Everyone, welcome back to theCUBE's coverage of Ansible Fest 2021. I'm John Furrier, your host of theCUBE. We're here at Eric Pettington, Director of Solutions Engineering and Mike Tadaro, Senior Epic Cache Consultant at Sapphire Health. Gentlemen, thank you for coming on theCUBE and chatting about the wave of cloud, cloud native and Sapphire Health and Ansible. Thanks for coming on. Thanks for having us. Thank you. So let's get started. Can you guys just briefly describe Sapphire Health and what you guys are doing there, the consulting services, the trends that you're seeing. Just take a step, a minute to describe the environment Sapphire Health and what you guys are doing. For sure, yeah. So Sapphire Health was a consultancy that was founded by the CEO back in 2016, Austin Park, who also serves as a CTO for some healthcare organizations because he was having difficulty finding an organization that really specialized in Epic infrastructure. So you might be familiar with some of the large players in Epic Consultancies, but they are typically focused more on the application side. So configuring like the ambulatory clinical system or something like that. And there really wasn't a solution that he could find in the market for an organization that was focused on Epic infrastructure and some of the more technical components of managing an Epic technical ecosystem. So Austin founded a team. Mike was one of the early folks to join. I joined a little bit later, but he put a team together to again, really focus on the technical components of an Epic implementation. And since then we've been providing managed services for Epic infrastructure for a number of organizations. We've been focusing on platform migrations from, for example, AIX to REL for Epic organizations. And we've been focusing on some growth areas as well in the cloud. Epic Systems is now able to be hosted on the public cloud. That's a relatively recent occurrence. So we're working with some organizations in that space as well. Mike, anything you'd add there? No, I think that pretty much covers it. We've spent a large fraction of our effort making sure that we're engineering solutions for these clients that move them in the directions towards cloud readiness, towards containerization, automation and those sorts of things. So that I think Eric's description spot on. So you guys must be busy. I mean, I can only imagine the action happening right now as people realize that the pandemic specifically, two areas that we've reported aggressive growth on was public sector and healthcare. Both were under massive strains of pressure to get faster. Can you guys just weigh in real quickly on what you guys are seeing? Because, and how's that impacted your consulting services but also the customer? What's going on in their minds? Absolutely. We had some customers very early on in the beginning of the pandemic where we were given the cadence of updates coming from Epic, the needs for growth for those customers where both in ICU surge capability as well as just general admittance, there was a flurry of hardware purchasing, provisioning set up and increased cadence around patching for various pieces of the Epic environment including Epic code directly, all of those things, all those, the tempo of all of that increased once the pandemic began. And we spent a significant fraction of time trying to find better ways, faster ways to engineer what we were already doing for clients simply so that we could continue to keep up with the surge in demand without requiring an additional surge in investment in people where it wasn't necessary. Obviously some growth was necessary but we wanted to help our clients get the most out of what they already had so that they could spend that money where it was needed to help patients. Yeah, awesome, great stuff. So we're here at Ansible Fest getting into the action, it's all about automation. So I got to ask you guys, what led you to start exploring automation solutions at Sapphire Health? Yeah, so there's quite a few reasons. I would say the most critical is that we've been providing managed services to organizations around infrastructure management for some time. And as you can imagine, infrastructure management has some repetitive tasks. And I'm quoting my colleague Mike here, but a good administrator is a lazy administrator. And what we mean when we say that is, if there's a repetitive task that's being performed over and over again, if there's an opportunity to automate it, that's going to save us time. But more importantly, that's going to, apologies, lights here. Let me move around a little bit, should come back, there we go. But it's going to provide an opportunity for us to focus on more value add services for the client. It's going to reduce cost for the client in terms of the services that we're providing. And I think most importantly, it's removing the possibility for human error or the possibility for error overall. So it's a natural evolution of us observing the time that we're spending with our client partners. And again, it really provides a lot of value to Sapphire as an organization and our customer partners as well. Mike, you want to weigh in on this automation trend? Well, how do you see it evolving? I mean, obviously it sounds good when you want to automate things you do repetitive tasks, but is there more going on that you see in automation that goes beyond just, okay, if you do it three times, automate it kind of vibe. Sure. Automating repetitive tasks is the kitty into the pool. That's how we get, that's how we sell the idea to people who just don't get the concept yet. But there are workflows that really aren't feasible without outside of automation. We tend to think of automation in some cases in this sort of limited way, but automation is really, what we really are targeting with automation is more about workflow. It's less about individual tasks. It's more about an idea, a workflow or a business requirement from its origin all the way through its implementation. So I've got it just the simplest case that jumps immediately to mine. Because I have a new hire, I've got to provision them an account. I need to provision it across multiple systems. I've got to do it in a single sign-on. They need home directories, they might need access, they need building accesses. We need to generate, you got to generate badges for these people. And these are all workflows that are normally disparate. You have to take your sheet to this guy, take your sheet to this guy. Here's my new hire form. Really, what you really want is we got a new hire, everything's checked out, put it in this basket here and let the automation move it through all of these systems all the way across. And that's the sort of thing, like I said, that's a very limited, very simple idea, but that's the kind of thing we really want. We want to get in the door with automation, with simple things, and then we want to teach, we want clients and ourselves to be challenged, to be creative, to find new ways to apply it that aren't immediately obvious. I was smiling because I love the example of the kitty end of the pool because automation is going mainstream. And it used to be kind of, for the geeks who were doing the hardcore stuff who got the whole big picture. Now you're seeing with AI automation moving in and with cloud and a lot more automation happening. So, you know, I can almost see in my mind, mental image of people wearing bubbles in the pool, kind of like going in the deep end, get back over here, stay in your lane. But this is the trend. And I want to get into this because you guys are involved in this epic migration has been talked about. So for the folks that aren't in, say the healthcare space, put a little context around epic and then I want to get into this whole migration discussion. I think that kind of points to some real value proposition. So take us a minute. What is epic for the folks outside healthcare? Sure. So epic is one of the leading EHRs or electronic health records software in the world. It is by far the most deployed in the United States. What's involved in building an epic or performing an epic migration, epic is hundreds of systems. When you think about epic as an umbrella concept, it is servers and end user workstations and all of these things. When we talk about a platform migration, what we're usually talking about is the transactional database.  When we perform on those migrations, we're usually talking about, when we perform on those migrations, we're usually talking about an AIX to Red Hat migration, although you can just do hardware to hardware. Involved in that is a number of things. You're building new VMs, talking about setting up patch cycles, setting up the patching server, installing the various administration scripts that epic provides, installing the software that runs the DB, which at the moment is either intersystems, cache or iris. There's the provisioning of the local security users. There's the configuration of the OS. There's, if you're moving from AIX to Red Hat, you're talking generally about a bit Indian conversion.  There's a tool for that. There's a lot of these little stats. And the thing is, is that they're all very, very well-defined and very similar. And so they look identical in many of these cases from one implementation of Epic to the next. And that's not true for the entire Epic stack. Not necessarily, but at the ODB level, this stuff is all very similar. And this is a very right place to automate. This screams automate.  You know, if you write and build your script and debug it, the script runs, it doesn't make mistakes. I make mistakes, the script doesn't. So we do that and we end up spending less time on these repetitive, unnecessary tasks. We guarantee the correctness of them or we do a better job of guaranteeing the correctness of them. And all of that ends up saving money in the long run. That's awesome. And thanks for the context. I was going to get there on the automation piece. It really sets the table for the automation. Real quick clarification. How much or what kind of software work is involved in a migration? How much? So there's the installation of, you know, you have the, from the installation of the OS and the configuration of the OS, the building and the patch server, the implementation and testing and patch cycling. There's those data conversions I talked about. There's environment refreshes where we copy an existing environment on a regular basis to another environment for things like testing, for troubleshooting purposes or for other reasons. There's more than one database for Epic. There's one big production database. And then there's, you know, you have training databases and you have playground databases for people to work in so they can learn to use the system better.  Oh man, it's a huge system. Okay, so I got to ask the security question. Sure. The security element is important when selecting automation or how's that factored in? I mean, right now that's super important. Obviously, records are key, but like obviously, where does that fit into the automation piece? How's security? Yeah, I think that's a very important question. And as you alluded to, security is incredibly important. It's very important in healthcare in particular. And in fact, with healthcare, there's a lot of regulatory requirements. There's a lot of requirements that individual healthcare institutions have that we as a partner to that institution need to follow. So as we were evaluating automation vendors and automation solutions, a highly secure system was not a nice to have or like a value add. It was something that was absolutely critical and paramount to being able to successfully automate any of the things that we're doing. So I'll turn it over to Mike to talk about some of the specifics, but as we evaluated Ansible, we saw that it really supported robust security. So Mike, can you comment a little bit more on that? Sure. So there's a number of ways that we use Ansible to help improve the security posture for clients. One of the ways is Ansible playbooks are written to be runnable against a server and then nothing will change unless something is set incorrectly. And this lets us assure that the configuration is where we expect it to be. So we don't get drift, we don't get drift on these servers. Now, remember I said an Epic environment is a lot of servers. If one or two of these servers- Mike, you don't mind, what is, when you say drift, what are you referring to? So when I say drift, what I mean is if there's a bunch of different servers and I as an administrator have to work on one or two of these servers just for little things during the day, I might make a change on one of these servers inadvertently or inadvertently. And then that server's configuration is now slightly out of phase with the other servers, which could be benign, but it could also be a security hole. Having Ansible able to run nightly and continue to adjust these servers back to the expected baseline and in the case of things like Tower, be able to report that these things were out of position. Let us know, hey, it lets us reduce the attack service. First of all, it lets us multiply, like force multiply our attention across this farm of servers. And it gives us that sort of clarity that we know we're doing what we have to do to make sure these servers continue to be safe. That's an awesome service. And that right there is, I mean, just going in manually trying to figure all this stuff out is just a nightmare. I mean, what a great relief that is. I mean, just the alternative is what? More pain and suffering human-wise as the labor and then risk on attack. Because people go to bed, you know? I'm a patient. The thing is on a personal note, I'm a patient too. All of us are. We all have doctors. We all have, we have to go to the hospital for things occasionally. And if we fail when we perform these security audits, if we fail when we perform these security checks, patient data can get lost. It can get sent to people who shouldn't have it. And I'm a patient. I have no desire for my medical information to be available anywhere, but in the hands of my doctor or myself. And that's the thought I try to stay with when I'm working on these systems. I'm a patient. It's not that I'm doing this because I mean, the knock on effects of reducing liability for the customers cannot be ignored or overstated. And they're critical, but ultimately my eyesight is on the patient. Yeah, and having that stability is huge. Okay, this brings up the whole automation thing as it becomes more mainstream. For you guys, specifically it's critical.  How are you guys continuing to push the automation envelope into the Sapphire Health's consulting practice? Yeah, well, as you mentioned, John, yeah, we're really taking a look at the entire technical infrastructure when we're working with our clients. And we are offering fully outsourced managed services for organizations, not just around the epic infrastructure, but things like networking devices, security, and other third party systems. So with that, we're seeing a lot of these things that are going on and we're always evaluating opportunities for automation. There's actually two areas in particular that we're seeing gain a lot of momentum with our customers. And we're seeing a lot of opportunity for automation. The first is business continuity and disaster recovery specifically within Epic. So Epic has very stringent requirements for resiliency as you can imagine. When the system goes down, a hospital can't really do what it needs to do from a billing standpoint, a clinical standpoint. So very robust disaster recovery resiliency standards and solutions are very important. However, there's not a lot of automation that's available either from Epic as far as I know other consultancies. So what we did is we built a script that provides failover automation. So some of the tasks that would be very manual in terms of failing over to your DR solution, we've automated that. And that, again, removes a lot of the opportunity for human error really speeds up the failover process. And so with the customers that we work with, that's something that we provide. Another big area that we're seeing is environment refreshes. So within Epic, there's different environments that are basically all their data is copied over on a recurring basis from the production environment. And the refreshes can have a lot of manual steps involved. So we've found an opportunity and have implemented some automation around environment refreshes for some of our managed services clients. And as we continue to go throughout, building our cloud practice in some other areas, I'm very confident that we're going to see, infrastructure is code more opportunities for automation around areas like that. And you guys got to love the DevOps vibe going on now. Mike, I mean, you guys have seen the movie before in the old legacy going back to the mainframe. So you probably still run into a lot of older systems that still do a purpose. I mean, I have a lot of friends and clients that are working in the big banks and they still have all the old school that does their job well, but containerization and cloud kind of give life to these systems. Because now we're living in this system architecture called distributed computing again with the cloud. It's the same thing. Different, different, different, different stuff though. Absolutely, years ago, almost every Epic client was running on AIX and maybe not mainframe, but more mini computer. And the migration path for almost all of the clients has been to move from those AIX mini computers down to VMs running Red Hat. Or running Linux and the natural evolution of that path is to move out of, is to move at least disaster recovery data centers into the cloud. And then for some clients, the economics say the whole data center to the cloud. So absolutely that path is well forged. It's there. I suspect that we'll see a lot more of clients, even larger hospitals beginning to move down that road in the near future. And for the folks watching who may not have the scar tissue that we have AIX was IBM's old Unix kind of mid range, mini computer, it was kind of client server, was client server, going now, being being modernized. So obviously Red Hat's not part of IBM, but it speaks not just to IBM. This is about Ansible, right? So this is like this action happening here. So this is a case study of pretty much all migrations. It's not just the fact that it's AIX to Red Hat. It's system to the new thing that has benefit. What's your take, Mike, on that kind of paradigm? It's a lot of people going through similar situations, just change AIX to something else. You have a lot of this migration replatforming going on with the opportunity to kind of tweak it and add stuff to it. What's your advice and what's your reaction to this big trend? My advice for this, honestly, my advice is when you're planning these migrations, you know they're coming. Even if you're not in the cycle yet, you know it's coming. My advice is start brainstorming your implementation of automation now. Get your automation into the system as you platform into your new platform because it is far easier to build that entire platform with automation as a critical component than it is to bolt it on later. And you will get much more out of your investment and time and effort if you've integrated it from the very beginning. I would say anyone that was looking to perform a platform migration now and hadn't already begun serious consideration of running automation or had had no plans for automation was setting themselves up for a very long and very difficult road to hoe. And I would advise against it at this point. Great, great insight, Mike. And thank Eric, thanks for coming on. I appreciate your insight here. You guys want to give a quick plug for the company, what you guys are looking to do, hiring, any update you want to share? Because great content you guys just shared here. Thanks for doing that. Take a minute to put a plug for the company. Yeah, I think a quick plug here.  So we're definitely looking for more mics. But more broadly, we're really looking to expand into the cloud space. We're rapidly expanding our managed services opportunities. And what we're seeing is a lot of organizations have like one ODB admin or one client systems ECSA admin. And what they run into is that person will leave, that person will retire, that person needs to get married and go on their honeymoon. It's kind of a problem. So we're working with a lot of organizations to not just fully outsource their environment, but to provide a hybrid managed service to provide overflow, to provide capabilities, to scale up with upgrades and projects like that. So talk to us. We're pretty darn good at it. As you heard from Mike, we've got a couple of mics. Again, we could use more. So if you are a Mike, please reach out. He could virtualize them. He would just virtualize Mike with, you know, that's virtualization is a huge trend. Data rights, Mike. We need to do that. Are you a body? Are you the real Mike? As far as I know, my wife would appreciate it if you guys would clone me a few times. You know, I've heard horror stories, Eric, around root passwords. Like, who has the root password? Oh, she left two years ago. Kind of situations. This happens. I mean, this is not, like it sounds like crazy, but people leave. I mean. Yeah. I mean, nobody works anywhere forever, right? I mean. Don't be that company where you lose the root password and never mind the ransomware action.  Anyway, we could go another thing and on that. Eric, thank you for coming on. Mike, thank you for your insight. Really appreciate it. Thanks for coming on. Appreciate it. Absolutely. Absolutely. It's our pleasure. Continue coverage of AnsibleFest 2021's The Cube. I'm John Furrier. Thanks for watching.


Okay, and a good morning to Chad, and a good morning to Zachy, Alam. Good morning to Zachy, how are you? Very good. Your name does not look familiar. Are you new to the call? I was there a couple of weeks ago. Oh, excellent. Where are you calling from? I'm calling from Boston. Excellent. Great to have you on the call again. And Walter, good morning. Glad to have you on the call. Hey, thank you. Where are you calling from, Walter? I'm calling from Costa Rica. Great. Good, good. Thank you. And just so everyone else sort of knows, Walter will be presenting at our next general meeting. So great. All right. Well, we're just at the top of the hour. So great to have everyone. We, we have a great presentation today. And so I just wanted to get ourselves started. And as always, first of all, welcome to everyone. And I'm glad to have you join us. As always, we do record this presentation or general meetings. And so just FYI on that as well. Please take a read on our antitrust policy notice, which is on the, on the screen right now. Feel free to read through that in your own time. But the upshot is it's all about being a good person. And so that's what that's all about. So thanks for that. And we started sort of walk through this a little bit as, as people were coming online, but it's always great to sort of meet people that are fairly new to the, to the group. And so if someone is new, it'd be great if they just introduced themselves briefly, talk a little bit about their interests in blockchain technologies and healthcare and happy to have anyone sort of jump right in. Anybody?  Chad, can we get an introduction? And Chad is muted. So we may have to wait on that. Ken is Jensen. Did you want to say hello? Oh, Ken from Central Health Systems in Virginia Beach, Virginia. Great. And is this the first time call for you? No, it's like my fourth. Oh, okay. Oh, there goes my mind. I'm losing my mind. All right. Well, thanks for that. Thanks. I'll go ahead. Monday. Yeah. Yeah. And remind me again, what do you do on the East Coast, sir? I'm a senior systems engineer. Oh yeah. Okay. I think I remember you. Okay. Great to have you on the line. Mark Krapels. Yeah. Mark Rappels, chief operating officer, instruments based out of Philadelphia. Oh, excellent. Oh, great to have you, Mark. Thank you. Happy to be here. Excellent. Neil Morton. Sure. Good morning, new Morton. I'm a solution engineer for Instagram. Oh, excellent. Oh, you got a good contingent going, Brian. Excellent. Good to have you. And, and Zaki, we've heard from Walter. Walter, do you want to introduce yourself briefly to the group? Yeah, sure. Thank you. Well, I'm the CEO of world civil.   I'm not specifically from the healthcare area, but I'm a friend of in some ads. So I'm here. Yeah. And, and Walter will be like I had mentioned, Walter's will be speaking at our next general meeting. And for those, those of us that have actually done some development work, he and his team developed tools, one of which is convector, which is sort of becoming the de facto tool for, for spinning up fabric installs. And so it's great to have Walter on the call today. And then it really in support of Brian and his team, because that's some of the work that they've, some of the tools that they've used through Instamed. And so just great, great to have the, the sort of the whole sort of environment here this morning. So thank you for that, Walter. And then of course we'll see you in a couple of weeks too. Yeah, sure. I'm excited about it. Thank you. Okay. So moving forward. I might have been on mute. This is Chad Small. Good morning. Yeah. Good morning. Yeah. I'm just, I'm a from bind. It's a on-demand health insurance. I'm the dev sec ops lead. And yeah, I'm interested to learn more. This is my first user group session with. Oh, outstanding. Great to have you, Chad. Where are you calling from? Minneapolis. Excellent. And tell us a little bit more about what you do with blockchain technologies and specific. Well, we're just starting to look into it. It's, we're about two years in and it's, you know, health insurance. So very interested. And this is one of our use cases. We're thinking about as we in the payment space between, you know, the future of the future. In the, in that space and with a network that we're building out. To providers. So we think this is. The future direction and one, you know, we're continuing to learn more. We're, we're not prototyped or beta or anything around it yet. We're just still in a learning phase. Excellent. Okay. Well, good to hear. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thanks. Thanks for being on the call. Is there anyone, anyone else that's new on the call that would like to say something? Okay. All right. Well, good to have everyone. I just, it looks like Steven and Bob just got on the call. So good morning to those gentlemen as well. Thank you for joining us. Okay. So we have a community announcement, which really came up through the, the listserv. So Cambridge University is doing some work in the field of academic research as it relates to blockchain technologies. They're, they're in the process of developing their, the second edition of the global blockchain benchmarking study. And I'll bring this up. And so you can see, this is the document that they are working on. I think this is probably the first version of the document. But what they're doing is they're, they're really looking for some good resources that are out there that are already using blockchain technologies in a production environment. And they want to use that for, for their inclusion in this document. So, or in this study, I would say, and so if you have an interest in getting your product effectively published through this, this research effort, feel free to contact Michele and, and, and or Appalene and, and the, the links for their email are in the, the agenda. And please, if you do, it'd be great if you could report that back to, to the group here. Cause it's always, it's always great to know that we have some, some representation of, of the Hyperledger team out there somewhere. And so this would be a great opportunity. Okay. Any other community announcements? Anyone else working on something that they'd like to share with, with the group here? Okay. Yeah. If you do feel free to use lift serve. And of course we also have an active rocket chat channel. Rocket chat is very similar to, and I just lost it. What's the equivalent out there? Slack. And so, so feel free to use our rocket chat channel. If you, if you want to take conversations offline or sort of correspond with a specific HCCIG member directly or a team of folks, cause you can do that very easily through, through the rocket chat product. Works very well. Okay. Well, with, with just being very excited about this, Brian Bento, whose head of innovation for instrument is going to speak, give us a little bit of a presentation on some of the work they're doing using Hyperledger fabric in, in the healthcare space. And so I'm going to hand everything over to Brian. And Brian, if you want to take control, feel free to do so with your presentation and, and go for it. Great. Thanks, Rich. Let me know if you guys can see my screen. Yeah, great. Looking good. All right. As Rich mentioned, my name is Brian Bento. I'm in the head of innovation at instamed and been working on healthcare payments for over 14 years. So we have been looking at blockchain for a while and we decided to create this prototype to get a better understanding of how it works and the strengths and weaknesses. So that's me. So here's a true story. I have a friend named Steve. He visited his, his doctor, his cardiologist. He was having chest pain after a bike ride over the weekend. And the doctor's office, they measured his blockage of his coronary artery and they said it was 98% clogged. The doctor was extremely scared that Steve was going to have a heart attack right then and there. So he called an ambulance. The doctor followed the ambulance to the hospital. They put an emergency stent in and over the next three to six months, Steve received a stack of paper bills from the ambulance, the surgeon, surgery center and several other business entities. And he half jokingly said to me that the billing, dealing with the billing was almost worse than the heart attack experience itself. And it just continued to drag on. It was very complicated and his out of pocket expense was actually pretty reasonable because he has pretty good insurance, yet still it was very painful dealing with all the payment aspects. What makes this so challenging is, you know, we have a three-party payer system and the patients are confused by the statements that they receive and the fact that they have to many times deal with separate payment processes for each provider and possibly separate logins. The providers complain that they're having to send on average three statements to collect on a patient bill, which is very slow and expensive. And health plans, they want an easy way for their members to be able to view their balances, pay their responsibility, and utilize their apps and web portals, and they want to improve provider satisfaction. So we had this thought experiment, you know, what would a system look like that would have provided a seamless payment experience for Steve? Given that in the U.S., the hospital employs independent contractors and facilities are part of separate business entities. So we can't just assume, hey, everyone's going to be, it's not a single provider system, a national provider system, it's a very complex environment. And I can talk a little bit more about this at the end, but this is kind of food for thought. So a little bit about Instamed. So we're focused on healthcare payments, and we have a healthcare payments network that connects providers, payers, and consumers all across the United States. We're focused exclusively on the United States. And Instamed was founded in 2004 by Chris Sive, our CTO, and Bill Marvin, the CEO. We're focused on simplifying healthcare payments, and we have many solutions like photo bill pay using our mobile apps that you can download for free from the app store, and patients can pay all their bills. We have solutions for payers and providers for consumer billing, something called member payments. But we believe that we can take it to the next level with blockchain. We integrate with both provider and payer healthcare IT systems, and as I mentioned, we deliver payment solutions for patients and members. So the objectives for the prototype were to assess the viability of blockchain and healthcare payments. And we paid particular attention to authentication, authorization, privacy, and transaction processing. Our philosophy for the project was we wanted open collaboration with a diverse set of industry stakeholders. And I do want to emphasize that the version one of the prototype is what we've completed thus far, and now is when we're really opening it up to collaboration. We're now starting to focus on version two, and we're taking input on what the V2 is going to look like. Interoperability through open standards and open source, focusing on the financial workflows, which is an area that is our focus. But we're also supporting, as you'll see, some aspects of the clinical side in trying to make that easy and something that could be expanded upon. Privacy and security are extremely important in healthcare, and we would meet HIPAA compliance, and we really did this to learn as much as we can. So the stack that we're using, hyperledger fabric with the Node.js SDK. We're using Convector from Walter's company, WorldSeaboo. We chose to use Fire version four and the financial management workflow as an open standard. I'll talk a little bit more about Fire later. Vue.js is a technology for the front-end application, and we're using Forma, which is another solution from WorldSeaboo that allows us to deploy our network on any cloud, and we're currently deployed on Google Cloud. So why we chose hyperledger fabric, it supports rapid prototyping using the Composer tool, although the Composer tool will not be supported forever. It was a great place to get started. It's open source and open governance, and it's Linux-based. It's modular and flexible and has a large community. So we definitely felt that it was a great choice and still is a great choice to build on top of. For Convector, it supports Enterprise Model View Controller software development. It uses TypeScript models with validation attributes, controllers, unit tests, and it was just very easy for us to get started. It also has a layer of abstraction. So if we had to change the underlying blockchain technology, we could. It's open source and it's a hyperledger labs project. It has great documentation, including tutorials for migrating from Composer, which we initially used to Convector. And it's a thin wrapper around the Node.js SDK. And so we still have access to all the other Node.js libraries and ecosystem. HL7 Fire V4, it is a standard for healthcare data exchange published by HL7. It supports both clinical and financial management workflows and resources. It's aligned with our philosophy of interoperability and open standards and not trying to own the standard for the network. And it currently has a very active community. And Forma, it supports multiple clouds. And even you can host it on your own privately managed cloud, which is how Instamed has its own privately managed cloud. And each participant can host wherever they want. And it was very quick to get started with. Here's a little about just the architecture and development. We use a tool also provided by World Subu called Hurly, which makes it really easy to stand up a set of servers on a single box. And then for the prototype we hosted on Forma on Google Cloud. And now I'm going to jump over to the demo. All right. So hopefully you can still see my screen. Looks good. Yep. This demo is available to anyone in the world to play around with. It's probably one of the first and only healthcare demos that anybody can play with. So it starts with, and this will write to the blockchain running on through Forma. This application demonstrates, you know, three separate applications and perspectives. So first as the provider, I would see a patient, I would perform, you know, one or more services. You can change the services. Then you click create claim. Now here we're going to submit data to a smart contract application running on the blockchain, which will generate fire based resources. At the top here, we're going to show the blocks that were created and their data for each of the different perspectives. If you click on the block, you can see the hash of the current block and the hash of the previous block. You can also see the data that was submitted to the blockchain smart contract application. And I'll have in this, this tool called the block browser lets you see the data that was generated on the blockchain. And you can see here, this is the data that's actually stored on the blockchain. And these are fire resources. So now after the provider submits their claim, the pair would receive the claim. You can change in the demo how much the plan covers. We're in this prototype. We're only supporting the happy path flow. And we have a really nice pair who's going to always approve claims. So now data was submitted to the smart contract application called adjudicate claim, which will create the claim response for the provider. It'll save a patient account and it's going to auto generate the invoice for the patient. Now the block from the pair will be created. Just as before. And you have the different adjudications for those charge items. Now the patient would get an invoice and they'd be notified of an invoice. They'd make a payment. However they want with a bank account credit card, maybe in the future, some cryptocurrency. Who knows. But then after they've made their payments, their payment will get recorded onto the blockchain and their invoice will get marked as paid. So this would complete the complete payment process. All right. And back to the presentation. So in addition to the demo application, we also have released our GitHub repository, which is here. And a lot of this, some of the code is auto generated by convector. The main area of interest is this financial CC, which is the set of, this represents the smart contracts for the financial management workflow. This file, financial.model.ts, which I'll load here is all of our models. And we built a tool that takes in the fire resources and auto generates and translates them into convector models with validation attributes. And I included both. I included all of the fire resources, both the clinical financial resources as well. So it will make it very easy for others to expand upon it and implement clinical workflows. All right. And you can also see the different controller methods, which represents the smart contracts in this framework. In addition, we also have this page on our developer portal, which describes this project. We have a video. We describe the problem. We describe the prototype, how it works. And we're asking people from the industry to join the conversation. And we've been having conversations with people from the industry, you know, on every week to discuss, you know, what they see as the next steps, answer any questions and so on and so forth. All right. The lessons learned. So during this process, as we were using fire version before, we found that it doesn't have a patient payment resource, although it does have an invoice resource. And so we've been working with the fire community, specifically the financial management group to add the patient payment resource. We also learned that there's too many resource definitions to translate them manually. So building a tool to translate them is a tremendous time saver, especially as there will be new versions of fire in the future. We found that hyper ledger fabric and its current state. It is somewhat daunting to set up. We included a installation guide on our website so you can stand up our prototype application and it has 16 steps. And also, there's a lot of confusion around blockchain and what it can and can't do. And it's important to note that it does not inherently solve identity verification and neither do public blockchains like Bitcoin as there are anonymous. It's the members responsibility to handle authentication and identity verification. The possible next steps for the project, working with the fire community, as I mentioned, we want to add some additional resources even to our financial workflow. We want to support more complex use cases in the financial workflow, including coordination of benefits, multiple payers, denials, claim resubmission, patient and voice disputes. We did this demo at our healthcare payment summit about a month ago and we basically demoed for 10 hours and talked to both providers and payers and some of this feedback is directly from them that they wanted to see more use cases in the prototype to see how some of these more complex scenarios would work. We also want to write to the blockchain as part of processing transactions in the instrument platform. That's one thing we could do and read from the blockchain from separate applications representing the separate entities. We want to start discussing the creation of a broad consortium. We are thinking that rather than having separate small consortiums be created for different aspects of healthcare, it would be much better if a broad consortium for healthcare could be created that allows exchanging data, not just for one specialty or one use case. I have a really good friend who has a company. He's the CTO of a company that tracks donor organs from when they're taken from one individual and eventually when they get put into another individual and they meet all of the regulations required for tracking that organ as it's transported. Rather than having to create separate blockchain consortia for each of those different use cases, if we could create one generalized approach and healthcare entities could join it once and be able to communicate securely and reliably with any of the participants, I think that would be a great thing to aspire to. Finally, we do have the clinical models. However, we don't have the clinical workflows implemented. We would like to work with others who are interested in the clinical workflows and implement them on top of our code base potentially if they want to start with it. If anybody has any questions, they can send e-mails to this e-mail address and somebody from our team will answer them. Excellent. Outstanding, Brian. Thank you. Questions? Yeah, it's Vipin. Hi, Vipin. How are you? Very good. Being the organizer of the identity working group in Hyperledger, I'm very interested in the last point that you raised, which was about identity. So does FHIR have an identity schema or a model? And if so, what is the bridge between what is represented on the blockchain as far as identity goes to the off-chain enterprise identity systems? That is my question. And also, I know that membership service providers in Fabric is supposed to do that translation and how do you have to create a bespoke MSP to do this? Or I mean, in other words, what are your thoughts on that? Sure. So I'm not sure if you're familiar with the CHIME patient ID challenge, but there was a... Go ahead. No. Okay. I think it was about two years ago, that CHIME put together a prize for a million dollars for a team to come up with an approach for a universal patient ID. And I competed in that challenge and followed it closely, you know, a national patient identifier, if you will. And the result of that process of analysis, what people realized was that HL7, including FHIR, support... They have a naming convention and a generic way of being able to pass identifiers. They also support passing along biometric data, including iris scans, retina scans, thumb prints, voice, et cetera. And the... And I'm not sure how much you know about iris versus retina, but you can take a picture of somebody's face and their iris, even with a relatively inexpensive webcam, and there's 20 different... Or I think 200 distinct characteristics of your iris, whereas with a fingerprint, there's many... Yeah, I'm familiar with that. Okay, so the idea was that in order to match patients across different organizations, that they would use biometric data. Unfortunately, the project never completed and the million dollars was never distributed. However, it seemed clear to me from the discussion that it was not tenable at this time to create a national patient ID and that the industry is thinking about using matching algorithms that leverages biometric data and otherwise. So in terms of the on-chain and off-chain, you know, there's... It's a very challenging problem. You know, health plans issue... Not unlike banks, issue cards to their members with their policy number and group number and so forth. However, that doesn't help you across payers. So I don't think that we have the solution yet and that's an area that we want to... We will need to discuss and have conversations about. You know, how do you translate... Intimate is both a clearinghouse and a payment processor. We were the first integrated healthcare and payment transaction processor. So bringing those two industries together, you know, we're very familiar with the way that banks authorize their, you know, card holders, if you will. And we've been thinking about this problem for a while, but there, you know, there needs to be a conversation, for example, at FHIR to talk about this problem and interoperability. We're hoping to join and have a discussion meeting at the September FHIR meeting in Atlanta and having kind of a working session to talk about interoperability, because it is important. You know, if you think about email, there's a simple protocol, SMTP, and all you have to do is you have an email address. If you know somebody's email address, you can send them an email. And they look up at, you know, at instrument.com. There's a DNS lookup. There are MX records that tell you which servers are hosting email for instrument, and it works. Now, SMTP has a lot to be desired, and this is what we've been thinking about, that it's very easy to spoof an email and make it seem like it came from, you know, the CEO of your company. And so that's one of the weaknesses of SMTP. A lot of companies have been created to create secure email. We believe that there could be a secure protocol, and secure email protocols have been talked about in the network communications community and RFCs have been created. We think we need something similar for healthcare. It's going to be a protocol that has, you know, it needs to have directory lookup. There needs to be a way to verify and validate that data was sent from the sender, and, you know, to verify that it gets to the proper recipient. It's going to need to support, you know, cryptography for encryption in transit. And perhaps encryption at rest. There needs to be a way for routing to occur, you know, across the network. So this concept of creating a protocol and a consortium that implements that protocol, you know, not unlike the Visa and Mastercard, you know, they each have their own consortiums, really, and they have their own message formats and protocol that each of the distributed ledger banks, as it were, implement. Yeah, actually, in this context, you should be aware that we have just incubated a protocol called ARIES, Hyperledger ARIES, which is attempting to solve this very problem and using DIDs. Oh, perfect. Yeah, so if you look up the ARIES proposal and there's a lot of actual code, you know, which people have contributed. So it's not just a white paper. It is more than that. It is actual running code. And it's, the Indie project is supporting this. But, you know, my question, which was about the current identity schemas, which obviously need to exist somewhere. And obviously, you know, the future is the future and we have to get there. But in the meantime, we have to deal with what is there currently. So, I mean, I understand, you know, I'm a technical person, so I understand in fact. Anyway, I don't want to talk about SMTP or, you know, PGP and blah, blah, blah. But, you know, we are very familiar with all these problems. But in the identity context, we want to figure out what can we do now, right? I mean, yes, biometrics, we, in fact, in the identity working group, which I chair, we had a paper presented on, we incubated paper on biometrics. In fact, it's available from as a link from that site. And I'm aware of the work done by ID 2020, for example, for biometrics to give the unbanked refugees, people like that, who do not possess any papers, but only their bodies. I mean, there's a lot of work going on in there, but coming back to the question, is there an identity schema in... I'm not talking about a universal identity schema, just, you know, just something very practical. Today, and can we attempt to bridge the gap between that identity schema and what we represent on the blockchain? So the short answer is that I'm not aware of other than what's in the fire spec, in terms of supporting the passage of patient identifiers and custom naming conventions. It's somewhat identification agnostic, is what I'm trying to say. I will say that I, as part of the, in the CHIME competition, I submitted a proposal. It was a 20-page paper on what I saw as a potential way to move forward, where you need to have entities that are similar to banks today, where they perform the onboarding and enrollment of new individuals and gather their biometric data and, you know, check their government-issued IDs and so forth, just like a bank is required to do today and sets them up with their digital profile and, you know, acts as their, the custodian of that digital profile, not unlike a bank is the custodian of your digital bank account. And in exchange for providing that service, you know, the banks would be able to charge transaction fees as data is moving across the network. So that would be the business model. I don't think that there's necessarily a magical solution to this problem. For example, Instamed, we onboard consumers. They can join our network. They will eventually get a username and password. We have capabilities for them to retrieve their account if they forget their password, et cetera, you know, and verify that they are who they say they are. And we've onboarded a large number of consumers already and we're continuing to do so. So I, you know, if there's companies like Instamed who can take on that responsibility and also be a member of this network, I think that that is one way to get there. Thank you. Thanks, Wippin. Appreciate it. And I'll follow up and see if I can get a link over to the identity workgroup that biometrics reference, because I think that's something that we would see particularly useful in the health group SIG here. So thank you for that, Wippin. Any other questions? Yeah, this is Chad from buying. I have just one comment on the SMTP kind of reference. It's interesting that if you're the new MTA STS initiative around making SMTP a little a lot better and Google and lots of players are in on that spec. But I like that concept for identity in healthcare. That's a great analogy. But my question was around kind of the business aspect on the provider side of the equation. And if you could speak to maybe what your thoughts are around adoption and incentives for adoption to this, I think I know some of them, but I'd be interested to get your take on that. Sure. So today, Instamed is a full service clearinghouse. We have several competitors as well. And providers utilize Instamed to outsource their consumer billing and payment acceptance. So they're already incentivized to use Instamed or one of our competitors to print and mail bills also to support electronic statements. Many other solutions that we build on top of those data feeds, automated payment collection, for example, and many others. So we already know from our own experience that providers want to outsource billing and payment collection. They want to make sure that they're PCI compliant. And that's what Instamed helps them do. They want to kill paper. I think everybody is incentivized to kill paper. It's slow and expensive. That's the common enemy. And I think there's a win-win situation. Now, Instamed will, you know, would be a member of this consortium. And so to the extent that the providers want to participate and opt in, we would do all the work, you know, of translating to and from their systems. If they don't want to join the network as a member and host their own node, we would take care of all the interactions with the blockchain. Now, other providers in large health systems, perhaps who are sophisticated, they could, you know, join the network directly. Once people have joined the network, the idea would be to have this sort of directory system so that if there's a provider, payer or patient that we have in R that's directly connected to our node and somebody else, just like this at instamed.com concept, that they would know that, okay, I'm going to send something to Chad at his Instamed blockchain account. And they would know that it needs to come to Instamed and there might be, you know, as it travels some sort of fee, you know, as the data moves around. So I think that the providers, you know, to the extent that it will further reduce their paper costs, I think they would choose to opt into it. Yeah, and I'll just add on the payer element, there's I think a lot of incentive just for the, the kind of lead time, the round trip around repricing and payment from the payer could be accelerated significantly on a blockchain integration, I think. And yeah, you could even think about cases where the payment, the patient payment is, is complete even beforehand. So, you know, like you said, that three statement chase of patient payments is in there too. Okay. Yeah, it makes sense. Not to, the consortium, is there anything started? Is there anything in this space? So we've been talking to several folks, like for example, hashed health, they've started a consortium for provider credentialing that they're helping manage. There's other consortia that are in different stages of development and discussions. Many of them are focused on one specific use case or specialty. That is not the approach that I would like to focus on. As I had said, I would prefer to create a generic protocol like SMTP and a process, and it would cover the entire healthcare market. It's essentially, you know, not unlike secure FTP, not secure FTP, secure email, secure SMTP. And maybe, and maybe that vision is some people might say it's a little too, perhaps too big to try to bite off. However, you know, that's to me, I think that's where the most value will be to get to a fully connected ecosystem. I'm also one thing I want to notice. I'm thinking that this connectivity and blockchain aspect is not something that InstaMed sees as a competitive advantage. You know, open standards aren't typically that. They should be just the cost of doing business. Security, compliance, connectivity. Those are just the cost of doing business. The way you need to differentiate yourself is all of the services and functionality that you build on top of it. You know, what's your customer service like? What's, you know, security and compliance? What functionality do you have, et cetera? What's your user interface? Yeah, I agree. Yeah, and I think, yeah, without momentum. Yeah, open openness to the. Yeah, it doesn't, I don't know. I don't see it working. Yeah. So, yeah. So I have a quick question. Right. Stephen Elliott. Great presentation. Like to see things actually working. And even though it's just a small slice. Really, really great to see the blockchain in function. It's a little surprise that use fire for a payment. That actually wasn't what would be the first implementation of fire on a blockchain that I had imagined. Coming much more from a clinical area. So I would definitely like to work with you. To see how we can combine what you've done with the clinical workflow and using fire for interoperable clinical data. And the question I had is how many, how many entities on the consortium did you have on the channel? And did you have just one channel? So currently we, we have just one channel in our prototype. And there are three members. There's a payer member. There's a provider member. And then there's kind of like a, an instamed member that's representing a large number of patients. And you had one CA on the blockchain. The number of CA's, you know, I don't recall maybe Walter can chime in because he helped set it up. Yeah, sure. In this case, each organization has its own CA from a technical standpoint. It's actually two instances. It's a root certificate authority, but organization and also an intermediate, which is issuing all the certificates for this current structure. Yeah, I was talking about the, the chain CA. So the observer, so to speak. So I've looked at the source code. It looks great. Like I said, I'd like to take a conversation and work with you and talk about how what we might be able to work into your existing prototype for what we hope to be the healthcare interoperability. I know that the inter, there is another interoperability work group at another level in hyperledger fabric. They're currently struggling with adding dynamically, another healthcare organization. I believe in this case, they're working to add another payer into the blockchain. Did any of that was, did you find that to be an impediment in, in growing the chain and growing the channel? That's a, that's a really great question. That is the area that we're talking about right now for the V2 is that the way hyperledger fabric handles channels. It's, it works okay for a relatively small network where you know all the participants are members upfront. However, with something, you know, with such a large, you know, healthcare industry, you'd need something that is more flexible and more dynamic. And, you know, has, has a way of growing more organically over time. And so that, that's an area that we're currently talking about. You know, is there a way to either completely eliminate the concept of channels as being statically defined and make them dynamic and perhaps on each particular resource, store information about who should be able to access it. You know, back to the email analogy, you have the recipients and you also have BCC and CC, you know, and putting that on a per resource basis. And then the protocol would handle making sure that the, the people who should have access have access, et cetera. So that's, that's one thought that we had. The other thought is using private data. You know, channels can have private data collections in fabric that supported, you know, I think as soon as 1.2 and we want to look at potentially using that as it already exists. So the question is, does hyper ledger fabric have what we need today or does it not? And if it doesn't, we are interested in, you know, maybe rich can help facilitate this, but we'd love to have a conversation with some of the core engineers of fabric to talk about, you know, the scalability and manageability of the channels and enhancing fabric to, to support it. Ironically, it's also an issue that's been felt by other parties. We've had conversations with, with other folks and they said that the concept of channels has been very difficult for them. They've had situations where they were trying to copy data from one channel to another and that completely, you know, subverts the concept of a single source of truth creates a whole lot of pain points and challenges. And so I, that's why I'm thinking and based on my experience with various technologies like couch base, where each document you can specify who has read access, who has write access and there is a service that takes care of ensuring that only people who should have access can access the things that they have access to and otherwise that, that handles the replication. Yeah. Consent management in short. What was that? Consent management. Yes. Consent management needs to be a core part of the protocol. And I'm, I'm perfectly, I would much rather improve hyper ledger fabric and make it better and address some of these challenges then throw the whole thing out and start a whole new platform from scratch. Completely agree. Until you understand the problems, you can't really say they're going to throw something out. I think that part of what we're looking at payments are relatively simple because they can, I don't mean to say that. I think you've done a very complex job and made it very simple, but they can be stored directly on the blockchain on the ledger itself. Medical clinical data by and large will have to find a side chain to, to be stored on and the resource metadata resource of fire resource put on me on the chain to preserve as assets, the resource that it points to, who has identity, who has consent to that resource, et cetera. So that makes it even more complex. Agreed. Now I definitely understand the complexity. The reason part of the reason why we are, we are payment focused, but I didn't want to limit ourselves and the, and our thinking to payment only. Because I do feel that solving the problem generically across use cases is, is ideal. And it would be much better if providers didn't have to have many different connections and ways of communicating. Well, I got to jump off, but I would love to carry on this conversation. Fortunately, it looks like my time has opened up a little bit this month. So I will reach out and get, get a conversation going and see what we can do to collaborate on building in a clinical workflows into, into the instrument prototype. Perfect. All right. Thanks for joining. Alrighty. Well, we are coming up to the top of the hour. If does anyone else have a sort of a quick sort of closing question or if not, Brian, maybe a closing comment. So last, last question. Anybody. Just reminding everyone that some of these things that you guys talked about right now is being looked at by HEPA ledger areas. Just, just want to remind you to get involved in the project. Yes. Great. Yeah. Great. Yeah. Great idea. And Aries is very, very new, brand new. And so it's just now coming together to Vipin's point, there's already code in place. And so it's, it's really kind of a spin out or a, I don't know, like a, like a brother to, to Indy in some respects. And so it's, it's moving along at a pretty good clip. Now that's great. I think we definitely intend to get more plugged in. You know, we're getting more plugged into the fire community. We want to get more plugged into the hyper ledger community. Right now we're, we're in the discovery phase. For the V2 of the prototype. And, you know, we want to tackle the hardest aspects, which include the identity verification. And the. Privacy and permissioning, if you will. Aspects at scale. So that, that's really the focus. And we don't want to reinvent the wheel. We want to work with, you know, as part of a team. The wheel has been reinvented many times. So we do have a privacy and security architecture working group, which call is coming up. You know, in three minutes, the other one is the, there's a general interoperability working group as well. Working group, meaning a sub working group of the architecture working group. So that is not specifically aimed at hyper ledger fabric, but at a general problem of interoperability. And those are the two that are cross DLT's hosted by the architecture working group. So you're welcome to join or look at the material that we post. Thank you. I definitely will look at those groups and, and try to join some meetings. And participate. Excellent. Well, thank you. And thank you, Brian, outstanding presentation. And for everyone that has been listening, this is all this is open source. It's out on GitHub. And so obviously, you know, you certainly have the opportunity to sort of dig into the code a bit and play around. And then Brian, I suspect that you're available for questions or comments. If people bring them up sort of post presentation. Definitely. Are these resources going to be available publicly? Meaning the links to the GitHub. All that stuff. Correct. Yeah. Yeah. It's, it's available through our, through our agenda. So we've got links there. And of course, obviously Brian will be available through through rocket chat or through our listserv. So if anyone wants to contact him, there are certainly ways to do so. Alrighty. Well, thanks everyone. We are at the top of the hour. Appreciate it. Again, thank you, Brian and everyone from Instamed for, for making this happen. Great presentation. And with that, I think we're all set. I have a great weekend and we'll see you in two weeks when Walter presents from global at Cebu. So thanks everyone. Take care. Thank you.


While a foremost anti-corruption group, the Network Against Corruption and Trafficking has called on the EFCC and the ICPC to probe the outgoing governor of across river state Ben Ayadeh, over 500 billion dollar embezzlement of the state's fund. The group spoke sparsely in Itaew, Epopobe, alleged that across river state governor squandered the state resources through spurious contracts awarded to his family members and creditors through withdrawals from various bank accounts. The coalition of civil societies led by Network Against Corruption and Trafficking NACAT embarked on a comprehensive audit of the cross river state government account between 2015 and 2020. The NACAT, through this comprehensive audit, discovered financial infractions and irregularities ranging from circumvention of procurement processes, suspicious payments of monies, possible money laundry to a ward of contrast to non-existing shared companies. These financial manipulations have caused the good people of cross river state money amounting to over 500 billion dollar under the watch of Prof. Ben Ayadeh, 38 years of Ayadeh's rule has set back the development of the state by 20 years. It is on this note that we are calling on the Economic and Financial Crimes Commission to be on alert to quickly invite him to give clarification on these blatant irregularities bordering on one-ton looting of the cross river state treasury to the tune of over 500 billion dollar. The father gave a breakdown of the illicit transactions perpetrated through fictitious company names and with the aid of his chief of staff, Martin's oren promising to take copies of the petition written by the group to the EFCC and the ICPC, as well as the embassies of the USA and the UK and Canada. 12th of August, 278 million by the chief of staff government as Martin's oren. There seem to be a lot of activities that are quite against the law committed by this office of the chief of staff to the governor and we do know that this is directly under the behest of the governor himself. So for 2018, a plethora of withdrawals and transfers running into billions were made between the government and persons in government and as well as companies with affiliations to persons in government.


Now, we're going to move ahead with our presentations. We're going to go from the one fellow who is speaking through residence third year to first year. Our first speaker, Zach Joss, finished as a resident here a year ago. He has been doing additional work related to the residency program. And he's getting ready to leave for an Oculoplastic Fellowship in Australia in a month. He is going to talk to us today about some quality improvement issues in the residency program. Did I get that right? That's right. Oh, good. Thank you. Morning, everyone. Sorry, it's a little early for this topic, but it's like getting a Band-Aid off. We'll just get it done really quick here. So basically, I'm just going to talk quickly about the university's kind of undergone this transformation over the last several years about incorporating quality improvement projects into the university setting. And they've really done a great job. And the Moran Residencies, we've developed some programs to try to keep up with this and make sure the residents are involved in it.  What is quality improvement? So this is Jeff Petty, our program director. And this is how he meets with the residents every morning up on the balcony, so he can pontificate about whatever. So basically, he asked the residents back at the beginning of the academic year, what is quality improvement? So we are going to move up the resident ladder. We'll start with the first-year resident. So Dr. Riesweis, we asked at the beginning of the year, what is quality improvement to mean to you? And he gave a pretty standard answer for a reason. He said, nobody knows, roll tide. He's from Alabama, so that makes sense. So and actually, he's given me this answer several times. It's here to other clinical questions, so it's not just quality improvement. So next, we moved up to the PGY2 ladder. Dr. Renee Choi, MD, PhD, asked Renee early in the year, what is quality improvement mean to you in the ophthalmology setting? And he kind of tried to confuse me with his intellect. And basically, he did a good job. And he basically, he pulled out a napkin and started drawing the entire VEGF pathway of the revenue. And albeit accurate, it was not the answer I was looking for. Then I moved up to our chief resident, Brian Stagg. Brian, what does QI mean to you? And in typical fashion, he said, super interesting questions, Zach. And he pushes up his glasses. And I've actually found over the year that this is the way his way of delaying an answer so he can think of a correct answer. And then he went on to say, QI is another project I can add to my already prolific CV. If you've seen his CV, it's crazy. And then he said, I'm thinking of doing a fellowship in QI, so in addition to his three other fellowships. So but those are not the answers we're looking for. So throughout the year, we've taught them what QI means in ophthalmology. So what is it really? QI is a formal approach to the analysis of performance and systematic efforts to improve it. What does that really mean? That's kind of a lot of words too. Basically, there's a lot of processes taken from the industry. Anybody that's working in the industry may have heard these programs called Six Sigma Lean PDSA, which is an acronym for Plan Due Study Acts. It's just the process in which people identify problems and improve upon them and re-evaluate them. CQI stands for Continuous Quality Improvement and then FADE is another acronym. Basically the same process. But each model basically reflects a common thread of identifying and analyzing a problem, implementing the problem, planning how to improve the problem, and then continuous review of the problem. So that's really the key point. It's a cyclical process. So once you come up with the process, you have to continually try to improve it. These are all designed to maximize value. Value is kind of a vague term. How do we define value? That's difficult. And then to eliminate waste. So why do hospitals care about QI? Some of the reasons that aren't necessarily proven. Does improving quality improve patient care, possibly in some settings? Does it reduce costs of health care, possibly in some settings? And also, there's potential for higher reimbursement with quality improvement. So what has the University of Utah done? They've actually designed this value university, which is a online training program for physicians and other health care professionals in which it ranges from online videos and lectures where you can just teach yourself at home how to start quality improvement projects, and all the way through semester-long courses at the university to really make people experts in the quality improvement process and leaders in that field. One of the other things that you can access of the university system is this value summary portal. All of our residence projects can be found in the Value Summary Library. Moran has ongoing probably about 15 projects that are seen on this. And throughout the university, why several hundred projects going on that you can actively look up and see what people are doing across all the other departments at the university. So what has the Moran Residency done to keep up with QI? We designed a QI curriculum this year with the help of Dr. Petty, Dr. Warner, and the academic team, and actually input from the residents and people up at the university where we've given them lectures and training them how to do a project. We've had journal clubs about it and giving them online training resources that I showed. And then each resident has either individually or collaboratively done a project together. Each of the residents will just show about one slide after their main talks today, just talking about what they've been doing for QI this year. And my last thing I want to leave you with is this was an article in Washington Post just a couple of weeks ago, written by Harvard Medical School Department and the Psychiatry Chairman. And I think it's just, I'm going to read the quote, so endless meetings and initiatives to make processes leaner and to remove waste may be imperative for the responsible viable running of the teaching hospitals, but the relentless focus on these real concerns increasingly comes up against the point beyond which staffing and funding cuts endanger the academic mission. Before endangering patient safety, the point no one wants to reach. So I think even though that's great, we have all these quality improvement projects and making processes leaner, I think that we also need to keep in mind overall that this is an academic institution just because we can maybe make a cut or make something more efficient, it's not necessarily totally in line with the academic mission of the hospital. This is kind of the end point of a lot of patients' care. So there's a tertiary referral center. We need to keep in mind that because this is the end of the road, it may not be the most efficient place. We can try, but we need to keep in mind that this is a teaching hospital and just because we can make something leaner necessarily, it may not be the best thing for patient care. So I'll leave you with that. Thank you to all the residents for their participation in putting up with me this year, pounding you about your QI projects. Dr. Warner for letting me kind of take this project on and she's been a lot of help. And then Luca Boyd, he's not here, he's actually in the Value Engineering Department, the department I never knew existed, but he's been a lot of help. So any further readings can be found on the University website and thank you all for your time today. Thank you.


Good morning guys welcome back to no I almost as I keep wanting to say welcome back to vlogmas to vlog week day four already That's actually really crazy. Um, yeah I kind of wish I would have done this on another week when I had like a lot more going on this week has been a lot More chill, so there will be more to come. Um, anyways happy Thursday Oh my gosh a new podcast episode went up a podcast is that this much podcast with Marco Oshry of the snatch alert and slash kind of the morning toast and all that She's the best and I'm so excited for this episode. So that is up. It's always linked down below go check it out Anyways, today's Thursday morning. I want to take Coco to the vet. Um, yeah, she's looking rough But it's not for anything. She just needs like her regular checkup I spent all morning looking at golden doodles on my phone. Um, I'm seriously still considering it But who knows what will end up happening.  Yeah, it's really close to me though. Honestly, if it wasn't a drop-off appointment I would probably just like walk or something, but anyways, I Just threw this on just for the morning.    She has looked better the poor little girl got really excited and started playing way too much with Bentley this weekend, but and they were outside and it's got so tangled and messy and here we are Great, that's it Thank you Oh, that's why I don't know why I think that just because I'm not really doing anything entertaining and I'm vlogging I feel like I need to go to Starbucks.  It's not good. Not good at all. So I dropped her off at the vet And then I'm supposed to pick her up in about an hour. It's so weird dropping her I'm like, is she taking care of herself, you know, so I need to also I'm trying to look for a new groomer So I need to call her groomer. They open in four a different groomer They open in five minutes and see when I can get her in so that she will Get groomed because it's really just like it needs to happen. She looks like a mop the poor girl I'm buying that this is really my last Starbucks drink. Also. I just never want to give my dad his car back because like, yes, I Was only driving this because I needed to go to IKEA but that was days ago and I've just been You know just waiting for him to say that I have to bring it back But it's really fun because I'm like small and this car is really big and it's just like makes me feel more powerful So anyways, I got an iced tea which makes me feel like I'm in junior and high school I normally don't drink anything with like sugar, but So there's a lot of espresso in it and this is what I need for today So today I'm recording with Connor and then tonight Brina has like a show gig thing But it's outside and it's all like benches and stuff. So it's like social distancing So I think I'm gonna go there with a friend and that'll be fun Probably hopefully get her flowers. It'll be a really cute thing. So that is the plan Yeah, pardon me is like I really shouldn't have a vlog week when there's like more going on You know what I mean? I'm home I got ready for the day just did my like really easy every day makeup. I feel like I always have mascara under my eyes now That was in another vlog. You know, I saw her look for that the blog for that. I'm just wearing all white I don't know what this like crease is right here. It looks like it's a black mark, but it's not These pants are revolved super down These shoes are docks white docks and then I just have this white crop top that I have no idea where it's from Honestly, then my normal bag Good to go to my office crazy crazy cameo, but I need to kind of just make a list and make sure I'm good I'm recording with Connor in an hour. So I'm gonna head to his office soon Yeah, I'm gonna show you guys what I use to record remotely So I have an Amazon shop page and I have an entire Category for podcast equipment. So if you guys are interested my Amazon shop page is down below And it's really easy to find but I have a zoom microphone So right now it's only set up for one because I kind of just leave this as is because I'm always doing random ads and Intros outros all that stuff. I have to have headphones. So this zoom mic It's really really easy to use even I can use it. So like that's how you know it's easy I have these headphones that are super tangled. I mean, they're not super tangled but They feel ancient don't they but I have to that's all I can hear with recording and then I only have one Mic connected right now But I have another one in this bag and then another cord that will connect it to mic 2 Right here, and then I just hit record. It's super easy. There's a memory card right in here The memory card has actually been acting weird So we're gonna end up using probably my vlog camera memory card again, but yeah It's really easy simple to use I get asked a lot what I actually use and this is my setup So right now I am importing footage to make my tiktok Transformation for my office. It's so much easier for me. I don't find on cup pro Everyone was bullying me for it until I found out it's kind of a normal thing to do also guys Cool, right? Wow Finished editing the tiktok in like 20 minutes and here we go. I'm gonna post my tiktok It's Kenzy Elizabeth. Hey go check it out if you guys are coming from this vlog comment on the tiktok Okay, guys, I'm ready to go to my purse and then I have this tote bag With all of my equipment. This is on. I just had to change the batteries. So Let's turn off. Okay, cool This bag is like not too big of a toe. It's literally the perfect size. It's just amazing and I love it I Wasn't really loving it and Kind of just decided to do something else. I'm gonna start my business All right guys, I'm back. Oh, I have more laundry than I need to do but I don't want to do laundry I actually make some salmon for lunch. I don't really have like let me see what I need to do I have my to-do list for today lately at night when I edit I just end up staying up and then I like get so much work done and I'm so much more focused at 9th and during the day I know that we've talked with us on this channel And we all just go through phases of like when you're most productive But I feel like I'm just most productive right now past 8 p.m So during the day is like chill home. The recording was really fun He's awesome the opposite will be up soon And then we're probably gonna like film some videos together too be this season will be this season that I actually Watch the bachelor so I curled my hair because it was just like Too clean almost like you know when it was too clean and there's no Like volume to it. It was just boring didn't even like it in a bun So I curled it just to give it a little bit more like volume and whatever I changed I'm now wearing this dress from Revolve super cute and then Air Force ones and socks I don't know what happened here, but I need to clean that off before I leave So this is my outfit. I just made some lunch. So I have salmon and broccoli Um, I have not made salmon and broccoli, which I used to eat every single day Since literally I think probably like the first month that I lived here. I haven't even touched my air fryer It's really crazy.  I'm going to my friend's show, which is to line up I'm so hungry. I'm having pressed juice. I made two pieces of salmon and then broccoli I this is like a really simple easy lunch, but I used to have it pretty much every single day And I like I'm so busy Um, but it just sounds so good and it's also so easy to make so I'm glad that I actually want to eat it again Because I ate it too much to the point where like I could never even think about it ever again Yes, everyone It is right about time um of the day when I start considering going to lala land for some ice matcha Yeah, I think I should honestly I think vlogging makes me some more money because I feel like I need to go do things Um, but also like I just want Strawberry fields literally it is like my favorite thing ever. So anyways, I'm gonna get some computer work done.  I don't feel anxious I have really nothing to be anxious about Um, not that that's like how anxiety necessarily works unfortunately But I can't like fully yawn and it's so weird and I know that caffeine is like not helping And I'm literally going to get matcha. Honestly matcha kind of chills me out. I think so.  Oh my god. I'm about to I literally almost found out myself At the time I'm about to leave I think I'm gonna pick up chick-fil-a or something that sounds really good I have a lot of blush on today Here we go Pretty much ready Oh my gosh, this has been like a really Like this has been one of those summer days where you're just like consistently tired because of the heat But uh, we're ready All right guys, I'm gonna give you a little book updates. Oh by the way, sorry as you guys can tell I'm home Um tonight was fun And yeah, I'm back home But I wanted to give you guys a little update on the books that I have been reading Just to give you guys some great book recs. Okay So I believe I don't even remember the last um I thought I talked about Verity on the channel. I don't know. I can't on the channel. Am I 40? Um, I am always posting book highlights So if you guys like ever need book recommendations, I have a whole Highlight on my instagram. So I'm always posting it stories. Not you guys again what I'm saying. Just go to my instagram I'm so sorry. Okay, so One day in december was super keel regretting you. I love that book the wife stalker Unfortunately didn't love and that's my favorite author duo. So it's okay. It was I mean, I just like didn't love it It ends with us. It's like one of my favorites. It's really emotional. Um, yeah, it's incredible I mean it also I feel like I should say this it does have um, some like domestic Violence type stuff. So that's a trigger like definitely don't read where the crowd I'd sing I know that that's like everyone's favorite book right now. I liked it I felt like it was a little bit over hyped and I'm not obsessed why fragility I think that literally everyone in the world should read this by the way It says like 1% and stuff because I always and like I don't know why that says 79% because I finished it But that's a honestly a pretty short read. I read that in a few hours And I think it's really really really important to read especially right now Um, but it says 1% on these because I always go back to the cover to take a photo for my instagram story Okay, wish you were here. That one was really good. Very sad. November 9th calling hooper.   It's so good. Okay. Maybe someday Um, I wouldn't recommend it Then the perfect couple. Oh, yeah, this is a great thriller because I hadn't read a thriller in a while So, um, I love that that's like a kind of a classic thriller. It's a wedding in nantucket Like that sort of vibe Um, and then the maid of honor dies. She's murdered and then it just kind of follows that story really good And then um, what i'm currently reading is night road Um, margo actually the episode with margo went up today, but margo Always I feel like we read the same books and we don't even like realize it She's always responding back to my stories like good luck because I mean, they're gonna like cry or like lose my mind from the book Anyways, um, she said good luck, which means that that's probably a good book if she didn't say it sucked So, yeah, very exciting So that is it for today's vlog. I love you guys so much. I hope you guys enjoyed if you guys did Let me know by giving this a big thumbs up Um and subscribe stay tuned for tomorrow's vlog. I love you guys so much and I will see you guys in the morning Bye


I left OTK, I'm joining FaZe Clan. Ground beef, pass. Actual defeat. It actually went right into my hand. How's it taste? No. Why? It's dirty. It came from the ground. What was it? It's 50% less scrubbing. So if you put this on, then you only have to scrub. It's not dish. One, two. Welcome to Eskordo. Season two, bonus extras DVD. Season 2.5. Season director's cut. Today, what we will be doing for Eskordo, we have our chef of honor, Ginny, who we have asked as part of the challenge to procure and retrieve and concoct the ingredients. So please show the ingredients and the potations of thus and to unto thee and for art thou whethermore. Okay, what? We're making milk steak burger. And milk adds savoriness to the meat and also it makes it more Also makes it more rancid. No, it doesn't make it rancid. Opposite of it, make it more less rancid. More pungent. No, not pungent. Not pungent, not rancid. Opposite of those words. Savory and very very soft. Savory and spoiled steak. No, not spoiled. What kind of milk have you been drinking? All spoiled. Two percent. Milk, really, really high quality. It's breast milk. It's just a normal milk. Whole vitamin D milk. I was just talking about it. See, this is like the, there's no extra vitamin D. That is mislabeled. That's the same amount of vitamin D as normal milk. It just adds more fat. Milk, but milk. Buns, burger buns and lettuce. They're buns, Jenny. These are buns. These are potato rolls. These are hamburger buns. We're going to make four burgers so each can eat two. Now we have a sharp cheddar cheese, which is like high quality cheese. And we have a small tomato, which is like a...  Yeah, no. Tomatoes are gross. You don't like tomato?  Oh my god. You don't like tomatoes? Are vegetables a fruit or vegetable? Tomatoes are vegetables. And we have onions. We're going to caramelize it with water. So we do have... Caramel with chocolate. Butter. Butter. And as a side, I've got gigantic potato that is so big and so thick. Very good. This potato was grown in my own backyard. It was. Cat chop. So you know what relish is another word for? Pickle. Pickles. They're the same thing. They just chop them up. Yeah. They try to make it fancy, but it's not. Neat. We're going to use all of this. Ooh, ground beef. 100% pure. 100% pure. Chad, this beef actually came from the same cow that Annie Fuchsia tried the milk and she got banned. Same cow. Yeah. It's cold. No, I'm LAS fan. What's up? First things first. I love Doty Cam. Join in face clan. First things first. You gotta wash hands. Always wash your hands. Chad, it's very, very important that you wash your hands. Oh, why do you think we should do first? So I think what's the most important thing is that I also wash my hands instead of not paying attention. Yeah. You didn't wash your hands after peeing. No, but that's different. How do you know I didn't wash my hands? Close. You peed and then you just left? No. Look, listen. I use hand sanitizer. I'm lucky I didn't poop. Yeah. First things first. We have to get out cutting boards. Wow. It's like the dusty tomes. Still have older, like a Korean grocery that I got in the refrigerator. Yeah, don't open the fridge. We need to make meat. We're going to make some meat chat. Yeah. So how do we make our meat? We're going to use ground beef pass. Yeah. Over the shoulder. Back shoulder fade. It actually went right into my hand. You threw it way harder. I thought you were going to... You did that on purpose. I thought you were going to like... And I was going to... Again. Do it again, do it again, do it again. Cut. I'm in the air, I'm in there, I'm in there, I'm in there. Touchdown. The S-fans win the Super Bowl. Why are you telling me what to do? I'm the master chef. Two. Okay, we're going to get a bowl because we're going to take the salt and pepper and we need to... Add milk. Add milk, no. Yeah, we have. So we need two bowls, actually. One for normal, one for milk, and you would not even be able to tell which one is which because they're both going to be really, really good. Okay. Okay. This is 80% not fat and 20% fat. So it's 80% lean? Yes. Or as some people would say, this is 80% lean and 20% not lean. So there are two types of meat. One, we're going to add a little bit of milk. There's two types of meat in this world. Okay. The predators and the prey. I think 2080 is like the good for burgers, yeah? Yeah, that's good, that's good. Because you want it to be a little bit like... Because if it's not and it falls... If it's too lean, it falls apart. I think 2080 is like... That's the guy, you know? When my mom makes hamburgers, she makes it with her hands. Well, I want the big one. Huh? I want the big bowl. Okay, I'm going to use my hands. Okay. That's a taste. Wait, it smells? Yeah, it's a little... I just bought it, but it smells... I see, I thought I'd smelled something too. Smelling. The reason why you should add milk in order to remove that smell... No, that's not what this... It doesn't remove it, it masks it. No, it removes it. As any true master chef, anything that I cook, I need to take a piece, a morsel of my heart, soul, body, and mind and leave it inside the food. And the only way that I can do that is through direct contact. That's why I like to use my hands. Yeah, and probably that one doesn't need salt anymore because Aspen is using his hand. Hands are salty, you know that, right? My hands are salty? Well, you washed your hands, so I guess it's okay. But unwashed hands are salty. What? Have you never cooked before? I have. That's how you cook everything. And a little bit of milk on this one, okay? And then you're going to use your hand to mix it. That's going to be really good! I'm telling you, okay. Just a little bit. What do you mean? Okay. Stop! Mix it, mix it. That's enough. Oh, the milk should actually... It loosens it. Yeah. I think this is too much milk. No, it's... Can I squeeze? Yeah, that's pretty good. Okay. Color is different too. This is a redder and that's a wider. Yeah, I can tell. Yeah. And also... I wonder if it's because of the milk. It's softer too. Yeah, it is actually softer.  Because the chemicals in this thing that has been created might burn your mucous membranes. It doesn't smell, right? It smells way better than this. Yeah. Let me smell it. Surely it has zero smell when this one smells. It smells like sorrow and broken dreams. No! Smell this. It smells like America. So meat is ready. Okay. That's the first step. How do you feel? I feel violated. Next step, we got to prepare our side ingredients. This is for the side, okay? Side, tomato, I mean potato. Tomato? Potato, side potato. Tomato. Then what we're going to do with this is... We have to mix this too. Are you going to put milk in the potato? No. Thank God. No. Why? It's dirty. It came from the ground. It's 50% less scrubbing. So if you put this on there, you don't have to scrub. It's not dish. We are eating the outside too. Look, they put ducks on here. It doesn't matter. You can put on anything. You can put on ducks, you can put on a dish, you can put on hands. It's up to my YouTube channel. If you want to.  We should peel it first. No. Wait, why? We're eating the outside. Wait, why? Why not? Wait, this isn't super thin? It's not super thin. This is super thin. It's the same. No, this is thin. This is like thin. That's thick. This is thin in America. Look at that. That one is good. That one's like really, really thin. That one's bad. This is so thin, you can't see it. One, two. Put it up. Up. Yeah. Almost, though. I hit my mouth. I just, my mouth's not big enough. This is ketchup that we actually, we churn this ourselves. We churn, this is churned in our own backyard. For marb. Yeah, because we only. Hedge of trees? We only care about, we only use organic. Everything is organic. Organic products. It's all music to our ears. We need another pan that is for cooking French fries, by the way. We have to cook onions first. And we're going to cook it and butter again over here. And while we're cooking it, another pan, we're going to start the potato. Go for it and. Go for it. Oh yeah, do it, do it. So this. Oh, very good. Okay, apply more butter. You want to apply lots of butter. Because butter is so good. Butter is so good. So good. So with this, you don't want to do like big flips, because you have a lot of little ones.  Heat, right?  A little bit. Catch up, catch up, catch up, catch up, okay? Catch up, catch up, catch down, catch down, catch left. No, no, no. That's a monster part. Oh, okay. It's okay, we'll feed that to the dog that we don't have. Do dogs eat onions? No, they don't eat onions. Okay, if any dogs are watching, you guys have to get your vegetables, fruits, all that kind of stuff. It's very important to have a well-balanced diet. Look at that, ooh. Lettuce, onions, and cheese. Lettuce, onion, cheese, ketchup, and mustard. Okay, so we are going to knead this. We're going to make it into a flat. But we're going to make it two balls. So we're going to take it, give it a big old pinch. So we've got two right here. Do one at a time. Do you want to give it a little roll? Look at the technique, right? Good, good. Put it nice and flat, like a patty, right here. Exactly, you'll work. So we have this, and now it looks like a burger patty. And that's the important thing. Is that hot? Look at that. The sizzle. Here's the sizzle. Eat it, no. Tomatoes are disgusting. No, it's healthy. Tomatoes barely even deserve to exist. If I had a genie and I had three wishes, all three of them would be, tomatoes wouldn't exist. What do you mean? Play-dohs are good. Okay, now then flip this. Oh, this might be a dangerous flip. It's a lot of juice. Three, two, one. Oh, didn't do it. I did it double. I got it double. I caught it. Double, ready? One, two. Oh, awesome. There it is, a bonus flip. Jenny, do you want a great job with the potato? Yeah, I put, I put potatoes in oil. Okay, what kind of oils do you use? Vegetable? Yeah, vegetable. And now it looks like a potato cheese. It looks really good. I'll make potato chips. Actually, I'll be honest with you. I don't think there's enough milk in there to actually affect it negatively. Oh, no, no, no. It affects positively. But if it does, if it does, I'll never eat hamburger again. Four burgers. These look good. Let's show it, let's show it. Okay, one with milk, the other one without. One of them, burger, the other one, no milk burger, look at this. Show them the other one. This one is without milk. Okay, so here's how we have to do this. Here's the only way this can truly be done and we can give it the true test. Okay, I have to eat it blindfolded and I have to guess when is milk. Is not milk. Yeah. Now is the time that we will know for sure if milk burger, which I'm highly opposed to and normal burger have any difference in taste. Ginny says it doesn't taste bad. I say it probably does. It tastes good. The hair. Your hair, that's your hair. I know. Give me one of the other ones. You didn't give me two milks, did you? Because I wouldn't do that.  They definitely smell different. But we will see which one is actually milk. Dude, I'm nervous. I'm nervous to guess which one is milk and I'm wrong. Because I'm going to guess the one that tastes better is not milk. I have my decision. I think the second burger tastes better. So I think that the second burger is not milk. The second burger that you taste it was the milk one. No! Are you kidding me? What is the milk one? No!  No, you put better lettuce in here or something. No, it's a statement. No, really?   I'm so embarrassed. And now you're going to be called milk fin. I like milk. I love milk. I never said that I dislike milk. What I do, I don't think milk deserves the right to go into meat. You lost. Milk steak is better and normal steak is worse. Okay, so my life is ruined and so is my taste buds chat. Because apparently milk did not taste terrible whenever I ate it in the burger. In fact, it tasted better than the normal one. So now I'm embarrassed, upset, and a little bit demasculated. Or emasculated. Demasculated. The masculinity has been reduced.