Digital Health Tools: Empowering PAs for Better Patient Outcomes

hello everyone welcome to digital Health tools empowering Pas for better patient outcomes my name is Dipu Patel I'm a physician assistant and I've have been a practicing PA for over 20 years my clinical background is an emergency medicine urgent care and Hematology Oncology I'm also an educator and currently hold a role at the University of Pittsburgh's PA program as Vice chair of innovation and Professor I want to thank you for taking time out of your busy schedules to join me in what I hope to be an inspiring and educational lecture today and I hope all of you the audience will engage with us and add questions can to be popped into the chat and we'll take them towards the end so without further Ado let's get started I have no disclosures to provide at this point all of the opinions that I'm giving are those of my own and do not represent any of the associations or organizations that I work with and our objectives here are pretty simple we're going to get a lay of the land of digital Health tools I do want to put a ?sic? on these I'm going to be talking about a lot of tools today a lot of them are in research form some of them are in Pilot form some have been implemented but not to the full scale so you may be familiar with some of them because they're available on the market but you may not be able to use them at your place of practice so let's get started we're going to talk about what is digital Health I'll give you a brief overview of what the history of digital health is and then we'll dive into the some of the specifics of it I want to know I want you to know that the overview aspect of this the wearables and the apps and the smart home are just one aspect of this digital Health ecosystem that continues to grow every single day and then we'll close with what the future of digital Health looks like it seems like this term digital Health has become some somewhat of a lay term these days before we were able to apply a lot of these things all in reality digital health and the tools that fall under digital Health have been used for many years so things like M Health electronic health records wearables apps tele health it and personalized medicine and then more recently AI all of these terms and aspects of care delivery and tools that we use fall under the larger umbrella of digital Health you will find various definitions of digital Health this is how I choose to Define it these are not the only areas that digital Health encompasses as I said there's areas and sub areas and you'll see remote patient monitoring all of those things kind of fall under this larger umbrella but simply put when we look at digital Health it is the intersection of health care and technology so whatever term you want to use at the end of the day digital Health kind of encompasses this umbrella term of everything we do to provide quality care for our patients so a little bit of a history here I'm not going to go through every single one of these but I have to say that we've had a pretty expedited time frame in terms of digital health and Technology kind of being immersed and Infused into the work we do a couple of milestones at an industry level the Swiss set up the international medical informatics Association in 1989 the American tele Medics Association was set up in 1993 and then Fitbit came to the market in 2007 which really changed the game in terms of Mo not monitoring but there was more of a lifestyle and wellness Gadget which has now moved into chronic disease management and we'll talk about that a little bit later but a couple of the bottom part of this timeline which is in 2017 FDA launched its digital health unit so it started focusing on the regulation and the application of all these technologies that we were seeing in 2018 the AMA published its policy on AI and in 2020 the FDA approved its very first AI guided ultrasound device and I put covid there because that's kind of I feel like has been the inflection point for the adoption and the expansion of all these technologies that were simmering in the background for a number of decades and have now kind of come to the Forefront and so we're talking about them not fully implementing them we're still talking about them and researching them and validating them so a lot of these tools will take time to come to fruition because we obviously have to validate them before we apply them to our patients but it's a very exciting time to be in healthcare because of all these Technologies so I just this morning looked up in 2020 I just mentioned here the FD approved its very first AI ultrasound guided device as of August 2024 so just last month the FDA has about 950 AI devices on the market that are FDA approved so that's four years and you somebody can do the math on it but needless to say it shows the interest and the expansion that we are seeing in in this in this world so couple of Statistics to kind of draw your attention into this was a study done by the AMA and it was I believe it was done in 2021 or 2022 and they asked several questions one was How likely a provider is to choose a provider How likely is a patient to choose a provider with online booking appointments that was 68% two was plan to adopt augmented intelligence that was to the providers 40% which my guess would be even higher nowadays acquire health information using chat Bots 52% that's a little scary to me but not surprising right so that's patients were using chatbots to provide to acquire Healthcare information and then the use of virtual visits 80% we were in the throes of the pandemic so this is not a surprising statistic and then the use of remote monitoring devices 30% this is used by clinicians so you can see that both the patients and the clinicians are interested in the use of digital Health in terms of engaging this with this technology to provide high-quality care I think if they did this study again this year or next year I would see a probably an increase across the board but the level of increase will probably be not as significant when it comes to things like number three which is acquiring health information using chat Bots there is I will caution everyone here who has used chatbot and we'll touch upon generative AI a little bit later on you know it's not perfect it's definitely not Google it's very different than Google in the sense that it has the ability to hallucinate and so really being cautionary with the use of these generative AI large language models that's a whole other lecture but I wanted to kind of point that out here I begin with this slide to kind of give you a sense of where we are in this ecosystem and so if you look at products one through five which are at the top here are products and tools six and eight are data driven data driven businesses and services and nine and 10 are services that are for public health public health and population Health prevention strategies and then the boxes are everything from primary prevention to surveillance and self-management you can see that digital health is really immersed and touches every aspect of patient care so the touch points at each po at each level impact patient care so we can use digital Health tools to support diagnosis which we actually currently do which is part of the primary prevention part of things all the way through advanced analytic in business which you can see which is number seven just for your reference crosses the entire span of primary prevention all the way to surveillance and self-management this is basically to show you that there's no part of our day-to-day clinical practices and no part of patient care are we not going to be touched by with a digital health tool we use a lot of them right now they're in the background I mean I think we all interact you know with our her ss but how the EHR surface alerts for us or reminders and all of these things that are now epic has I'm sure those of you use epic they have the chat features or the search features all of these things kind of have digital health and some semblance of AI behind them right so we're already interacting with these I think the intentionality with which we interact with each of these tools that we're going to talk about is going to change and it and your practice is going to shift over I would say the next five to 10 years you're going to start seeing more and more of the kinds of technologies that I'm going to touch upon today so I'm going to kind of lay the land with a couple of definitions or six definitions to be to be to be more accurate and these are not terms that some terms you may have heard some you may not have it's important to just kind of get a sense of what you're kind of dealing with so AI I think everyone kind of knows AI artificial intelligence it's the capability of a computer to mimic human thinking or cognitive functions right machine learning so a machine learning is actually a subcategory of AI which is using mathematical models to help a computer learn and there's several areas under machine learning and several branches within machine learning generative AI is like that big in the machine learning ecosystem so that's where generative AI Falls and then remote patient monitoring I think in the world of telehealth we kind of know this term but basically it's using patient driven data that can be sent to the provider for clinical decision- making right so this is the patient that comes to you with their heart rate and their weight and their blood pressure they that's sent to their provider or they bring it with them on a device like a smartwatch or a Fitbit and then you're making clinical decisions based on that or even now datacom the glucometers also do a similar thing and then I have a c two technical terms for you IOT so and then IOT is Internet of Things Network connected devices that facilitate communication it's a general term for everything that's connected basically I kind every time I think of IOT I think of that I don't know if anybody's watched Transformers but if you remember that annoying little robot that was Tiny and it was the mean little robot that would transform itself into everything and using sucking up energy of every tiny thing it was the very first one I'm probably dating myself but anyway that's what I think of iot like everything that is connected that is iot fire is the other technical term which basically stands for fast healthcare interoperability changes and that is where data formats elements exchanging HRS it's a secure way of sharing and storing data in light of HIPPA we want all of our devices on the phone on the apps wherever we are communicating to be fire compliant and you'll often see that term being used in when let's say vendors will come to you and say we want you to use this device and they'll say are you know is it fire compliant and they usually have to be in order for them to be to be on the market and then DSS decision clinical decision support tools so these are just tools that help assist in clinical decision making and so these are just some terms that I want you to be familiar with that I think will help kind of deepen your understanding of what we're going to talk about in terms of the next few slides before that these are some older headlines actually these are at least three years old but I find I kept these because I find them very fascinating in their own realm and area of expertise so decoding thoughts this is from the University of Texas Austin I believe MRIs can now AI has been able to detect your thoughts through the use of AI don't worry it's not coming anywhere to a theater near you but then you have ai speaks clones parents voices to read bedtime stories as a parent who has been previously sleep deprived I would have loved to have this when my kids were born when my kids were little and then 3D printed nose grown on a patient's arm really changes how Plastics will be practiced in the future and then d y blood draws imagine not having to go to a lab to have your blood drawn and then the final one here is about funding digital Health funding and how it's growing in it was 15.3 billion in 2022 across 572 deals this is according to rock Health reports this is dipped slightly but I think it's gaining momentum again and I do in fact think that in 2025 we're going to see a reinvigoration of the investment in a lot of these a lot of these deals and I will say that the funding is what the funding and the research is what drives our ability to do the research and scale these tools so that we can then Implement them in a safe manner for patient care that Gap is still being bridged right like we have not even built the foundation of it yet so but that that build that bridge is going to be built very quickly because healthcare data doubles I'm sorry medical knowledge doubles every 73 days now I remember when I went to PA school I went to PA school where I had a projector and the teacher wrote the professor wrote the wrote on the projector and then you know you copied what they what they wrote there were no PowerPoints when I went to school there are PowerPoints now and you're expected to have them but imagine a world where when you're teaching there will be no PowerPoints that is coming to a program near us it is coming to many areas of clinical practice as well so and that will only happen as we start building the foundation of all of these aspects of clinical practice through the use of Technology leveraging them as tools not as replacements for clinicians so let's dive into a couple of examples here wearables this is probably the one that most people are familiar with right smart watches and rings and glucose monitors as I mentioned the chest traps a lot of athletes wear them nowadays EKG you've seen the ads for cardio mobile where you can you know have an EKG no matter where you are couple ones that you may not have seen digital tattoos so these are inks that are used and infused with various layers of whether El a small circuitry that can actually U mimic our own biorhythms they can also interact with our skin to show various electrolyte levels and I have a link you can certainly watch the digital tattoo which I think is one of the more fascinating aspects of it because I can imagine a time in the future where I had a patient whose electrolytes I wanted to Monitor and all I would have to do is put a tattoo on them and it would it would tell me they it would report out what the electrolytes were over a set period of Time Imagine not ever having to do a blood drop for that another one that I think is worth mentioning here is VR for pain management and surgical training and that one I think is a little bit more used now it's becoming I don't want to say in vogue but it is becoming more and more common in clinical practice because we have seen some trials that VR does help with pain management it helps with various Behavioral Health disorders depression anxiety PTSD and then in surgical training we're also seeing the use and practicing of surgeries before their practicing not practicing before actually operating on a real patient and I do want to give a shout out to all my Gamers out there who have helped this industry really come to life if it wasn't for all the gamers my kids included who remind me very on a regular basis that I'm not just playing a video game I'm training for the next generation of clinicians they're not going to be clinicians but that's what they're saying and say they say you should think us and I and I do I a lot of the AI modeling and a lot of the work that has happened in the digital Health space has come out of the gaming industry okay this is a very busy slide I'm not going to spend a lot of time on it but that triangle in the middle of your slide is a video of a magnetically controlled I'm going to call it a worm Playdoh Worm but basically it is a video of a worm that is controlled with a magnet and can go and grab foreign objects inside your body so imagine a kid has swallowed a battery or something it would the child would swallow this piece of magnetic Play-Doh and then we would be able to manipulate it from the outside and be able to bring it out it's still in research phase but the promise of these kinds of tools and technology is there and then this is a graphic that I really like it and I know it's tiny so you guys can you know zoom in on it at your own at your own pace apps now we all have apps I probably have close to you know 70 apps on my phone currently but you know the app ecosystem has really grown some Studies have said that there are about 350,000 healthcare apps I think that's a too a number too high if I had to kind of make a really educated guess I would say they're in the 100,000 100,000 range is where I would put it which still is a lot of Health Care apps just Healthcare right but what we've seen in terms of the apps app ecosystem is that there's been a splitting off of apps before apps were there for you know games and tracking my steps and tracking my heart rate and that kind of stuff which still exist but that area has become richer and richer as technology has evolved and now we've seen kind of a splitting of apps into Wellness management and then health condition management and so if you go back to think back to that slide that I showed you where all the areas that we can impact care prevention all the way to surveillance and self-management we're running the gamut when it comes to apps on these things so we have apps for fitness and weight loss we have apps for patient monitoring reminders for medications and things like that we have apps for clinicians like us to use with our ehrs think Hau right for those of you who have epic and then we have regulatory apps for medical compliance so that ecosystem is continuing to grow and I would not be surprised if a lot of our future practice as clinicians is going to be first line management is to prescribe an app to a patient right when we say diet and lifestyle modification is the first step to any treatment we're probably going to be prescribing apps in the in the future so just to kind of put a finer point on this this is app growth I believe this was a 2020 oh late 2021 or 2022 report by ?sic? and they've seen a segmentation of wellness and health and health chronic health condition management so you can see like the breakdown and you can see that the number of exercise and fitness apps have gone down from 2015 to 2020 but the disease specific apps have increased from 2015 to 2020 and that's going to continue to grow as we get more and more specific in terms of using these apps for specific disease management and then the pie chart on the right shows you the light blue 22% is mental and Behavioral Health disorders the dark blue is diabetes and the green is heart and C circulatory system and 8% is digestive this is probably changed now because we have a number actually mental health disorders and behavioral dis will always be on the Leading Edge of these of these growths because they seem to have had the most research behind them and have had the most applicability in real life so I would not be surprised to see that mental health and behavioral disorders is still in the lead but I think diabetes health and respiratory are going to kind of you know take kind of fight it out for second third place I also think that things like endocrine disorder metabolic diseases is going to make a play in the next few years and then skin and subcutaneous tissue disorders how to manage a laceration you know skin lesions and is this cancer is it not all of this kind of stuff is going to happen and we'll talk about that in just in just a minute actually we're talk about it right now so Dermatology there are a lot of apps I'm just going to put them all up here for you Dermatology has an app called Skin Vision that that's one of many I've just called out a few here Cardiology has a live core which is the cardio mobile one that you've that you've seen in fact you probably all now know the Zoop patches the Zoop patches are the new Holter monitors right they're so great patients don't complain how annoying it is to carry a pack with them because they just put the patches on their chest and you know there are a number of other ones here I'm not going to call them all out but the one that I do want to call out is the surgical one called gauze pixel there are others but this one was started out of an incubator I early two early 2010s called Gau pixel out of Stanford and they Gau pixel can give you an estimated blood loss in surgery right so right now when we write our notes and we say estimated blood loss we kind of estimate the blood loss and what this app and Tool does is you take a picture with your iPad that is provided in the O of all the gauges and the fluid in the in the various buckets and through machine learning algorithms it will calculate you calculate for you the blood loss and it's fairly accurate based on what they've seen so this is still again in the training phase it's not out for public use but it's been out there since 2012-ish or something they've been experimenting with it so that I thought was pretty cool right like we may at some point in the future not need to estimate blood loss we will know exactly how much blood loss we will have had so shifting gears a little bit or at least you know picking up speed on this digital Therapeutics is another area that is growing very quickly it Cancer Care Behavioral Health Sleep Disorders all of these areas are U being impacted by digital Therapeutics when I said to you earlier that we would be prescribing apps for patients this is kind of part of it right we're going to start seeing areas where we will optimize medications and prevent diseases based on certain digital Therapeutics that we will we will prescribe for patients whether it's saying you need to go home and do VR therapy and today I'm going to prescribe you looking at mountains and rivers or it may be something a little bit more intense so it really just depends on where we're going to be and this area currently is really booming especially in the Pharma space okay we're g to get down to some pretty cool things that will come into a home near you TVs we have Smart TVs now so that's not a big deal like we know that but I think in the future we're going to end up doing telehealth visits on our TVs the apps much like Netflix and Disney plus and all these things show up you're going to have a telehealth app on your on your TV and you're going to be able to see patients through their TV in fact LG has already kind of launched versions of this in various parts of the globe in terms of fashion we're seeing see more experimentation with Fabrics a lot of the designers are experimenting with Google and Amazon and all sorts of other tech companies on how to infuse embed all sorts of devices into clothing so that we're not thinking about wearing a wearable right and then silverware right so Chopsticks and spoons and forks there are electric spoons out there spoon Tech is the one that comes to mind where it has a very mild electrical sensor where it makes Foods taste sweeter than they are so think of a diabetic who's supposed to avoid sugar but really likes yogurt well they can have plain yogurt and it will taste sweeter to them similarly the for similarly Chopsticks also have a thing when the Chopsticks connect and you put them in your mouth they have a small electrical current that interacts with the Sodium channels on your tongue and it makes Foods taste saltier than they are so if someone's on a low salt diet they could potentially still get the sense of eating salt but not have any salt smart Forks similarly are being used for patients with tremors so we're seeing you know adaptations of forks and the fork is able to move with the Tremor to stabilize so that patient can feed themselves yeah and these by the way are available commercially the spoons and the forks are available commercially you can go buy them I think they're like 20 or 30 bucks continuing on to smart home and devices because we're going to see patients in our homes we're going to need devices as clinicians to kind of see the patient so there are things in the work around a virtual stethoscope a virtual otoscope a virtual you know all of these aspects are coming and I'm going to touch on the next slide one of the examples of what we're doing this is voice is biomarkers there are a lot of algorithms and models being trained right now on voice just your daily voice like I'm talking right now or you may be talking and a device may be listening and recording your voices and matching it against a database of number of patients and you they will be able to diagnose you with covid or Parkinson sometimes years weeks days before onset of symptoms this has already been proven in areas like Parkinson's in fact this week alone and depression this week alone I read two studies one in South out of South Korea where the just having conversation on your phone like you normally would an algorithm is able to detect depression weeks before onset months before onset think phq9 on steroids basically so it's a machine learning algorithm can detect depression before onset so the intervention can happen sooner rather than later similarly a second study that came out another study that I read this this week is on hypertension this one is very much being trained on the model right now but so far early training models show that it can Rec you can diagnose hypertension based on a patient's voice so imagine never having to well not never but like imagine having yet another tool in your toolbox to diagnose blood pressure coughing and breathing I'm currently testing out a tool right now on my phone in terms of diagnosing covid and flu where I teach the model what my Baseline cough would be so I cough into my phone and it knows what my Baseline is and knows I don't have any symptoms today it knows what my environmental factors are it knows what the air pollution quality is near where I live and then if I'm feeling under the weather I can cough into it and it runs the algorithm behind that that it's been trained on it'll say do I think I have the flu and it'll diagnose you whether you have and it is able to recognize the cough based on sound discrepancies and sound levels whether it's covid versus flu they are currently training it on more chronic diseases like COPD and asthma and TB so just to kind of give you a flavor for of what's kind of coming for us okay generative AI this has been the game changer this is the thing that we've all been talking about for the last few years we're not going to play a game normally I would but time constraints are a little but you should know that there are several large language models out there Chachi P Gemini CLA all of these are large language models that fall under the general umbrella of artificial int intelligence or generative excuse me artificial intelligence they're there to help certain aspects of the work that we do they're definitely not there to help diagnose a patient although that has been done for rare diseases I certainly would not put any personal or patient or private data into any of these because they learn they learn on the data that you enter into them and so it's just a word of caution I won't dive deep into this this is a whole other lecture in and of itself I've already touched on some health algorithms here I mentioned depression and hypertension there are a whole slew of them that are being that are being investigated and researched currently and I would not be surprised that as I said in the next five to 10 years we start having a shift in our longstanding algorithmic approaches to patient care I wouldn't be surprised if our jnc 8 or jnc 10 whatever it will be back in the in the future would have an app or an algorithm behind it to inform our decision making in the in the future so that brings me to the last few slides I have here before we move on to questions the future of healthcare is beyond the walls of the clinic we have historically thought of care being delivered within the hospital but I think we're kind of coming full circle right we started with the in the really old days where the doctor would come to your house if you were sick I think we're going to return to that era except you won't physically be visiting a patient you'll be zooming in or virtually dropping in on patients for their care so I think there's a we've come full circle with a Twist right with the technology as a tool this means that our training is going to have to shift what we learn how we learn and where we learn to apply it is going to have to shift that also means that the recipients of our care our patients are going to need to be educated on this so there's a digital literacy component of this for both the patient and for us as clinicians and it's important that we start thinking about this now rather than reacting to it when it is already here there are a few challenges obviously to this system the where it's going to take time and I think the biggest barrier is going to be the human beings in all of this which I think is a good thing because we do need to slow down and make sure that all of these tools that we're using are safe and do not compromise the quality of care that we're providing to our patients but when you zoom out from a systems level technology we're not quite there in terms of the interoperability standards you know one system can't talk to another quite yet so we're still working that part out Health Systems there are no National guidelines and standards for Health Systems to kind of share data there's no regulatory standards around that patient literacy I already touched on I would actually also add provider literacy is also poor in this in this regard as well as healthcare Workforce literacy and the perceived Effectiveness so we have lots of work to do and I feel like this slide to me shows that for all the fears we have that AI or all these tools are going to replace us as healthcare providers I think this slide shows me the opposite in fact we're going to need to be there to help patients navigate this and but we do need to learn this tool so that we can be better at delivering the care within the new ecosystem so this is kind of what the world of 2040 will look like in healthcare the consumer as the center the patient right we're they're going to take care of a lot of their needs within their community and will end up kind of having these touch points that are remote for the most part and then they'll only come in when there truly is an emergent need but that requires all of us this requires not an evolution of our current system it requires a revolution of our current Healthcare System and so obviously we have lots of places where all of us as clinicians you know you could take one of these and become the person who's the go-to person at your institution or your organization and be the expert in it because this is not going away we are going to need to step up to the plate and be the clinicians at the table to ask the right questions as this technology evolves I have my last couple slides here is just to kind of show you where we're going in terms of Trends these are the top 100 digital health and AI companies to watch in 2024 from the medical futurist and this shifts every year but you can see every little bubble has multiple little areas that we're going to end up needing Health Care expertise on and so the way we teach how we teach what we teach is going to have to shift from that traditional aspect of sitting for 10 hours in a classroom which I did and I'm still part of we're going to need to shift how we do that so that you our next generation is ready to be asking the questions and perhaps leading all of these areas and then this is an older one this is from 2022 but I just don't have a more recent one the red dots are not much progress expected the yellow dots or orange dots progress moderate progress expected and then the green ones significant progress expected I don't know where these sit now but the ones that I am looking at are the ones on the upswing 3D printing drugs Ai and Diagnostics portable diagnostic devices augmented reality in surgery portable ultrasound devices which already has come to fruition so you can see that we're already seeing this trend of movement of all of these Technologies and we're going to need to be prepared to really understand and grow with these and so in light of PA week I want our prep week I guess I should say I just want to share that Pas and all APS and all clinicians are actually perfectly poised to address all these areas and be able to provide high quality care for the patients that we see and be leaders in our organizations thank you very much this is my contact info this is my book that's coming out in November by Elsevier also the QR code I believe will take you to my LinkedIn page I'd love for you to connect with me and I'd love to hear your thoughts I think we'll move into QA Stephanie I'm going to stop sharing just so I can see everyone excellent we have a few questions queued up in the chat okay great just okay couple of questions all right so we have a question favorite tools to use in your practice so I am a full-time Professor just so just for everyone to know but when if I were in clunker practice I think the tools I would really enjoy using are the telehealth tools and the tools of AI Diagnostics now I say that but there are very few that are out and ready for prime time right but the ones that are out there and the ones that I would encourage everyone to use are the ones that are embedded in your EHR if you have epic there's a lot of AI and algorithmic learning and machine learning going on in the background your fall risk alerts your medication alerts all of those things are driven by a lot of algorithmic Learning and Development so that's where I would start I can't see who asked that question but and then another question is are there any tricky issues or ethical dilemmas that PA should be aware of when it comes to using technology in their day absolutely I would use your organization's guidelines as the metric if they say no it's a no I would definitely just say across the board do not put anything into chat GPT or any of these like Gemini any of these models they are not HIPAA protected so please do not put anything even if you feel like you're de identifying information please do not put anything in in them without you will have legal calling you very quickly how can PA keep up with the latest tech advancements in healthcare and actually use them in their practice the use part I will answer first the use part is really going to be dependent on where you are and where you're practicing if you're practicing at a large organization that is Forward Thinking and investing a lot into these Ai and digital Health tools I would look for opportunities to participate on committees and pilot projects and kind of learn in that in that regard in terms of keeping up you can follow me I post fairly regularly on Healthtech there are several other blogs that are out there and newsletters that are out there that you can certainly use and follow what new Cool Tech Trends do you see that are re revolutionizing how Pas work and interact with patients I think what the I don't know cool but like I think telehealth has really changed how we are interacting with our patients I would not be surprised in the near future where we'll see a lot more of engagement with our patients I would actually I'm going to predict that our patient panels will decrease because we'll have not one-on-one but like a better panel size so that we can provide high quality Care almost Around the Clock if we need it to depending on the Acuity of the panel that we're doing that we're that we have Tech trends that that I'm seeing that's it's harder because I kind of feel like Trends tend not to be the thing that are sexy for practice you know but I think a lot of times to me remote patient monitoring has been the game Cher the fact that I can see the steady state of glucose levels in a patient versus having three readings a day is really a Gamechanger in really fine-tuning patient care and long-term outcomes so that is one that I'm seeing quite that I think that is out there and that we're using other things that I talked about they're in the works and are coming it's just going to take a little time for us to vet them and then scale them it's going to take a little bit of time I think I got them all any other questions okay well I don't see any further questions so thank you for joining thank you for taking the time out of your busy day reach out if you have any questions I can be found on LinkedIn and have a wonderful week helping current and future clinicians Focus learn retain and Thrive learn more ?Music?