes or a red X for no.
47:51We also included a column for Visit
47:54Ready comments and that allows the
47:56practice nurse to make comments in
47:58that specific area so that number
48:00one they could.
48:01It can remind themselves of who's
48:03to visit ready and who is not,
48:05as well as what they need to follow
48:07up on for that particular visit.
48:09This is also viewable by the provider
48:11if he rents it into your multi
48:14provider schedule.
48:15So that the providers are able to
48:17see their clinics prep as well.
48:19Isn't that the next slide?
48:22So in order to convey
48:23this new workflow, we performed formal
48:26team trainings to discuss this with
48:29each individual that included the
48:31discussion of the workflow itself,
48:34the huddles that we wanted them to do,
48:37as well as the tools that we developed
48:39to help streamline this process.
48:40We also offered initial first huddle,
48:44guidance and facilitation for the
48:46new Members that were being part
48:48of this pilot and the session
48:50involved all team participants.
48:52And were completed prior to the GO live.
48:55Go to the next slide.
48:58So as as we have alluded to,
48:59this has been a really big work in progress.
49:03We currently have North Haven,
49:05Guildford and Greenwich
49:07underway with our pilot sites.
49:11North Haven was our first site to
49:13go live in October of last year.
49:15Greenwich currently went live.
49:17I believe last week and we also
49:20have planned sites that are going to
49:22be going live in the near future.
49:24Thoracic oncology head and neck
49:26surgery GI met on.
49:28As well as classical hematology and
49:30malignant hematology and North Haven,
49:33we also have incorporated trumple as well.
49:35They're not on this side, but again,
49:38this is a work in progress and
49:41a huge team effort.
49:42And go to the next slide.
49:44So now on to the data.
49:46So we looked at many elements
49:48and we created this workflow and
49:49one of those included physician,
49:51disposition,
49:51compliance rate.
49:53This data represents 3 physicians from
49:56the North Haven site which looked at
49:59data from pre pilot to April of 2022.
50:03So as you can see the provider see and
50:06the green line really was compliant
50:09with this throughout they acted more
50:12as our control line or participant.
50:14And we saw that as we went into October,
50:18we saw a gradual increase in provider
50:21a during the pilot phase as and
50:25tapering off into about a 90th,
50:2890 high 90 percentile of completion
50:31as well as provider be as well.
50:34But the next slide.
50:36So in addition to the provider compliance,
50:40we also get practice nurse preclinic
50:43preparation compliance rates.
50:44This represents graphs in the
50:46Helix report format that we looked
50:48at from North Haven and Guilford,
50:51so you can see that North Haven had a
50:54huge uptick in their compliance when
50:57they actually started the pilot in October,
51:00and they really maintained that compliance
51:02rate into the above 95% throughout their.
51:06The time in this study within Guildford.
51:09They went live in February of 2022
51:11and you can see that with them it
51:13was a little bit more of a gradual
51:16rise in compliance,
51:16but overall has again tapered off
51:19into a great compliance rate for the
51:22remainder and go to the next slide.
51:25In addition,
51:26we also looked at patient visit
51:28unreadiness volumes and reasons for
51:30why patients are deemed unready
51:32for their visit for North Haven.
51:34We calculated that about 17% of
51:38patients 170 out of 1098 over the
51:41course of eight weeks were visit.
51:43We're not visit ready as well as Guilford,
51:45which was about 22% or 206 out of
51:49930 scheduled visits and the real we
51:52listed the actual categories
51:54for why this was.
51:55But we actually found that the
51:57most common theme was the test
51:59ordering and scheduling that they
52:01were not performed or testing
52:02was not completed in a timely
52:04manner by the patient.
52:05Go to the next slide.
52:11So in addition to our data collection,
52:13we are also really interested in feedback
52:15from the end user and ask them to
52:18respond to the following questions that
52:20you can see listed here for example.
52:22We have seen that the doctors
52:25have found fewer interruptions.
52:26They can review cases at the same times
52:29and our nurses have found that the
52:32huddles have really helped maintain
52:34helped manage patients efficiently,
52:37as well as some of the other
52:40providers noted that.
52:41Improving the preparation really
52:43highlighted what patients did not
52:45have done prior to their visit.
52:47Move to the next slide.
52:49So during this process we
52:51definitely learned a lot,
52:52including the fact that specific tools
52:55can really streamline the process,
52:57but it also requires training
52:59and consistent utilization.
53:01In addition,
53:02consistency with performing huddles
53:04as well as physician leadership
53:06and engagement is really a key
53:08player and a huge role in the
53:10success of this initiative,
53:11especially with regards to the disposition,
53:14completion and leading post clinic
53:16huddles in a A in a consistent manner.
53:21Next slide.
53:23So for our next steps,
53:24as we look to the future,
53:25we plan on working with it to refine
53:28our compliance tools and really
53:30refine our epic related tools based
53:32on feedback from the end user and we
53:35will continue to perform a systematic
53:37approach when rolling these out.
53:39To really ensure success of this program
53:42for those in the ambulatory setting,
53:44we'll likely be working with you
53:45in the future with you and your
53:48teams to help improve your clinics
53:49and enhance patient preparedness,
53:52and we really look forward to
53:53your collaboration.
53:53During this huge team effort.
53:56So thank you so much for your
53:57time and we will now answer any
53:59questions that make people may
54:01have with Doctor Kochanski as part
54:02of the discussion as well.
54:12Thanks very much.
54:15Questions.
54:22The you know the only thing I
54:24will there's a couple things.
54:25One that we also are looking at, the press.
54:28Gainey, we have to understand how
54:29this is what the meaning is for
54:31patients as we're doing this work.
54:33So we're looking at the press
54:35ganey aspect of of this.
54:37These this work and the only other
54:39thing I didn't get a chance to say is
54:41there are so many people that have
54:43been involved in this this the practice
54:45nurses the access team pharmacy.
54:47Obviously the physicians,
54:49the AP's and I just want to say
54:51a huge thank you to all of them.
54:53As well as Christina and Mandeep you
54:56know and Jeremy I'm going to ask
54:59you if you have any kind of pearls
55:02or words of wisdom that you might
55:04offer as an end user of this work.
55:07As we, you know, finish up.
55:10Sure, you know. I think for our
55:14team this this meeting has really
55:18been transformative for our group.
55:21And while there is a a core group that I
55:25think needs to be there which includes
55:27the the physician and the practice,
55:30nurse and PFA SII think that
55:35the larger the group is,
55:37the more productive those meetings are.
55:40And we have included in our meetings,
55:43our AP's the infusion nurse as well as
55:50pharmacy and in doing so you really
55:54capture all of the different ways that
55:57we need to prepare for the visits,
56:00not just including whether a scan has
56:03been scheduled as ordered and will
56:05be available in time for the visit,
56:07but also where chemo orders need
56:09to be entered.
56:10Or informed consents need to be completed.
56:14It's dedicated time to review the
56:17schedule with with PFA SI think we all
56:20of us you know have these long lists
56:22of patients that have acute issues
56:24that we need to get in and rather than
56:27being disrupted all throughout the day
56:29to to figure out when that should be,
56:31we now have dedicated time to do that.
56:34As a physician.
56:35It also allows me to follow up with
56:38infusion nurses and the APP's to find out.
56:41Uh,
56:41whether there are any urgent issues,
56:43dose modifications,
56:44things that need to happen with
56:46patients that I haven't seen that
56:48week so that everybody on the team
56:51is really understanding where all
56:54of the patients are in their course?
56:57You know who we can anticipate.
57:00Might be progressing,
57:01or is having a lot of trouble where
57:03you know there might be flags that
57:05we say oh we need to bring in OCMD
57:07or social work or palliative care.
57:09It really is a a holistic approach
57:13that can only be done when when
57:15you have some dedicated time.
57:17And while I know that for for my
57:20team we we take an hour on Friday,
57:23I understand that not everybody
57:26has that much time.
57:27But in that hour we review.
57:30All of the patients from the week that was,
57:33and all of the patients that
57:35are in the week that follows,
57:37and so it can be done in a shorter
57:40amount of time by just breaking
57:42it up into fewer days to review.
57:45You
57:46know, Jeremy, I think that the I think
57:48this team work is really essential.
57:50I think it can be done as
57:52an hour that you set up.
57:54I think that in some cases it needs
57:56to be a huddle in the morning.
57:59That I think it's really important.
58:02One of the things that can happen in that
58:04that huddle on the day of treatment,
58:06or for that matter the week before,
58:09is to identify patients where
58:11if it gets busy,
58:13that person might be able to be shunted
58:15to the infusion room because you know
58:18they're going to get a treatment anyway
58:20and see you afterwards as opposed to,
58:23you know, waiting for everything.
58:25I'm the one question I have is,
58:28and you may have.
58:29Said this,
58:30but to what extent have you been successful,
58:32either in New Haven or at
58:34some of the other sites?
58:36In pairing infusion nurses with
58:41physicians so that a physician
58:44isn't necessarily working with every
58:47infusion nurse in the infusion room.
58:51I and maybe you do that,
58:52it's just my experience in the past
58:54is that that has been challenging.
59:02You're on mute. Yeah,
59:03we, we actually haven't with this work.
59:06We have not focused on
59:08the pairing or the team.
59:11I mean, we definitely have an infusion
59:13nurse as part of the huddles,
59:14because whether they're, it's the charge
59:16nurse that represents the infusion,
59:18but we haven't done that.
59:19And with lean toss,
59:20I think we're going to have to.
59:21You know, we're looking at it a little
59:23bit differently, so I'm not sure.
59:26What that will look like just yet?
59:29So I guess to be determined.
59:31Yeah, I know we had looked at it
59:33initially in hematology a long time ago,
59:35and with the move from
59:37New Haven to North Haven,
59:39it kind of it didn't work correctly.
59:42But I do agree that there's
59:44a lot of value in that.
59:45It's always challenging with
59:47schedules and what have you.
59:48Although my my strong sense is that
59:51there's a real value of caring physicians
59:54with maybe not one person because
59:56that one person could be off, but.
59:59Two or three or four people, as opposed to.
01:00:0215 right in any case, I just want to
01:00:06say you all have done a great job.
01:00:08Thank you so much both for presenting
01:00:10the work, but more importantly,
01:00:11for all the all the really
01:00:13great work you've you've done,
01:00:15and there'll be more to come, I'm sure.
01:00:17Thank you so much for the opportunity.
01:00:19Ohh thanks all of you.
01:00:21Thank you so much. We appreciate it.
01:00:23Thanks, Jeremy. Bye bye. Bye bye.