Peter Giammalvo:  Better than we know, maybe a mistake we have to be cogniscent of putting too much information out that maybe make some bad decisions.

Tom Lloyd: Right. When we say, when we put up a website, 1-800 called in—

[Laughter]

Tom Lloyd: Let’s get the whole phone number.

Female Audience 1: Yeah, people do, from all over the country. 

Female Audience 2: I guess I have two thoughts. One would have been, you are talking about the five-year old being an extremely complex example and perhaps you can address that need. I guess, I feel like if we’re really truly looking to the future what we can do to help as soon as it's in Florida, I think there’s an opportunity to address that very complex five-year-old’s needs because we have children’s medical services, I mean, there should be an opportunity.

Again, to me a common theme that I hadn’t really heard of was this patient profile. I don’t know what else to call it, but if you had that patient’s demographics out there, there's an opportunity to go in an gather information from my child, the doctor got clinical information.

Perhaps CMS' website link there somehow, too. And there’s an availability or there’s a CMS clinic in your community here. Because they take care of chronically ill children, complex cases. They’re going to know what’s out there to help you.

There should be some ability to integrate those agencies or mechanisms out there because that’s what’s needed.

Audience: If your talking about CMS children’s medical service who pledge to CMS, there’s several like these.

[Inaudible]

Female Audience 2: So, for that, it might be complex too. I think there’s opportunities to bring, as well as AHCA has all this information about the children’s hospitals when we start to look in pediatrics standards. So, I don’t think it’s—I think it’s something we’re very much should look at and there is opportunity.

Mark Frisse: Well, to borrow from another industry, we looked at airlines this morning. But look at the world of marketing and imagine a marketer saying, "Well, that person’s too complex to actually marketing towards." That’s the opposite of where it’s going to be. The tools are so sophisticated now that so many parameters and characteristics can be attached to each individual user.

So that that notion of— Well, there are only 10,000 of those kinds of kids in the state. I mean, to me that’s like, OK that’s a huge market. And it was presented as well, that's not enough that you care about to address in a website. I mean Amazon has had at this technology for over 10 years where you start buying folks, asking questions, and it knows exactly what you refer to, without you going in and checking off any boxes or any of that stuff. Yes?

Male Audience 1: I've had the opportunity to sit back and watch what’s going on through all of that. There seems to be a piece missing. If you’re a healthcare professional, your patient is sitting in front of you and you just told him, “You have brain cancer.” I would assume the next questions would be, “What do I do?” How many of you will send them to a web page?

Peter Giammalvo: No, yeah. I won't need to answer that. When you’re ready.

Male Audience 1: I’m ready.

Peter Giammalvo: Yeah. I think what’s missing or the mix up there is that what is the decision that we’re trying to get the information for? I mean, it’s not the--this website, in my opinion, is not to answer. Think of it as perhaps before the physician and for information that the physician has not communicated or hadn't communicated, because I agree with it. 

I mean, there’s certain information that it’s the physician who’s supposed to make what decisions with the patient. And the patient, if he’d go there for that.

So, I didn’t want to segue for a question, a comment I wanted to make about the information kind of the same line. Partly, I think it’s about scope versus depth. We want to make sure that this is the kind of site where people will want to go to, to be able to get all of the information to make healthcare decisions.

But it's a certain type of decision. So the depth, it’s not the what particular drug should I choose as a chemotherapeutic agent for my particular type of brain cancer. That’s a physician’s, that's for your primary care physician.

It might be, what does this type of brain cancer mean? What are the different modalities of care so that an uneducated consumer when I go to my physician? But that’s the kind of thing I think that we need to think about as one point. Because I agree, I'm not disagreeing, I agree that certain things are not our scope. 

The other point I wanted to make is that I believe that one of the things I took for granted was the different kinds of information that have to come together to make a healthcare decision. So financial information, facility locator, is that person near my house? Do they have an open panel to see those types of things? So, integrating the right information to make those decisions, information that I don’t know that your physician would have or would be able to give.

And in the last comment I wanted to make was, one is that we don’t have to necessarily build it all ourselves. I mean, for example, there are sites, and I think we'll see some things tomorrow, there are sites that have all the information on diseases.

They are there, that you either contract with if you have a trusted site. If you want to contract with where you click on that link, when you’re in our website, or you can click on that disease, but it’s not us that built it. That’s one thing I want to make sure everyone is clear on.

And the second thing is that I like to think of this as... when I say take politics out of it, also I would take the state hat off this. It’s not so much in my mind, it’s not so much what should the state do. It is more about you'd stripped AHCA off that website. It’s not an AHCA website. It’s a Florida healthy person website.

What would you want to have there as opposed to, politically, what should the state do versus what should other people do? So, I think that would help expand the horizons of what we might be able to accomplish.

Male Audience 2: I think the point to me was very good.  When you’re having something like that, there are really two types of patient. The first type of patient will say, “I don’t know anymore than you do. Tell me what the--"

But you have another type of patient that questions. And I think the purpose of maybe what we’re trying to do here is that they have a place to go to where they get information. They would come back and say, “I have some additional questions based on the information.” We can give people they wish to know.

And as a doc, I wouldn't want to be a patient.  I think they lied to me if he doesn't any information. So to give them information so that they’d be better informed. I think we’re really doing them a service.. the performance, you inform them like costs. I think there’s going to be better patients if they go online, maybe you have to repeat that. So, I would definitely--I have to see this one.

Peter Giammalvo: So, the topic that we’re going to aspire towards is that we don’t have to build it ourselves. This is just a part of the people pursuing their own healthcare. And that whatever we produce needs to fit in to technology that exists, that’s about to exist and the way people live their lives.

I’m showing you my personal iGoogle homepage, OK? So, this is free, cheap, easy. All these tabs I just created by adding 'Add tab' and a tab just gives me a page filled with content. So, I’ve suddenly been diagnosed with diabetes. And I’m going to ask them, I click here, “I’m feeling lucky”, automatically I added stuff based on the tab name.

And automatically, it’s going to give me the diabetes web search, a RSS feed about diabetes, diabetes news from the Medical News Today, diabetes self-management, MedicineNet diabetes journal.

So, right here, in just a second, I have a whole suite of choices. Now, Google did not go out and research all of these and find out the exact information that I needed, it just guessed. And it trusts all these sites here. Now, I can delete them if I want. I can change the type of content that’s there. I can customize for myself.

This is in the field of what we call 'mashups'. It's sites or engines that borrow content and feeds from all sorts of different sources but provide a user experience that is customizable, and useful, flexible, adaptable all these words that we listed down. Tom, do you have some..?

Tom Lloyd: No, go ahead.

Peter Giammalvo: So well, I’m going to show you a couple of other mashups and some of them maybe familiar to you and some of them may not be so familiar.

Female Audience 1: If in your basic Google profile, you were from the state of Florida, what the sites about diabetes come up or would it still be limited to national information?

Peter Giammalvo: We can try, we can try that. So, let’s see. I’m going to delete this and write a new one. Now, Florida diabetes! Because we like it sweet down here.

Male Audience 2: And Google keeps changing things on the accounts, their fighting over time.

Peter Giammalvo: All right, so here it just added in the miamiherald.com. Looks like a lot of other content, breaking news from South Florida.

Tom Lloyd: In case you want to get your news and your diabetes at the same time.

[Laughter]

Tom Lloyd: It doesn’t look like there's anything there.

[Inaudible]

Female Audience 1: And Miami Herald covers diabetes?

Male Audience 2: Yeah. But there's nothing really--

Peter Giammalvo: So, I use guessing this would be something for the site would have a search engine that would create profile for you, or say you—I’m just showing what already exists.

Tom Lloyd: So, there’s two ways you could go about that. One is, you can try and replicate this capability. So creating a—you know maybe talking with them or whomever, Yahoo! I mean. We use Google a lot as an example but any portal provider is moving in this direction.

You could do that or you can figure out what are the AHCA widgets so that somebody who did put in Florida diabetes, it would pull your information to the front. So how would you need to organize and build some capabilities to be able to integrate with this?

Peter Giammalvo: So, Beth?

Beth: Yeah, so if I could just comment here. One of the unique things about what we’ve done in AHCA is actually measure performance. And some way, somehow, I mean, that’s not going to show up on Google but what we’ve done internally is we've collected the data, we've analyzed the data and we provide measurements, set measurements on how to measure quality and outcome within healthcare facilities.

That’s what I see in this scene, on an iGoogle type of website is the analytical function that AHCA can provide in creating standards on measuring outcome, and quality and pricing.

Tom Lloyd: So, there you go, a very unique capability that AHCA has.

Beth: Right.

Tom Lloyd: That if you could figure out how to create a, wrap it up in a way that you could send Yahoo!, “Hey, we want you to plug in our stuff using this API, that they could pull in that information and that’s—

Peter Giammalvo: Yup. And that’s what these other groups have done. So, this is all content or services produced other organizations, like yours, that sink in with iGoogle. So--

Tom Lloyd: And if I don't need either two. I don’t want you to get the wrong idea. I’m not saying you do want one or the other. I mean CNN has a widget here that you can plug in but I bet a lot of the links, once you plug that widget in, take you back to their homesite where they are then... So this is a way linking out into other networks, other communities, if you will, and bringing direct links back to your capability in the state.

Male Audience 2: I have a question. How does this relate to the previous assignment, what we are being shown now?

Tom Lloyd: So mashups is the direction that... technology and information systems are moving in this direction. So, we have heard a lot of conversations about the ' website' and all we’re trying to introduce to the conversation is that that’s not probably going to be sufficient in the future.

I mean, how is AHCA going to—right, I’m on my way to the emergency room, how do I get on to my PDA, phone with a browser and say, “OK, where are they taking me and is that a good place?”

Male Audience 2: I think I heard, if I may just follow up my question of it. I heard from several other groups and several in our group, Diane's idea. The idea of a profile and the iGoogle would go down to the demographic and diagnostic information to then pull up the information, specific reforms, specific to providers, specific to performance, that an individual might be interested in. And this really puts the focus on the individual to go down to go to those sites, to interact with them as well.

Beth: I think we’re just saying the iGoogle refers to persona, it would be a Florida person with all of that information with R&D there. So that iGoogler is somebody who is, they are at the machine, already knows he has these issues.

Male Audience 2: There’s two things. We’re going to be talking a lot more about the website and where you want to go with that as a means to an end. One thing that these technologies are showing is that - and we’re seeing that in the health information exchange .

You could become a publisher so that your stuff is automatically somebody who subscribes in doing that. There’s no reason why an AHCA site opinion quality given to other people can start publishing in a common means and then if you have the right access to that and publish that information, besides your people didn’t want financial and pension plan.

The second thing that we talked about, I share the optimism that we ought to be able to do something for five-year old Josh. Well, it maybe that the answer there is to create a functionality in AHCA or somewhere else where you pull the right state and get the resources based on the search to pull those things together.

Because the point is, I don’t think you want to be in the place where you are now where everything's being sent in hand or electronically is sent over to wall and typing the meeting. The more you can get direct publishing data and you oversee the quality of that information and the timeliness of that rather than just retyping it in, the better off you’re going to be.

Male Audience 3: I think what am I just following-up here at some of these questions, and I was scratching my head too. I mean, let's just simplify this. I mean, a lot of this is out there right now. And we all know that if you go on the Internet, you look for information. And especially if you're not an expert, we customize tabs or whatever, you end up going to as you said, many different sites that you’re not sure that the validity of various information, OK?

So, my question is, given the scenario - let’s take Lupita for example. Show me how Lupita with her concerns about pain management, being in Mexico, trying to find out what financial assistance and all the rest of it, show me how using this mashing that you talked about, how she can get to that information. Let’s do that now and see how she can do it. This is a potential solution, correct?

Tom Lloyd: No, we’re trying to expand the thinking around what---

Male Audience 3: I understand. But I take that as an example. Take hers as an example. How would she, so your Lupita, how would she get the information that she needs to get into your web, your AHCA?

Male Audience 4: When you say expand, are you in essence saying a couple of things: one, that we still have a website but maybe large pieces of that are virtual because we’re pulling them out of somebody else’s database, and vice-versa, right?

Male Audience 3: And I understand that. I just want to see how that would work right now because the technology is available right now, correct? We're showing this.

Peter Giammalvo: The over-55 demographic, is the demographic that is the fastest growing population on the web. So, Lupita is connecting with other people who share her interests not because they’re over 55, because she’s finding that this is a great tool, great way to get connected. So let’s pretend, let's say, her husband wasn’t very nice to her and they filed for divorce and she’s decided to start dating again.

Male Audience 4: She can’t possibly.

Peter Giammalvo: No!

[Laughter]

Peter Giammalvo:  She’s created her own Yahoo! personal page to begin dating. But through that, she started to find other friends who also have her care, may or may not be in the same geographic location. And through that, they’ve started to share stories about managing their healthcare. And so, that’s a peer-to-peer, a person-to-person connection.

The widget in the iGoogle - and I’m not an expert. That’s iGoogle, it’s free, you just start it, it takes no education, there are no instructions. You just kind of start figuring things out.

That is a technology that brings us together. But there are ways to do social networking and that is the other huge trend that this tends toward, which is linking up people with the same cares and concerns in the social web, I mean, that’s hugely important. I think that came through as well that social—

Male Audience 2: If you look, I mean, we think of the web as a static site with link rights now, most of us do.   We asked our kids, they think that when I say ' social networking', my kids live on them. And so, instead of doing a search and getting a link and say that's the answer to my question, you say, "That is a source of information that AHCA can't [inaudible] it’s important to you right now." You subscribe to it.

So the point is,just to help you understand, it’s going to be easier and easier to move from this is an answer right now and I got to keep current, to say, "This is a point to people who are already experts who I could subscribe to—" And so I can create that network—

Tom Lloyd: Because the example on the back, it was done earlier, you know, that you just told someone that got brain cancer and there's a, "Now, what do I do?" I got to tell you, if you told me I would have brain cancer and then you tell me what I’m going to do. I don’t know, maybe everybody else in the world isn't like this but I’m going home and I’m going to prove to myself because I’m in denial that I got brain cancer, that I don’t have brain cancer.

So, I would be up all night, searching the web, I’ll go to every website. And we can talk about this as if we’re putting a burden on the consumer. I mean, if you spend more time on the web trying to buy a car than you do managing your health, that’s a problem that I think we’re trying to address through some of these strategies. So—

Male Audience 4: Statistics prove.. I mean, statistics prove that of all the places, love it or not, they don’t come to my websites, they don’t come to doctor’s website, company websites, they’re going to general internet and surf for their needs.

Female Audience 3: Hi! I can’t get what you’re saying in terms of diversifying the different avenues to get the same information. I’m just curious. I don’t know if you worked with anyone and seems to me like an AHCA Myspace account or an AHCA Facebook account and see how people utilize that information and see that brought people back and if you got or—

I don’t know if we can do cellphone updates or something that. Where I get the news, they create a 90% of the information, and how do I get lots of different pockets in the Internet. I don’t know if the state would authorize making a Myspace page but see if you can utilize it, see if it brings other people to our website.

[Inaudible]

Male Audience 4: I was brought into that earlier. The Department of Health hired my kid to do a portal. He has his own website, he has his own Myspace. Department of Health has a website to him. You can watch TV commercials, you can see billboards on any one of those, you can also connect to YouTube and vote on it and it’s all paid for by the State Department of Health and it’s all out there.

Female Audience 2: And the CDC had blogs on their section---

Male Audience 4: The neat thing about it is all of a sudden in YouTube, you can get to all of the Department of Health state. Look at the bottom of it, there’s a connect back in. You go to his website, you go to "See you on TV" same thing, you can pop back in. So there’s a lot of ways to cross-generate communication.

Peter Giammalvo: And what’s amazing and very powerful and if you miss this, you’re going to miss the biggest wave and that is user-generated content, OK? This is not about the state creating and then the citizens receiving.

OK, so on Myspace, this is the diabetes chapter. Here’s the group leader, Matt. He’s got a picture of him picking his own nose, OK? So, this is the diabetes page. So, this is where everybody goes. They tell each other where they are in the United States. I can add myself. This is a scroll of people - they're at the bottom - who are associated here, OK? And it’s about life, I mean you can—

Tom Lloyd: So this is an example. When we say a mashup, somebody has taken the Google Earth application API and they’ve combined that API with a text-shadowing API and they layered those things together and said, “I’m going to throw this out there.”

So, if you want to show somebody’s face and contact information on a map, use this tool and it’s out there on the web. I bet you can find a hundred free locations you could go get that.

Peter Giammalvo: And this is beautiful because if I am a young person or another person who’s suffering from diabetes just diagnosed, I see right here that there’s a whole network. Look at everybody pop up. Type 1 since May ’07. And so, right there you are linked in with the community that has a face, has names—

Male Audience 3: That takes a lot of these ideas that kind of pulls them together because you got the community piece of it. I’m sure each of them has information they can share about ratings of doctors, or rankings of hospitals—

Tom Lloyd: I mean, this is maybe another example, but the reason people stay at church - and I just use that broadly to any kind of religion - is based on the relationships they build with people, not necessarily the person who is leading the service, so to speak, or who’s running the college, right?

It’s about the fact you’re doing life with people and so that is an aspect, I mean has come up but that the technical implication to that as you start to think about five years in the future. So, we’re not really tring to--the Vanderbilt Center for Health is not about giving answers, we’re just trying to let you know this is stuff that’s out there and you should be thinking about it.

Peter Giammalvo: So, here is some Daniel, who’s got Type 2 diabetes and this is his news program on it. This is on YouTube. They spotted 12, 13, and 14.

“Hey Matt, which shed of blood goes in?”

[Laughter]

[Video Playing]

Go ahead with your reporting on screen.
Today, I got to give that beep.
Weights, weights, weights, weights.

[Music Playing]

Peter Giammalvo: That’s his big brother, Toby. 

[Video Playing]

Daniel: You got too much sugar and low in insulin, you now have diabetes. All right now, we need to help this guy out. The treatment for the diabetes and therapies out there, for those of you who are here and think you have diabetes, don't work unless you have symptom like very hungry and very thirsty.

[Music Playing]

Peter Giammalvo: The three brothers are eating and drinking Coca-cola and Rice Krispies.

Daniel: They have diabetes... There are two types of diabetes, very simple two types.

Tom Lloyd: So, this is an example of—a lot of people would listen to this before they’d ever listen to a doctor. And the fact that this is just as a—I mean, in some ways, these kinds of things are what support confidence in us. I’ve got, “My friends said this, and the doctor said it too.” Right? And as we grow up and live in a more transactional society, I mean, with the whole concept of medical home is a---

Peter Giammalvo: Now, let’s compare that to the Joslin webpage. Now, Joslin - millions of Dollars, Harvard-based, oops--

Female Audience 3: Not there.

Peter Giammalvo: Not there?

Tom Lloyd: joslin.org

Peter Giammalvo: .org, sorry.

Male Audience 3: And the other thing is when you say you are empowering consumers, you’re letting the genial of the bottle with this kind of technologies, the good and bad news is you are really empowering consumers. There is no authoritative, there is nobody in charge, there is no doctor saying, “This is what’s or not.” This is the course that our kids are paying attention to, the public’s paying attention to.

And this is where the consumers--there's no. Again, as Peter is trying to emphasize here, you don’t need a top-down McKinsey strategy to do this. You don’t need corporate sponsorship, you don’t need the data form. This is the kind of stuff that people just going out there and doing.

Peter Giammalvo: Now, if you were that kid, you had diabetes, would you connect to this? I mean, it covers the same content. But you know, the media has the message, and you have to be aware of the media that’s out there, that’s connecting people to managet of their health.

Tom Lloyd: All right, so, what’s next?

[Inaudible]

Male Audience 4: Could you just have a state website that’s quitely place? Or would you need to do the links?

Peter Giammalvo: You’d have this content.

[Laughter]

[Inaudible]

Peter Giammalvo: We’re still trying—we’re trying to show you all the different types of ways that people have tried to address this problem and the new tools that are out there that are free or almost free.

Tom Lloyd: And again, I can only stress - we’re really talking... I mean, AHCA is a very—Florida is very unique in how far you’ve gotten, right? And some of the capabilities you brought to bear already on some of these things. All right?

So you in some ways, ahead in capabilities of other states. So, you have now unique challenges, unique tool sets that you need to figure out, “How do I leverage those into a world that’s headed in this direction?”

And that’s the real work of your strategy, I think, is to try to understand. I bet this people would like to be able to click and find—maybe it’s not a picture of a person but it’s maybe it’s the picture of the doctor that’s going to help them, or maybe it’s the pictures of the top ten doctors who have the best scores in supporting kids with diabetes.

Female Audience 4: And Tom, couple that with our capability as the regulator of healthcare providers to assimilate certain information that you can’t get right now in any shape or form to measure the quality outcomes by providers.

And I think that our group will agree that we need to, first of all, agree to the measurement of quality as it relates to, we’ve done that very well in a hospital environment. We need to move on and measure quality in the physician arena and once we get beyond that, this is what it seems like to be the next step in incorporating these different types of data.

Male Audience 3: I think what I’m hearing though from all of these today is that the measurement of the comparison of outcomes qualities done by physician and in the hospital is only a piece of a much bigger amount of information that has to come together, at the same time, probably and to be in different stages of development for it to have value to the consumers.

I will thank you by the way because I’m very—I’m much clearer now on this and I think you were saying it doesn’t have to be either/or, it can be both.

Tom Lloyd: Absolutely.

Male Audience 3: But it is intriguing, how giving the consumers a voice and helping them to help us to both create value, where people will actually click on something to go and watch it and learn about it,but also to put even content, and to get the whole thing about community. And if I had brain cancer, I think I would want to talk to other people that have the same diagnosis in the same state, especially in my same area. It'll say , which doctor to Google to.

Female Audience 4: Exactly, and I think for me that when I said earlier, I said that age, customizing information. I can see where for a 16 or 18 year old, you might want a link to this guy’s website. For me, on my age, the Joslin thing was just fine. I could read it at my own leisure.

[Laughter]

Male Audience 5: I might want to have a link to you on that website. You might add the person.

Female Audience 4: I did have an experience that is somewhat related. I was given an inaccurate diagnosis and I spent an inordinate amount of time learning about a disease that it turns out I don’t have.

But one of the things that was useful was finding out who were the experts on that, where do they reside, what kinds of efforts you have made to go. Lisa talks about having to leave town. We all have the need to know and we learn in different ways, and generationally we learn in different ways, ethnically we learn in different ways—

Tom Lloyd: Another comment. There’s been a bunch of conversations about the word 'quality'. And so there are some resources if you go back, being an engineer and there’s this whole thing... I mean how many people live for TQM, all of the men, right? The Japanese actually live by that so they talk about totally, total which means everything.

Quality and they break quality, the word quality and I have some Japanese word which I won't even tried and say, but roughly translated it means quality has three components. There’s the processes are visible, repeatable, and measurable. So, that’s one, it’s how we do it. Think about quality and how we do it. Because if you don’t understand that, then you’re not going to ever—I mean if you don’t have a repeatable system, you don’t have a quality system, it’s basically that point.

The second thing is that quality is a functional outcome, right? You buy an eggbeater and it actually beats eggs. And that’s a--a lot of things that I hear people talking about is that functional part of quality. And then there’s the, what they call the experience of quality, which is, “You want to use my eggbeater.” Right? You get into my car and you’re willing to pay more because of the experience of using my car.

And so, that’s probably a part that we’re really not talking about because that is going to be how organizations instantiate the evidence, if you would. It’s how take evidence and turn it into practice that creates an experience for your patients. And thatis what’s still way out there for organizations to control.

The three perspectives that they have on quality is there’s quality in the return on investment for the shareholders. There’s a quality of the product or service for the customer. And then there’s a quality of life for the people who actually create the product or service.

So, I’m happy to show that to anybody but just as you think about it, don’t think of it, the word quality as this one big word that means everything. Start to break it down and tear it apart and figure out what are we talking—are we talking about process quality now, because if we are, that’s this. Are we talking about functional quality then that’s this.

Female Audience 4: And we have to translate that into quality measures that exist today in global reporting on our website. We’re reporting quality process measures, the SIT measures. We’re reporting how prophylactic antibiotics are delivered prior to surgery and after surgery for every hospital in Florida. That’s a process quality measurement.

Then the outcome measurement that we’re reporting on, or how many of those surgical patients actually ended up with that type of infection, even though we have this process measure in place, what is the outcome?

Tom Lloyd: Right, which is probably something in the organization are measuring now, which is their customer satisfaction, their patient satisfaction, if you will.

Peter Giammalvo: I’m sorry. I don't know how but I just wanted to echo, add to that. I think that’s partly why we sometimes have the questions about fairness of these quality measures. Because I think a lot of the providers appropriately know that it doesn’t capture the whole picture when it’s just the outcome that is important. But there’s other aspects to quality as well, and I think we have to strive in terms of fairness to be—and also the experience of the patient to be able to capture all of that.

Tom Lloyd: Right.

Female Audience 3: I think there’s also in the outcome measure a lot of data that’s out there that maybe we’re only not always the most appropriate outcome measure, for what we’re saying is the outcome measure that we have but that data is not as accurate as it should be.

And I think we can’t lose sight of that when we’re trying to provide information to the consumer, that we have to look at what’s being done nationally, what's being done in evidence-based medicine so that when we started some of it, we took it because it was quick and easy.

But we wanted to- 20-80 or whatever - we wanted to get something done but I think we have to keep looking for new things, defined as new things are available, new information. Because if the data’s not really as reliable as it should be, we have that risk of unintended consequences, we don’t have the whole picture and we're misleading.

Tom Lloyd: There’s a lot of work. I mean a lot of people are still coalescing around that--

Female Audience 3: Right.

Tom Lloyd: Have the leading organizations, I think, I don’t mean leading necessarily in the quality measure but in their ability to capture things efficiently and report that efficiently. I think there are—I mean, people are learning how to do this. The whole industry is learning how to do this. If I remember correctly, GM is still having issues around quality. Could be wrong, I don’t know.

[Laughter]

Tom Lloyd:  Or maybe what you said, you said we built the really big ones and I feel the smallest. So, as we talk about, the Center for Better Health, we do and trust it. We guys are talking about trust, well, Lisa and the team has been designing this.