In today’s healthcare environment, building trust, ensuring accessibility, and understanding real-world patient behavior are critical to delivering effective care. Human-centered design offers a powerful framework to reimagine health experiences and move beyond surveys to direct observation of how people interact with care in context. This approach uncovers deeper insights that drive more inclusive, practical, and compassionate healthcare solutions.
On today’s episode of In Network's Designing for Health podcast, Nordic Chief Medical Officer Craig Joseph, MD, talks with Brandy Parker, Senior Director at IDEO. We discuss Brandy’s journey from social science to design innovation, and how early-stage, even poor prototypes can drive smarter design and stronger team alignment. Brandy also takes us inside the design of Teal Health, an at-home cervical cancer screening solution aimed at increasing access and comfort for underserved communities. We unpack the importance of unboxing experiences in healthcare, and how design can remove invisible barriers that build trust for patients and providers.
Listen here:
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Want to learn more from Dr. Joseph? Order a copy of his book, Designing for Health.
Show Notes:
[00:00] Intros
[04:15] Teal Health
[09:41] Why unboxing matters in healthcare design
[13:16] Rethinking patient “adherence" through accessibility
[18:07] History and hidden barriers to health research
[20:33] The value of bad prototypes
[25:21] Testing that helps teams learn
[26:30] The power of workarounds
[31:54] Brandy's favorite well-designed thing
[34:03] Outros
Transcript:
Dr. Craig Joseph: Brandy Parker. Welcome to the pod. Where do we find you today?
Brandy Parker: Thanks for having me on. I am in Chicago. I'm in this IDEO office.
Dr. Craig Joseph: Awesome. So, you've given away that you work for a company called IDEO.
Brandy Parker: I do; I do.
Dr. Craig Joseph: So first of all, I'd love to get some background, you know, how did you get to where you are now? And then tell us a little bit about this company that you work for that no one's ever heard of. And by no one, I mean everyone's heard of them.
Brandy Parker: Yeah. So, I work for it. Well, maybe I'll start there. Yeah, I work for IDEO. IDEO is like a global design innovation consultancy. It's been around for about 40 years and it's most famous for having a strong relationship with Apple at the beginning. And so we designed the first mouse for Apple, for example, had a really strong partnership with Apple for a number of years and mainly started with in product design, but we kind of expanded beyond product design. We now do service design, digital design, really any kind of any kind of design. We're there.
Dr. Craig Joseph: Yeah, I was going to say. How does one get a job there?
Brandy Parker: Well, it was a long path. But my whole career really has been in design and innovation and research. I started my background in the social sciences. So, I really come at it from the language of consumer health and really thinking about behaviors. And like the feelings that go into design is really what I focus on.
So really thinking about behavioral design and came at it from that direction, I started my career at a little place called Conifer Research, which is a small design research consultancy. I accidentally found my way there. It was long enough ago that I was hired as a temp to do transcription for their ethnographic interviews. So, it's a lot of anthropologists at Conifer Research, and they were doing deep ethnography to kind of understand business problems. And so, I was doing transcription. I started out doing transcription of their interviews, and I guess then I was asking the right kinds of questions, because within a month or so, they asked me if I would join full time. I was noticing things in the interviews like, well, someone said this, but their face said something different. Should I capture that somewhere in the transcript? So, I think that they just saw that that background in behavioral science being aligned with their approach. And so they asked me to join the team full time. So, I was trained there by anthropologists for a number of years, worked on projects across industries, and really got exposure to like deep, deep ethnographic research methods there.
And so, from there, I really wanted to, I noticed that I liked working on everything I could be interested in anything I had, that I have that capacity, but I was drawn more. I was drawn most to the projects that were about health, that were really thinking about how do we create conditions under which people can thrive and lead healthy lives. And those were the types of projects I started to gravitate towards.
And so, I started to kind of make a path for myself within that. I didn't have a health background I had a social science background. So, I started to make a path for myself within that. I eventually then thought that I might want to go into the clinical space. So, I did a masters of nutrition and I did pre-med. Actually, I almost went to med school and I was working with a lot of doctors at that time who just kept asking me questions about what I did. They said, what you do actually sounds really interesting and I would like to switch into that actually. How might I work in design or innovation consulting? And so I kind of had a moment where I had to make the decision, do I keep pursuing this path to go into medicine or do I continue in design? And I realized that I had accidentally ended up in an industry that I really loved. And so, what I wanted was just to have that focus on health. And so then I kind of redirected my design career to be design for health. That's where I've been ever since. And so I am a senior director, design director here, and I lead the health portfolio of work.
Dr. Craig Joseph: Oh that's a great kind of story and pathway. And I just want to call out two things. One is for some of our younger listeners, transcriptions used to be generated by humans. So I just I want to throw that out there because I know it's kind of like the typewriter. There's some kids listening. You don't understand that.
So the second thing I want to call out is you were not doing strictly what you were told to do. You started asking questions like, well, they said this, but I'm thinking from their expressions that they might be thinking something else. And how do I put that in there? And just to, you know, again, call out for the kids AI is not going to do that. And so sometimes there are jobs that, you know, maybe technology can do, but, humans can bring or certain humans at least can bring a different perspective. I love the fact that you were pre-med, you were thinking about going to medical school. And many of the physicians are other than, other clinicians that you were interacting with, said, we don't want to talk about health care.
We just want to talk more about what you're doing, because that's more interesting. And how do I get a different gig? That is really quite common. I get this, I get a similar reaction sometimes. Since I'm not practicing now and, you know, people ask me how did you get into that? And maybe I should do that, but very few people do, right.
Brandy Parker: They actually would tell me to they would say you're wonderful and you will hate it here. I could tell you just based on how you're asking it, you know, you're asking a lot of questions. They're really good questions. You're actually going to probably enjoy what you do more.
Dr. Craig Joseph: You know, I thought it'd be fun just to dive right into a couple of the projects that you've done. And the first one I want to call out is Teal Health.
Brandy Parker: Yeah. So Teal Health is a project that I did. It's one of the projects that we're really proud of at the moment. What it is, is an at home cervical cancer screening. And so, if you know anything about cervical cancer, you know that cervical cancers, it's one of the cancers. It's actually nearly 100% preventable. But if you catch it early but 1 in 4 women is not. They're not up to date on their screenings for cervical cancer. And that that's something that disproportionately impacts Black and Asian and Hispanic women. And there are a lot of reasons for that. I mean, cancer screening in general, it's hard for people to stay up to date on their screenings. But pap smears in particular, they're really uncomfortable at best. And they're just completely inaccessible at the worst. And particularly if you think about trans women, minority women, disabled women, it can be tough. It can be really inaccessible for them to get that smear. So telehealth, what they really wanted was to create like a comfortable and accurate at home test that women could use at home and they wanted to improve the screening rates.
So, working together with IDEO, the team set out to really design something that was going to be a functional prototype, something that we could actually test. It would be the first of its kind, and so want to make sure it actually delivers accurate results that would be comparable to something that they would get in office, and just make sure that the idea was viable. So we set out to design that. Some of the things that went into that design, things like it has to be designed to be standing up because the private place in your home is going to be your bathroom. And so it's going to be something that you have to design to be used standing up. It's going to have to be easy because people aren't going to have medical training to do this. It has to be pretty comprehensive. It has to look easy, too, because people are going to be worried that they're not going to do it correctly. So the team really leaned on some key factors to make sure that this was accessible. One example of that was things like leaning into shapes that women are already familiar with.
For example, the design that we came up with is somewhat similar, it has a cylindrical shape like a tampon would. So that's a shape that a lot of women are familiar with. So kind of turning towards items that represent, I don't necessarily want to say comfort when we talk about that, but items that will be familiar that they understand how to use. And so those were some of the things that the team was thinking about as they designed it in collaboration with users. And the results of it were pretty impressive. I think as idea. We are really proud of the results that we saw from the participants. So, for example, 92% of the users said that if they knew the results were equal to that they would get in an office that they would prefer to do self-collection. So, it was like 87% said that they would be more likely to stay current on their screening if Teal was an option that was out in the world. So that's extremely strong results and results that I get really excited about, because if you design something that can be more accessible, particularly more accessible for folks that might be at the margins, then that just makes it easier for everyone. We're really hoping that once Teal is out on the market, it can start to improve that early screening rate and get more people screened sooner.
Dr. Craig Joseph: Yeah. And one of the things that you mentioned is that idea was involved with Apple, a term that I've heard called unboxing. It sounds really crazy, but I think we all acknowledge we all understand what that is now. But Apple certainly has mastered that. And my understanding is there's something with Teal Health that said you make sure to kind of create that cool unboxing experience is there. Is there something that you can talk about from that perspective? I'm just fascinated by the fact that how something is stored and delivered to you will have a significant impact whether or not you use it and how you feel about it.
Brandy Parker: It really does. Really, really, it really can. And that's what excites me so much about design is there's so much potential for small, really small changes to have a really significant impact. And one of the things that excites me as a designer and as someone with a social science background is designing for how people feel during a process, because how people feel matters. And that's when we do a number of at home kits, home health kits, not just Teal. And one of the things that we found across these is that unboxing moment is super important in terms of how people are going to react to the idea of taking this test because they've agreed to take the test. It showed up at their door. So, in theory, they've agreed to take it. But it's different when you actually get to that moment of following through with it versus it just sitting at your counter. And what gets you over that hump. So for example, one of the projects that we're working on, we developed something that we joked about, we called it the Gumption Graph, which is how much gumption does it take to work up to actually do the test and not just have it sit on your counter?
Like, what is it that helps you overcome that? And we found that there are small changes that you can design. So, for example, since it's not something that people are used to doing, they're worried they're going to get it wrong. Everything about the design when they open it should look simple. So even something as simple as having to take something out of a container that it's already in, it already looks harder. Just have it sitting out invisible, have everything that's possible. Be visible and laid out in a way that makes it look easy. It makes it look like there are three steps to do it. Make the instructions super clear. Very visual. Simple things like that can make all of the difference. Another thing we think about is a moment where this can potentially be a reminder of, especially if it's a cancer screening. But it really with a lot of screenings, it's potentially a reminder that you're going to get diagnosed with an illness. It's potentially a reminder of your mortality. It could bring up feelings that you have about family members who have maybe passed or have a particular condition. There are all sorts of things that might make you want to push this away.
Maybe I'll just do it tomorrow. Maybe I'll do it at a different time. And so, some of what we do is look at how we can reframe the visual language, or even the actual language that's on the packaging to communicate, rather than it being an illness test, communicate to them, this is about you taking care of yourself. This is something positive that you're doing for your health. This is something that should be energizing, that you should be proud of yourself for.
Dr. Craig Joseph: It's amazing how little we, most of us, think about these little design ideas. We just send you a box and. Right. And we told you about it and we told you it was really important. And that was the end of that. And it's going to get shipped, and we'll talk about it. Or when we get the result, that's actually practicing really good medicine. What I just said, and without thinking anything about all of the different ideas about disease versus health, is it too complicated? And if I do it wrong, does that mean I'm going to get diagnosed with cancer when I don't have it? Or worse, am I going to get diagnosed as being fine when I do have it? And so yeah, lots of different emotions there that you have to think about. Let's talk about patient adherence. I know you love that term adherence, or compliance is another term that people really love when patients are non-compliant. Non-compliance means that they didn't do what I told them to do. Exactly. My children are often non-compliant with what I tell them to do. And so yeah patients can be non-compliant or not adhering to it. So, let's talk about that. How does that approach what we need them to do, but not just one time over the course of days, months, or years?
Brandy Parker: I do use the term patient adherence, but I just don't particularly like it. I also don't really like the term behavioral design. I use it, but I don't particularly like it. And the reason I don't like it is because I think that there's something about it that implies that there's a problem with the person and their motivation, and there's a little bit of an undercurrent of, to me, I don't think it's intended to have this necessarily. But to me there's a bit of an undercurrent of, you know, these pesky people; they just won't stay on their treatments. How do we get them to stay on their treatments, or how do we get them to make these behavioral changes and I think to me, I think maybe it's my perspective as being a designer who actually works on what do we actually do to change some of these things.
Because when you work on these problems as a designer, you realize the issue is not adherence. It's often things like patient education or patient accessibility that are really what we're talking about. Adherence implies stubbornness or refusal to stick with the program. There may be that in some sense. But let me give an example. So, I did some work designing a patient experience for clinical trials process. So, it's a process that, I don't know if you've ever worked on clinical trials yourself, but it's notoriously difficult to recruit clinical trial participants. It's notoriously difficult to get them to stay within the clinical trial for the length of time that’s needed. There's a lot of drop offs within the clinical trial experience. Talk about an adherence problem with clinical trials. Right. Or and so when we worked on designing the solutions for that, it was the things that we uncovered that would be really helpful were things like, here's all the materials in the language of choice for the person. Can we design some, can we start using and working towards AI translation tools that actually get all of the materials into the person's language of choice?
It's something that seems simple, or maybe unsexy to design participants first language or language of preference. But they're getting materials that they don't understand, then how are they supposed to actually follow up? Right. So, it's things like that. We explored things like transportation services because some of the biggest barriers are just getting to the clinical trial sites. How can we optimize where they're going to go for the clinical trial and how they get there? It's things like, how can we eliminate the wait times? A lot of times people drop out of clinical trials because they go to the clinical trial sites and they're sitting there waiting for an hour or sometimes even two hours before they're able to see the people that are going to be taking their readings for that day. And obviously, if you go and you sit there for an hour, two hours out of your day, it's not a great experience that really cuts into your day. And so, how can we explore processes on the back end that actually reduce those wait times? And the consent process can be extremely laborious. There are so many opportunities to streamline the consent process in clinical trials.
So, it was things like that that we were designing. It wasn't necessarily about the motivation to sign up for a clinical trial and the education about a clinical trial is important, but actually retaining people in a clinical trial, it's often because the experience is just a really challenging one. Or that it's an inaccessible experience. And so oftentimes what you're designing for is accessibility or education, not necessarily motivation.
Dr. Craig Joseph: I remember the first time I heard about Uber with respect to health care, I think they have a division called Uber Health. And at first, I was picturing them doing culture in the back of the car. But that's not what they do. What they do is they transport you to and from your appointments to your point, if you have trouble getting there, especially for research, you're not going to go. And if when you get there your time is not valued and you're just sitting there waiting and it's not efficient and it's not pleasant, then you're not going to go and remember, half the people generally in a research study are getting placebo. So, they're kind of doing all this volunteering. And they don't, you don't know if you're really getting something. And boy, those little things that make you want to drop out. Maybe it's not the blood draws and they're having to take the pills all the time. It's just being able to get there. It seems straightforward and obvious afterwards, but it's not that way at the beginning.
Brandy Parker: Through even thinking about things too, like, I think that companies underestimate things like the importance of confronting, for example, within clinical trials, confronting a real history of medical abuse that has happened in clinical trials and the ongoing impact that that has on communities. There's a natural skepticism of some recent medical research because of the history of things like the Tuskegee experiments, where people were intentionally not treated for syphilis to see what would happen to them. Over time, they were not given access to treatments, things like that that happened in our medical past still have an impact today. And so even things like standing up and talking about how as an organization we are working to combat things like that can actually make a difference for your patients and show that you that you care and that you're thinking about it.
Dr. Craig Joseph: Yeah, it's fine to say that. Yeah, this is a work in progress at this respect, at this aspect of it. When we were preparing for this, one of the things that you'd mentioned is that you love bad prototypes. Tell us why. Why do you love bad prototypes? I would like good prototypes, I think.
Brandy Parker: Well, sure. I mean, so ultimately the point of prototyping is to get to the right design. But I think people put too much pressure on prototypes and they put too much pressure on the prototypes being exactly the right thing. And they work really, really hard on one prototype. And then they put it out there and they get it out there and there's something massively wrong with it, and they've put so much time and energy into this. They've ended up with a bad prototype. Anyway. I think one of the things that IDEO as a designer and that, you know, that we have a philosophy of it at IDEO and other places that utilize prototyping methodologies is that it should be rapid process where you are starting with a high volume of prototypes and some of those prototypes are going to be bad or they're going to be completely wrong. The thing is that you're learning that quickly, and so you need to get them out and not be so precious with your initial prototypes that you miss out on the opportunity to learn. Because part of what we're doing with prototypes is not actually in early stages, is not actually getting to the exact right thing right away.
Prototypes are also a method of learning. So, by putting out a prototype, you learn more about what the actual solution that you're going to design in the future should look like. One example of this is I worked on a something that was a medical implant and this isn't an example necessarily of a bad prototype, but just that a prototype you're meant to do prototypes, low fidelity prototypes to learn more information earlier on in the process. So I was working on a device that was to work with a medical implant. So this would be an implant that would be within your body, and it would be inserted surgically, and you would use a handheld device or a device of some kind to apply it to this medical implant and take a reading from this device. Can't get into too many details because it's confidential, but I know that just to give that high level overview, that's what it is. So in our initial conversations with the client, they had assumed that this device would not give any kind of reading to the patient, that it would just be a standalone device that would send the reading to the doctor.
And this is because they had done a lot of conversations with physicians that said, you know, where should these readings go? They had said it should come directly to me, and then I can inform the patient if there's a problem there. All kinds of reasons for that. Some doctors know that they could get more questions. If there's too much information that's given, they would get a lot of calls. People worried when they don't have to be, things like that. So, we created this out of low fidelity prototypes and we took them out and they didn't have anything that indicated that there would be a reading on them at all. And we actually didn't ask people about that. We just set it on the table and said, how would you use this? They picked it up and they said, okay, great. So I would take this, I would apply it here. And then so where does it tell me I'm okay, like it, would it be on here or would it be on there. And it wasn't even a question to them of whether or not they would get a reading.
It was where would the reading be? Like, is it showing up on the device or is it on the base station? And they had opinions on where it should be, but it didn't even occur to them that they would not be able to get a reading. And when we told them that, they were very confused and almost hurt by that because they really wanted to see some indication, one that they had done it correctly, but just some indication that they are either okay or might need to check up. So it became really clear very quickly that that was something that probably needed to be incorporated into design. And we can design it to make sure that it's not alarming or to make sure it's the right level of information. But by putting that prototype out there really quickly, we learned something really important right away. And it also helped drive alignment within the design, because then all of the people on our client team saw that all the participants were asking where the reading would be, and so it quickly it also by putting it out there without any kind of reading, it quickly showed them that it should probably have something that indicates reading it. And so everyone was then more aligned together too. And that's one of the other power of bad prototypes is I like to include, even if we think that it might not be the best idea. I like to include prototypes that people feel really passionate, low fidelity prototypes that people feel really passionately about in early designs because it can help drive alignment.
So sometimes a subset of a team really thinks that they know the answer to a problem. And so let's put it out there. Let's put it out there in a small way, and let's see if it works. And let's see where it fails. And then that will help actually drive alignment. So by making it real faster you can help identify where the challenges are and learn a lot more information about what you do need to ultimately design. And that's why I like that. Prototypes because they help you understand and illuminates almost like negative space that's illuminated around and around what should actually be created. You're ruling things out or seeing where things maybe don't work or aren't the right solution. And that can help drive you towards what the right solution is.
Dr. Craig Joseph: Yeah. Well, and it's kind of like the Silicon Valley ethos of, you know, fail quickly and cheaply, right? If that's what you're talking about. Low fidelity. So we can make it cheap. And if it's bad, that's fine. We've learned a lot. Now we know what's good.
Brandy Parker: We do a lot of work, too. When we’re in the research process there's that kind of move fast and break things mentality. And I think we do. We also think very carefully about we are putting people into a research process that is temporary, but it is a meaningful process to engage in research with someone. And there are actually power dynamics there. So we do think about things like, we don't want to embarrass people with our bad prototypes, right? Like we do a lot of work in the setup of saying, okay, you may not understand how to use this, and if you don't, that's not a problem with you. That means it's a problem for us. That means we've done something wrong. That means we're not doing things correctly. Because if you don't set that up, then sometimes people can feel embarrassed or ashamed that maybe they aren't using something correctly or that we're not getting the right information from them. And so we do a lot of work with our participants just in how we set up the space of showing them prototypes, helping them to understand that we're here to learn from you. You're the expert. If you don't understand this, then they're going to be plenty of other people who don't understand this. And that's not a problem with you. It's a problem with prototype.
Dr. Craig Joseph: Let's pivot just a little bit. And I'm fascinated by the workarounds. And the power of workarounds like in the electronic health record I've seen workarounds. I actually said to a physician once, and kids don't try this at home, but I told him that after watching him, you know, perform some workflow, that if I were being paid to come up with the worst way to achieve the outcome, I would not have been as creative is as he was. You know, he made his life as difficult as possible. And then I said, let me show you how to do that much faster actually, and he was not interested. It's like, no, no, no, I've got it down. I got that muscle memory thing going. It's, you know, it takes me a while, but I know how to do it. And, I was just wow. The power of that kind of muscle memory and those bad workarounds that people develop. So, you know, how do you deal with workarounds?
Brandy Parker: I love workarounds for business purposes. Workarounds really point to huge design opportunities. And so that's a reason to love them. One of the things I find fascinating about them is that people don't realize or forget that they have them, and so they can really only be observed by going in context and viewing them as an outsider, almost. That's one of the reasons why we do what we call contextual research, which is just really going into context and doing more observational research and watching how people do things and asking them to show us how they do things, because that's where you really see the design opportunities. Honestly. They help us understand what people actually do versus what do they see that they do.
So that one of the classic examples of this, one that we like to talk about this idea, this is one of my favorite ones, is setting out to design a better experience for arthritic patients. And so, they're interviewing an arthritic woman in her home. And the team was asking her, you know, do you have any problems opening your medication? And she said, no, no, absolutely not. I have no problems opening my medication. And so, they thought, that's interesting, yet she has severe arthritis. So can you show us how you open it is really curious if you don't have any problems with it. And she said, oh yeah, absolutely. And she went over, she took the pill bottle over to her. She had a deli meat slicer in her home, and she took the pill bottle over to a deli meat slicer, and she chopped off the top of the bottle with a deli slicer. And she said, see, it's no problem. Yeah. We love to tell that one because it just really illustrates the power of observation and why we do contextual design. Because if you watch someone do something, they created the solution that works just fine for them. But lots of other people are having the same problem that she has and they haven't developed that workaround. And so, by seeing that workaround, we can really see where the opportunity is. There's a huge if she had been answering a survey, for example, she would have just said nope, no problems opening my medication.
When we go in context, we can actually see what the problem is. A lot of times people can't articulate the problem that they have, even if they have identified that they have an issue with something, they just say, it's just really complicated to do. Well, show us what you mean by complicated. Like what makes it complicated. Show us. Show us how you're doing it and where the problem is. That's where we can then see what we need to design out of experience. It makes it more tangible. It makes it more concrete. And we can see we also can gain inspiration from how people do things. Sometimes the workarounds that people develop for themselves can actually have really powerful things that we could share with other people.
Dr. Craig Joseph: I just can imagine myself in that group and saying, hey, can you show me in having a deli meat slicer in your house and just slicing off the top of the package and acting like, yeah, that's how we do it. That's how it's done. Unfortunately. I have to ask you my final question, and this is a question that we typically ask. Is there something in your life, and I suspect there is as a designer, or is there something in your life that's so well-designed that you love interacting with it, using it, and it kind of brings you joy and happiness?
Brandy Parker: Yes. So, I thought about this and I thought, what am I going to pick? And the thing that brings me, I think some of the most joy is the, have you have you been in the Rainbow Tunnel at O'Hare Airport?
Dr. Craig Joseph: I have.
Brandy Parker: So, I think it's called The Sky's the Limit. And for those that don't know, there's a tunnel. There's one of those long airport tunnels and it's in an underground tunnel at O'Hare Airport. You get from one side of the airport to another, and instead of it just being like a blank wall of advertisements, they've paneled it. It was probably in maybe like the late 80s or early 90s, perhaps. I'm not sure when, but somewhere it looks like it's somewhere around them. They paneled it with just a bright array of pastel that looks like giant paint swatches. And then overhead there are these long neon tunnels that correspond to this kind of otherworldly music that plays at the same time. And it's just this ridiculous sensory experience. It feels kind of magical. The reason I was trying to think of the reason why I like it, is completely unnecessary. And it feels like it's just there to spark joy. They didn't have to put that in that space. It's not like an advertisement that they're making money off of. It feels like it was designed just to have an experience that you otherwise wouldn't have if you were walking through an airport. And it just makes me smile every time I just look up at the lights and just take it in.
Dr. Craig Joseph: Yeah. It's, it's a bit of whimsy in the day as you're running from one airplane to another. Well, Brandy, it's just great. Thank you so much. I learned a lot, and it's, I'll never forget. I will never forget about the woman slicing the top of the pill cap off with a meat slicer. And many other things that you taught us. I really appreciate it. Thank you so much. And, we look forward to all the cool things you're going to do.
Brandy Parker: Thank you. Thanks for having me on. This was fun.
READ THE TRANSCRIPT
Show Notes:
[00:00] Intros
[00:46] What is TEAM
[06:06] The importance of consistent care pathways
[08:41] Data, surgeons, and the patient voice
[22:26] Pre-surgical prep
[23:25] Tech tools for follow-up and recovery
[26:36] Rethinking clinical decision support with AI
[29:25] Turning data into actionable insights
[32:32] Karen’s favorite well-designed thing
[33:52] Outros
Transcript:
Dr. Craig Joseph: Welcome to the podcast, Karen Joswick from Benevolence Health Advisors. How are you today?
Karen Joswick: I'm good, Craig, how are you doing?
Dr. Craig Joseph: I am, as always, excited to talk to people like you. Where do we find you today?
Karen Joswick: East coast, Delaware, the first state.
Dr. Craig Joseph: You and I met when we were, you were trying to educate me on the TEAM program, and I had said to you, I use Teams every day. I can even chat on it. And I told you I didn't need to know anything. And you were. You were like, no, no, no TEAM was with no s.
Karen Joswick: Yeah. We use the word TEAM in all senses of the word. I can't tell you how many times we've approached organizations and said, so how's your team doing? And people go; they're great. What are you talking about?
Dr. Craig Joseph: Why don't you tell us a little bit about yourself? How did you get to become the person that you are now?
Karen Joswick: Let's answer what TEAM is. TEAM is the new mandatory bundle payment program from CMS. It impacts about 25% of the hospitals across the United States, and the hospitals were selected based on their geography. Or CMS has a term called CBSA or core based statistical units. And so, it's kind of a big deal because it's a mandatory model. And there was a little bit of betting going on about what was going to happen in Washington. Was the administration going to keep it, you know, move forward with it. And there were a lot of naysayers that said it's going to get wiped like everybody else, or it's not going to be mandatory. And actually, that's not true.
The administration kept the TEAM model. They came out with some new proposed regulations in the last couple of weeks on it, and it's mandatory. So that means these hospitals have to comply. I went into healthcare wanting to make a difference and a change. Same reason why you probably went into medicine. You want to help people and make a change. And I started my career in it and then was asked because I understood all of this data and analytics and informatics work. Could I help the operational teams implement these programs? And kind of just grew from there. And I think part of it, I had a good amount of my career in the state of Maryland, and Maryland's known for innovative models. And so, I think it kind of was a natural growth in that way.
Dr. Craig Joseph: Fee for service versus value-based care. Fee for service, as I understand it is, hey, you do this thing, you get paid. Whether it turns out well, whether the patient really needed it, none of that really matters. You're going to get paid this amount of money with value-based care. It's more like the payer. In this case, the federal government is interested in results and paying for results.
And so, we've had value-based care for decades. That concept kind of started with the HMOs a gazillion years ago, I believe, and it's kind of been some fits and starts, and it's kind of going back and forth. So, this is, yet another, another attempt from the biggest payer in the United States for health care, the federal government, to make sure they're getting their money's worth. And as you mentioned, TEAM is not optional for the 25% of hospitals that were selected by the government. And they, I presume, know who they are at this point.
Karen Joswick: Gosh, I hope you do know who you are. I mean, there's a list out there. I will say, as of a couple of weeks ago, we've done some outreach, and I think most hospitals know. But early on, when the list was out there, there were some that were a little surprised, like, oh, we're on the list.
Dr. Craig Joseph: So hopefully people know, you know, if they're on the list and what do they need to do? So how is this different from other kinds of, value-based care who's being evaluated and what kind of information do they need to present and that kind of stuff.
Karen Joswick: Well, so first, if you don't know, check the list. So happy to send the list and where you find it. But one check the list, and two, if you're on the list, make sure you identify who your point of contact is going to be with CMS. They want to know who they should send emails and data files. There's going to be a whole bunch of information that's going to come straight from CMS to your organization. More importantly, it's going to be a reflection point for an organization to understand the volume of these surgical procedures and understand the key service lines.
So, in prior bundle payment programs, they were predominately in orthopedic space. This program's a game changer and includes cardiac surgery. Not a surprise, right? Think about what the federal government pays for a lot of open-heart surgeries. Right. So, they put CABG in. There is one example. They also included some spine in some bowel surgeries.
And so, I think this is indicative of where the government's trying to go is to lean into the high-cost procedures or also procedures where there's we know care continuum across whether it's in skilled nursing or home health. And, where we think there's opportunities to bend the cost curve and improve quality. And boy, when you think about seniors and the cost that Medicare is underwriting, cardiac surgery seems like a great place. So, the hips and knees and spines.
Dr. Craig Joseph: And I assume the idea from the government is that if this goes well, it won't be 25% of hospitals. It will be.
Karen Joswick: More. Yeah, yeah. All right. It's going to be more. And if it goes well, by the way, they save money. So, if it goes well, it doesn't mean the hospitals will make more money. There are some hospitals that are in a favorable position based on what we've kind of modeled and projected that some, some hospitals, because they're already a low-cost, high-quality provider, may be positioned well. There are most hospitals who are not, and so this is a haircut. Right. And for some of these health systems, it's not a trim. It's a pretty big haircut a couple million dollars a year. Craig, you know, in this day and age, that's huge. That's not just a rounding error for some of our health system partners. These are big cuts.
Dr. Craig Joseph: Maybe let's just dig in on one example. And so, you had mentioned CABG. You were talking about, bypass graft. So, a heart bypass, which is a major, it's a big operation. So maybe talk us through how it is today and then how will it be tomorrow or early of next year for those quarter of hospitals that are on the list?
Karen Joswick: Sure. Well, CABG is a is a good example to talk about. You know, there are patients who get, emergent CABG and there's not really much you can do about that, right. There are patients who are in the CATH lab. They get balloon pumped and they sent to the O.R. and kind of like, that's just going to run its course. Those are patients that you need a clinical pathway for. You need to be able to make sure you have data and insights, and you've got good partners to manage them across the continuum.
But then there's a cohort of patients which is most patients, right, where it is considered, a scheduled routine procedure. And so those are patients that are known to you as a provider ahead of time. And so there's an expectation that, how are you engaging those patients ahead of time? Have you been educating them on what their plan is after discharge? Right. We know for patients who have had this surgery that they need to be up and moving around, and they need to be exercising. And the patients who are up walking around the nursing unit in the hospital are going to be better walking around at home and going to cardiac rehab.
And so there's kind of these basic tenants that good science, right, good care we know about. But frankly, sometimes we're inconsistent and how we do it. And part of it's the patients not being educated, not being aware, not having the right support system at home. And some of it's that we are inconsistent in our clinical practice at some of our facilities, right, for lots of reasons.
And so the model really is kind of pressure testing and saying you need to be consistent, right. Reduce care variation, but also engage the patient ahead of the surgery and also figure out what your plan is going to be after surgery so that those patients who have a CABG, then maybe go home with home health or with cardiac rehab services and not get transferred to a skilled nursing facility for 20-30 days. Right? So really try and manage the cost of that episode and also improve the care. And we know patients who have a good destination right at home and good support system. They're going to be less likely to end up as a readmission. And I think we all know, like the challenges with readmission, not only around cost but quality. And it becomes a downward spiral.
Dr. Craig Joseph: Is the government looking, how are they going to be evaluating how consistent the care is? How are they going to be evaluating what kind of rehabilitation? That's one of my favorite terms as opposed to rehabilitation, you know, how do they evaluate that? Or is it just no, it's the outcomes. Like we don't really care what you did. If you have, majority of your patients don't bounce back and they're meeting certain criteria afterwards, it doesn't really matter what you did before. It sounds like it's somewhere between those two extremes.
Karen Joswick: Yeah. No, you're exactly right. So I think there is an expectation on your benchmark cost. That's just it, it's a cost program. There's a cost savings program. So are you less expensive than your competitors in your market? And also how do your outcomes fall? So, there's a variety of quality measures that are included in this program. Right. Some of it around patient experience. Some of it's just around like all cause readmissions and all cause morbidity mortality rates. So, there's measures in place to look at, like you said, outcomes. But then there's the biggest stick, or carrot, really is the cost.
Dr. Craig Joseph: You're being evaluated about your cost compared to your competitors compared to like kind of peer institutions in your area. It sounds like.
Karen Joswick: Yeah, your market. And the challenge with these, you know, sassy CMS is word CBSA. So, score based statistical areas I'll use in the word market. In some organizations, their market is small. In other words, it's like California, Oregon, and Washington, right. And so like, they're massive geographies being compared to Sacramento when you're in Oregon may or may not be right. Really fair assessments based on Metropolitan. And we see this in New York, on the East Coast. There's a lot in the New York New Jersey area, etc.
Dr. Craig Joseph: Is this significantly different than two years ago with a different program for a different surgery? Like you'd said earlier, orthopedic surgery tends to be the one that payers in general and the governments specifically look at. But is this much different? It sounds like one of the things that sounds different to me is the fact that I'm going to be judged based on how much I bill versus my other people, either in my region or my state. Is it more of the same or is this a particularly different kind of approach?
Karen Joswick: Yeah. So, yes. So, it's a little bit of the same. It's a bundled program. So we've had bundles for decades and decades in health care. So that part's not new in the fact that we're including orthopedic procedures. There's been a huge shift right over the last 15, 20 years to move routine hips and knees out of the hospital into ambulatory care. Right. Bundle those, that parts not new. What is new is that some of those other specialized procedures, like we talked about cardiac surgery, is a perfect example. And the fact that you're going to be graded, if you will, and compared against your market. So you're not beating against yourself, right.
Comparing against yourself, but you're trying to beat the market, not just improve your own cost. And that's important. For lots of reasons. One, you may not know where you sit compared to your market. Right? So, a lot of health systems don't have good benchmarking information and data about where they sit relative to the hospital down the street. The other thing that I think is a game changer on this one is the service line engagement typically and a fee for service world cardiac surgeries. The last area you touch for lots of obvious reasons. And so, this is one that's going to really challenge health systems to have their foot kind of in both canoes. Right. How do you balance fee for service and value-based care and hope that you don't hurt either side?
Dr. Craig Joseph: One of the things that was initially confusing me, and some listeners might be confused about with respect to needing to know how much I charge for this, my hospital charges for this procedure versus others in general.
I've always taken this simplistic view because I'm a simplistic person, that, hey, I could charge $100,000 or I could charge $1 million for this procedure, for this admission, this hospitalization, I'm going to get paid X number of dollars based on the DRG. And so that was always my kind of assumption. It doesn't really matter what I charge because I can send a bill for anything. I'm just going to get what I'm going to get. But now that's actually or maybe never, but certainly not now that that's not the case. The more I charge, even though I can charge $1 million and I'm going to get $50,000, it's going to not work great if I'm charging $1 million. And if my, others in my area are charging, for the same procedure, DRG half of that, it looks bad and it's going to be calculated as such.
Karen Joswick: Right. And I think the best way to really kind of needle down more on that is the total cost of care. So, for these patients, yes, you can charge for your surgery, but are your patients going to home health, which is, you know, maybe $1,000 of expense versus skilled nursing, which is maybe $25,000 for that post 30-day window? Are your patients having a bunch of extra scanning and imaging and so forth pre procedure that maybe they don't necessarily need is a is it a necessary variation in care based on the standards. So those are kind of the puts and the takes.
And then to your point, yes, there's a whole internal exercise that health systems should be doing around their fixed costs. So what are you charging versus what does it cost you to actually provide those services. And that's really where I think there's a sweet spot. Organizations that are looking at their internal cost structure, how well they're managing their internal costs to provide the care. And then also looking at the care continuum, what are those patients experiencing? Are they going to skilled nursing? Are they going to home health? Are they getting extra physical therapy appointments, imaging etc.?
Dr. Craig Joseph: So now that we all understand what this is, sounds like, step number one is to know if your hospital is in the group or not, which most people probably know by now. But sounds like there's a link that you can go to and see that list.
And then step two, once you know that you're in this list and probably it's not a bad idea for folks who aren't on the list now, given the fact that they might everyone might be on the list soon, is to start collecting some data and some of the data they surely have. Surely there are other programs or other quality metrics that hospitals have to be collecting. One of the new ones is, hey, how much am I charging for this on average? And again, not just for the procedure, but for all the care that's involved versus my competitors. So, they need to get that information. How you get that information, Karen, do you just call up? Hey.
Karen Joswick: It's a yes or no, right. So, if you're on the list and CMS has your contact information, you will eventually get claims data from CMS. But that's not going to be until later this year. So, you're going to need to look at your internal assets and tools. So, you know, depending on whether you're currently in MSSP. So a Medicare shared savings ACO, maybe you already have claims data, maybe you already have a pop health platform or a tool that you're using to do that, that some of the hospitals, for sure, there's many hospitals that frankly, they don't have those tools in play, and they're on the list and they don't have access to the data. And so, then there are certainly partners that have access to benchmarking, where they can give you the analytics to help at least start planning to do that work. And that's some of the work that we're doing to help organizations right now is forecast where they have opportunities to focus on care redesign.
Dr. Craig Joseph: Are there other data points that folks should be collecting that you're seeing that they don't have, that are unique for this program?
Karen Joswick: I'm a firm believer they really should know by those service lines which of those stocks are employed versus a community-based or a partner. I think that there is an opportunity around provider engagement to really be intentional. Certainly with your employee docs, but also with your community docs that you know right now, if you've got, you know, maybe a spine surgeon that's in the community, but they have privileges and they operate, but there's an opportunity to lean in around quality and engagement in this. There should definitely be conversations, right. And an evaluation of who's employed, who's in your community. The same thing is true with your post-acute partners. Who are you sending these patients to? Do you have their data? Do you have a partnership? Do you have a preferred partnership? So there's definitely some internal operational areas that the organizations should be evaluating as they prepare.
Dr. Craig Joseph: Is there anything that differs based on the specialty? So ortho versus cardiac versus GI is pretty much all the same. Or are there any numbers? Oh my. For gastroenterology really need to know X.
Karen Joswick: Cardiac surgery is usually the most expensive, and spine, kind of you know, follows some of the bowel surgeries are pretty expensive because they're usually very medically complex. You know, if I were sitting right there in the hospital today, I would want to look at my outliers. So, any patients in the last 12 to 24 months in your med teams, right? You're made exactly like they'll know that they'll know your outliers for your CABG. They'll be monitoring that, especially if they're involved in other registries like STDs, registries. Any of the quality improvement work that you're doing? I pull all of that and really dig deep, on where you are performing right now.
Dr. Craig Joseph: Okay. And you mentioned engaging with your clinical team, especially the surgeons and procedural, as.
Karen Joswick: I enjoy working with surgeons. And maybe it's because throughout my career I've had the ability to do that. So, you just kind of learn what motivates and engages them. Right? So, these are typically very passionate, quality focused. They truly are outcomes focused. They don't want a bad outcome. Nobody wants a bad outcome. And so I think if you position this program as an opportunity to really evaluate how their patients outcomes are doing and get them the support needed, whether it's special care protocols or figuring out how your care management team can help support them for discharge planning or realization like you talked about.
I see this as a great way to engage those surgeons, maybe in ways that you haven't since maybe the service line launched, or a program opened, or a new surgeon came on. Right? Typically, those movements are when organizations will have a, oh, we should. We just hired a new cardiac surgery specialist. Let's look at our clinical protocols.
Well, you should be doing that more routinely. So, I think this is a great opportunity to have those conversations. And then I'm a big proponent of sharing the data with them, helping them understand where they're sitting and help them be competitive, because by the very nature they're competitive. They want to know; they want to be better than others. And so, I think supporting them in that way is the best way to do it.
Dr. Craig Joseph: Yeah, I love that. From an intentionality perspective, physicians are 100% and surgeons 1,000% are competitive. And, sharing those data points with them, whether they agree that they're important or not, they want to do better than that next person, and especially if they have a negative opinion of that, of someone, they're like, oh, they're beating me at this thing. I don't really, even if I don't see the value, I will not allow them to beat me at this thing. So, yeah. And so, engaging with the surgeons and procedurals makes a ton of sense. We haven't talked about another, important person in this endeavor, which is the patient. Are there things that we should be doing to engage the patient directly, or is this something that now the clinical team and the operations folks are the ones who are the only important keys in this puzzle?
Karen Joswick: I think you know the answer to that one. Right? Patients are at the center of all that we do. It's amazing how many patients don't have a good understanding of what their recovery process could look like for these procedures. It's I mean, even for things that are, that are routine, like, like a knee, some people feel really, you know, you have different experiences. You'll ask a patient or a friend, hey. And they'll say, I had no idea it was going to be so hard to get up the stairs and shower. I had no idea what it was going to be like. So, there's I think there's an obligation, right, to make sure that we are really arming patients and families and their support systems better when they have these procedures.
And I think that's ultimately going to get us into a better place long term around outcomes. But if you haven't invested time and energy resources into educating patients ahead of the surgery, right? Not immersion. Right. But for the routine and scheduled, I just you're just not in a good place long term. And if people have time to focus and plan and worry about the steps to get someone into the house or make sure they have time off those first couple days, you know, as a supporter for their family or their loved one. It makes a big difference. And there's a lot of digital tools too, right, to be checking on your incision site and send us a picture of that. Right. There are so many tools that are out there now that it's kind of like we have to be doing this, in my opinion, for sure.
Dr. Craig Joseph: We need to involve the patients. And I love the idea of kind of doing, again, that pre check of trying to get you in the best shape you can be before the surgery, assuming that it's not urgent. Of course. You know, can it wait a few months for you to quit smoking or for you to start exercising a little bit? Yeah. If so, we know you're going to do better afterwards. And the concept of oh, no one asked you where your bathroom was located because it is upstairs. So that's where the showers are, we're going to have a problem if there's no one there to help you. And that's going to lead potentially to you, not to you kind of failing at home.
And then having to go to a post-acute facility. And then that's going to cost a lot more money. And it's also not as much fun to be in a facility like that as it is to be at home. It's certainly better to be at home. So sometimes these little pieces of work which don't cost a lot can really bring some value. Let's talk about how you kind of teased us a little bit with some digital tools that might be helpful. One of them is using the patient portal or an app that can take a picture that you can use. Take a picture with your phone and send it to your surgeon or your surgical team. And hey, there's really no reason for me to come in the main question that you're going to that you need to see me for is just to look at my wound. If the rest of it is just me talking to you on the phone, or over a video, then that's easy. And then that saves everyone time and money. Are there other things that you've seen kind of be successful in general for patient engagement for some of these, these procedures?
Karen Joswick: I think there's some really interesting ones specifically around I've seen for cardiac surgery and or those reminding the patient of just some of the exercises that they need to be doing. So, you know, like, did you do these exercises kind of post-surgery, you know, for cardiac surgery, it's, you know, making sure that they're doing there is, you know, incentive spirometry and they're coughing. Right. Just some of these basic things like, have you done this? And those are in the early days. We know that makes a big difference for folks that have had, you know, orthopedic procedures. It's obviously watching the, watching all of these surgical sites, but exercising and moving and, you know, did you get up and move around.
And so, I think that there are gentle reminders and app tools, right, that are ingrained into folks' phones that they can either go to the patient or to their supporter. You know, did mom get up today? And I think that we've certainly grown and evolved so much. I mean, we have reminders to my Amazon is going to run out of paper towels, and I get a reminder, hey, Karen, do you want to order more paper towels? Right? As opposed, why can't we do this with some of our surgical is, and I think we're seeing it, but it's not embedded in just this is good care. Then it goes back to that clinical pathway. This is just good care.
Dr. Craig Joseph: Yeah. I, you know, and that good care concept I think really resonates with clinicians especially. We don't really need to talk about TEAM versus another program. It's just oh it doesn't really matter what your insurance is. It doesn't matter how you're paying for this. These are things that we do for all of our patients who are undergoing these procedures.
Karen Joswick: And oh, by the way, come with some of the other commercial insurance companies who are having conversations if they haven't already. They're looking at this to say, well, why would it matter if it's Medicare or a commercial plan? Why wouldn't we want you to save money for our patients, too? So, I think I've heard from some health systems that we're doing work with that their commercial plan has said we'd like to talk about doing bundles and for these patients too. So, I don't think it's that far for health systems to see a knock on the door about this one.
Dr. Craig Joseph: It makes complete sense. And again, that I typically say that, my job when I, when I've been the CMO before with one foot in the I.T world and one foot in the clinical world, is to make it easy to do the right thing, that the hard part is figuring out what the right thing is in this case where we're being told, and I think there's some consensus about what the right thing is, and then we just need to enable it, pivoting off of that, enabling, making it easy to do the right thing. How do we do that? And the tool that most clinicians use all day is the electronic health record.
So, we're kind of like, I know I've just opened up a whole can of worms. Are there clinical decision support tools, or do we really need to rethink how we use clinical decision support for some of this? Have you seen any organizations successfully figure this out?
Karen Joswick: It's interesting. You said clinical decision support and I think probably everyone listening just like, got a chill, right? I mean, think about how we spent the last 20 years implementing these rule-based algorithms. If this then this, right. And these alerts that we have out to folks. And now we're moving towards more AI tools where we're trying to really learn from prior decisions to make more informed and more enabled, you know, decision support. And so, when I think about how clinical decision support can evolve with value-based care, we really need clinical decision support tools that help us manage some of the outliers and the ones that are, if you will, where we have blind spots. And that's not always been the case for CCDs or, you know, the decision support tools at the 80% that fits in the square peg.
Right? We'll tell you to do this. And so, you think about the patients who we'll pick on the cardiac surgery patients, since that's our theme today that we've been talking about. What about the patients who maybe don't have a good support system, or they don't have transportation, or they are not going to be able to get food at home. And we need to worry about meals on the wheel, meals on wheels, or we need to worry about follow up, transportation to home, whatever it may be. I think that's where there is power in some of the new models and some of the new testing that's happening in their EMR around AI, clinical decision support. And I think this is whereas informatics leaders, we've got to lean in and kind of harness that because it's the 20% that we keep missing. That can be a challenge.
Dr. Craig Joseph: Do we definitely focus on the easy part? Why? Because we're humans and that's easier to do that. And so, but your points well taken in that I found if I really, really want to irritate a physician, I should remind them to do something that they were just about to do. Yeah, they really dislike that. That's a big bummer. And so, kind of making sure that clinical decision support helps, whether it's a physician who's seeing the patient, pre-op or in a, in a follow up, appointment or it's more of a kind of a population health perspective.
Are there any tips or obvious things that we should be doing from a population health, from dealing with multiple patients for team or for other programs like it that we don't that you typically see folks aren't doing.
Karen Joswick: You know, I think that there is a tremendous opportunity to kind of keep your head down and lean in on some of the projects that a lot of health systems are already doing. And, right, those are data standardization. Right now, so many health care organizations are receiving claims data, maybe from a payer or from the federal government, and they just don't know what to do with it. You've got to be able to integrate claims and clinical data together. And if you don't have a roadmap and a plan for that, you're going to be behind. You're just going to be behind. It doesn't matter what model it is. So that's something that's really important. If you don't have a way to give performance dashboards right back to your providers, sometimes we would lovingly call them provider scorecards, right? So, if you don't have those things in play, and that they're actually being used. Right. So, it's not enough to have a dashboard, but are they actually being used in a collaborative sense and driving outcomes? You need to look at that because that kind of data is what's ultimately, we, we see the people who are top tier, top performers in these value-based care programs.
It's because they have the data right in front of them. And they are, you know, just moving right along and using those data insights. And then Craig, the last one I would say is it goes back to the claims a little bit. If you don't have a collaborative relationship with your payer, CMS or your commercial payers. And what I mean by that is there's some sort of data sharing. Right? So, think most health systems work with ten or 15 different insurance companies rate payers. And guess how many file formats are sent to them? Exactly. The number of payers is. Like nobody's using a consistent file format. Nobody's using consistent tools or definitions. And so, the onus, unfortunately, is sitting on the health system, and there are some tools that have starting to improve that. But if you don't have a strategy to take all of this external data in, normalize it and then share it with your clinicians and your operators, you're going to be very hard to blindly perform well without those insights.
Dr. Craig Joseph: Let me just jump up. And in that last word you said insights. That's so it's not the data that I'm interested in. It's what I am doing. What am I doing wrong or what am I not doing right that these insights can bring to me so that I can say, you're right. I never asked about stairs, or no one on my team asked about stairs, or they did, and the patient said, yeah, I have stairs. And then that was recorded dutifully in an electronic health record. And then no one did anything with that information, and we were setting ourselves up for failure. So, yeah, that, that that plan to actually take data and move it into insights and then make actions out of those, that's where a lot of people don't design their processes. Well, this was great, Karen. Thank you so much. We always end with the same question, which is that we're talking about design and intentionality. Is there something that you use that's so well designed that you feel joy whenever you interact with it? Anything like that in your life?
Karen Joswick: I've got kids, probably like most folks, and I have to track them all down and they are everywhere. So, I really appreciate some of the calendaring options to just share with them. But also, there's an app called Life 360 where you can track your kids. And so, like the teenage driver that's driving fast and so forth, so I think me, on a personal level, the ability to monitor and know what's going on with my kids in this tech-enabled world and still be close to them is a good place.
Dr. Craig Joseph: It was much more complicated than now to know people they needed to be. And so, I accept your calendar option, and I think there is some joy in that. It's a lack of stress. Right. Where's my kid? He was supposed to have called me. He didn't call me. Let me track his location. He's still on the baseball field or at the high school where I know that he's okay because he's obviously been paying some more attention to sports than to answering my texts.
Karen Joswick: For me, the calendar growing up was the calendar on the wall of the kitchen, and my signal to come home was the streetlights turning on when it was dark. So, it's, it's a very different world to imagine all of parenting and so forth. So, yeah, that's my season of life right now.
Dr. Craig Joseph: I love it; I love it. Well, thank you again. It's been a pleasure. And look forward to seeing how, team works out for the 25%, lucky participants starting next year.
Karen Joswick: Thanks, Craig. A pleasure. It's always great talking to you.