DR. RESNECK: Thanks so much, and thanks for having me today.
MS. STEAD SELLERS: We're delighted to have you.
I'd like to start by talking about what we've learned about telemedicine from the pandemic. What did COVID-19 show us about the value of telemedicine?
DR. RESNECK: Well, it really, during an otherwise very difficult time for the nation, for the world, and for health care, was an example of a shining success. In a very short period of time, we went from telemedicine and digital health being a very small portion of how we delivered care to in a matter of weeks being a way that we were delivering care to millions of patients around the country. It really was a chance--once the coverage got turned on, it really was a chance for physicians across multiple specialties, all across medicine, to really quickly figure out where it was best deployed, when we could use it best, and in which circumstances patients needed to come in, in person, and I think as we talked to our patients, they really liked it.
They saw benefits far beyond just being able to avoid leaving the home because of COVID and achieve social distancing. It was a great way to improve access and convenience. Patients didn't have to be in cars or public transportation to get to offices. They missed less work. They had fewer issues with child care in order to come to see their physician. We had patients in rural settings who don't have great access to physicians, who got to see us more easily. So, it really was a shining success story.
MS. STEAD SELLERS: I'd like to ask first about primary care, and then we'll talk about specialties, but I've heard in interviews, doctors tell me it can be almost like doing a home visit and that you can see inside somebody's home if you're in telemedicine. But tell me, with primary care, is telehealth here to stay?
DR. RESNECK: Absolutely. I think it's going to be an integrated part of the way that we deliver care. There are obviously certain instances where it's really nice to have a patient in the office to be able to do a physical exam, to be able to have some in-person counseling.
At the early stages of the pandemic, though, about 44 percent of all of Medicare's primary care visits were actually being done by virtual means.
You mentioned getting to sort of look into somebody's living setting. I think as we think about disparities and all of the challenges our patients are facing with food insecurity and housing insecurity and other things that actually affect their health and the diseases that they have and that we manage, we had a lot of instances where actually getting to see somebody live in their home setting made a difference. If you're seeing a patient in primary care with diabetes, for example, and you're talking to them about their diet and what they're eating, they can literally carry their iPhone or their laptop over to their refrigerator, and you can talk about the food that's right there in front of them and ways to maybe change their diet. So, we saw a lot of examples where actually it was useful to take a look right into those social determinants of health.
MS. STEAD SELLERS: Then let's talk about some of the more specialized areas, cancer, neurology, some of these other areas. Are there disadvantages to virtual care in very specialized areas?
DR. RESNECK: It really depends on the patient and what they're bringing to you and their condition.
I happen to be a dermatologist, and so you would think skin would be an easy thing for telehealth, and in many instances, it is. Patients can show us things on a video or upload photographs, and we're a specialty that actually had been doing telehealth for years before the pandemic, although it dramatically increased with the pandemic.
But we quickly realized, and as I was sitting there on my computer doing a lot of telehealth visits, that there were certain patients--a patient I knew well where I was seeing them to maybe check in on how their condition was doing, update their medications, make some changes in their treatment--where the telehealth was fantastic.
There are other times where I was seeing a patient who had had a couple of skin cancers in the past, and we really needed to do a full-body skin check and look for new skin cancers, where it turned out not to be as useful, and I really needed to see them in person, or maybe I needed to do a biopsy that required seeing them in person.
So, I think we've learned a lot during this year and a half about exactly which patients it's great for and which patients we will really need to bring in the office.
MS. STEAD SELLERS: You're drawing these clinical distinctions, which are very interesting, between what you can do and what you can't do. Should a telehealth visit cost the same as bringing somebody into the hospital? Are they equivalent in those?
DR. RESNECK: I would say, in some ways, it depends. So, when you think about--we really think about payment as just being a way to sort of fairly compensate for the amount of work and overhead that's involved in providing a particular service. So, if you're doing the equivalent of an in-person visit and you're spending the amount of time and diagnosing a complex thing--and, by the way, most physicians who are doing a mix of integrated telehealth and keeping their office open and keeping their nursing staff and front desk staff present--you can imagine that might be valued similarly.
You can imagine other services that are quite distinct that are done differently by telehealth where the amount of resources that go into providing that service might be a little bit different.
MS. STEAD SELLERS: This is obviously an issue that has gone to the Hill. Do you support efforts from lawmakers to keep expansions on telemedicine permanent; if so, with what conditions; and if not, why not?
DR. RESNECK: Absolutely, I do. This is critical. I don't think my patients want to go back to the way things were a year and a half ago when this wasn't an option, and it really was the expanded coverage that made this possible. So, within a matter of weeks, we saw both government insurers like Medicare and Medicaid and private commercial insurers really open this up and turn on coverage for telehealth that hadn't existed before the pandemic that allowed us to be able to provide that care to our patients.
It turns out that for Medicare, there's some really old rules that date back to the 1990s, this thing called Section 1834(m) that essentially said before the pandemic that you as a Medicare patient could only use audiovisual telehealth if you were in certain geographic areas and if you went to one doctor's office to see another doctor via telehealth. You couldn't use your own device at home, and this may have made sense back in 1997 when it was put in place, but it really doesn't make sense today for patients to have to do that. Those rules were waived during this public health emergency, and we have been really encouraging Congress to make those changes permanent so that patients can continue to use telehealth.
We've seen some similar issues with the commercial private insurers. A lot of them before the pandemic had some telehealth services. For example, some of my patients who I knew well weren't allowed to do a follow-up visit with me via a video visit, even if they lived two or three hours away, but their insurance company gave them access to some internet-based corporate telehealth provider with physicians or other clinicians that they had never met who didn't have access to their records. We'd like to see them expand and continue the option for our patients to be able to see the health care team and the physicians that they already know and who know them.
MS. STEAD SELLERS: One of the things that the pandemic has highlighted is healthy inequities across the country, and you mentioned that earlier on in terms of getting into people's houses and understanding the unique problems they face, but many people in this country don't have broadband. How are you going to ensure moving ahead with telemedicine that it's available in an equitable way to people from all different backgrounds across this country?
DR. RESNECK: You're right. Those inequities and the disparities that we see in outcomes certainly aren't new, but I think the pandemic made them visible to large portions of the American population that maybe hadn't been aware of them before. We really saw unconscionable, just disproportionate impacts of the pandemic on our Black population, our brown patients, our Native American communities, and telehealth is a part of improving that. But it has to be done in a way where from the very beginning, you build in on-ramps to help patients get access to it, and you really think about those disparities and that equity up front.
I was really surprised as I was providing care via telehealth just how many people had limited broadband access. For example, I had farm workers who were using the telephone to be able to get care directly from the fields, and maybe that was less surprising, but I had patients both in urban and rural settings who, for example, didn't have access to or couldn't afford broadband internet access. I had patients who had wildly different sort of levels of digital literacy in terms of how comfortable they were. So, the tools have to be made in ways that a wide variety of patients feel comfortable using them and have access to them. We have to have broadband access. We have to have insurers actually cover this so that patients across the spectrum have access to these services.
Another thing that we don't want to see in terms of a problem potentially with health equity on telehealth is we also don't want insurance companies telling individual groups of patients that either they can't use telehealth or that they have to use telehealth or have to pay extra to come in, in person, because as we mentioned earlier, there are times where it's actually really useful to see a patient face-to-face as well.
MS. STEAD SELLERS: One of the points of contention over telehealth has been over licensing and where doctors practice. Could you tell me about your views on this and why you oppose, I believe, making permanent some of the relaxation of those rules that happened during the pandemic?
DR. RESNECK: Well, licensure is really--the main function of licensure is that it allows states in the current setup to really hold physicians accountable for the care they provide, and it means that if I have a patient who is unhappy with my care--and I happen to practice in California--my patients can go to the licensing board in California and make a complaint or ask them to look into something I've done, and all of the rules of the road around end-of-life care, around medical marijuana, around reproductive care, all these things are really set at the state level through that system.
One of our concerns is that if you all of a sudden say physicians are licensed federally or only have to be licensed in the state where they're providing care, all of a sudden, if I am caring for a patient in Florida and that patient has concerns about the care I've provided, they have to come all the way to the California Medical Board to file a complaint against me. That's one of the important reasons we really believe in state licensure.
It turns out that there are a lot easier ways, though, now to practice across state lines. There's this thing called the Interstate Medical Licensure Compact, which essentially says, "Okay. I have a good license in California. I don't have complaints filed against me." A number of other states across the country if California were to participate in this, I can now easily get licenses in multiple states. That way, I am held accountable when I provide care to patients in those areas.
Another thing that we're asking the state medical boards to do from the AMA is to say, "Look, if you already know a patient who has seen you in person or who you've provided telehealth to locally in your own state and that patient happens to be away in college or off on vacation or a snowbird who's in a different state for a while, it's perfectly reasonable to continue to provide care to that patient while they're out of state.
MS. STEAD SELLERS: Just to sort of get down to brass tacks, I was talking just recently with a nurse practicing in rural Maine who does telehealth, and she said, you know, there's a neurologist that she works with in Boston, but that person isn't licensed in Maine. It seems like a huge roadblock for some rural communities, particularly if you're close to a state line, not to be able to have these cross-state--
DR. RESNECK: They can be. Yeah, there are a lot of work-arounds for that. I mentioned this interstate compact. There are also regions of the country where particularly in rural areas where multiple states get together and honor each other's licenses across local state lines and where enforcement is actually quite possible because the region works together on it.
There's also a way that--so I happen again to be a dermatologist--where I can do what's called an "interprofessional consult," where a patient goes to see their primary care physician, maybe out of state, and that primary care physician can do a consult with me about that patient. And that way, the patient has a local person who's there if they have a problem. So, the person who is actually prescribing their medications and doing some of the follow-up is their local physician that they have access to, if they have a side effect or need a backup plan for local care, but I can assist in sort of thinking through their management plan.
Because another one of the challenges sometimes with telehealth--and when it's done well, this works great, but when it's done sort of poorly--and again, we see this with some of these corporate internet-based sites--is that you have situations where a patient gets a prescription from across state lines. Something goes wrong, and they have a side effect, and they have nowhere to go. So, I'll have patients call my office saying, "I got my eczema treated by this online provider who happens to be across the country. They're not available today. Can you see me in your office? Because now I'm having a problem with the medication they prescribed."
It's really useful when you also have a physician in your state who's helping to take care of you, and they can also utilize the specialty and subspecialty care across state lines, which the rules permit.
MS. STEAD SELLERS: I want to ask you one more question about this licensure because it's so complicated. A recent disaster, of course, was across the country, but I've covered stories like the Pulse shooting in Florida where doctors, specialists could not fly in from other areas to help doctors who were under extreme pressure there to treat emergencies. Does that make sense, or should we be relaxing licensure in those situations?
DR. RESNECK: No. And, clearly, this is important. There are all types. You mentioned that terrible tragedy. There are all types of emergencies, natural disasters, all kinds of things, where we see physicians actually--and other members of the health care team eager to really run towards the fire and provide care.
I work at a hospital called UCSF in San Francisco. Early on in the pandemic when we weren't having a lot of COVID cases in California yet, we actually put a lot of our physicians and nurses on planes to go to New York where things were worse and to go to the Navajo Nation where things were worse early on, and it was incredibly moving to watch that.
We've seen a lot of states and state medical boards make allowances during declared emergencies to allow physicians to come in and practice across state lines, and we need to continue to fix those rules so that that continues to be possible in emergencies.
MS. STEAD SELLERS: One of the huge triumphs of this pandemic has been technological in the invention of the mRNA vaccines. Do you see them as a game changer going ahead in the way medicine is able to deal with infectious disease?
DR. RESNECK: Yeah. I mean, there have been a number of silver linings in this pandemic, and I think in addition to telehealth being one, science has really been a winner in the last year and a half, the speed with which these vaccines have come about. I think health care workers and watching what they did during this pandemic has been another really inspiring success story.
It's been interesting reading about some of the potential new applications of mRNA vaccines. As you know, they've been around for a while, but this was really a first in terms of such a successful deployment, and the way that they can be quickly designed for particular uses, I think, is really exciting. And I look forward to seeing where that goes as we think about applying them to other diseases.
MS. STEAD SELLERS: Talk to me a little bit, if you could, about artificial intelligence, its role, and the AMA's standing on how it can be integrated into care.
DR. RESNECK: It's pretty exciting. We have seen across multiple specialties really pull early applications of AI, but as with anything in health care or frankly in anything else, you see great tools and you see some pretty lousy tools out there as well. We try to start at the beginning with every one of these ideas, and often they are accompanied by a fair bit of hype with some really basic questions. Does it work? Does it do what it actually says it's going to do? And is it going to be actually useful to physicians and to our patients, even if it works? Is it going to ultimately improve their health?
We've seen examples where sometimes the hype doesn't pan out. Augmented intelligence basically requires computers to learn from what's called a training set. They take a big dataset, whether it's a ton of pictures or a ton of electronic health records, and they go learn from things that have happened in the past to try to help us predict the future.
So, for example, you see really neat applications where you look at hospitalized patients, and AI is sort of combing their medical records while they're in the hospital and can help us predict, for example, which pneumonia patients in the hospital might do poorly and need more attention early on, but sometimes the tools looking back kind of learn the idiosyncrasies of the place where they're being taught. So, for example, there was a tool like this that learned that patients who come to the hospital, who have a pneumonia, who also have really bad asthma actually do really well and don't need extra attention, even though they have asthma, and it learned that because those patients at that hospital, if you had asthma, got immediately taken to the intensive care unit and got all this extra care. It sort of learned something that was maybe wrong and wouldn't necessarily apply to another hospital.
I've got another example just in my own field of dermatology where we had an AI tool that helped us look at a mole on a patient. So, this is a dark growth on a patient's skin that could potentially be a skin cancer or not, and it would help you decide does this lesion really need a biopsy, and this is an exciting use of AI. I think it's going to get better and better. But it turned out we figured out months later that this tool had learned that if physicians had drawn a circle around the dark mole, that was more likely to break one that they were worried about before they took a picture, and that was one of the things it was using to actually guess whether the patient has an melanoma. I think we have to be careful too about these tools.
There are also some equity issues--I don't know if we have a moment to discuss that--where we're also worried about these tools being deployed equitably and not sort of cementing existing inequities in the health care system.
There's Optum, a large company who put out a tool, again, with good intentions, I think, that was designed to help us predict, to help insurers and health care systems predict which patients in the next year might get sicker and need more health care resources directed at them to prevent their chronic diseases from getting worse and to prevent hospitalizations. Great idea. But the tool had learned from the way we had delivered health care the last few years, and it learned that minoritized populations got less health care. And so, it took what it learned from that, and actually, if you gave this tool the exact same health background of a Black patient and another patient who was a nonminority patient, it would direct more resources to the nonminority patient. There are real dangers, and if we don't design these tools really properly and thinking about health equity from the outset, it's really important that we think about it at the front end.
MS. STEAD SELLERS: That's fascinating. I want to ask one quick last question, if I may. The White House conceded this week that it would not reach its goal of 70 percent vaccination rate for the adult population. What in your view does that mean for the country's recovery? And I'm sorry, a big question, but if you can answer it quickly, that would be great.
DR. RESNECK: Yeah. Well, we've made tremendous progress and are incredibly fortunate to have had vaccines so quickly and to have the great uptake that we've seen. We still have patients that we're taking to who are hesitant, and fortunately, many of them, as they talk to their physicians, learn more about the benefits of the vaccines, maybe have some of the stuff that they've read on social media counter that's not true out there. We're still very optimistic about the progress we're making, and we really urge everyone out there, particularly with the new Delta variant increasingly circulating around the world and now in the U.S. as well. Those patients who aren't vaccinated are going to be at particularly higher risk, I think, in the coming months. We'd love to see continued progress.
MS. STEAD SELLERS: That's all we have time for. Dr. Resneck, thank you so much for such a fascinating discussion.
DR. RESNECK: Thanks so much. I appreciate it.
MS. STEAD SELLERS: I'll be back in a few moments with Dr. John Brownstein from Boston Children's and Dr. Tufia Haddad from the Mayo Clinic.
MS. MESERVE: Hello. I'm Jeanne Meserve.
During the pandemic, we were advised to stay away from hospitals and doctors' offices as much as possible unless we were suffering from COVID-19. For many of us, telemedicine and other forms of digital health care were a blessing. They allowed us to continue to communicate with our health care providers. What did we learn from this?
Here to discuss is Dr. Jay Schnitzer. He is chief technology and medical officer at MITRE. Dr. Schnitzer, thanks so much for joining us today.
DR. SCHNITZER: Thank you, Jeanne. Great to be with you.
MS. MESERVE: So, from your perspective, what were the big takeaways from our experiment with digital health during the pandemic?
DR. SCHNITZER: So, with all we've known about the challenges for digital health for many years, COVID-19 served as a wakeup call about just how vulnerable we are as a country, as a globe, in fact, to rapidly spreading disease. COVID-19 has been both a catalyst and an accelerant, particularly for telehealth. The pandemic opened our eyes to broad health disparities across the nation. It also has underscored the glaring need for a national digital health strategy that has amplified that need and identified illuminated and magnified the gaps between here and where we need to be. It is our responsibility now to make sure that the lessons learned over the past year prepare us for the next global health emergency and improve the health and well-being of all Americans every day.
MS. MESERVE: Now that the imperative to use these digital tools has passed, do you worry that the momentum in this area will be lost?
DR. SCHNITZER: Not at all. I think we've seen just by what we've seen over the past year, year and a half, how valuable these tools are and how much they help particularly telehealth, particularly for things such as mental health, and yes, we'll see some ebb and flow of that over the coming months and years. But telehealth, digital health, they're here to stay, and they are making a difference.
MS. MESERVE: You mentioned a national digital strategy for health care. What would that look like? DR. SCHNITZER: Well, we actually put that together over the past several months in conjunction with our MITRE Health Advisory Council and identified six goals that need to be part of the strategy. They include access to universal broadband for everyone, a workforce that is tech savvy for health care delivery, digital technologies that work for the individual, different types of architectures and standards that can be used to create interoperability across the spectrum, an ecosystem--an ecosystem that supports public health--and last and most important in many ways, the governance of all of this for the system to work.
MS. MESERVE: So, if this national strategy were put in place, what advances do you think we'll see short term and also in the longer term?
DR. SCHNITZER: Well, in the near term--and by that, I mean within a year or two at most--I think we should see some very quick wins that are going to matter. First of all, I think we are going to reach or we could reach ubiquitous, secure telehealth access and utilization for everyone. We could obtain appropriate levels of sustained, reliable reimbursement for telehealth, which would be the gasoline for the engine that keep us going, and equally importantly, we hope to reach a state in which our federal government assumes the leadership role in this complex ecosystem and engages effectively with all components and stakeholders for telehealth and for digital health going forward.
In the longer term, up to five years or more, perhaps, we hope to see a transformed health ecosystem that leverages these digital technologies that improve health and well-being for everyone. We would expect to see broadband access for everybody. We would expect to reach a state where information that is needed is available at the right time, in the right form, to the right people, wherever and whenever needed, securely, simultaneously preserving privacy and with the access controlled by the individual patient. Next, we would hope that we'd have a tech-savvy workforce, and finally and most importantly, it would lead to improved health for everyone.
MS. MESERVE: Expand capacity, improve health outcomes. Reduce cost too, potentially?
DR. SCHNITZER: Should be. I mean, we've seen in many other industries where digital technologies ultimately lead to reduced cost. We haven't seen it yet in health care. In a contrary fashion, usually in bringing digital technologies to health increases costs, but in the long run, we should see that with health as well as in other areas, so yes.
MS. MESERVE: And we have to leave it there. Dr. Jay Schnitzer, thanks so much for joining us, chief technology and medical officer at MITRE. Thank you, sir.
DR. SCHNITZER: Thank you.
MS. MESERVE: Now back to The Washington Post.
MS. STEAD SELLERS: Welcome back. If you're just joining us, I'm Frances Stead Sellers.
This next segment is going to focus on the new frontier in medicine, smart hospitals, and I have two experts joining me today, Dr. John Brownstein from Boston Children's and Dr. Tufia Haddad from the Mayo Clinic. A very warm welcome to you both.
DR. BROWNSTEIN: Good to see you.
DR. HADDAD: Thank you.
MS. STEAD SELLERS: John, let's start with you and paint the big picture. If you could design the smart hospital of the future, what would it look like?
DR. BROWNSTEIN: Yeah. That's a great question. I mean, we've been on this digital journey at Boston Children's now for at least a decade now, recognizing that the data that we are collecting in the process of taking care of our patients can actually be fundamentally used to actually make better decisions.
So, yes, you know, when you think about a smart hospital, it's really fundamentally just optimizing technology to support a better experience for patients, really a concierge true experience like we see in other industries. It's about automation. It's about taking away all of those administrative tasks from our providers so that they can practice at the top of their license. It's really all about thinking about how we improve clinical decision-making.
The EMR is full of huge amounts of information, but we don't actually leverage it to the best of its possibility to really build sort of a clinical intelligent system, and so there are so many areas of the hospital that could be transformed with sort of the intelligence that we have in the data, whether it's radiology, pathology, whether it's in the emergency department.
We're already embarking on that, but it really changes the game in terms of how we support our patients and really thinking about likely would any other industry where we leverage data about our populations to make better decisions.
MS. STEAD SELLERS: I just wanted to remind EMR stands for electric medical records. We have some listeners who probably won't know the acronym, so we'll step back from that.
Tufia, the Mayo Clinic was just ranked, I think, number one in the world as a smart hospital. Can you tell us what you're doing there to improve both operational functions and patient experience?
DR. HADDAD: Yes. Thank you very much for that question and recognition of this honor at Mayo Clinic. We're very proud to be recognized amongst these other wonderful health systems to be leading in the use of telemedicine, artificial intelligence, robotic surgery, digital imaging, and having robust information technology, infrastructure, and a shared electronic health record system across our organization.
These investments in technology are really aimed to support the transformation of health care, and utilizing these technologies with that human touch, our incredible health care workforce, to really enable them to be more efficient, more effective, more engaging in the care that they deliver.
I really believe that the smart hospital and hospital of the future really begins with how we are caring for patients are home and leveraging these technologies to do remote patient monitoring, to be assessing our patients' symptoms, their vital signs, other physiologic data, and to be assessing those data and information and using robust data analytics platforms to earlier identify adverse trends, so that our nurses and our teams who are monitoring, virtually monitoring these patients at home, can earlier intervene when problems arise, sometimes even before the patient feels different or notices symptoms.
But we know from research that that remote patient monitoring can reduce the need for hospitalization, reduce total hospital days, reduce the need for hospital readmissions, and that is a wonderful benefit in terms of improving our patient outcomes, reducing those hospital-associated infections, falls, deliriums, and allowing patients to remain in their home, the comfort and convenience of being at home. And all of this translates to reducing the total cost of care.
The smart hospital of the future really starts with monitoring of patients in the home to hopefully avoid the need for them to be in our hospital.
MS. STEAD SELLERS: John, if I use the phrase "human touch"--and there's evidence to show that spending time with your physician is actually beneficial, makes people better more quickly--is there a balance here between operational efficiency and patient care in that traditional sense?
DR. BROWNSTEIN: Yeah. Well, actually, I think that these things can go hand-in-hand. The idea that if you can optimize technology in the clinical environment, you actually create more human interaction.
If you think about documentation--so, in the electronic medical record, a provider will spend the bulk of their time both in the visit and after the visit documenting the interaction that they had with a patient. That is time that could be spent in direct engagement and engagement with the patient themselves.
We, for instance, are deploying now augmented listening devices in the clinical room, so the idea that you can actually listen to the conversation that happens between a provider and a patient and extract important elements from that conversation that can actually carry forward into the notes and the documentation of the patient in their electronic medical record. What that means is, in fact, technology is optimizing the human-human interaction. It's not taking away from it, and I think that's what we're seeing more and more is where can we take away all the sort of repetitive tasks that a provider is experiencing and make them more of a human engagement with their patient. I think that has to be fundamental to every technology that we look to deploy in our hospital setting.
DR. HADDAD: I agree with that comment. We know that our clinicians spend more time in front of the computer screens trying to abstract information from the EHR to guide their decisions at a two-to-one ratio, in fact.
I think as we apply these advanced clinical decision support systems to do the data mining, the interpretation, and find those insights for us, that will give us more time, then, to spend together with our patients in counseling and actually enhancing that face-to-face time, whether it's by video face-to-face or in our hospitals and clinics. It's definitely an efficiency gained that allows our clinicians to do what they do best, and that's interact with our patients.
MS. STEAD SELLERS: So, you've been at the forefront, both of you, at the forefront of these trends. How did the pandemic accelerate the move towards smart hospitals across the country? John, maybe you could start, but I'd love to hear from you, Tufia, on that too.
DR. BROWNSTEIN: Yeah. No, I mean, clearly, as we heard from the previous discussion you had, I mean, it was essentially a game changing and one of the sort of major--one of the few benefits of the pandemic.
We had a team in place, a digital health team in place at the hospital, but we were just seeing a trickling in the use of virtual care.
Now, of course, with the pandemic, it forced us into an environment where we had to really deploy virtual visits, telemedicine at scale. Luckily, we had the underpinnings, and what was great is that our providers adapted to it incredibly well and in fact loved using these tools, and our patients really loved them as well. The cat is out of the bag a little bit when it comes to these tools, but it allowed us to do other things. We had a conversation about remote patient monitoring. We could bring devices into the home and do remote visits. We could actually think about better ways of engaging with our patients after visits, the ways in which we can continuously engage with our patients, not sort of this one-off engagement.
It really did change our ability to engage with our patients. Of course, we had many technologies that we deployed because of the pandemic, whether it's symptom checking or new devices to do screening of our patients, but overall, the tools that we have built will last far beyond the pandemic. Of course, there's going to be a conversation about whether there's going to be a willingness on the part of providers and patients to do this. I think there will be, and then we just have to make sure that reimbursement stays with us so that that parity exists between an in-person for a visit and a virtual visit that so many of our patients have been asking for, for many years.
MS. STEAD SELLERS: Tufia, go ahead. I'd love to hear from you.
DR. HADDAD: Yeah, I agree. Yeah. Thank you. I completely agree with John's comments here. The pandemic certainly was a catalyst. Adoption of telehealth and telemedicine and the Hospital at Home model really was limited in part by licensure, regulatory reimbursement barriers, and some of the flexibilities that have been abled in part due to the public health emergency has allowed us for broad adoption and expansion now of these services. That definitely is part of it.
There's been academic progress, research studying the impact of these different ways to deliver health care. We hope that the research and those outcomes and findings will allow us to sustain and again upon the momentum and hopefully to persist some of these regulatory changes.
As well, you know, COVID-19 was so unique in that we wanted to give as much care for our patients in the home to reduce transmission of the virus. Enabling remote patient modeling, which historically had been developed to serve patients with chronic condition, during the pandemic, we saw this shift, and now we're managing acute conditions like COVID-19 with remote patient modeling in the home. Our patients really loved this. They felt connected to their care teams. They felt we were paying attention to their symptoms, their oxygen saturation levels, responding to trends, and making sure they felt supported on their road to recovery.
And, importantly, for those who were experiencing more severe symptoms or having some instability in their vital signs, we were able to early intervene with different types of care interventions in the home that allowed us again to earlier reverse sort of the trajectory of their disease.
But, also, we recognize that we can only go so far with monitoring in the home. We actually need to deliver care in the home as well, and that is what the Hospital at Home model, something that Mayo Clinic has now invested in and now is--that has the advanced care at home through our strategic investments and partnership together with Kaiser Permanente investing in Medically Home, the technology enables services, company, and supply chain that allows us to bring and administer IV fluids, IV medications, perform some diagnostics as needed to help support and bring that hospital-level care into the home.
MS. STEAD SELLERS: John, I was talking to Dr. Resneck about disasters and doctors helping each other out and trying to move and go towards the disaster, but one of the things I learned a little about during the pandemic was doctors sharing information technologically, virtually. Is that a growing trend too, so doctor training, in effect, indirect patient care?
DR. BROWNSTEIN: Yeah. I mean, I think that the speed of information sharing broadly has changed, you know, like, fundamentally right now, and I think it goes for clinical decision-making but also scientific research.
I mean, we saw the advent of the preprint and the sort of outward sharing of data. As soon as we started to understanding sort of the symptoms set for COVID patients, that data was being made available freely. There was huge amounts of sort of aggregate information that was shared. Our team worked on a number of different surveillance tools, one around symptom checking and the ability to fully understand how to understand what a patient would be presenting with, what symptoms they would be presenting with that would indicate COVID especially in light of lack of testing. That information was shared across many different types of social networks, ones that were more sort of physician-based like ProMED but also more broad social networks like Twitter, and I think that is something that we're going to see more dramatically change over time.
Now, the question, again, becomes how does one get sort of academic credit in this world of vast information sharing. Our promotions and academics or success depends on sort of traditional peer-reviewed journal articles, and that's how you get promoted through the academic ranks. But in a world where there's such vital need for information and the cutting edge of data to respond to a pandemic, but now, you know, for whatever next comes out way, I think we're going to have to think about ways in which providers by exposing information, by exposing data still get that credit to move through their own sort of professional journey. So, a lot of open questions, but I to think, again, like digital health, our sharing of information has sort of fundamentally changed going forward.
MS. STEAD SELLERS: Tufia, Mayo has had this great honor of being so well ranked around the world, but when you look at other countries and other models elsewhere in terms of smart technology in hospitals, where do you look? Are the models out there that the U.S. should look to?
DR. HADDAD: Well, I think one of the advantages I have seen in other countries is just a shared electronic health record throughout the country and the ability to share data and have that interoperability amongst their different systems because everything is unified and shared. That is certainly a distinct advantage that I see in other countries in terms of their ability to deliver telemedicine and to really use that as a primary driver for primary care, for specialty care as well, but then to harness all that data and to be able to leverage it in ways that we can develop these predictive analytics in advanced clinical decision support. They have kind of that unique opportunity of leveraging very large datasets from the many patients in their country, and so I think that is a unique advantage that I see.
We certainly have limitations in our country with the lack of complete interoperability because people are on different electronic health records. Not all health systems yet even are on electronic health records, but that certainly poses the challenge for us to develop these large datasets to be doing some of this additional work and development.
MS. STEAD SELLERS: Can you be just a little bit more specific about what those large datasets offer in these other countries? What advantages specifically?
DR. HADDAD: Yeah. So, you know, leveraging the big data in order to develop these predictive algorithms and turning those algorithms, then, into clinical decision support systems and integrating them into our clinical workflows.
An example, one that actually we have here at Mayo Clinic, was the development of a predictive model. We leveraged over 60,000 electronic medical records from individual patients to develop a model that predicts for a need for palliative care. We were able to bring that model, then, into our clinical workflows in the hospital to identify patients who had benefits from having a palliative care team provide additional supportive care to help improve their health and their outcomes. Being able to develop that framework, to develop not just one model but multiple models, and to be able to bring those into the workflows in a seamless way that again allows our clinicians to be more effective in terms of the services they leverage for the patients' care, to help improve our patients' outcomes, we see that happening in our own country and in our own individual health systems. The ability to share that cross multiple different health system is where we have some limitations in the U.S.
DR. BROWNSTEIN: And I'll just add maybe to that. You know, I think that the point of having the largest, most representative dataset to build algorithms, AI, machine learning tools is super important, and I know that there's conversations about bias in AI, the issue that you don't have a diverse or representative sample in order to sort of make these predictions, and that can lead to real problematic outcomes because your tools do not serve everyone equitably.
I know you talked about this a little bit in the previous session. This advantage of potentially having a large health system for an entire country means that you have much deeper representation across different groups, and in order to do that, then you--of course, having more data means the algorithm is more robust, but having a broader representation also means--and then we've had this struggle even in our own hospital setting where if we only build a model just based on our own patients, how extendable is it to another pediatric hospital or to another country? And so, the more that we can be inclusive in these tools, the better the algorithms are but the better they'll serve all our patients.
MS. STEAD SELLERS: I think we have time for one question left for each of you and unfortunately rather quick ones. But, John, you are working on the VaccineFinder, which I think started right after H1N1 in 2009. Can you tell us what has happened with it--it's now a government--
DR. BROWNSTEIN: Yeah.
MS. STEAD SELLERS: --find for vaccines, and whether--what role it's going to play now that we have heard from the White House that they will not reach 70 percent of adults vaccinated by July the 4th?
DR. BROWNSTEIN: Yeah. No, so we--thanks for the question. We've been running a VaccineFinder tool for many years. We ended up becoming part of the sort of response with Operation Warp Speed and CDC to build the sort of integral dataset that captures where vaccines are deployed, that--the supply chain of where essentially vaccines are across the country, across pharmacies, and a variety of different types of vaccination sites. That ultimately transformed to vaccines.gov, and it's been sort of the main tool that the White House and others have focused on to drive people to figure out where to go in their community to get vaccines. And it's been used over 25 million times, and it's been sort of a vital resource as part of the sort of strategy to get the vaccine deployed.
Now, we are, unfortunately, probably going to miss it. This is a problem, and there are multiple reasons for that. I highlight access as being an issue. Even though we have this vaccines.gov tool, still millions of people live in vaccine deserts, so there has to be a strategy to figure out how to reach that last mile of people that are in low-access environments. So, yes, that July 4th deadline may not be within reach, but of course, there’s the highlight of certain states being well beyond that mark, and many states, particularly many in the South, still have a real challenge, and so there’s going to have to be a focus on thinking about how you take those populations of people that are on the fence and whether it’s full vaccine authorization or other types of incentives. We know that paid leave or child care, certain types of incentives will work for certain populations, so there’s still a ways to go. And, yes, we have the Delta variant emerging, so time is of the essence to get everyone immunized ahead of the surge that is coming later in the summer.
MS. STEAD SELLERS: Unfortunately, we're right out of time. I want to thank you both so much for joining me and for such an interesting conversation. John Brownstein from Boston Children's and Tufia Haddad from the Mayo Clinic, thank you.
DR. BROWNSTEIN: Thank you so much for having me.
DR. HADDAD: Thank you.
MS. STEAD SELLERS: And I'll be back in a few moments with HHS Secretary Xavier Becerra.
MS. STEAD SELLERS: I'm back now with America's first Latino Secretary of Health and Human Services, Xavier Becerra. A very warm welcome to the show, Secretary Becerra.
MS. STEAD SELLERS: I think you may be having a little bit of trouble with sound.
SEC. BECERRA: Uh-oh. Can you hear me now?
MS. STEAD SELLERS: Okay. I can hear you loud and clear now. A very warm welcome to the show.
SEC. BECERRA: Thank you very much, I said, Frances. I appreciate your having me.
MS. STEAD SELLERS: Well, we're delighted.
We're going to focus the show on digital health, but I do want to first ask about the Supreme Court ruling--that must have been a great triumph in your view--and to ask specifically about what the next steps are in expanding health coverage. Where do we stand with the public option, which was something Biden campaigned on?
SEC. BECERRA: So, first, I think you have to say that common sense won in the Supreme Court, and as a result, now we can build. The president said it from the very beginning. He wanted to build on the successes of the Affordable Care Act, and so we've already begun that. The American Rescue Plan allowed us to expand coverage, make it more affordable. So far, we've been more than 1.2 million Americans signed up for new coverage under the Affordable Care Act. That means that some 31 billion Americans today now have received coverage as a result of the Affordable Care Act. That's a record number.
We also see that because of the special enrollment period that President Biden asked us to start, over a million people now applying for new coverage, better coverage, in some cases, we've seen over a billion people now receive coverage at about $10 a month, their premium cost, which is incredible when you think about the quality of care that they're going to be receiving.
We're going to continue that. We're going to continue to lower the price of that health care insurance. We want to continue to lower the price of prescription drug medication. We've got lots to do.
MS. STEAD SELLERS: The public option, again, with a 50-50 Senate, where does that stand, and what are the political prospects for it?
SEC. BECERRA: The president is supportive of the public option. I worked on passing the public option when we did the Affordable Care Act back in 2009-2010, and we will work closely with our colleagues in the Senate and the House to try to get something done. The public option, as you're aware, actually saves the American taxpayers money. It gives Americans a choice, a better choice, increased choice in terms of their different health insurance coverage, the kind of plan they want. By having a public option that looks a lot like what seniors in America are receiving in Medicare, it's another chance that Americans have to select the kind of health insurance they want to use, and the public option, very similar to Medicare, will give Americans another choice.
MS. STEAD SELLERS: Secretary Becerra, I'm afraid we're having a little trouble with the audio. I know our technology team is working hard on this, but forgive me--if I can hear you, we'll carry on, but forgive me if we miss a few sentences.
I wanted to ask you as well about prescription drugs. This is another issue that the president campaigned on.
SEC. BECERRA: Absolutely. Yeah. And, hopefully, you'll be able to hear me. I apologize if the technical problems are on our side. But on prescription drug medication, many administrations have tried to tackle this. The previous administration tried to tackle this some as well. We're intent on doing this. It's no longer just able to see how much Americans have to pay for their prescription drugs, especially when we see outbreaks in other countries using the same drug and paying less for those drugs in other countries, and so the president is intent on working with Congress to lower the price of drugs, and where we have the authority already, we'll try to take action if we can to lower the price of prescription drugs.
MS. STEAD SELLERS: You mentioned the large number of people who have enrolled, and of course, this is a huge change in--from the early days of the Affordable Care Act when there were problems with the website and enrollment. How has technology played and what technological improvements have happened to make this possible?
SEC. BECERRA: Well, technology is so much a ballgame these days. Without technology, you're a lot slower. You're not as nimble, and we're making use of technology every way we can. We've seen as a result of COVID how important it is to be able to reach folks. You played a clip about telehealth and where I testified on the importance of telehealth moving forward.
But we have to make sure we use the technology the right way as well. We can't leave people behind simply because they can't afford the technology or the technology hasn't reached where they live. We want to make sure that everyone benefits from the utility of technology, and what we'll see is that we're able to deliver care faster, cheaper, and with greater quality and better results because we're keeping track of data in a better way, people's health data through technology. We'll see better results because fewer mistakes will be made.
MS. STEAD SELLERS: Thank you.
Secretary Becerra, the White House conceded this week that it would not reach the goal by July the 4th, vaccinating 70 percent of adults. From the beginning of this vaccination campaign, I talked to public health experts who predicted a dramatic drop-off. Why didn't the White House see this coming? Why weren't we better prepared?
SEC. BECERRA: Well, I think that actually the White House and President Biden have done a great job to forecast where we're going. Where we are today compared to where we were the day before President Biden became president, it's a sea-change, and I don't fault the president for setting very ambitious goals, not just for the administration but for the country. When he said we would get out a million shots in the arm in his first 100 days, a lot of folks really didn't know if that would be possible. Not only did we do it, but we went to 200 million shots in the arm within the first 100 days. The president sets high bars, and we have to know how to jump really high and fast, and we'll do as much as we can.
Sixty-six percent of adults in America have become vaccinated--or have been vaccinated, and while we were hoping that by July 4th, we could say it's 70 percent, we still have some days left before we get to July 4th. The good thing is you have a president that's going to push this really hard, because at the end of the day, the harder we push and the more we get, the better for the American people.
MS. STEAD SELLERS: And you are now responsible for a new drive in some of the hotspots around the country to get the vaccine hesitancy in young people. Can you tell me about new strategies and technologies that you are employing to reach those resistant groups?
SEC. BECERRA: Well, we established a COVID health corps that helps us reach all parts of America. Some 12,000 individuals, organizations, nonprofits have teamed up to be part of this corps. Over a thousand physicians, by the way, are part of the corps, and they've helped us reach out to all parts of America.
We've also now established a COVID-19 youth corps, where we have asked a lot of younger people, 16, 17, 18, to serve as our youth ambassadors to help reach that population that is less vaccinated.
We're going to do everything we can, but the most important thing that we're now trying to do is we're going to go to where you are if you need to be vaccinated rather than wait for you to come to us. We know a lot of people, because they have to work multiple jobs, a family that everybody has to work, or if they're too far from the nearest site, or they're not--they haven't got all the right information. We want to make sure we go to you to make sure that if you are at all willing to be vaccinated, you get that vaccine.
MS. STEAD SELLERS: One of the things that's very striking is how political campaigns have honed their skills of targeting the persuade-ables, the middle group, the ones who go one way or another to vote, and it's very much the same thing with vaccines. Are you using the same sorts of social media tools to reach young people who are on the fence there, in the middle?
SEC. BECERRA: In many ways, that is absolutely [unclear]. Think of it this way. Political campaigns are happy when you get 50 percent plus 1 of the votes, and they consider it a landslide if you win an election by 55 or 56 percent. We're at 66 percent, and so, in most cases, that would be considered a resounding success in politics.
But we know we're not playing politics. We're playing with the need to vaccinate people against a deadly virus, and so 66 percent is great. The president would hope to get 70 percent real soon, but we want to get as close to 100 percent as possible, and so the game is not over until we make sure Americans are safe.
MS. STEAD SELLERS: Dr. Fauci has warned that the Delta variants could cause a lot of problems in the future. I'd like to hear your views about that now and looking ahead as you're struggling to get these holdouts vaccinated.
SEC. BECERRA: It's a scary thought, a very chilling prospect to allow a variant like the Delta variant to sort of take over when it comes to COVID, and what we know is that we have vaccines that help protect Americans against the COVID-19 virus and disease. What we don't know is how quickly these variants will arise, the mutations that occur in the existing forms of COVID-19, and we never know how well the current vaccines will protect against these new or coming variants, and so what we want to do is protect the population so that the variants don't have a chance to take hold. And that's why it's so important to vaccinate.
You may feel like you're the invincible 25-year-old, totally in good health, never had to visit a hospital, but you could be a carrier, and who knows? You could infect your grandmother who may have been completely vaccinated, but if you happen to be carrying a variant that is more powerful than existing forms of COVID-19 and infect a person, it's unclear how safe we'll all be, and so the more we're protected against COVID-19 and all its forms the better off we'll all be. And we have a responsibility to each other to make sure we're safe, so it's time to get vaccinated.
MS. STEAD SELLERS: We're still having a little bit of trouble with sound, but I just wanted to follow up on that, or what I think I heard. Could we have a new variant that is actually more dangerous for young people if we let this virus just rampage across the parts of the country that are not well vaccinated?
SEC. BECERRA: Frances, the virus is always mutating, and we never know what form it will take, but certainly, when it mutates, the forms that are more resilient against vaccines, forms that have more an ability to take over the body of the host are going to be the ones that creates the most, and they're, of course, the ones that will survive against a good vaccine.
What we want to do is provide the blanket protection for society so that these variants don't have a chance to take hold, that we can catch them before they spread too far.
The Delta variant was detected in places like India first, but quickly, even though countries are trying to protect themselves like the UK--I remember being there about a few weeks ago where they were getting close to opening up society again, and they weren't too--they were very concerned about this, but they didn't expect that the variant, the Delta variant would take over. But today that's sweeping through the UK, and now, of course, it's thought that it will become the dominant variant here in the U.S. as well. The sooner we're vaccinated, all of us, the greater protection we'll have against the Delta variant, but the Epsilon variant, the future variants that could be more difficult to beat down than even COVID-19 has been so far.
MS. STEAD SELLERS: Secretary Becerra, we are having trouble, continued trouble with the sound. We're going to try and drop the signal and reconnect very, very briefly, so stay with us. It will just take a second.
SEC. BECERRA: Okay.
MS. STEAD SELLERS: Welcome back to Washington Post, and welcome back to Secretary Becerra, and I think we can hear each other loud and clear now.
SEC. BECERRA: Excellent, Frances. Good.
MS. STEAD SELLERS: I wanted to talk about the new bills in the House and Senate with telehealth expansions. Are you in favor of making these expansions permanent?
SEC. BECERRA: We are absolutely supportive of efforts to give us the authority to be able to utilize telehealth in greater ways. We want to make sure that we don't leave anyone behind, as I said before, so that telehealth should be available to all Americans universally, and we want to make sure that that includes, of course, making sure broadband and quality broadband is out there for all communities, whether it's a rural part of the country or an inner-city poor area of the country, and we want to make sure that there is accountability.
When the services are used, we want to make sure that Americans are getting a valuable service. We want to make sure that these providers are providing a service that might not have been available had we not had telehealth but that it also results in better quality services and treatment, because we don't want to be billed for things that don't result in better health for Americans.
MS. STEAD SELLERS: Just to follow up on that issue of equity, you mentioned broadband. For all the advantages of telehealth, it does require the ability to have a smartphone and coverage. Do you see it could actually exacerbate inequity going ahead, or do you see it as curing those problems?
SEC. BECERRA: Well, not under my watch. We're not going to do things that increase disparities. We're going to do everything we can to include everyone. It should make no difference what Zip code you live in, in America. You should have access to whatever technologies we as a government through our taxpayer dollars make available, and so that's why we want to make sure we do this the right way and that there's accountability on both ends of the system.
And by the way, when we talk about this new type of health care, it could be visual or could be audio. There are circumstances under which you don't need to have a smartphone. A phone, any kind of phone, might be enough. We just want to make sure that we're taking advantage of all the technology that lets us communicate with each other to make sure that we're also providing health care where possible.
MS. STEAD SELLERS: I wanted to raise an issue that we walked with Dr. Resneck about earlier on, and that's licensure across states for telehealth. During the pandemic, there was some relaxation. There's a compact that allow some--there's some state agreements. What's your position on this? Do you believe that we should have the ability for doctors to work outside their states?
SEC. BECERRA: That's again the accountability issue. The farther away you go from the direct connection between patient and provider, the more difficult it will be to try to provide for the accountability, quickly and fairly, for the patient, and so if your doctor is 30 miles away and you live in rural America, we can track down that doctor 30 miles away from you. But if your doctor was 3,000 miles away from you, that's a tougher sell for a consumer who is now trying to get accountability for a service that wasn't properly provided.
MS. STEAD SELLERS: We've been talking a lot today about telehealth with individual health. You're obviously involved in rebuilding the U.S. public health infrastructure. What role will digital technologies play in that?
SEC. BECERRA: Frances, probably a great deal. COVID-19 showed us where the holes are in our public health system. That's what happens when you have the most technologically advanced health care in the world, but it's not evenly distributed, and as a result, we had pockets in America where COVID was devastating. And technology helps us close those gaps faster, but once again, we want to make sure that technology is our friend and technology is being used properly, so accountability will be so important.
It helps that as a former attorney general, a state attorney general in California, to me, accountability is very important, and so we're going to do a lot of bird-dogging, a lot of oversight.
MS. STEAD SELLERS: And talk to me about the role of smart hospitals, which our previous guests referred to a great deal. In the future, what is the role of smart hospitals?
SEC. BECERRA: Well, the role of smart technology, period, whether it's in hospitals or whether it's at the mechanics shop, it's going to be critical because, again, it should give us faster service, better quality service, and more reliable results and the ability, we hope, to trace, do a quick chain of events, find that chain of custody to what happened, so that in the event that there is something that didn't go right, you can quickly go back and follow that chain of custody to figure out where things went wrong and exact accountability. So, hopefully, technology will be our friend and let us do everything better and faster and cheaper.
MS. STEAD SELLERS: Secretary Becerra, you took a trip to Texas last week, to the border. Could you tell us what HHS is doing to alleviate the situation of unaccompanied children coming across the border?
SEC. BECERRA: Frances, an important question. Thank you for asking.
Here in this country under our laws, the Border Patrol Services, Customs and Border Patrol Protection Services, they have the responsibility of protecting the border and dealing with those at the border, but when it comes to children, especially if they're unaccompanied by any adult, they must quickly, within a matter of three days or so, relinquish control or custody of those children and place them in the hands of the Department of Health and Human Services as the now custodian of those children temporarily. Since they don't have an adult custodian, we become their guardians for that temporary period of time. We must then, by law, provide them with the protection and safety that you would expect a child to have, and so that's what we've been doing.
The challenge has been that there have been a large number of these children who have crossed the border unaccompanied by an adult, and so we have had to move as quickly as we can to find a safe, proper place for these children to be cared for temporarily while they go through the immigration process. Usually, that means finding a licensed care facility that can provide that service.
Because of the large number of children and also because of COVID, COVID reducing the number of beds that these licensed care facilities have, we've had to turn to other means of providing safety and the type of basic services that these children by law are entitled to receive, and so we've stood up these emergency centers where we house the children. We provide them--we feed them, and we provide them with the basic care, medical care, behavioral health care, and the services that they would need in the process of being transferred over to a custodian in the U.S. who could care for them while they go through the process.
It's been a tough challenge, but we've done it protecting these kids, and having been the attorney general of California and actually taking on the previous administration for not doing it right, as I said from the very beginning, we're going to do this right.
MS. STEAD SELLERS: Secretary Becerra, I think I have time for one last question. You attended the G7 health ministers conference. What was your biggest takeaway from that?
SEC. BECERRA: Frances, I'd say probably the big smiles from my colleagues in the G7 that America is back, and that we want to engage as a global partner, and the amount of importance that people place in America being part of the world stage and being a fair and critical partner. It is nice to be wanted. It is nice to be liked, and it is nice when you can help deliver results, and so it's great when President Biden gets out there and says that we're going to be providing more than half a billion vaccines for the world. It's a sign: America is back.
MS. STEAD SELLERS: Secretary Becerra, thank you so very much for joining us today.
SEC. BECERRA: Thank you, Frances.
MS. STEAD SELLERS: And apologies to you and to our audience for those technological difficulties.
We will be back later on today. Please stay with us. My colleague, Jonathan Capehart, will be here at 12:30 with CNN Chief Media Correspondent Brian Stelter.
I'm Frances Stead Sellers. Thanks so much for joining us. This is Washington Post Live.
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