Hey everyone. Thanks for coming. I'm Chris Ritzo and I'm with the Measurement Lab Project and I'm our program management and community lead. A new title for me since we just shifted and became a fiscal sponsor program at Co4Science. And so we're really happy about that and being a part of that family now. My goal with this talk is to expose you to Measurement Lab and our data set and see what people are doing with it and see what you might be able to do with it if you're interested, but also to give kind of an overview of the project. So we are an open data platform that provides a measurement service, an internet service measurement platform. So we host measurement tests on servers around the world and then people can run tests against them to understand the characteristics of their internet connections.  And then all of the data goes into a public domain data set that's available openly to anyone and a big part of my job is supporting people who want to use that data. The GitHub repo, well our organization is up here on GitHub so you should check those out. And there's a lot of repos in there so if you're getting into the code just come up to me and we'll talk more about what you're looking for. So a real quick quick start if you're in the room and you want to just start diving into ideas, code, what's there. I wanted to put this slide up here to highlight a couple quick things. We have a visualization website that aggregates our data by location in different locations around the world and a couple little screenshots here. Illustrate that. Comparing ISPs in this case in Portland over the last six or eight months on this little graph and then the right hand or this side under the data it shows that you can access that data via the NAPI. So that's a quick way to get started looking at our data if you want to start if you're building your own applications. Just start using that REST API with or download raw data. And then of course if you want to dig in more deeply and look at individual test rows for a specific location or time period we have all of our data stored in BigQuery and there's a quick start guide that we've written that helps you get started with that. And of course the support address if you want to contact me or some of my colleagues to get help. So our mission is here on this slide measure the internet save the data and make it universally accessible and useful. This is quite huge and aspirational but it keeps us moving toward a real that really aspirational goal. So I'm going to talk about some of how we measure it how we save the data and then we'll switch and look at the accessible and universally accessible and useful part because that's I think the bigger thing that we can't do by ourselves. And this slide kicks off this part of the talk because our community is made up of a lot of different types of communities from companies who donate money or server space and transit to our servers to the folks who design researcher research experiments that are run on the platform to the policy space and academics who want to use this data as a secondary resource in their in their work. So tons of different types of audiences and this is a big challenge for us to try to you know balance meeting all of their needs. We run a bunch of different types of experiments or tests and these are some of the ones that we've hosted over the years. The most highly used is this network diagnostic tool from that was originally built by internet to and it's a speed test. It's you know measures much like some of the commercial speed tests you might have encountered like speed test.net or Oocla. But all that data is openly available and all the code is open so people can integrate that code into a web site or software or hardware product. These are all tests that have come from the academic community primarily. So folks studying the internet about ten years ago started to think well we need this global platform to try to understand how to make the internet better and that's how MLab eventually came to be. So we have quite a number of tests that originate through the computer science and network measurement internet measurement community at different universities. Over the last ten years we've grown from and this is sort of a platform growth slide to show sort of how long we've been in existence and where some of the milestones of where we've placed servers over time. We have servers in lots of places. About 130 locations, 500 plus servers not in all areas of the world. So we're working on that. But you can see we've got a pretty heavy North American and Europe but a smattering across the rest of the world. All this means that users will be directed to the test based on their geography. So if you're in South Africa you'll be directed to our servers in South Africa and unless you use a tool that lets you select that. Color in this case is a bit dated. Excuse me, sorry. Yeah, color. So these dots essentially come from the map on our website. Red are some servers that are currently offline or when I took this snapshot. And then because each of the servers hosts a series of experiments some of them are fully available and some were not at this time. So that's the different shades of green there. We do all this work through a variety of partnerships and so different companies can and organizations can contribute in a variety of ways and this is just a smattering of the different logos from our site. We get a lot of corporate funding and we're working on sort of diversifying that. But much of our hosting already represents that diversity from the global research and education network of which some of these folks represent. Now the volume of data is quite large. So we currently get about 2 million speed test measurements a day from the network diagnostic tool and we hit a milestone two years ago with a billion rows of data. So it's quite large and that doesn't include any of the other tests that we run. So there's a rich, rich data set for researchers and advocates to use to understand internet service in a variety of ways. I am going to get to the data. Just wanted to call that out and what some of the people are using it for. The real spike in volume over the last three years came when the Google search team integrated NDT into a little widget. When you search how fast is my internet or internet speed test, Google provides this little widget where you can run our speed test. That data goes to MLAM and provides a service to anybody who's doing that search. So that's that huge spike and we have other integrations that have also helped with getting test volume. So I'm going to show some of those but Fingbox, if you've used the Fing app, that is a measurement of network quality, speed. They have a little device that you can place in your home that runs a speed test every so often and gives that information to their users. MLAM also has a Chrome extension for Google Chrome and if you'd like to run our test and save the results locally, that's a quick and easy way for you to gather data about your own connections. So those are more software and website type things but some web integrations are actually quite interesting. This is a screenshot from the Canadian Internet Registry Authority and they have built this internet performance test portal that integrates our tests and some other types of network measurements like DNSSEC and things like this and then they've mapped the data in Canada across, you know, in little hexagons down there on the map. This is a really great partnership because not only did they integrate our tests but they also host and sponsor servers in Canada. So this is a really good example of the type of partnerships that help us do what we do. So that starts to get into the last part which is how do we make it universally accessible and useful and we can't do that alone. It's a huge, huge goal. So what we do that is also through partnerships and supporting developer communities who want to use our infrastructure as a service and provide the data to their projects or analyze it in some way. So how is the data used is a good segue to this because it gets to the end point. What are people doing with this data? And this is a link to our publications page on our website where we try to list that some of the different types of things that people are doing. And so from left to right we have an academic paper that was recently published. It was just using our data to estimate household speeds and tiers of service from the University of New South Wales and some academics who are working there and they published a nice methodology. We did a paper with Alliance for Affordable Internet last year where we took our NDT data and segmented it by mobile and non-mobile tests and then kind of looked at the aggregate for a short exploratory report with them on mobile broadband service in various countries. And then the third example is an example of advocacy organization that's looking at media ownership and consolidation issues in Venezuela. And for the last year or year and a half we've given them some data exports to support their journal, their advocacy. This particular one was around their elections, their special elections last year. So they were looking at public media and how much did independent media, independent journalists, how much of a voice were they getting and they were doing some traditional type of election monitoring as well sending people to polling places and seeing if they were asked to stop taking pictures or something. And then they also looked at internet speeds in aggregate for the different areas in Venezuela around those election dates. We don't often go out and seek to find these these publications, but some most of the time people just tell us about them. We're not doing a ton of data mining. This isn't on that where is an area where we could we could expand. Another project that actually brought me out here last week was this was a project that we're doing through the Institute for Museum and Library Services where we're taking our client test code and putting them on small computers, placing them in a library and those computers are automated to run our tests at regular randomized intervals. And that data will then go to a digital visualization platform that we're building for that project. It's a really exciting connection to the on the ground use of why why will we have this why will we do this to help public institutions understand the types of speeds that they're getting. So now we'll get into a few more web integrations. And this is kind of illustrating a few mapping initiatives. So combination of like a website that runs our speed test and then aggregates the results on a map. In this case, and in some cases asks communities to answer a survey set of survey questions. So these are targeted more at cities, regional governments that are, you know, wanting to understand the state of broadband in their communities with an open data set and open source code. And so what they've done and we've done in partnership with many cities and groups or to build, you know, build this website or help them work on it to build kind of a community engagement tool and like planning an analysis tool. So we partnered with this year and last year with the Center for Royal Pennsylvania at Penn State University, the Institute for the Local Self-Reliance. And they are building a report and have published that back, shared that back to the state legislature in Pennsylvania. And we've done some other smaller scale like pilot studies in partnership with Seattle and some other rural communities in Eastern Washington state. And then this is another example that was built not by us, but was supported by MLamb. Louisville Kentucky did a website like this that aggregated our data by zip code. The same idea, take a test, answer a survey, give the community data aggregated by zip code in order to really understand like where they have good service in their community and where they don't. And they leveraged that to decide where to build out fiber to areas that were underserved. And so this was a really big digital inclusion win that, and this code is now being taken up by the Tech Association of Oregon. And they did a hackathon last two weeks ago, where they're trying to build a national model out of this code to aggregate and share, make it something that many communities can use. So that was a great opportunity there. But the same sort of thing, you know, they're running a test, doing a survey, looking at the results and making decisions about it. One other example in the same vein that we published and worked with the Merit Research and Education Network and Michigan State University this year. The same kind of idea, but they hooked in a homework gap component where they built the science and then they are engaging with a sampling of K 12 districts across the state to take a home and assignment and run a speed test from their home to understand like, where the kids in the in their homes, you know, what is their service like? And a couple other screenshots there. And then this is another example that's looking at the large scale of the US. So this is a project that's soon to be published from our friends at Open Technology Institute, New America Foundation in DC, where they're looking at speeds from measurement lab in comparison and difference between our data and the FCC's data that ISPs submit about where they provide service and how fast it is it and what type of speeds is it. And then the last example is sort of a it's a mix. So right now, this is a great tool for aggregating data of various types, including M labs data called the internet is infrastructure.org and the I three connectivity explorer. And so the developer of this product had this this site. It has done lots of grad GIS work to bring in many different types of shape areas and to bring in data from the Census API and the ProPublica API, lots of different data sources to understand and look at public data alongside of M lab data and other data sources to really get to interesting planning outcomes for for communities that that that's his goal. So it looks at count, you can look at counties, you can look at sub county regions, you can look at tribal communities, you can look at micro urban communities and shapes and areas is a really powerful tool. And so what is all this mean for us is the next bit. M lab supported quite a number of these initiatives. And that's why we're here talking about our data and with you because, you know, we, we have supported lots of different individual initiatives. But to really scale and grow the power of our data in communities. Thank you. We are wanting to bring all these things together into a unified set of community tools that give communities and organizations options for doing what they need to do for their for their communities. And so we're planning a developer and stakeholders convening to scope and build that project. And if you'd be interested in that, we can talk more about that. But that's kind of the reason we I wanted to share kind of the ecosystem of different tools. Just dipping into the possibilities of what we can do with our data and to give a few examples. And now just stop talking and see what you have to say. I'd love to take some questions.


Okay, so let's try this one. It says which of the following chemical formulas is not correct for the given name. And what we'll do is change the name when we figure out which one it is. Okay, so let's do the easier ones first. What about this one? Is this correct or incorrect? That's correct, right? Okay, what about this one? Correct. Okay, what about this one? Incorrect. That's correct. Okay, this is right. Okay, ferric is this one. Okay, so you got to remember this is negative 2, right? So this is going to be in this case positive 3, right? That's ferric. Okay, positive 2 is ferrous. Okay, so that means that this one must be incorrect. What's the actual name for this molecule? Or this compound? Chlorate. Chlorate, yeah, potassium chlorate. If you remember that gummy bear video that I showed you when you put the gummy bear into the test tube, it's in potassium chlorate and the gummy bear like screams. If you haven't looked at the website then you don't know all about it, okay?


Welcome everybody to today's webinar. I am Donna Prosser, I'm the Chief Clinical Officer here at the Patient Safety Movement Foundation. And today we're gonna be talking about healthcare data and what data belongs to the patient, what belongs to the organization, how do we use that data to improve improved healthcare? So we're very excited today to be able to offer continuing education credit for nurses, pharmacists and physicians through MedStar Health. This CE is only available for those who attend the live webinar today. We have a great panel of speakers today and none of us have any financial relationships to report and neither does our planning committee. And so today, as I mentioned, we're gonna talk about healthcare data, understanding what is currently happening in our electronic health records and both from the clinician and the patient perspective, understand the safety and issues and the challenges with that. And then also we're gonna talk about some better ways that patients can access their healthcare data. And so we have some fabulous panelists here joining us today. We have Dr. Raj Ratwani from MedStar Health. We've got Martin Hatley who is with Project Patient Care as well as MedStar Health, Helen Haskell, the President of Mothers Against Medical Error and Ana Luisa Naveis who's joining us from Imperial College in London. So I'd like to welcome our panelists and I would love for our panelists to introduce themselves a bit. Helen, let's start with you. Tell us a little bit about your background. Well, I'm Helen Haskell. I'm a patient advocate. I came to this through a personal tragedy many, many years ago when my young son died from medical error in a teaching hospital. And we were so shocked really at what we found when he died that I ended up just, it seemed to be sort of a never ending project. And here I am 20 years later still working on the patient safety project. And transparency has been a big part of that as we'll discuss further on. Excellent, thank you Helen for joining us. Raj, tell us a bit about your background. Great, thanks Donna. Well, it's really nice to be here today. So I'm Raj Ratlani. I have two roles at Menstrual Health. I serve as the Vice President of Scientific Affairs for the Menstrual Health Research Institute and as the Director of the Menstrual Health National Center for these factors in healthcare. And today I'm here to share a lot of our work and thoughts on electronic health records, usability and safety and what that means to the patient. And really my work is driven. The whole reason I'm in healthcare is really because of my mother who's a physician and who's always loved practicing medicine. And several years ago, my weekly conversations with her, I, she lives in California, I live in Washington D.C. I call her every Sunday. And she used to always talk about how much she loves practicing medicine and how much she loves caring for her patients at the small community clinic. And that conversation shifted as electronic health records were rolled out very much to, I'm spending way too much at night documenting, I'm not as fast as the other physicians. This is too stressful. I wanna leave medicine. And my background is in human factors and usability. And so I thought, gosh, there's gotta be a way that we can try and resolve it. So that really pulled me in and looking forward to talking about that today. Again, great to be here. Oh, and I should warn everybody working from home with two kids, eight-year-old, four-year-old that are all doing virtual school of some sort almost guaranteed that they'll come bursting into this room at any moment. So please don't be alarmed if kids come sprinting in here. I've warned them that they're not gonna listen. The joys of a pandemic. So thank you, Raj. Thank you so much for being here. Marty. Good morning, Donna and everybody. I'm Marty Hattley. I'm the president of Project Patient Care, which is a small coalition in Chicago that really is dedicated to using the voice of the patient and family in improving care. So I think of myself primarily as a patient safety advocate. And within that pretty large space of interest and a lot of issues, I'm really, really interested in engaging patients and family members as more complete and more full and more ramped up partners in producing the best outcomes and the best experience for patients. So great to be here with you today. And I'm a lawyer by background. All right, Anna. I think you're muted, Anna. Great, classic music. So I'm a research fellow at Imperial College London. So my department works mostly on patient safety. So actually the name of our department is Patient Safety Translational Research Center. And most of my research interests are about digital technologies and how can we use them to actually partner with patients, engage them in the process and improve quality and safety of care. So I became actually much more interested on the electronic health records aspect and sharing the electronic health records with patients through portals or other kind of interfaces. And this has been pretty much the focus of my research. I was smiling when I heard Raj's story because I think I have two things in common with the story. So I'm also a family doctor by background. And I could share a lot of things that you mentioned about your mother. And I also have twins, which hopefully you won't see because they are back to the nursery, which is a good thing. So yeah, that's me. And thanks for the advice. Excellent. Well, thank you so much for joining us this morning. I know it's late for you over there in London, much later in the day than it is for us here. So thank you. All right. Well, let's go ahead and get started. We have lots of questions to get to today. I'd like to start first with Helen. Helen, talk to us about what data should patients want to have access to? How can we make it easier for them to know what it is that they should have access to? Well, in my opinion, from my perspective, patients should have access to anything. Nothing about me without me. So patients should have access to the entire EMR, especially while they're in the hospital, which is of course right now the most difficult time to get it. Plain Tree has always had that philosophy. I don't know exactly what they do in Plain Tree hospitals, but certainly the idea that patients should have access to their own medical records is a pretty old one. And I think now EMRs are pretty sophisticated. They can generate patient-friendly records if they want to. And one of the things that I have learned in my years of working with patients and providers is that if something is comprehensible to patients, then it's also comprehensible to healthcare providers. And the reverse is also true. Often people just don't understand things, and they don't of course want to say that because they feel as though they're supposed to. So having a plain language EMR for patients might well be a benefit for everyone. And I just want to add, I don't want to go on too long, but there are larger things than personal data. So healthcare ratings, infection reporting, for example, which I've been involved with for many years. It's limited to a very small number of specific infections which are no longer really the biggest threats to patients. We need things like hospital-wide infection reports. And we need reports on outcomes, long-term outcomes for procedures. And this can all come from real-world data and also from patient reporting. I think none of this is gonna work without patient input. So when I started in healthcare 30 years ago, it was pretty clear that the hospital felt like they owned the medical record. And this idea of sharing data with patients wasn't something that we did. So can Helen talk a little bit about the background here. How did this movement get started? You know, it's very interesting. So it started as part of the consumer movement in the 1970s. The patient rights movement was part of the consumer movement. Nader's Raiders is what most of us have heard about from that era. But all of that really sort of transformed our ideas across society about safety and transparency and really linked the two for the first time. It's just hard to remember that people in the 1970s didn't have access to any kind of medical information, including the medical literature. Medical knowledge was a closely held secret. And some of the very first patient groups like the Center for Medical Consumers in New York City started out by creating medical libraries for patients where they could come and look up their conditions. They would even, you know, they would mail, they'd copy things on a copy machine and mail them to them. Getting hold of your own medical record was sort of the flip side of that. People didn't really know when they'd been hired. And it happened a lot less because it was a lot less medical care going on. As there was more medical care and more knowledge, and especially with the internet which sort of blew everything wide open. People naturally wanted to know more about what was going on with their own care. But it's never been easy to get hold of your own record. It's taken really the recent actions by the federal government to make it clear that patients do have access to their records. But there are often still issues. The medical records are scattered across various departments. If there's harm involved, providers aren't necessarily keen to have patients see all their records. We still have a long way to go. Marty, I know you've been working in this space for a long time. What do you, anything else to add to that? Yeah, it's interesting to me to hear you, Donna, and Helen talk about who owns the medical record. Cause from a legal point of view, it's pretty established that the patient owns their medical record. And the struggle in the courts usually, and it's usually in the context of a professional liability suit is getting access. So ownership has been kind of honored by the law, but there's been a tolerance of quote unquote reasonable restrictions on access. And often that came about as you would be charged a lot by your doctor to see your medical record. So they would charge you $5 a page, something like that that, you know, would strike most of us as unreasonable when there was a copy machine right around the corner. But anyway, that the legal principle is clear. And then I think the real issue has been access. And I don't really think of it as driven primarily by the consumer movement. So Helen, I learned something from you. I think of it really as being driven by the patient rights movement, which is an extension of the human rights movement that we're entitled to information about our bodies. We're entitled to be the decision makers about our bodies. And that goes back really to, you know, a lot of the ethical work after World War II about who owns our bodies and who's entitled to information about them. Well, I wonder if you can also then talk about open notes. There are some folks on the line who might know about that, might not, just tell us a little bit about that. Well, open notes is, it's an approach. It's an approach that really, you know, at its very simple level is to provide complete access to all of the medical records. Everything that Helen wants, open notes is the approach that would give you access to your complete medical record. And it's also a movement. So there's been a lot of thinking about this since the 70s, when I think the first articles were published saying that people should have access to their medical records, not only to improve safety and quality, but to improve the physician-patient relationship, that will be stronger and to empower patients to become people who can actually do something about the rights that we're now acknowledging that they have. So it's a movement and it's also a really sort of well-organized organization. OpenNotes.org has a lot of current information, easily explainable to people if you wanna learn more about it. So it's all those things, but basically the concept is really simple and that is we have a right to our records and we're going to make those records more and more accessible. By records, I mean everything.  Would the patient understand them? Do we really want the patients to know what we're saying about them? And that's being driven by transparency. Donna, though, if I can add, OpenNotes doesn't do that yet. I think that is the goal, but OpenNotes has been very incremental in their approach. So they're our notes program, which is the patient sharing program is really sort of an agenda setting by the patient. The patient submits information and then the providers decide whether they want to include that in the record. So it's sort of like a be prepared. That's a program at AHRQ that MedStar created. And there are others too, just sort of a way to talk better to your doctor. But it's interesting to me, when this started, there was a lot of opposition. The doctors were opposed, the patients all loved it. There was actually a 99% approval rating from patients, which I've never seen anywhere else in medicine. And 90% of them wanted and extended the hospital stay. So clearly this is something that patients want. I remember meetings as early, as late as maybe 10 years ago, where the topic of the conversation would be, oh my gosh, can you imagine what patients would say if they actually saw their records? If they actually saw what we write about them? And I think it is, Helen, I agree, it's a call to action. It's a movement in the sense that there's not everybody sort of agreeing on the details, but they're all agreeing on the direction and sort of at the more extreme end of that is propositions that we're hearing more and more about, about patients actually being able to add to their records or to correct their records or to make notes themselves in their records. So there is kind of sort of a range of pieces to it that are all still in development, I think. Many of them are still in development. And until you have that, I think, that's when you will get accuracy, when you can have patients adding to the records. And correcting. I mean, I think we're already seeing the literature emerge where if you do have access, people are finding the errors that we in the patient safety movement know are pretty routine in the system as complex as healthcare is and as complex as record keeping in healthcare is. That's right. Empowering patients is safe for everyone. So, Raj, you have a, you got a campaign there at MedStar Health called the EHRC What We Mean campaign. I wonder if you could tell us a bit about that and what the impact of that campaign is on patient safety. Yeah, absolutely. We'd be happy to. So if people are not familiar with it, I highly encourage you to check it out. You can go to EHRCWhatWeMean.org. And really the campaign is about bringing greater transparency of electronic health record, usability and safety. And we launched the campaign in February of last year which marked the 10 year anniversary of really the big legislative act to promote the use of electronic health records. That was passed way back in 2009. And over the course of, if you look at it from 2009 to today, we've moved to nearly every healthcare facility in the United States using electronic health record, 90 plus that use an electronic health record. And what people probably don't realize because you're probably not thinking about this every day, nor should you be, is that the way these electronic health records are designed and the way that they're implemented and used can actually facilitate a whole host of really terrible errors that impact our care. And so we see errors where wrong patients are being selected out of the chart and then medications are ordered for them or procedures are ordered for them. Wrong weights are documented on our children. And then that means that when they're prescribed the medication and most children's medications are based off of their weight, that means they're gonna get an overdose of medication. And we've just done study after study on this and found these really poorly designed electronic health record system better leading to errors. And the campaign really was sparked because in the contracts, at least historically in the contracts between the electronic health record vendor companies that develop these systems and the hospitals and other healthcare facilities that buy them were something called GAG clauses. These clauses actually explicitly prevented, forbid the sharing of screenshots and examples of these errors, which we thought was just horrific. I mean, if you look at any other aspect of medicine, medication errors, medical devices, you name it, there's incredible transparency and there's databases to collect those issues so that we can fix them. And that has not been the case of electronic health records. And so the campaign, and if you go on the website you'll see very explicit videos of actual physicians using the electronic health record and the challenges that they face. So for example, one of my favorite ones to cite is we have a physician, emergency physician that's trying to order Tylenol, pretty basic medication order. They type in Tylenol to search for the medication in the electronic health record. They get 86 different options back. And they're trying to place a medication, they're trying to place the Tylenol order for a young male, 22-year-old male. They get children's Tylenol examples, infant Tylenol, Tylenol for women, all kinds of things in those 86 options. So why do we care? Why does that matter? Well, imagine if that's the kind of interface and system you're using for a 10-hour shift. There's such a huge likelihood that they're gonna select the wrong medication. Now thankfully with something like Tylenol it's pretty low risk, but when you start thinking about all the other medications and procedures that they order, of course errors are gonna happen and they're gonna select the wrong thing. And that has very, very serious implications for patients and patients have actually died because of some of these issues. So the goal of the campaign is to heighten awareness of these kinds of issues. Thankfully, the Office of National Coordinator that oversees electronic health records in the United States has moved to remove those gag clauses, but the work's not done. You now need to have a central reporting system for these. And this goes back to the central conversation around making sure patients have access to their records. One of the critical things that we tell patients is we know that these errors are gonna happen because of the design of electronic health record and patients are a critical line of defense to make sure that the information in the record is accurate. And so I always tell folks, check the most basic information, check the demographic information, check to make sure that it's actually you that it has the right age, the right weight, that the procedures in there and the medications are actually yours because people will be shocked as to how many times incorrect information gets placed in the record. And it may persist in the record that our clinicians who are all well-intended and doing their best, that the records are so dense that they simply may not see that wrong information is there. And then at some point in your care trajectory, they may look back that information and make the wrong decision because that information was never supposed to be there to begin with. So that's sort of the gist of the campaign. And again, the big next step here is really making sure that we can find a way to capture all of these safety issues into a central database so that we can analyze them and improve the system. And it's worth noting that we're not, this is not about, this is not anti-EHR. If you think about where we are in terms of technology and you look across domains, it's a no-brainer that we need electronic health records in medicine. And if you talk to physicians and nurses and other clinicians and you say, do you wanna go back to paper? The majority of them would say no. There are tremendous benefits to this technology. But what we need to do is we need to optimize this technology and make sure that it's safe for everybody. So that's the big challenge ahead of us. There's several positive things that are happening, but that's certainly the big challenge ahead of us is making sure that these EHRs are properly designed to implement to ensure safe care for everybody. Sonika, can I weigh in here on this question too? Because I am a huge fan of Raj's campaign. And I know it's not just your campaign, Raj, but it's a campaign you put together. So EHR, see what we mean. Go to that website. And one of the many reasons I'm a fan of it is that Raj is walking the talk of engaging patients and families. So we're not only talking about them getting access to their own records and all of the areas that they're gonna find, how they're gonna help us make those records better. But he's also engaging them politically through a request to write your congressman. Get educated about this. Let your elected officials know how important this was to you because with all due respect to the OMC, they didn't move that fast on this. They needed some prompting. And these gag clauses were really, really aggressively enforced that he's talking about. I mean, it was that there were threats. If you share the error that you found in our system with anyone else but me, the vendor, then we're gonna go after you legally. And that of course allowed the vendors to charge every client. So you would learn from one client where your problems were and then you would charge other clients to share that knowledge with them. And that is just completely anathema to the spirit of a systems approach to safety, which is spreading lessons learned as rapidly and as extensively as we can. So it's a brilliant campaign and a great website. Well, thanks, Marty. I really appreciate that and Marty's always been so supportive. And I think as soon as he starts talking, it gets me fired up again about the whole thing. And keep in mind that this was a $40 billion US tax investment so that's all of us here. Won't make any political jokes, but most of us are paying taxes and those taxes are going to pay for these systems. Yet we can't make the improvements to them. And Marty's exactly right, is these clauses have been in those contracts for a very, very long time. And the other clause that is noteworthy and needs to be removed but still persists is the hold harmless clause. So that essentially says if a patient is harmed because of an issue related to electronic health record, the electronic health record vendor, the company that produced the electronic health record cannot be held viable for that. And that's nuts, right? And what it should be is we have to go back and we have to look at how that issue emerged. And if the vendor was responsible or partially responsible, they need to be held responsible for that. If it was the healthcare facility that made a change to the system and that's what resulted in harm, then that entity needs to be held responsible. So that's the next big push for sure is trying to start tackling that hold harmless clause. One more word and then I'll stand down. But the other place where we really happy working on gag clauses is in the settlement of professional liability claims because that's the other place where they're used so extensively. So just thinking about it, you've litigated over a problem with care, breaching the standard of care allegedly, you've come to a settlement and then we gag the family from being able to talk about it. And it's the same principle. If we don't talk about our mistakes and learn from them, then we repeat them. I mean, we're exactly, we're putting fuel on the fire of them getting repeated from place to place to place that haven't heard about as early as they could have. And there are amazing case studies of just problems that have emerged in healthcare, you know, at different facilities around the country that stay quiet for years and years and years because of these gag clauses. So it's a bigger principle, but one where we're getting some traction with EHR, see what we mean by the website. Excellent, excellent. Anna, I'd love to have your perspective from the international community. Raj just talked a lot about some of the issues that we're facing here in the United States. Can you talk to us about the user issues that you're having and whether or not you have any challenges like what Raj was talking about here with the ONC? So I think actually they are quite similar to the challenges. And one of them from the physician perspective, as Raj was saying, of course, is the user friendliness of the system. Sometimes it's just too complicated to find or to prescribe a given treatment or to prescribe an exam or whatever it is in the list. But it's also a problem with interoperability because quite often as a GP or as a secondary care doctor, you need to open two, three or four different softwares to do three or four different actions. Let's say I open a window to enter my patient notes and I enter another window to do a prescription and then pop up to stratify the risk of cardiovascular disease. So it's actually quite a burden. And actually family doctors and general and secondary care physicians actually state this very loud and they say sometimes it's just such a burden to tick all these boxes that we don't really have the time and the energy to focus in the patient. And they actually say spend more time looking at the computer or at the screen that's at the patient. So these are big issues. Of course it has huge implications in communication, patient-doctor relationship, et cetera. So the challenges are quite similar from the user side in what concerns physicians. I guess, I think it's also important. I really like one of the points that we raised before about the safety implications of these because of course if a doctor is tired he's not going to register things as he should maybe or maybe some information is going to be lacking there because there's no time to tick all these boxes. And of course these guys direct implications into patient safety of these patients in front of us. But nowadays we have actually higher implications because as you know, all these data from electronic health records are more and more being used for studies to stratify risk, to predict risk and to generate knowledge based on that. So one of the big issues is that actually electronic health records and data contained there have a lot of quality issues. And we are using datasets with quality issues that we fully acknowledge to generate conclusions and to apply these to general populations. So I think that's actually a second layer of complexity in what concerns patient safety. And I don't think there's a way back there because we just understood the potential of these datasets but I think there should be a huge drive to find strategies to mitigate these quality issues because otherwise we'll be impacting patient safety in too many levels really. So that's from the user perspective. I also think that from the patient perspective in what concerns usability of patient portals or other facing interfaces, I think in Europe we have mostly two problems. One problem is about information as Ellen said before. So classically medical records or medical notes are not written for the patient, they are written for the doctor themselves. So we are not really trained and I think this is something that will change and must change. As doctors we are not trained to write patient notes that are understandable to the patient. We write things that are understandable for ourselves and for our peers. And I think the more and more we understand that patients are part of the process, they will read it, they will contribute, they will check error, they will amend them if possible, I think the more we get aware of these, the more we need to actually adjust the way we write patient notes so that our writing actual lines with these overall culture. And I think that there's an issue with information and with patient notes that needs to be adapted with time. And of course, apart from the information itself we have the problem with interfaces that sometimes are not very friendly, very intuitive for the patients. And something that we have been discussing quite a lot recently and particularly in our research area is how do we engage patients and doctors in the design of these interfaces? How do we make the process more interactive? How do we get them back versions of the software so that they can contribute, send their comments back and we can adapt these rather than having this top-down approach where someone's in company with a multidisciplinary team, that's fair, but they provide a solution that starts, basically, that keeps the same and doesn't really evolve. So I think that's something that's quite critical for the future to improve usability, really, to evolve patients and to try to have a user-centric design as much as possible. And how do you find the public perception there in Europe? Helen Haskell mentioned that here in the United States 99% of patients that they wanted to see their information. Is that also true in Europe? Yeah, I think so actually I wanted to share some results with you. I'm not sharing the screen, I can just give you a summary. So overall patients want to see their records, but what is also puzzling is that, so we ran a survey, so this is published, I can give you the reference and make it put it in the chat. So there was recently, there was a recent survey in the UK and US asking patients, do you know that you could have access to your records and 20% of them didn't know that this was actually a possibility in both settings. So this is a survey, take it with a pinch of salt. I'll share the link here in the chat and you can read the details. So for me, this is something quite puzzling and tells me that there's a lot of work to do in communication to tell patients actually, there's 20% of patients that doesn't recognize this as an opportunity. So we need at least to try to pass this message as much as possible. Overall, yes, they are willing to read the records as you said, there are different views as Martin said, actually there are different views on the details on whether they should see doctor notes or results. So of course the results and tests, so this is something that's quite accepted globally. When you start talking about patient notes even between patients, some patients actually say that that could create anxiety, they would like to see a kind of a more digestible summary of the information and something that I find really interesting. So we got that in one of our recent studies. We asked patients about their experience reading the notes and they said, I'm okay about reading the notes, I'm okay about reading the results, but I would like to have some kind of explanation of what to do these results mean. Because what's happening here in the UK for instance, is that sometimes some providers actually send you a text message or saying just check your website because we have test results there. So as a patient you go there and you see something like liver function tests of normal or outside of normal range. And for a patient this can be really stressful because they don't know if the slightly high value is something really bad or is something that's kind of normal. So just plugging the information sometimes is not enough and for some groups of patients they would like to see an extra layer of information so they could interpret these a little bit better. So I think as Martin said overall, yes, their support, we all agree that that's direction, but we might not all agree in the details really. Interesting. Well, Marty, I wonder if you can talk to us about the new ONC role that has just come out here in the United States about data sharing. Donna, I can try. There is a new role that I think has the potential to be very transformative at least in this country. So I'm really curious, Anna, just as you sort of survey the world where you think are the countries that we should be looking at as leaders because I'm impressed right now that we are stepping up in our country. And this new role came out of something called the 21st Century Cures Act, which was passed in 2016, which was really intended to increase usability and interoperability of the electronic healthcare record. So it's not an open notes rule. It's just one that overlaps and frankly brings in a lot of the thinking of the open notes movement. And there's parts of it that are very clear and it includes a list of the different kinds of records that patients and family, the patients are going to have access to, must be given access to. And it's a pretty interesting list. It's consultation notes, it's discharge notes, it's procedure notes, it's progress notes, all those things where there's some variation in addition to just results, labs and pathologies. There are, where it gets confusing is that there's a timeline that looks pretty aggressive in terms of the way the rule actually reads. And it's supposed to start in November where what the rule refers to is actors, but think of actors as health systems and other people with access to this information have to start making this information available. But then there's a whole section of the rule that just takes into account COVID and says, you know what, here's our timeline and then there's COVID. So there's going to be some delays in the implementation of the timeline. So the train has left the station but whether it arrives at its destination on time and the stops it's gonna make along the way remain unclear. And then there's a list of exceptions to the rule. Certain things that I just can't find detail on yet and that's where I get really confused. So there's an exception for things that are sensitive information like psychotherapy notes. There's an exception for information about it's generated in anticipation of litigation. But there's other things that are just kind of in fact, Adam mentioned one of them will provide you access to the records actually create harm for the patients. So one would hope that would be a very narrow exception perhaps where we see that mostly in law is when we're dealing with children is really do children have access should they have access to all the things that we're writing about them? But those things are gonna have to be worked out. There's also some wiggle room for cost how much we can charge for this for technology to be able to do it. But the goal ultimately the station if we will that we've left the station the arrival station is really complete access across all devices for patients and families including smartphones. So that's where it feels really transformative to me that we're gonna have in these super computers we all carry around in our pocket now at least in my country, pretty easy access when this is fully realized to our information in a way that really is usable by us. And the, I also just wanna say the best place I can see for tracking the rule is the open notes website. There's an infographic there about the timeline. It's not a clear timeline to me but there is an information there that's up there in real time. Ross? If I could just quickly jump in I think Marty summarized that really nicely and the other important part of that 21st Century Cures Act legislation that the ONC is really pushed for and is a great thing is the idea of application programming interfaces. So APIs for short and all of us whether you know what they are or not we've all experienced them. So if you're searching for a, when we used to fly around the world when you were searching for an airline ticket instead of having to go to every airlines website you could go to essential hub you could go to kayak.com you could go to cab velocity and what those websites do is they're using these APIs to ping those different airlines websites and source all that information into one place. So why is that important for us as patients? Well, what the 21st Century Cures Act and the ONC has done is said those APIs have to be enabled for electronic health records for a certain subset of information and that information will continue to evolve and grow over time. So that becomes really important for this conversation for multiple reasons. What that's gonna allow us to do is to have new tech companies come in and develop new apps just like we have on our smartphones that are gonna potentially resolve a lot of these usability and safety issues that we've been talking about with the electronic health record and those apps would be accessible by patients so that they can look at their data in a different way. So for example, if I wanna look at my I use running apps, I like to run a lot. So if I wanna look at my blood pressure levels and my other patient information in conjunction with my running data somebody could build an app to do that and they could source the data directly from my record. Similarly, if I want help managing diabetes somebody could build an app that would do that and would directly source information from the electronic health record. So that becomes really, really powerful and it starts to solve this issue of EHR usability and it starts to get more data into patient hands but the risk with that is as soon as you have a third party company come in and build one of these apps I'm sure everybody reads those legal agreements whenever they download an app. You know the ones that have like <IP_ADDRESS>.5 in multiple pages and we usually just click agree to everything because we just wanna use the app. We'll embed it in there is what that app developer gets to do with your data. And so now as we start thinking about how this unfolds download an app that allows this new company to access my health information because I want help managing my diabetes but in that legal agreement it might say oh by the way Raj, we get to use your data for all these other purposes we get to sell your data we get to share your data et cetera. So it's a really positive thing because it's gonna help resolve a lot of these issues but it also opens up this new challenge of really ensuring that patients are aware of what's happening to their data with all these apps. And that actually I think is not too difficult to solve if we get our act together and come up with a standardized form that basically says here's how your data is gonna be used and here's what happened. It'll probably take us years to do that but that's where we have to go. So if I might jump quickly there, that's okay. I think that's a very important point and it's actually quite a discussion right now here. So it's wrong except that patients should have access to their data, their own data but the more these apps are coming and they're already happening, the more the debate goes around what is happening to these data and whether it will be shared with third parties. And I think again that's an aspect which is really important to listen to the patients again. So the experience that we have here and I'm talking just in the UK, I don't know the reality specifically on these other countries but here in the UK most of the studies show that up to 95, 98% of the patients say please do use my data anonymized for whatever they consider greater goods. If you want to use it for research, if you want to use it to find what works better, what kind of treatments for patients would do best with a given treatment, et cetera. So most of the patients are fine use it. If they are anonymized, you can use it for that. Once you raise the problem that this is potentially shared with third parties, with potential commercial interests and possibly they can be monetized to generate profit, of course, acceptance rates fall to 20, 30%. So I think this is a very, very interesting area. I think we'll hear a lot on that in the next years slash decades. And again, I think it's a point that we should really discuss with patients and try to hear what they say. And as Rach said, I think whenever this comes an issue, this just needs to be said upfront and very clearly to patients. So this is your data, this is for how long we'll store it and this is the people that might potentially have access to it. And of course they have a say there, really. So, Donna, if I can also add something. So my perception of this rule to take a slightly different tactics is really mainly focused on interoperability between institutions. And there are, well, that's a great thing in a lot of ways. There are also concerns there because as we've been discussing, records are inaccurate. They're often wildly inaccurate. And if you get an inaccuracy in a record, a significant one, it can follow the patient wherever they go if you have interoperability. So there are a lot of patients like people with chronic diseases who really fear interoperability. So I think again, I hate to sound like a broken record, but this is where you need patient input, including corrections and by correction, I would say addition. But it really is the patient input that will make these things work and make them helpful and make sure you don't have that sort of democles hanging over people's heads. And then the other thing that, you know, the list of things that are available to patients that Marty cited. So I've been trying to figure out this rule as well. And one of the things that I would say is that previously patients had access to all their information with the exception of psychotherapeutic records, which I think open notes is trying to address in a different way. But in general, you know, I think there is a possibility that in this giant flow of text, we'll end up limiting the information that's available to patients. And that's something that we really need to watch out for. There's been a rule against withholding data from patients for a long time, but it's never been really enforced. There are just almost no cases that I know of. I know of a couple where HIPAA violations in the US have been, where hospitals have been cited or doctors for failing to give patients their records. Thank you, Helen. I wonder if you can kind of take us into the final stretch here. I'd like to ask each of you to give me your final thoughts. You know, what do you see as the broad long-term goal for data sharing and what do you think we need to do to get there? So Helen, I'll start with you. Well, you know, I think I was thinking about what Marty had said earlier about the human rights movement. I just wanna sort of go back. I think the consumer movement is part of the human rights movement and part of the patient rights movement. They're all intersected with this, the idea that has gradually grown over the course of the 20th century and hopefully now the 21st as well, that people really are autonomous and have rights. But again, the consumer movement, looking at it from that angle, which is sort of a practical angle of how do you get this information? We've always focused on how do you get improvement. We've always focused on transparency. Now you can't necessarily, we're not medical experts, but we can keep an eye on our own care and what's going on in healthcare facilities. And people now have the ability to learn a lot about their own conditions and about what can and should be done in safety and quality. So people are part of the team, patients are part of the team, and they can potentially contribute a lot. And if you pull back a little bit, I think the potential for patient level data is really enormous. So there are any number of studies that have indicated that patients can contribute valuable data to their own records and that it's often more accurate than information that's been filtered through the provider. And that's the standard way we put it in the records now. But right now the main way for patients to contribute data is through patient-reported outcome measures. Those are pros or prompts. But most of the prompts are still pretty restricted by the notions of what a patient is supposed to know. So they don't really include the patient's opinion or their thoughts, but just sort of raw data on functionality. There are a lot of people who are really aware of the need for better prompts and I'm hoping they will be forthcoming soon. I'll just say that one of my favorite researchers is a doctor named Ethan Bosch from North Carolina who's followed oncology patients for years. And he has found that patients whose chemotherapy was adjusted in accordance with their own reports of side effects live significantly longer lives than those who got standard treatment. This is really groundbreaking, right? How widely applied is it? I don't know of anyone else who's doing it. I'm not in the world of oncology, but I don't hear much about this. And then if you take it up a level, you get big data, so accumulated patient records, what we were just talking about, what you're now being used for all sorts of other purposes that don't necessarily benefit patients. But at the same time, these have the potential to tell us more than anything about safety and quality and the effectiveness of medical care. And there may be people who are sort of vested, have sort of vested interest in not looking too closely at effectiveness, but what medical treatments work? What facilities are safe? Studies, even large studies are often written in a way that look at pretty narrow topics and that can be written in a way to provide sort of desirable results. And I think big data, including patient reported information, and for that matter, provide a reported information on safety issues aside from the official information. Those things can really provide a foil to the limitations of studies, real world data. That's my feeling. Thank you, Helen, I appreciate it. We do have a few questions, but I'd like to get everybody else's final thoughts before we jump in there. Raj, how about you? Great, thanks, Donna. I'll be really brief. So just two things from my side. The first is now that we've made the tax dollar investment to digitize medicine and we have electronic health records in place, there's so much opportunity with the apps and so many other different pieces of technology that are evolving and that world moves really, really, really fast. I mean, incredibly, incredibly fast. And so as patients, we all have to stay on top of this and we have to get involved in one way or another. And so we spent a lot of time talking about these ONC rules. Well, when these ONC rules are first proposed, they're up there for public comment. And I know for sure, because I've read them, that the electronic health record vendor companies and everybody else is commenting. But my bet is that 73 attendees or 71 attendees that we have now on this call, I'd be shocked if anyone else other than Marty and Helen responded to comments. And so we have to mobilize and get together and be commenting on that legislation because we're the ones that are gonna be impacted by whatever is formulated. So that's kind of critical point one. And then the second one is it's always shocking to me, I'll talk to friends and colleagues and always when we're talking about this issue, I'll always say, well, how often do you check your financial data? And most of them will say, oh, crash, all the time. Like sometimes I log into my online bank account daily just to make sure everything's there at least weekly and I'll certainly look over my credit card statements. And then I'll say, well, how often do you look at your health data? And they'll look at me like I just landed here from the moon, like what are you talking about? What do you mean look at my health data? Why would I need to do that? How do I do that? It's just shocking. And so we have to build that into our behavioral norms. And I think the financial industry is such a good model for us because I can log into whatever number of bank accounts. I can also pull those all into one place, their websites that offer that. I can also transfer money to Anna in pounds in minutes. So that's interoperability, that's safety, that's checking our data, that's access all already solved in the financial industry. So I would just encourage people to think about these other domains and what's happening there and then ask themselves, why can't healthcare be that way too? And what behaviors am I using with those other domains that I should also be using for myself in healthcare? And I'll stop there, thank you. Wow, what great, I love that analogy. Thank you, Raj. Marty. It's a huge topic. So what I've been focused on mostly are the obstacles to getting usable information that's accurate to patients because I do think the empowerment potential, which I've already mentioned is huge. And the EHR for me is something that I'm worried about because I don't think it was really designed with the best interests of the patients in mind. We say it was, but it's far from that goal. We've still got a lot of work to do there. When I look at it, I think of it as being driven a lot by billing and administrative procedures than really being a patient centered. And I think this whole movement can help us pull that in the right direction. I'm really making that a tool that's useful for patients and the people who treat us. I am worried about the big data piece and I also am excited about the big data piece because I think if we can, again, the potential and the best of all possible worlds is to see data synergizing from different places to really be something that patients and families can use. And then I'm just really interested in best practices. So as we talk about what needs to be done next, what are the countries or where are the places where, you know, accuracy is being paid attention to and the use and sharing form that Raj mentioned is being developed. And whenever I kind of jump onto the net and try to figure out what's going on around the world, I find myself kind of going to countries that are really celebrating patient engagement and patient empowerment already. And that's where you find some of the best advocacy about open notes. So Scotland, for example, I don't know what's happening in Scotland, but there's just a commitment there at a policy level to fully engage patients and families. And I think that will be another place to watch is just countries that are doing that are probably gonna be a source of some good tool development. So those are my very random thoughts. Well, thank you, Marty. And then finally, Anna. So I'm not going to repeat what everyone just said and I completely agree with everything that was said so far. I would say that a different aspect that should be considered on patient engagement is actually to measure what the patients want because there's no proper research on that. We need to actually listen to patients, ask them what do you want to see in which format? Do you have the skills to assess these? Do you have the literacy, general literacy skills, but also the digital literacy skills that you need to do that? And once we get a clear picture, we can design strategies to help them or to help those that need and want to engage with the system. And I guess an important aspect here is also health equity because we are moving to digital. There's no way back, I assume. And we just need to be very aware that while patient portals and electronic records accessible to patients via websites or other kinds of interfaces, they do improve patient safety. We gave several examples. They do improve medication discrepancies. They reduce the number of errors. This has been documented. But we must be aware that maybe these benefits are just going to be for a small slice of the population. So we need to try to understand who is being left behind and why and how can we try to support everyone in the same direction? Because what we do not want with all these is to create benefit that is actually entrenching inequities that are already there as well. So that's the final thought on this as well. Very good point. Thank you, Anna. Well, we have just a few questions. The first question, Roger, I'd like to direct to you. That's coming from Teresa Gentry. She's talking about a situation that happened at MedStar where the storage company was hacked. Can you talk a little bit about that and what happened in that situation and what can we learn from that in the future? Yeah, absolutely. So this is an unfortunate incident that's happened to several hospitals across the country where the company that stores health information can be hacked. And sometimes it was happening all the time last year pretty frequently where hospitals were directly getting hacked and there's elsewhere events. And so I think, Teresa, and I'm looking at the question here specifically about what's the responsibility of disclosure to patients? So the HIPAA rules here are very clear that that information needs to be disclosed to patients in fact for one of our children was born at a noma nearby and they were hacked and we just got the letter in the mail that said your information has been exposed. So the HIPAA guidelines are very clear and other regulations are very clear about disclosure. And I think Teresa's real question is what about the timeliness of this and timeliness seems lacking? I'm not aware of the details of the investigations here but what I can certainly say is that when there is a pending investigation by the FBI DOJ that will slow down disclosure and that's where there can be exceptions to immediate disclosure, totally out of my wheelhouse. But I have seen that and heard that and seen the policies on that. And it's certainly the case that if there's a federal investigation which should happen because of a hacking or other incident that can slow down the timeliness of any disclosure to patients. So I'm wondering whether that could be the case here but I'm not familiar with it. Helen, a question for you. You talked a lot about patients being able to add to their own records. And one question that we had was related to errors that could occur if the patient were to have access. What are your thoughts on or your concerns about patients being able to potentially delete something or enter something incorrectly? You know, I think that nothing should ever be deleted from the medical record. That's my perspective on this. You can add, we have a problem with that already. The records that patients receive are often changed and that certainly creates a lot of suspicion. You know, when they've been corrected and sometimes that suspicion is justified if there's patient harm, now we can use metadata to sort of go back in some records and see what the original was. But it just makes sense to me that whatever is originally written, you keep that and then you add comments or corrections underneath that. Great. Anna, we have a question from Brazil. And so I wonder if maybe you can help us with this. They're saying that most hospitals there are still using physical medical records. They haven't gone completely electronic yet. Any thoughts on how we can improve data access to patients when there isn't an electronic environment? So, I don't know the reality in Brazil. I know quite well reality here in the UK and I can say, although there was a huge drive to digitize whatever you could, this was quite successful in primary care. So basically in primary care, everyone is using later on the records. It was not as successful in secondary care. So the problem in Brazil is not only in Brazil. So here in UK, we have same problem in secondary care. So there's a process to provide access anyway. So there was a process before. So as we discussed for 30 years, that is legally slash ethically a knowledge that patient owns the data. So even if it's paperwork, there's a process you can just ask to the hospital and they will provide you a copy of the notes, of the exams, et cetera. There's another thing that for me, so I'm originally from Portugal where everything is free as a patient. You just ask your notes and they'll give it to you and that's done. Here in UK, you do have to pay a fee and that brings me back to Martin's comment before. So that you have an example. Myself as a patient, I asked for my patient notes 20 or 30 pages and I had to pay 50 pounds. So this is something that for me as a patient is kind of surprising when we all acknowledge that patient owns the data. But in some countries, you do still have to pay to have access to the copies. And for me, that is a barrier to access because for some people might be fine to pay 50 pounds but for others might not. So I think that's a barrier to access. Answering your question, there are a lot of countries that haven't transitioned completely. They still have a process, so patients can still access. And I suppose that they might waive the fee if you say you don't have conditions to pay it. So you might possibly still have access to that even if it's not electronic. Excellent. Well, we are right at eight o'clock. So I want to thank all of our panelists. Thank you so much, Helen, Raj, Marty and Anna. I appreciate you being here today. And thank you to our audience members. We are always available here. If anybody has any additional questions, please send them our way and we can get your answers from the panelists. So as always, the recording of this webinar will be available on our website. If you are seeking continuing education credit for this activity, then if you registered with your proper credentials, then you'll receive an email from MedStar with information on how to collect that CE. Again, we can only offer that for the folks who joined this webinar live today. So thank you very much, everybody. And I hope you all have a wonderful rest of your day.


Hello friends, welcome to the session I am Alka and we are going to discuss matrices. We have to find the value of x and y if 2x plus 3y equal to matrix 2,3,4,0 and 3x plus 2y equal to matrix 2 minus 2 minus 1 and 5. So let's start with the solution. We are given with two equations 2x plus 3y equal to 2,3,4,0 matrix which we name as our first equation and 3x plus 2y equal to 2 minus 2 minus 1,5 matrix which we name as our second equation. Now we will multiply our equation first by 3 and on multiplying equation second by 2 we get 6x plus 9y equal to matrix 6,9,12,0 and 6x plus 4y equal to matrix 4 minus 4 minus 2,10. Now we name it as our third equation and this as our fourth equation. Now on subtracting equation fourth from third we get 9y minus 4y equal to 6,9,12,0 minus 4 minus 4 minus 2,10. Or this can be written as 5y equal to 6,9,12,0 plus minus 4,4,2, minus 10. This is equal to 6 minus 4,9 plus 4,12 plus 2,0 minus 10. This is equal to 2,13,14 and minus 10. This implies y equal to one-fifth of matrix 2,13. This implies y equal to 2 by 5,13 by 5,14 by 5 and minus 2. Now we have to find the value of x. So we will substitute this value of y in equation first or second. Now we will substitute this value in equation first. We get our equation first is 2x plus 3y equal to matrix 2,3,4,0. Now we will place the value of y. This gives us 2x plus 3 into value of y. That is 2 by 5,13 by 5,14 by 5 and minus 2 equal to matrix 2,3,4,0. This is equal to 2x plus matrix 6 by 5,39 by 5,42 by 5, minus 6 equal to matrix 2,3,4,0. This implies 2x equal to 2,3,4,0 matrix minus the second matrix which is 6 by 5,42 by 5, 39 by 5 and minus 6. This implies 2x equal to 2 minus 6 by 5,3 minus 39 by 5,4 minus 42.5 and 0 minus 6 which is plus 6 because minus minus will get plus. This implies x equal to 2 by 5 minus 12 by 5 minus 11 by 5 and 3. Thus, x equal to matrix 2 by 5 minus 12 by 5 minus 11 by 5,3 and y equal to matrix 2 by 5,13 by 5,14 by 5 minus 2 which is the required answer. Hope you understood the solution and enjoyed the session. Goodbye and take care.


Hello, this is day six of recording. Yeah. Hello, this is day six of the Tightwad Dad vlog. I'm back. I'm back. I've did it We've already started the spending Oh, you've spent on the pound shop How much joy 10 and did you buy anything else in there? Um Hey, can you get a shot of this they also spotted this bag in the charity shop Amazing And that was four hands. Oh, yeah, we don't usually say the prices But that's basically like five dollars Five dollars. Yeah That'll be a thumbnail Now I shouldn't really spend any more should I because we should we don't need stuff Oh, yeah, we need to get something to assist them. Okay drone, don't you? 15 But you know it will last about two minutes And Okay, so we went a bit nuts, so I've got a squishy ball The seller I've got a real cable because I'm fed up with our one falling apart This is so pointless we got hot wheels that holds a GoPro Okay, so the squeezy ball lasted about four hours. I guess we're ruining the the planet for four hours of fun joy to Get 1,000 subscribers just click on his face


What's going on everyone Sam here with the late in sports card driven 23 bowman chrome baseball hobby at 12 box case break number 43 Pick your team style. We got Anton H twins Bob C with the Rockies Bradley C diamondbacks Cardinals Charles A Nats Chun Wei W red Sox Angels David G Blue Jays Eric M. Braves Gabriel C Orioles Padres Mariners Guangxi W with the white socks Jeffrey H reds Guardians Giants Yankees Rays John W Tigers Jonathan L Brewers Kenny K Pirates Lee Wei H Mets Mitch D Cubs Royals Nathan J with the Astros Rob W Dodgers Marlins Robert Pete Rangers Robert G with the athletics and Zach D with the Phillies Brody pick up the race in 51. We are down to eight on Cosmic everybody. All right, let's do it Why the hell not let's get started and we're in my knife There's never like the Cowboys and some oh no Brian. Oh, no Yeah, Ganon seems to be doing actually a pretty good job there. I gotta give him a I gotta give him check out for the year now No, I mean Like it's kind of nice like just being out there and just being like hey, just go do what you can You know what I mean? They're not like they're not the starter, but go do yeah Hey Josh like go out and win us when it's well games, you know what I mean like No, I like Kyler to I like he's such like a Anomaly of a quarterback though because I mean like Like freakishly athletic in terms of like I mean the guy got trapped in the first round the top 10 picks in two sports like that's Ridiculous, bro Yeah, his athleticism is unmatched gotta be when he's healthy his most athletic quarterback in football outside Put him what you've been probably over Lamar in terms of like raw athleticism I think it's just it's so hard to build a scheme around that Dylan Beavers It's just you have to be so like creative Because he's not the tallest guy in the world either So it's not like you could have him sit back behind the blind a lot Andres Jimenez to 499 Crazy athletic oompa. Hey, what up Mitchell? Honestly pretty fast gory Mitchell, what up dude? What up? Shema of on health sepata smart honestly base auto Luis Laura nice one Mara brewers He's one of the chases for the brew crew in her Delgata Miguel Vargas to 499 Felon and Celestin Check my mail. Jose Ramirez to 299. I have like a ton of mail that I just haven't gotten Sebastian Walcott Dude, I know Matt Canada needs to go For I would have been so mad if I was a Steelers fan I saw the recent report that came out That was like they're giving him more of a role in the offense. Yes Like the like the Steelers plan to that Matt Canada is their guy and like they're giving him He wants they wanted to work more closely with Kenny Pickett. There's to 150 Nick York It's like everyone's like dude. You're the offensive coordinator You should be working pretty closely with the quarterback if you're the offensive coordinator White speckle Luis Perales to 299 congrats the Red Sox there you go Boston Joseph with the Phillies Marlins and Astros in a Cosme. Thank you, buddy Appreciate that there Joseph Yeah, we're really dwindling down spots today everybody we are getting close to that full sellout Mitchell, I don't think so. Let me see if I don't think Forrest has any But there is one tomorrow. Yeah, there is one tomorrow Mitchell We have a UEFA Club competition Finest half-case tomorrow Tomorrow night with me. Oh Yeah, I know the overreactions with QBs are just unreal man and go coach a toddler's football team Yeah, just tomorrow. We've got one. I don't think we have we don't have one today now A lot of guys Jordan Beck, I mean look at bro looks horrible Yeah, you can't write anybody off, but everybody at the same thing happened with the like Deco 12 artists 99 It was fun puka. We had a good time man. It was a good time It was good to just like hang out with everybody in the non-mike work environment That's he was kind of a baby Purple shimmer Jacob Barry the Marlins to 250 we squany buffers But yeah, no, it's not you don't need to panic on Tila junior Franco for the Dbeck's first day saw Maya first Andrew Jones Yeah, it's way too early to hit the panic button on Trevor Lawrence Like I want to play off game last year. I mean, I don't know. I think it's just cuz Colorado I think it's just the Rockies. There's you any Oswares to 150. I think it's just like nothing wrong with the Rockies I think the Rockies are just like They don't get a ton of they don't get a ton of attention. You know what I mean outside of like outside of Rockies fans But dude, they always hit in this they always they hit and they're good in every single bowman They're always good. They always have somebody Well been Francisco first nice one for the Guardians on the base. We got an orange. Hey, Sue's Caba a nice one there true orange for the Phillies There you go, Philadelphia Nice one there another team that sat around a little bit there Guerrero and Alfredo. Do know My guy keep Jay picking up a spot in cosmic It's gonna be the Marlins and the Dodgers Marlins and 52 Dodgers and 51 Thank You Keith blue ray wave Darryl Laverde going it to the angels the big-ass print line in that I'm gonna send an empty box and wrapper. All right. Let's keep it moving everybody Next box Well, I'm gonna lose the Donnie dude. I'm gonna lose the Donnie and he started Brandon. I I'm gonna lose my team I bear I guarantee you I did not score more points. Do I have the least amount of points or like a hundred, right? Kate Horton Oh, dude, I scored 89 this week large new bar to 499 my team Great, of course even trying and I'm still gonna barely limp by him Cannondale got it. Yes, dude. Look at my bench, too Brooks Lee. Yep. There you go That happened last week and it happened the first week. I've started the wrong people every single week There's Jacob Melton first base auto for the Astros No, cuz you know what the problem was I started Pierce last week and I sat swift because the first week Pierce was okay and Swift had like one carry Yeah, and then he went and then he had a hundred seventy yards and two touchdowns last week on my bench And Damian Pierce had like four and then this week Pierce scored.  Kevin Perotta to 75 orange yellow vapor wave guaranteed man You can take that one to the book Not going great In the dynasty Corey If you got to look back in like in like three years you'd be like man, I am the king of this league With that strategy though Team to get their first win. That's good at least oh Chad first is on house of Peta. That is very true to be honest shady Donnie was at that game when I was out there and Donnie's like dude that kick return looks so slow in real life That's Luke Berryhill first for the Astros Astros doing well and To base as well. Yeah, my team put my dude in my school league team. I'm by far the best team in my league It's like a last-place punishment League so I'm not probably not gonna finish them last that team is I have I have legitimately Eviscerated all three people I've played Like Yeah, yeah, same Teach show with a couple of cosmic or pristine spots. Thank you, buddy Again guys cosmic down to four to go Orioles Cubs pirates mariners four to go Orioles Cubs pirates and mariners So one of the better teams still available Cubs are pretty good morale some some vet color as well And then pirates are decent and the mariners are good because you have the second second-year chase of J rod One been show in Victor. Yeah cosmic is doing it. Well now. Thank you all again on helps the pay-dots in 99 Yosi galan Camilo Diaz Appreciate you guys filling all this stuff up today Andy Acevedo shimmer journey to Valdez jet Williams and a James Wood base base auto Carlos de la Cruz going to Philly's nice one there base base Once that you guys want to check one thing really quick T-law picket nausea Garrett Wilson London deuce Acres Rondale Conkin Kate. That's actually a pretty solid squad though.  We the bug people again, dude. Tell him in Celeston probably No, I'm Sebastian Walcott first. That's refractor of Jackson Merrill to 499 And base don't leave me a message base auto is Kristen Monroe nice one there for the angels Zavala and Nelson Thank God it's one sec one sec. Sorry everybody Yeah, wouldn't shock me either to be honest if nausea got traded. How she doesn't look good He does not look good right now Yeah, dude, I don't know what that's all about Green Kyle Schwerber to 99 Soto and Osario well-been Francisco first and Braylor Guerrero And all teams are marked down in cosmic that do remain Kevin picking up a couple of spots tomorrow. Thank you Kevin. It's a shimmer of Roger Garriott's Duno and Cam Collier Yeah, Steelers are struggling a little bit. It's that OC dude the angel of Sarmiento going to the Mets nice one there That's a Jones and Jackson Merrill. Oh god.  I haven't signed it to plot for a job Geez man. I hate that.   Nice one there Braves Thanks, Nick. Let's appreciate you buddy. This is a Toronto Raptors city edition city edition hat Dario Laverde first base auto for the angels and base Just a few teams to go and flawless as well everybody. I think just three now remain I think it's the Saints the Packers and one other team The Lions. Hello Ramar. How you doing, buddy? I know no raise yet. Surprise man. I'm doing no raise yet They're doing beavers to 150 nice one there purple on house of Peta to 250 That's what I'm saying, dude. That's what I'm that is what I am saying Edger and Rodriguez Gold shimmer Hans Montero for the inks to 50 nice one there in New York, Eru and alien so so Thank you and base auto Javier Valdes going to the Braves Nice one there Joe picking up a 10 case or Well-been Francis I think Kyle and I are gonna sit this one out. Yeah, right honestly Yeah, he is pumped dude. He wore the chain That sounds pretty cool Corey. Yeah, he did I know we had him We had Jake wearing an EPL Jersey To 99 Kevin Perrata.    That's not on a kids menu at most restaurants I Serena that is a Jeremy Payne in a 499 Ethan solace Hunting fishing that is pretty cool. Yeah, the discounts. I have to imagine would have been awesome there Gordon Grisepo to 299 for the Cardinals Pinso and Hans Montero Blue on Hell's Sipeda to 150 Omeda that means there'll be a Salas in this pack. You ready Dylan me Ethan Salas first card. There it is told you Hey, Jim, since I know who runs together now Montero Brooks Brandon Probably some big names. I know who runs together Joey Weimer refracted a 499 Sipeda Brooks Lee Yeah, that's fair. Yeah fair. She's man Lou Rayway of Yonatan and Rika is going to the Mets to 4 150 excuse me base and base Sal Stewart Delgado Aiden Sanchez that's a Yeah, or a teal aqua pink vapor wave the 125 to Mar Johnson Jesus Kaba victors Thurus Just was not happy at my old job and I mean I've been collecting cards and doing cards and you know I did a lot on eBay a lot on eBay Before I moved down here close to Montgomery since I started doing this full time I've done a little bit less because sometimes I get home. I don't want to look at carts anymore Based out of Abner you're eBay for the brewers. So I just apply honestly. I was so unhappy at my last job I applied for like a sorting and shipping position here and Just got to talking and they're like we have a breaker position potentially available and I was like, yeah, I'm in Got that Picked up my life from Connecticut moved down here got an apartment and I have been here since April of 2022 now No plans of leaving Anytime I love Florida Rainer Arias, I'm a big Florida fan. No income tax man. God. I love that Refractor Jackson, man, do we pull at least like 10 of these today? 99 He's higher on yeah, dude, honestly Yeah, like I knew I knew about rich and I knew about the company for a long time because When group breaking started getting really popular Purple Vladimir rest of two year to 250 there was like Fell in Celestyn there's like four or five huge companies that are all still here Yeah, I'm Jason Caleb they they oh, yeah pirates gone to 51. Thank you Matt P down to three But yeah, man the trading card world's fun, dude Gold mini diamonds hobby or rebus to 50 fashion walk up But I was also thinking about it, too I'm like if I want to go and work for us if I want to get into trading card world and work for a Sports card company. I want to work for one of the best Like this is this is like working for like the Google of group breaking yellow is Jason Shuri out to 75 Because that's like like a lot of people ask me all the time like what hey, I want to start a card breaking company What do I do? There's Miguel Amaya to 299 and legitimately my my answer to everybody now is Find a time machine go back to 2014. That's that's that's how you do it, man You can't do it now.  I love sorting cards Especially because then you see a lot of like base auto Camilo Diaz nice one there for the Astros because then you see like Like I'd sort breaks that I would do and I'd see like oh I remember pulling that card for that first and you see like like I recognize all so many of our customers at this point Yeah, you get to see all the hits and stuff like I know you guys are always like oh dude look what? Yeah, we're only doing this.  No? It's always a big thing out there like dude Look at this thing Which is cool William Burgoy upbringing my a through Jones Miguel Marcus again to 490 pulling eight of those do the Carol they do run very very like Like very similarly and that's come parada That's shimmer of Brooks Lee The twins never auto in this that is a base auto Lura Luis Rodriguez for the carts On their STL Yeah, I got to handle some absolute monsters. Oh, yeah Rice Harper to 199 seal ray wave I Do is von Grissom to 150 nice one there for the Braves and Ronaldo Lantigua, but it is gonna be a Henry Chevilli Yep, first card. It's gonna be Henry Chevilli after the auto purple Christian Serda to 250 for the Dive Max nice one there Henry Chevilli Happy a reverse Again guys, we're down to just three to go in the next break or no one to go in the next break just the Orioles That's it man. Just the Orioles Who wants some Adley who wants some gunner and spell Orioles right look who's talking, bro That was Matt taking the athletics and pirates in 52. Thank you Matt Matt P It's really a Bofa Donnie Chris J. Joe Los Romantes the 499 I might as well have shiz and Kyle out there. My god, dude That's gonna be noel v. Marseille nice when they're the 150 for the Reds on the Arizona fall league It's not good, dude That's a bad. That's a bad crew of people out there runichi Valdez There's a lot of wall walking a Lot of it out there for sure. I think brights didn't see her too. That's another bot god There's yellow Edgerton Rodriguez to 75 Might as well have Jake come in to Jake Kyle and shiz. Oh my god Be an ultimate like free win in fortnight. There's Jor-El or tega nice one there base auto for the twins Yeah, we did It was fun me and me and Jake beat your dad and Kyle I me and him played against Bofa and Jake the other day We didn't I mean we still we shot 17 under we still lost they shot like 22 under dude I know But I kind of fell in and sell us and I kind of sold a little bit for when we played But to be fair, we were both missing a lot of big putts. You want to see Vargas to 299 nice one there dodgers Congrats on that wallcott first genero miller It was good p. It was a lot of fun. We had a good time, man Yeah, it's good to see everybody is like everybody in one place at one time because that never happened seven days a week, uh We're open and uh green shimmer brooks lee to 99 To be in one place at one time base auto mike coyado going to the uh, garden Cheerio and Ludwig espinoza. But yeah, it was a good time, man Lee and all messy kind of a confirmed baby kind of kind of a confirmed baby, but uh It was all good. It was still fun, man. It's cool atmosphere. I've never been to a professional soccer game, so I was kind of in Can only imagine how crazy it is in Europe, dude. That's what I'm saying You want to be Vargas?  Masataka Yoshida nice one there for the red socks For the red socks Um, so yeah cosmic coming up next 51 is just at the Orioles and then six to go on the other one as well That is kevin parrata to 2 99 Rainer Arias first Purple shimmer is Jonathan mehia To no, that's fuchsia shimmer 199 Yeah, that's what I'm saying grandpa. That's what I'm saying, man. I can't even imagine What it's like over there Henry Ramos that's going to the Royals There is a big Ding on that one. I'm going to send an empty box and wrapper with kc That one's kind of unavoidable Oh, yeah, but dude, I mean, I'm sure he came to miam and he's like look whatever I say goes Doesn't matter. It doesn't matter what I want.  Oh, okay. Okay. Okay, leader. Okay. Okay He's probably at the crib the whole time. Oh, yeah, dude There's you on Moncada to 4 99 Jackson chariot honey, not chariot here Let's say wave mookie bats to 100 Jesus Galiz Anderson de los Santos Refractor, Girolo Quintero to 4 99. Nice one there braves Restatuyo and Jacob Melton and Mola Oh my god No, they don't dude. They do not That is a way of legitimate legitimate way of life over there uh Jackson Meryl refractor Almeida and a Ethan solace first nice one there. You're in a pinto Shimmer is kevin iru base auto bj cook for the ace Marj Johnson there's Vinny Pascantino 4 99 Slow news day on ESPN Uh, Nolan Arnauto to 2 99 Canada Elgato Cava purple yosi galon to 250 Brigoya and Luis on jalapeno And last pack blu ray wave auto. It's Aiden Sanchez going to the Cubs. Congrats. Chicago. Nice one there Either Raptors gone in a mosaic break. Greg picking up the ramp sold out on the first uh mosaic football now Base and base quick recap here everybody Masataki Yoshida Michael Harris Uh, that's Hans Montero gold orange Jesus Cava. Noel v. Marte We had base autos of Henry Ramos the angelo Sarmiento Javier Valdes bj cook avnery riba driller tega camelo Diaz Mike Coyote Darryl Laverde christen Monroe louise rodriguez carlos de la cruz luke berry hill jacob melton jr Franco louise Lara before 99 gerudo cantero to 2 99 louise paralysis gordon graceffo to 250 christian serda To 150 Aiden Sanchez Darryl Laverde yannis in our net uh, Enriquez and Javier reboss 50 I'll do it for the break guys. Thanks. Come for the film coming up next. He's cuspic