Taking Healthcare by Storm: Industry Insights with Dr. Rich Greenhill

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Rich Greenhill, DHA, FACHE, Chief Transformation Officer at Quality Insights.

Learn more about The International Society for Quality in Health Care (ISQua). 

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This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-GEN-092024-GK

Transcript

Welcome to Taking Healthcare by Storm, Industry Insights, the podcast that delves into the captivating intersection of innovation, science, compassion, and care.

In each episode, Quality Insights Medical Director Dr.

Jean Storm will have the privilege of engaging with leading experts across diverse fields including dieticians, pharmacists, and brave patients navigating their own healthcare journeys.

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania, and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hello, everyone, and welcome to Taking Healthcare by Storm.

I am Dr.

Jean Storm, and I am the Medical Director at Quality Insights.

And today, I'm very excited to be joined by our guest, Dr.

Richard Greenhill, D-H-A-F-A-C-H-E.

He is the Chief Transformation Officer here at Quality Insights.

And I'm going to say, I just love that name, because that's what we need to be doing in healthcare, right?

And to make changes, we need to be transforming and making things better.

So I think that's just a fantastic name, and the title suits him very well.

He is also the Editor-in-Chief of the International Journal for Quality in Health Care Communications.

And I am just delighted to talk to him today.

I thought we would start by just getting a background on what he does, what he's involved in, and then we'll delve into some healthcare quality issues facing the US.

So, Dr.

Greenhill, Rich, thank you so much for joining us today.

Thank you, Dr.

Storm.

You know, Jean, it's great to be here and great to be part of Quality Insights.

I am very excited about the work we do and just happy to be here.

So, you know, I started my career in the Navy around, I guess what, 32 years ago, more than 32 years ago, and it really began in lab medicine.

And I was in the laboratory medicine, blood banking, microbiology were kind of my focus areas and areas I was interested in.

And over time, being in the Navy, I kind of roasted the ranks and I got into Six Sigma and project management.

And then when I retired from the Navy 12 years ago, I went to the private sector and made my way through just a litany of roles.

And so quality and performance improvement has always kind of been the center of my professional life.

And analytics has always been kind of part of that, but I more formalized that experience a few years ago and I'm also a data scientist now.

So I'm not a practicing data scientist, right?

Because it's a full time job, but definitely have those skills and understanding.

So it's good to be here.

Well, yes, we are delighted to have you here.

And so you kind of gave us a little bit of a background into how you came to do what you do.

So what were you doing right before you joined us at Quality Insights?

I know you were doing some teaching.

Yeah, you know, I was a professor down at Texas Tech University Health Sciences Center in out of Lubbock, Texas.

And also I ran the university's first, you know, technology accelerator for artificial intelligence and advanced manufacturing.

So basically I was running a startup outfit where, you know, we took teams through, you know, ideation all the way to create the minimum viable product.

So that was really cool.

And, you know, kind of fits in line with what we do here, you know, around some of our offerings.

So I would I would definitely agree.

No, now you have done some training for us here, Quality Insights around TeamSTEPPS, something that I am so excited about, passionate about.

I love patient safety.

So can you talk a little bit about TeamSTEPPS?

Absolutely.

So HRQ and, you know, I have to be careful with that for them.

So the Agency for Healthcare Research and Quality, as well as the Department of Defense, you know, created TeamSTEPPS a few years ago in the mid-2000s.

And what the program was, it was based off of research around high reliability organizations like the aviation industry, you know, nuclear propulsion and power industry and in military.

And so TeamSTEPPS is important because what it does in those industries, as well as now in healthcare, is it's about making sure that communication and teamwork happens in a way that supports processes in complex, you know, systems.

And so we know that, you know, it's important because in aviation and nuclear power, you know, if we have a risk from an unintended event is really high, it could be catastrophic, right, for society.

So it's the same in healthcare.

I mean, you're a practicing physician, so you know that communication is often the biggest issue with patient safety errors as well as events.

And so TeamSTEPPS really helps us make sure that communication happens and collaboration happens through sound processes, where staff really feel comfortable to step up and say, hey, I think there's an issue or whatever, and particularly in high-risk areas.

But TeamSTEPPS is amazing.

And I think we're on a new iteration of it now.

I think 3.0.

But it's always been something that I've been interested in.

And a little did I know when I was in the Navy that we functioned on the ships in a high, reliable type setting, where communication was always stressed and safety.

So very happy that those things lined up with my health care work and patient safety.

Yeah, I would agree.

I really find it interesting that processes that work in one setting can be transferred to another setting.

And I feel like TeamSTEPPS is definitely that way.

And I think you mentioned Six Sigma, which is similar.

I think it was used in like, I think it was started by an engineer at some point.

And so can you tell us about Six Sigma and how it applies to health care?

Sure.

Well, Six Sigma came out of the movement.

If you have a few revolutions around the moon, you remember tone quality management.

So Six Sigma sort of cascaded from that.

And really what it is, is it's a methodology that focuses on removing variation in well-established processes.

So it's a sibling to Lean.

And Lean is about flow and streamlining.

And then you use Six Sigma once you have a streamlined process, then to control the variation.

Because variation, for example, manufacturing, which is where Lean came from, is detrimental to products being produced with speed.

So Lean is about speed, Six Sigma is about removing variation.

So they go well together.

And if you put those two things with TeamSTEPPS, just as an example, you can really have a very efficient operation.

It's not easy though, I'll say that.

It's a lot between getting to a high-reliable organization and high-functioning.

But those are the ingredients, if you will, that organizations can use.

I would definitely agree.

So I know you're also very active in the American College of Healthcare Executives.

So can you tell us a little bit about this organization and the part you play in it?

Sure.

So ACHE, which is called, is the premier healthcare organization, professional society for health care leaders and managers and executives.

And so they have all types of events that promote knowledge and lifelong learning.

And also they have the only board certification in health care management.

It's called fellow of the American College of Healthcare Executives.

So I'm a faculty member there.

So what that means is that sometimes I'm asked to present material to senior executives around the country and in some cases the world.

I'm also one of their speakers.

So I get invited to speak at Congress that we have once a year.

It had been in Chicago for many years, but it's moving around now and it's just really a wonderful event of collaboration and learning.

And then I also am an author more recently on one of their quality textbooks through Health Administration Press.

So it's really my way to give back and to continue my life-long learning journey.

Just as a health care leader, things are changing and it's always wonderful to hear other perspectives because we can get siloed in our organizations.

So ACHE is that substratum, if you will, to let people collaborate educationally.

So it's great.

I love that.

I think we were talking before we started recording about that.

You just became editor in chief of the International Journal for Health Care and Quality in Health Care.

I'm sorry.

Let's start again.

You just became editor in chief of the International Journal for Quality in Health Care Communications.

That's a mouthful.

Something that I know you're passionate about.

So tell us about the journal and what are the hot topics in the journal right now?

Yeah.

So, you know, like leaving academia, I was there for five years and I love learning, right?

And so I was always a deputy editor since they started this journal, which is a journal, another of the two journals of the International Society for Quality in Health Care.

So it's an open access journal, it's peer reviewed and we have readership around the world.

And really the focus of this journal is, you know, implementation science.

And, you know, so we take articles, you know, regular research articles, you know, but also healthcare evaluation and technology assessment, healthcare economics and utilization review, those kinds of practical things that people from around the world can read and really apply to their own processes.

So the hot topics are the hot topics of really, you know, what's going on in health care today, it's, you know, being efficient, it's technology use, it's performance improvement, artificial intelligence, you know, we have a lot of experts in the International Society for Quality that do, you know, a lot of processes around co-production and co-design of care, right?

Where the patients and clinicians come together to really create that plan and so forth.

So that's the journal and it's great.

You know, we have a big kickoff re-grand opening, I guess, if you will, coming up in January.

That will be taken over where we're going to unleash some great content for our readers.

And again, it's all about, you know, pushing health care improvement and quality and helping those that are most vulnerable among us.

Yeah, I love that you said that co-innovation, co-creation between clinician and patient.

I mean, you'd think that that is very, very common sense, but it is extremely innovative.

It's not something that many clinicians even think of.

I think you're right.

I think, you know, not just here in the US., but what I've seen in my global health work is a lot of times we see the physician as, you know, the captainship and that's fine.

But really, you know, I think physicians are facilitators of care, right?

And making sure that patients get what they need and sometimes some cultures, including, for example, my parents, if the doctor tells them, you know, do a backflip, they're going to do a backflip.

But they may not question why or how that fits into their life goals.

And so co-producing care, co-designing care, you know, is it makes sense, like you said.

Yes, definitely.

So your new title, your new position, Chief Transformation Officer.

So tell us in your words, what is a Chief Transformation Officer?

Well, you know, it's interesting.

That's what I've probably been doing the last 20 of my 32 years, you know, going in and, you know, really being a facilitator of change.

And so I'd say that, you know, several, you can read by the lines, several people have described what the role is, right?

But it's really a balance between short-term improvement and long-term value.

And I see myself, you know, on the executive team of the organization as an executive change facilitator, right?

And of course, here at Quality Insights, we're continuing our journey towards being more efficient and increasing value for our current and any future clients we serve.

So, you know, it's really, you know, being a voice for change and pivoting to be more efficient.

And, you know, value creation.

Those are kind of the the baselines.

That's how I would describe it.

I would love to hear what you think it is from your perspective as medical director.

So, you know, I would agree, like with all of what you've said.

What I really enjoy is that you'll maybe I feel like even just, you know, you just came on with the organization, but, you know, we've we've kind of been engaging and communicating with you for.

I can't even remember.

Maybe it's been a half a year, maybe now or a little bit more.

But it's like you plant seeds and then we kind of we grow the seeds.

And I think that that's like, you know, it's it's that is the best way to encourage change in my mind.

Because, you know, if you just tell somebody you need to do this, you need to do this.

People like don't don't do well with that kind of thing.

But if you give them kind of an idea for transformation and then and then the individuals come to take it on themselves and then they kind of drive forward, I think that is that is the recipe for transformation.

And that's what I've seen you do in the organization.

And it's just it's really it's fun to watch, I will say.

It's good to yeah.

And that facilitation piece that I mentioned is really important because every week we have smart.

I mean, we have smart people in the organization just like every organization does.

And so it's really about letting people be their best.

And that's kind of what I feel like I'm someone that can help shine a light where people can be their best and as we move forward.

So, yes, absolutely.

So I thought we would talk about some big issues facing health care quality in the US.

So let's just dive in access to health care.

Let's let's talk about your take on access to health care currently.

Well, you know, it's always been an issue back from the Triple A when that started, costs, patient satisfaction and outcomes.

And of course, now we're in the quintuple A where we've added provider satisfaction and health equity.

We know we've burned out some of our physicians and clinicians.

But the Affordable Care Act, you know, kind of expanded coverage back when it as it rolled out.

And so we have more insured people right now.

But care is still cost prohibitive for many because they have high deductibles.

I mean, drugs are really expensive and just the other pieces around health care, right?

Medical equipment, those kinds of things.

So access used to be really about coverage.

And now it's about how do you pay for care and even access it based on where you are in the country?

Right.

We have a rural health care crisis where if you live in certain parts of West Virginia or Texas or wherever, you you don't have the same access to care, even if you could pay for it.

You know, you can't get care.

The other problem I think we have with access to care is provider shortages.

I mean, positions, I mean, every everywhere you look, your colleagues are leaving the field and or not going into the field because of issues with burnout and so forth.

And so I think initially access was about being insured.

And that's what people thought it was.

Now we're at the point where access is about where you live and shortage of physicians.

Because I remember a few months ago to get my old man check up.

And my primary care provider, in when I tried to schedule the appointment in April, couldn't see me till October.

And I'm just like, okay, well, what if I had something I needed to be seen for now?

Would I just go to urgent care or whatever?

So I think access to care, even if you have insurance, is still hard even if you can pay for all of it, because we don't have providers and we have shortages.

So it's really a challenge.

I would agree.

It's definitely an issue with provider shortages in states like West Virginia.

It's really a huge, huge problem.

Leading into our next issue that I would love to get your take on, health disparities.

Yeah, health disparities is interesting.

You know, in a lot of talks I've given around the country, you know, maternal outcomes are, you know, we're, you know, we're a wealthy nation.

And so we have the worst maternal outcomes of all OECD nations, right?

And black women, for example, are worse than any of the countries, you know, maybe all put together.

And just, you know, with mortality, infant death.

I mean, again, we're high there.

We that's not something to celebrate, right?

So we also have geographic disparities.

Again, people can't access care because you don't have a physician.

Or if you're pregnant and you're, you know, ready to give birth and you have to drive 60 miles, that's that's not that's not great.

So I think we're still suffering from a lot.

And, you know, with inflation and all the other pressures, it's just kind of made disparities worse because there was some studies I was looking at and from the Commonwealth Fund that, you know, people will not get the care they need or not pick up their medication because they can't afford it because or maybe they just avoid getting care if they're diabetic and say, well, I'll go when I feel bad.

And you know that just being diabetic, for example, just because you don't feel bad doesn't mean there's not something bad going on inside of you.

So I think health disparities are a real challenge right now.

And, you know, I don't know what the answer is.

I think some of what we see around the use of technology.

Telemedicine was big back in the pandemic, but it seems like that's sort of been pulled back a little bit because, you know, it's not necessarily high revenue generating for a lot of folks and kind of levels the playing field.

So unfortunately, you know, some of that has gone away.

But I think we're going to have to think outside the box to really help people that are struggling with disparities.

I would agree.

I said, I think about that often about telemedicine, because it was huge in, you know, during the pandemic.

And, you know, physicians got paid for it.

And, you know, with that kind of access.

But it has kind of scaled back.

So I do think we need we need something else most definitely to reach the most vulnerable individuals because they aren't being reached now.

Medical errors, your thoughts on medical errors?

I bet we probably could talk for hours and hours.

Well, medical, this is where I cut my teeth.

And in quality, you know, it's the third leading cause of death in the US.

And misdiagnosis, I mean, you know, surgical errors.

I mean, if you just go to the Joint Commission or its website and look at the National Patient Safety Goals, it's all the things, what I call, unfortunately, the greatest hits, and that's not a good thing, that we still harm patients far too often.

And, you know, whether it's anesthesia errors, errors, rather, or communication errors, delayed treatment.

So we have a lot of work to do.

You know, we work in a complex adaptive system, which is health care, and it's like, you know, the system is doing what it was designed to do, and so we have to think differently.

And what we keep doing is lobbing technology on top of processes that really may not even need it, where we need to go back to the basics of communicating with each other and making sure that the systems talk to each other.

And so I saw a study by the Joint Commission that saw that more than 70 percent of medical errors are due to communication failures.

So which is why things like TeamSTEPPS, those kind of communication methodologies are very helpful to make sure that we don't harm people.

I mean, we don't want to hurt people when they're at their most vulnerable, right?

And maybe they're unable to tell us what they need.

So it's a real problem.

Yes, I have seen it first hand and I would agree.

TeamSTEPPS is just, it is such a fantastic model to apply.

And it works in any health care environment, so I would agree.

So I know you're very interested in health care information technology.

Where are we with health information technology?

Wow, that's a big question.

That's a big ocean there, that's a big question.

I'd say that, you know, so the big buzz, of course, as you know, today is artificial intelligence.

And I feel like it does have a lot of great potential.

And, you know, again, I'm off to speak in Brazil about this next week.

But it has potential.

But because our system is designed the way it is right now, where we do not have full semantic interoperability among our systems.

And even the data that we have is not in great condition or, you know, I can list 10 things.

I mean, we're all excited about AI.

It's being used to help, you know, enable and supplement some things in the EHR.

That's fine.

But I think that there's too much emphasis on the tool and not on the simplicity of focusing on the processes first.

I mean, I was speaking with someone and they said, you know, you don't go out and just buy a fancy hammer, you know, and you don't have a use for it, you know, an expensive fancy hammer, and just to have it, you know, there.

You know, we want to make sure that, for example, with artificial intelligence, we have a business case, a defined operational business case to use it with, and, you know, there are studies out there, I was talking to a colleague, and there are studies out there that show that some of the tools we use AI for, you could just use like logistic regression or, or, you know, so I think there's a lot of buzz about it.

It does have a lot of potential.

It can do great things in precision medicine, in diagnostics, in lab, in radiology, but I don't think it's a panacea like some people think it is, and I think that because of the condition of our data and how our systems are not set up right now to have great sources of data, we just have to be a little cautious because we could wind up harming patients more or creating more disparities, depending on why we're using the technology.

And in my last point, I'm a little long-winded here, but that if we're going to use AI, there's really three dimensions, I would say, to think about it.

And the first thing is, are we going to use AI to just do what we've always done?

Just go after these measures that we are measuring that aren't perfect and confirm what we're doing and focus on revenue generation?

Or are we going to use artificial intelligence to challenge our current assumptions about how we provide care and give us alternate ways to think?

Or are we going to use this technology to really create something new and novel that maybe we didn't even think of?

So those are sort of the three dimensions when organizations I think are looking at using artificial intelligence.

We're going to either keep doing what we've been doing that's not working well and maybe harm people worse.

Or we're going to use AI to challenge us or to create something new.

So AI is the buzz in HIT today, and so that's okay.

I mean, but I think we probably could stand to go back to the basics of a lot of things.

Yeah.

And then you've touched on how health care information technology can harm patients.

And I just want to talk a little bit about something I've been interested in for a long time, which is bias in medical decisions and how bias affects clinicians and how they make medical decisions.

And I recently learned about some research showing bias in health care documentation and how that can affect patients and adversely.

So I'd love to hear your opinion on bias in health care documentation.

Just to the point.

I think the word bias has been politicized in some ways and it's triggering to a lot of people.

And when I talk about bias, I tell them that it's not a bad word, right?

We all have biases, right?

If you like pizza, which is something I should need at my age, you know, we have biases.

And bias only means that you see things through a lens that you've been conditioned to see.

It doesn't necessarily mean that you're doing anything wrong, right, per se.

So when clinicians come in, like, I mean, you're a clinician, I mean, you can think that you're a person, you're a human.

So when you see things, you've been conditioned to think a certain way.

That's not good or bad.

But if you come in and you see something different, or you see a person that comes in, maybe, you know, you might make a decision in your care or documentation that is based on your experience.

It doesn't mean that your experience is bad or wrong, but it's limited because maybe if you're not open to see another perspective about that patient, then you may assume something and then your assumptions that are biased or wrong or right are put in documentation.

So then when we apply artificial intelligence to it, now we've perpetuated the monster of bias, right?

Just because, you know, you have a certain way you were trained or you have a certain point of view about a certain topic or whatever, or person or people or group of people.

And so it's important that, you know, clinicians, I think, and really all of us take a step back and think about our unconscious biases, the things that, you know, if you even think about how you see, I don't know, politics is not a great thing to say anything about, but, you know, you see anything, right?

You have a view of it.

And for all of us to think about how our views might help or hurt that patient in front of us, that's a beginning, right, of a movement, I think, if we don't, we're going to keep doing the same things we've been doing and have the same results that we've had, because we're not able to challenge ourselves about what we think.

And that's important, I think.

Oh, it's so important.

And I and I've it's transformational, like it is it's transformational, most definitely.

So a big buzzword, it too, I guess, it's the buzz term since the COVID pandemic is physician burnout.

So do you have any solutions?

Or what is your opinion on where we are with physician burnout currently?

Well, you know, it's interesting, Jean, you know, in the sort of toolbox of Lean, when I was training years ago, we said that if you have people do things that are not aligned to their workflows, it's disrespectful.

So we have created systems to quote unquote, support physicians, and it has complicated your life.

Now, I think you were around before the electronic health records, so and now with it.

And so the electronic record does have usefulness.

But most of these electronic records were not created by physicians for physicians.

They were created by other folks, maybe engineers, and then they drop it in your lap and say, oh, Dr.

Storm, now you need to use this in order to see your patients.

And you're thinking this doesn't align with how a patient flows through the horizontal of my clinic or my practice.

So if you look at studies, I was one that came out last year, I think by the American Association of Physician Associates or something like that, that talked about the EHR is a big chunk of why people are burnt out by physicians are burnt out.

And so when we keep adding things or just one more reminder or one more button to click, and then the physicians get stressed because they can't really set, you can't really sit and talk to your patient, right?

You didn't go to medical school so you could be a computer data entry person.

And while some of it's important, I think it seems like my physician friends believe it's a little out of hand.

And so, as you know, it's driving people to leave the field and not want to do it.

So I can understand that.

I mean, so it's unfortunately a problem.

And the solution would be to let clinicians, physicians design their processes so that they can see their patients.

And what a concept, right?

So, you know, let you control your world, because that same study that I mentioned said that physicians are stressed for really the three big things.

First, the EHR.

The second is not having control of their workday, right?

You come in, you gotta see 50 patients, you got 20 minutes each and you got a full panel.

Well, that's kind of satisfying.

And then I only can talk to my patients for five minutes and I'm off to the next burning fire, you know?

And so I think letting physicians and nurses and physicians, that is, get back to practicing medicine.

And so I hope that artificial intelligence will help with that because that would be a real win for the industry.

I would agree.

I will say, I know the most meaningful encounters I've had in medicine are where I have to do like an advanced care planning and talk to a patient and family about their wishes at end of life or maybe a big change in their health.

And I would go into the office where the social services individuals were, and they would join me and we would close the door.

No, I would have no computer, I would have no phone, and I could just sit and talk however long it took.

And that is what is important.

And I think that's where we need, what we need to get back to in medicine.

Yeah, I agree with you.

I mean, I often, you know, I've moved quite a bit in my life, and I'll tell you the most fun appointments with my doctor, because I mean, I like y'all as human beings, but I don't like going to the doctor, because I don't.

Nobody does.

But the biggest times I've been, the times I've enjoyed most were, I could sit there at first appointment, you could sit there and you talk, and you talk about your history, and I love that, maybe because I like to talk.

But I think those are the most impactful moments with my clinician, but every other time is like, I feel like I'm a cow being shoved through a slaughterhouse.

Yeah.

It's painful, I think, for everybody.

Rich, I really appreciate your insights.

They've just been really valuable.

I just have one last question.

I ask almost everybody who comes on the podcast, if you are in charge of health care in the United States, what is the first thing you would do?

Wow.

Well, I will make sure I'm not controversial with this, but I would say that focus less on intervention.

I would set a policy to focus less on intervention and more lifestyle, and I would incentivize that.

I would incentivize eating right, exercising, lowering sugar intake, and malnutrition, meaning nutrient deficiencies, I think, as well as control of inflammation.

Because even looking at my own health and sort of bouncing back from some things that happened to me a few years ago, being unhealthy to where I am now, I focused on these things, lowering my sugar intake.

I mean, it causes inflammation.

I mean, it's out there, right?

Focusing on controlling inflammation, making sure I get my omega-3s, right?

And exercising and moving.

I think we are far too focused as an industry on intervention and not looking at causes of disease, right?

What causes hypertension?

Is it really solid intake or is it magnesium deficiency or is it vitamin D?

I mean, if you look at the literature, for example, vitamin D and magnesium, I'm not a physician, right?

But I'm just saying I've done this research on myself and practice on myself and I'm healthier, right?

Because I focused on prevention and making sure that I eat right and get the nutrients I need that I'm missing, right?

And trying to control inflammation.

So I think I would focus on lifestyle and I would find a way to work with Congress, if you're saying president or secretary, to incentivize that and not just this whole thing of intervention.

I mean, there would be a process, right?

To get through that because you can't just turn one spigot off.

But I think prevention in lifestyle is really the way out of this.

And unfortunately, sugar is way too prevalent, sodas and all that.

I mean, I'm not saying I don't like it, but I think it's killing us, so.

I would agree.

I mean, a bottom up versus a top down, right?

It makes sense.

Definitely.

Yes.

Dr.

Rich Greenhill, thank you so much for joining us today.

We are so delighted you are with us at Quality Insights, and perhaps you can come on again.

There's many, many topics facing healthcare quality, and I would love to get your insights on the podcast once again.

Thank you.

It's great to be here, and look forward to continue to work with you.

Thank you for tuning in to Taking Healthcare by Storm, Industry Insights, with Quality Insights Medical Director, Dr.

Jean Storm.

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So until next time, stay curious, stay compassionate, and keep taking healthcare by storm.