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NAMSS
H&HN Daily: Putting the Focus of Medical Education on Competency
Med school ideas target competency, population health.
By Paul Barr, June 17, 2013
When Susan Skochelak, M.D., recently sat down to talk about the American Medical Association's $10 million effort to kickstart the the transformation of medical education, she offered a good account of why it was needed.
Skochelak, AMA group vice president of medical education and director of the association's Center for Transforming Medical Education, described how the world of health care is changing drastically in areas such as reimbursement and technology, and medical education needs to change with it.
Read the rest at hhnmag.com.
By Paul Barr, June 17, 2013
When Susan Skochelak, M.D., recently sat down to talk about the American Medical Association's $10 million effort to kickstart the the transformation of medical education, she offered a good account of why it was needed.
Skochelak, AMA group vice president of medical education and director of the association's Center for Transforming Medical Education, described how the world of health care is changing drastically in areas such as reimbursement and technology, and medical education needs to change with it.
Read the rest at hhnmag.com.
AHANews.com: AHA backs emergency care liability bill
June 10, 2013
AHA today voiced support for the Health Care Safety Net Enhancement Act (S. 961/H.R. 36), legislation that would provide medical liability protections under the Federal Tort Claims Act to hospitals and physicians providing emergency care. Specifically, the bill would extend to hospitals, emergency departments and physicians who provide services pursuant to the Emergency Medical Treatment and Labor Act the same medical liability protections given to employees of Community Health Centers.
Read more about it at AHANews.com.
AHA today voiced support for the Health Care Safety Net Enhancement Act (S. 961/H.R. 36), legislation that would provide medical liability protections under the Federal Tort Claims Act to hospitals and physicians providing emergency care. Specifically, the bill would extend to hospitals, emergency departments and physicians who provide services pursuant to the Emergency Medical Treatment and Labor Act the same medical liability protections given to employees of Community Health Centers.
Read more about it at AHANews.com.
Part Two: HCAHPS -- What is this and where did it come from?
For this week's guest feature, Nancy English returns to provide information on the HCAHPS survey. Welcome back, Nancy!
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is performed after patients have received inpatient care. One might think that this would only impact hospitals when, actually, questions on the survey relate also to the physicians we credential and work with every day.
There are 18 questions on the HCAHPS survey questionnaire that cover 8 areas relating to the patient’s healthcare experience:
1. physician communication2. nursing communication 3. cleanliness and quietness of facility4. management of pain 5. communication about medications6. discharge information7. staff responsiveness 8. overall perception of the experience/facility
The survey also includes a question about the patient’s willingness to recommend that facility to others.
I listed “physician communication” first for a reason. Do you have physicians who do not seem to communicate well with patients….or anyone else? We all probably have one or two whom we could name right off the top of our head. How is that physician affecting your HCAHP scores? What kind of rating would you give him/her if you were his/her patient? In a true patient-centered environment, we would want to find out!
You may still wonder what this means to each of us as MSPs. The answer ties directly to...yes, you may have already guessed...reimbursement. Scores are calculated and compared to other facilities for percentile ranking. Reimbursement from CMS is based upon the facility’s ranking. As we move further into the unknown future of healthcare, it will be important for each of us to understand our role, whether great or small, in helping our facilities improve HCAHP scores.
More to come next time. Learn more about HCAHP here.
If you are interested in becoming a guest blogger, let us know! We'd love to hear from you.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is performed after patients have received inpatient care. One might think that this would only impact hospitals when, actually, questions on the survey relate also to the physicians we credential and work with every day.
There are 18 questions on the HCAHPS survey questionnaire that cover 8 areas relating to the patient’s healthcare experience:
1. physician communication2. nursing communication 3. cleanliness and quietness of facility4. management of pain 5. communication about medications6. discharge information7. staff responsiveness 8. overall perception of the experience/facility
The survey also includes a question about the patient’s willingness to recommend that facility to others.
I listed “physician communication” first for a reason. Do you have physicians who do not seem to communicate well with patients….or anyone else? We all probably have one or two whom we could name right off the top of our head. How is that physician affecting your HCAHP scores? What kind of rating would you give him/her if you were his/her patient? In a true patient-centered environment, we would want to find out!
You may still wonder what this means to each of us as MSPs. The answer ties directly to...yes, you may have already guessed...reimbursement. Scores are calculated and compared to other facilities for percentile ranking. Reimbursement from CMS is based upon the facility’s ranking. As we move further into the unknown future of healthcare, it will be important for each of us to understand our role, whether great or small, in helping our facilities improve HCAHP scores.
More to come next time. Learn more about HCAHP here.
If you are interested in becoming a guest blogger, let us know! We'd love to hear from you.
The Data Bank: The Top 5 Continuous Query Questions Information Answered
Before organizations decide to enroll their practitioners in Continuous Query, they often have basic questions about the service. The Data Bank answers the top five questions that may persuade your organization to switch from One-Time Query to Continuous Query.
Many organizations consider Continuous Query to be a "best practice" because subscribers receive an initial query response for each enrolled practitioner and continue to receive ongoing monitoring for one year. When a report of a medical malpractice payment or other adverse action (such as a licensure or privileging action, Medicare/Medicaid exclusion, or health care-related conviction or judgment), is filed with the NPDB on an enrolled practitioner, your organization receives immediate notification.
Read the rest at The Data Bank.
Many organizations consider Continuous Query to be a "best practice" because subscribers receive an initial query response for each enrolled practitioner and continue to receive ongoing monitoring for one year. When a report of a medical malpractice payment or other adverse action (such as a licensure or privileging action, Medicare/Medicaid exclusion, or health care-related conviction or judgment), is filed with the NPDB on an enrolled practitioner, your organization receives immediate notification.
Read the rest at The Data Bank.
HCAHPS - What is this and where did it come from? A Guest Post from Nancy English
Hello Readers,
In order to provide diverse, original, and up-to-the-minute information on important industry topics, your NAMSS Blog will now feature guest bloggers. If you have some ideas for a blog entry and would like to be considered for guest blogger opportunities, please contact us.
Our first guest blogger is a knowledgeable Medical Staff Professional with more than 20 years of experience: Nancy L. English, CPMSM, Director of Medical Staff Services at Texas Health Harris Methodist Hospital HEB in Bedford, Texas. Her years of work and study in the Medical Staff Services field have given her a significant knowledge base from which to draw and willingly share with others.
Nancy is passionate about education, particularly when it comes to matters relating to any and all MSPs. Nancy will provide a series of blog posts on timely topics. Her first post, "HCAHPS - What is this and where did it come from?", is below. Thank you, Nancy, and welcome aboard!
HCAHPS - What is this and where did it come from? HCAHPS is an acronym for Hospital Consumer Assessment of Healthcare Providers and Systems. It is a standardized survey of patients (post-discharge) and their perspectives on the care they received during their recent hospital stay.
The HCAHPS came from the Centers for Medicare & Medicaid Services (CMS) as a way to measure hospital quality, and to compare hospitals locally, regionally and nationally. This survey has been endorsed by the National Quality Forum which has representatives from health care, patient/consumer groups, the government and other groups with vested interests in the health care provided in our country.
One purpose for HCAHPS is to collect data from patients, compile a statistical picture of quality provided at health care entities across the nation, compare those statistics, and publish their findings so the public can make decisions on where they want to go for their health care needs.
There is actually much more to it than explained in this brief post. So, what else is there and what does this mean for my health care entity, physician group or network? Stay tuned for more on this topic.
In order to provide diverse, original, and up-to-the-minute information on important industry topics, your NAMSS Blog will now feature guest bloggers. If you have some ideas for a blog entry and would like to be considered for guest blogger opportunities, please contact us.
Our first guest blogger is a knowledgeable Medical Staff Professional with more than 20 years of experience: Nancy L. English, CPMSM, Director of Medical Staff Services at Texas Health Harris Methodist Hospital HEB in Bedford, Texas. Her years of work and study in the Medical Staff Services field have given her a significant knowledge base from which to draw and willingly share with others.
Nancy is passionate about education, particularly when it comes to matters relating to any and all MSPs. Nancy will provide a series of blog posts on timely topics. Her first post, "HCAHPS - What is this and where did it come from?", is below. Thank you, Nancy, and welcome aboard!
HCAHPS - What is this and where did it come from? HCAHPS is an acronym for Hospital Consumer Assessment of Healthcare Providers and Systems. It is a standardized survey of patients (post-discharge) and their perspectives on the care they received during their recent hospital stay.
The HCAHPS came from the Centers for Medicare & Medicaid Services (CMS) as a way to measure hospital quality, and to compare hospitals locally, regionally and nationally. This survey has been endorsed by the National Quality Forum which has representatives from health care, patient/consumer groups, the government and other groups with vested interests in the health care provided in our country.
One purpose for HCAHPS is to collect data from patients, compile a statistical picture of quality provided at health care entities across the nation, compare those statistics, and publish their findings so the public can make decisions on where they want to go for their health care needs.
There is actually much more to it than explained in this brief post. So, what else is there and what does this mean for my health care entity, physician group or network? Stay tuned for more on this topic.
The KHN Blog: Docs, Nurses Disagree Over Expanded Nurse Roles
Alvin Tran, May 15th, 2013
As nurse practitioners lobby to expand their authority and scope of practice in many states, a New England Journal of Medicine study released Wednesday documents a deep chasm between how doctors and nurses regard the issue.
The study found the two groups overwhelmingly agreed that nurse practitioners should be able to practice to the full extent of their schooling and training. But doctors were less likely to concur that advanced practice nurses should lead medical homes, which deliver team-based, coordinated care to patients. Only 17 percent of the 505 primary care physicians surveyed agreed with that notion, compared to 82 percent of the 467 nurse practitioners surveyed.
Read the rest from KHN here.
As nurse practitioners lobby to expand their authority and scope of practice in many states, a New England Journal of Medicine study released Wednesday documents a deep chasm between how doctors and nurses regard the issue.
The study found the two groups overwhelmingly agreed that nurse practitioners should be able to practice to the full extent of their schooling and training. But doctors were less likely to concur that advanced practice nurses should lead medical homes, which deliver team-based, coordinated care to patients. Only 17 percent of the 505 primary care physicians surveyed agreed with that notion, compared to 82 percent of the 467 nurse practitioners surveyed.
Read the rest from KHN here.
Medscape: Want Hospital Admitting Privileges? First Pass a Drug Test
NAMSS President, Melissa Walters, is quoted in the article below.
By Robert Lowes
May 16, 2013
Physicians seeking medical staff privileges at a hospital should first go into a bathroom and fill a small paper cup, all for the sake of patient safety, suggests an article published online April 29 in JAMA.
Requiring physicians to take a urine drug test as a condition of employment is already the norm at hospitals, but lead author Julius Pham, MD, PhD, and colleagues recommend that hospitals also screen medical staff applicants for possible impairment by substance abuse.
Read the full article and see what Melissa had to say at medscape.com.
By Robert Lowes
May 16, 2013
Physicians seeking medical staff privileges at a hospital should first go into a bathroom and fill a small paper cup, all for the sake of patient safety, suggests an article published online April 29 in JAMA.
Requiring physicians to take a urine drug test as a condition of employment is already the norm at hospitals, but lead author Julius Pham, MD, PhD, and colleagues recommend that hospitals also screen medical staff applicants for possible impairment by substance abuse.
Read the full article and see what Melissa had to say at medscape.com.
NEJM: Expanding the Role of Advanced Nurse Practitioners — Risks and Rewards
John K. Inglehart, May 16, 2013
As the 2014 expansion of coverage mandated by the Affordable Care Act (ACA) looms larger, one question with no ready answer is how health care providers, policymakers, and payers will cope with an expected surge in patient demand for services. A shortage of primary care physicians to treat newly insured persons is the most immediate health workforce issue, but when added to the nation's population growth and more aging patients who require treatment, finding a practitioner may become an even more daunting challenge.
Read the rest at nejm.org.
As the 2014 expansion of coverage mandated by the Affordable Care Act (ACA) looms larger, one question with no ready answer is how health care providers, policymakers, and payers will cope with an expected surge in patient demand for services. A shortage of primary care physicians to treat newly insured persons is the most immediate health workforce issue, but when added to the nation's population growth and more aging patients who require treatment, finding a practitioner may become an even more daunting challenge.
Read the rest at nejm.org.
OIG Issues Update
On May 8, the Office of Inspector General issued an update to its Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs.
The full report can be found here.
The full report can be found here.
HHS: The NPDB-HIPDB Has Become the NPDB
Effective May 7, 2013, the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) are now one Data Bank: the NPDB. The official website is http://www.npdb-hipdb.hrsa.gov/. Users should update their bookmarks with the new Data Bank website address.
Users will experience no disruption in Data Bank service, and essentially no change to their reporting workflow or requirements. The HIPDB information did not go away, but was integrated into the NPDB. Users’ access to Data Bank information may expand, meaning that query results may include reports that were previously only accessible through querying the HIPDB.
Read the rest here.
Users will experience no disruption in Data Bank service, and essentially no change to their reporting workflow or requirements. The HIPDB information did not go away, but was integrated into the NPDB. Users’ access to Data Bank information may expand, meaning that query results may include reports that were previously only accessible through querying the HIPDB.
Read the rest here.
NYT: Why Doctors Are Sued
Nicholas Bakalar, April 29, 2013
What kind of medical error accounts for most malpractice payments: Surgical mistakes? Overdoses? Obstetric errors?
No, no and no. The most common cause of paid claims for malpractice is making errors in diagnosis.
Using the National Practitioner Data Bank, which records actions taken by state licensing authorities against health care practitioners, researchers found that 28.6 percent of malpractice payments are for diagnostic mistakes.
Read the rest at well.blogs.nytimes.com
What kind of medical error accounts for most malpractice payments: Surgical mistakes? Overdoses? Obstetric errors?
No, no and no. The most common cause of paid claims for malpractice is making errors in diagnosis.
Using the National Practitioner Data Bank, which records actions taken by state licensing authorities against health care practitioners, researchers found that 28.6 percent of malpractice payments are for diagnostic mistakes.
Read the rest at well.blogs.nytimes.com
amednews.com: Calming a hospital culture clash
Bridging communication gaps between medical staffs and hospitals can prevent unnecessary lawsuits.
Alicia Gallegos, amednews staff, April 29, 2013
After two years, a heated dispute between Memorial Hermann Memorial City Medical Center and its medical staff finally came to a head in 2012. The conflict arose from a set of amended bylaws the center's administration wanted to enact. The medical staff refused to approve the bylaws and recommended a separate set of bylaws.
“At that point, we had reached an impasse, because the medical staff bylaws can't be amended without the medical staff and the governing body's approval,” said Bernard Duco Jr., chief legal officer for Memorial Hermann Health System, based in Houston.
Instead of moving toward litigation or allowing the dispute to fester, the hospital and medical staff engaged in a conflict intervention. Leaders from both sides agreed to a series of sit-down sessions to discuss their concerns. They reached a compromise on several major issues.
Read the rest at amednews.com.
Alicia Gallegos, amednews staff, April 29, 2013
After two years, a heated dispute between Memorial Hermann Memorial City Medical Center and its medical staff finally came to a head in 2012. The conflict arose from a set of amended bylaws the center's administration wanted to enact. The medical staff refused to approve the bylaws and recommended a separate set of bylaws.
“At that point, we had reached an impasse, because the medical staff bylaws can't be amended without the medical staff and the governing body's approval,” said Bernard Duco Jr., chief legal officer for Memorial Hermann Health System, based in Houston.
Instead of moving toward litigation or allowing the dispute to fester, the hospital and medical staff engaged in a conflict intervention. Leaders from both sides agreed to a series of sit-down sessions to discuss their concerns. They reached a compromise on several major issues.
Read the rest at amednews.com.
Medscape: New Bill Would Clarify Who Is a Medical Doctor and Who Isn't
Marcia Frellick, April 24, 2013
Sponsors of a bill recently introduced in the House of Representatives aim to eliminate consumers' confusion over who is considered a medical doctor.
Rep. Larry Bucshon, MD, (R-In.) and Rep. David Scott, (D-Ga.) are cosponsors of the bill, called the "Truth in Healthcare Marketing Act of 2013," (HR 1427), which was introduced on April 9 and referred to the Energy & Commerce committee.
The bill would make it illegal for any healthcare professional to make false or deceptive claims in advertisements and marketing materials regarding their training, degree, license, or clinical expertise. Anyone marketing a health provider's services also must clearly state the license the provider holds.
Read the rest at medscape.com.
Sponsors of a bill recently introduced in the House of Representatives aim to eliminate consumers' confusion over who is considered a medical doctor.
Rep. Larry Bucshon, MD, (R-In.) and Rep. David Scott, (D-Ga.) are cosponsors of the bill, called the "Truth in Healthcare Marketing Act of 2013," (HR 1427), which was introduced on April 9 and referred to the Energy & Commerce committee.
The bill would make it illegal for any healthcare professional to make false or deceptive claims in advertisements and marketing materials regarding their training, degree, license, or clinical expertise. Anyone marketing a health provider's services also must clearly state the license the provider holds.
Read the rest at medscape.com.
WSJ: The Talking Cure for Health Care
Improving the ways doctors communicate with their patients can lead to better care -- and lower costs
Laura Landro, April 8, 2013
Doctors need to work on their people skills.
It's something patients have grumbled about for a long time. Doctors are rude. Doctors don't listen. Doctors have no time. Doctors don't explain things in terms patients can understand.
It's a familiar litany. But here's what is new: The medical community is paying attention.
Read the rest at wsj.com
Laura Landro, April 8, 2013
Doctors need to work on their people skills.
It's something patients have grumbled about for a long time. Doctors are rude. Doctors don't listen. Doctors have no time. Doctors don't explain things in terms patients can understand.
It's a familiar litany. But here's what is new: The medical community is paying attention.
Read the rest at wsj.com
Pennsylvania State Board of Medicine Approves Temporary Authorization for Physician Assistants to Practice Pending Board Approval of the “Application for Registration as a Supervising Physician”
At its meeting on March 21, 2013, the State Board of Medicine approved a temporary authorization for Physician Assistants to practice pending formal approval of the "Application for Registration as a Supervising Physician."
Upon submission of the application, Board staff will review the application ONLY for completeness and issue a letter to the supervising physician providing the temporary authorization for the physician assistant to begin practice.
Read the rest of the notice here.
Upon submission of the application, Board staff will review the application ONLY for completeness and issue a letter to the supervising physician providing the temporary authorization for the physician assistant to begin practice.
Read the rest of the notice here.
fiercehealthit.com: Robo-surgery mistakes land physician in hot water
April 15, 2013, Susan D. Hall A surgeon at Porter Adventist Hospital in Denver faces 14 counts of unprofessional conduct associated with use of the hospital's robotic surgery arm, according to the Denver Post.
The Colorado medical board alleges that Warren Kortz, in procedures performed from 2008 to 2010, made errors including injuring patients through improper padding and positioning; subjecting some patients to overly long surgeries; and leaving sponges and instruments inside patients. The board claims Kortz had to abort kidney donations because of mistakes. Read the rest of the story at fiercehealthit.com.
The Colorado medical board alleges that Warren Kortz, in procedures performed from 2008 to 2010, made errors including injuring patients through improper padding and positioning; subjecting some patients to overly long surgeries; and leaving sponges and instruments inside patients. The board claims Kortz had to abort kidney donations because of mistakes. Read the rest of the story at fiercehealthit.com.
Pharmacy Choice.com: Texas Emergency Physician Sues Hospital in EMTALA Whistleblower Claim
Robert A. Bitterman, MD, JD, FACEP
A U.S. District Court in Texas allows a physician's retaliation claim against the hospital that allegedly terminated his privileges for reporting violations of the Emergency Medical Treatment and Labor Act (EMTALA).
The Case of Dr. Walter Zawislak v. Memorial Hermann Hospital System1
Memorial Hermann Hospital suspended the medical staff privileges of Dr. Zawislak, purportedly for substandard care, and reported the adverse action to the National Practitioner Data Bank (NPDB). Consequently, his employer, Team Health, terminated his contract to work at Memorial Hermann.
Dr. Zawislak claimed that the hospital rescinded his clinical privileges in retaliation for disclosing and reporting EMTALA violations committed by the hospital. He alleged that two unstable emergency department (ED) patients were transferred from Memorial Hermann to another trauma center because Memorial Hermann's trauma surgeon on-call was either unavailable or unqualified to manage the patients' injuries. He reported the trauma surgeon's conduct to the ED medical director and the hospital's "Root Cause Analysis Committee."
Read more about this case at pharmacychoice.com.
A U.S. District Court in Texas allows a physician's retaliation claim against the hospital that allegedly terminated his privileges for reporting violations of the Emergency Medical Treatment and Labor Act (EMTALA).
The Case of Dr. Walter Zawislak v. Memorial Hermann Hospital System1
Memorial Hermann Hospital suspended the medical staff privileges of Dr. Zawislak, purportedly for substandard care, and reported the adverse action to the National Practitioner Data Bank (NPDB). Consequently, his employer, Team Health, terminated his contract to work at Memorial Hermann.
Dr. Zawislak claimed that the hospital rescinded his clinical privileges in retaliation for disclosing and reporting EMTALA violations committed by the hospital. He alleged that two unstable emergency department (ED) patients were transferred from Memorial Hermann to another trauma center because Memorial Hermann's trauma surgeon on-call was either unavailable or unqualified to manage the patients' injuries. He reported the trauma surgeon's conduct to the ED medical director and the hospital's "Root Cause Analysis Committee."
Read more about this case at pharmacychoice.com.
amednews.com: Court upholds same-specialty expert witness requirement
In addition to ruling that the Arizona law is constitutional, justices defined “specialist” and “board certified” and outlined how courts should apply the law.
Tanya Albert Henry, April 3, 2013
Arizona physicians say a state high court ruling will help prevent frivolous medical liability lawsuits from moving forward.
The Supreme Court of Arizona in March ruled that a law requiring experts in such cases to share the same specialty as the treating physician does not violate state or federal laws that guarantee people the right to go to court.
Read more on the ruling at amednews.com.
Tanya Albert Henry, April 3, 2013
Arizona physicians say a state high court ruling will help prevent frivolous medical liability lawsuits from moving forward.
The Supreme Court of Arizona in March ruled that a law requiring experts in such cases to share the same specialty as the treating physician does not violate state or federal laws that guarantee people the right to go to court.
Read more on the ruling at amednews.com.
amednews: Unseen and online: What are the limits for patient care?
With telemedicine expanding, doctors and others are puzzling out if there are acceptable substitutes for an in-person medical visit.
Sue Ter Maat, April 8, 2013
Having clinicians diagnose and treat patients over the Internet, without their ever having seen those patients in person, is making a comeback.
In the early 2000s, a state medical board shut down one attempt to make such online care legitimate. But today, in an age of greater comfort with telemedicine and delivering care over the Internet, the strategy is getting a closer look, as health leaders try to find ways to reduce costs and help expand patient access. Regulations generally don’t declare explicitly that treatment of previously unknown patients over the Internet is wrong. This provides an opening for an activity once associated mostly with online pill mills to be embraced by mainstream medicine.
Read the rest at amednews.com.
Sue Ter Maat, April 8, 2013
Having clinicians diagnose and treat patients over the Internet, without their ever having seen those patients in person, is making a comeback.
In the early 2000s, a state medical board shut down one attempt to make such online care legitimate. But today, in an age of greater comfort with telemedicine and delivering care over the Internet, the strategy is getting a closer look, as health leaders try to find ways to reduce costs and help expand patient access. Regulations generally don’t declare explicitly that treatment of previously unknown patients over the Internet is wrong. This provides an opening for an activity once associated mostly with online pill mills to be embraced by mainstream medicine.
Read the rest at amednews.com.
NAMSS Comments on Proposed CMS Rule
Shortly after CMS issued its proposed rule to "promote program efficiency, transparency, and burden reduction" in early February, NAMSS compiled a volunteer task force to review the proposal and respond to CMS.
The Task Force specifically responded to five components of the proposal: dietitian privileges, physician representation on the governing body, medical staff membership criteria, medical staff requirements for individual hospitals, and outpatient service orders from practitioners who are not members of the medical staff.
Our comments to CMS are posted on the NAMSS website. We will keep you updated on CMS's final rule, and as always, are happy to answer any questions that you may have.
The Task Force specifically responded to five components of the proposal: dietitian privileges, physician representation on the governing body, medical staff membership criteria, medical staff requirements for individual hospitals, and outpatient service orders from practitioners who are not members of the medical staff.
Our comments to CMS are posted on the NAMSS website. We will keep you updated on CMS's final rule, and as always, are happy to answer any questions that you may have.