2015 Meaningful Use Final Rule: How the New Rule Will Impact Your Practice November 4, 2015

Transcription

1 2015 Meaningful Use Final Rule: How the New Rule Will Impact Your Practice November 4, 2015 Please stand by for realtime captions. >> We will go ahead and get started. Welcome to today's program, 2015 meaningful use final rule. How the new rule impacts your practice. My name is Kelley Carnwath and I will be moderating our discussion today. We will hear from two resident meaningful use experts here at Qualis health. Lisa Packard and Shauna Banner. Before we start today's discussion I want to be sure we set ground rules to those who may not have join us for webinars in the past. We have muted your phone so we request that you don't place a hold because sometimes that music will come through. Try not to put us on hold. If you have a question you can go ahead and type it in at any time into the chat section. At the lower right-hand part of your screen. Then we will get to as many questions as possible at the end. If you do want to ask a question by phone there will be a queue and during that question-and-answer session at the end we will un-mute your line and we will work in those questions. To participate you have to be logged in with the item number that you received when you logged into the webinar. That way we can identify your phone line. If your name is not visible as a participant when you look at your participants list, you will need to log back in and into your ID number. If you do want to call in your question. The slides from today's presentation will be available on the Qualis health website. Please remove her to give us feedback through the survey that will appear on your screen when it ends. We take that seriously in order to plan future events. Here is a brief injection to Qualis help it we are the quality innovation network while the improvement organization for both Washington and Idaho. As such we provide quality improvement consulting services to various types of organizations like primary care, nursing homes home health agencies critical access hospitals and others. Most of you doing today are from primary care settings. Please be aware that Qualis Health is the recruiting for some of the programs that we run here. You may be interested in learning about some of them. Most of our programs include help with meaningful use and federal programs in addition to patient engagement, care coordination and others you see here. Which can help transform practices. >> A couple of commercials for upcoming webinars. Now we're back in business. The first of our webinars will be in honor of national diabetes month. We will hear from that community health Association of Spokane. About how they build and are sustaining ex-successful self-management program. Their program is part of the evidence-based self-management program. That was developed at Stanford University. He will be a great way to learn about this program and see whether or not it may be helpful for your patients with diabetes. Second our own Wallace health analysts Megan Donahue will be talking about the 2014 resource reports. Finally I guess you introduce our speaker. So Lisa Packard is a knowledgeable meet meaningful use one expert. She's well versed with consulting at practices and comparing them with successful applications. She's a number of the Washington regional extension center team she is gained valuable health skills and experience as a member here at Qualis Health she is now a quality improvement consultant. With that, I will turn it over to Lisa. >> Thank

2 you, Kelly. Good morning and today dose and today. Thank you for joining us. Let's get started. Our objectives today will be to go over the modified 2015 meaningful use final rule for eligible professionals. We will do a brief overview and provide a timeline and discuss reporting for successful 2015 patients. We will take a closer look at the objectives and measures to demonstrate meaningful use. We will discuss the QM's are the clinical quality measures and finally, we will offer some next steps and have a questions and answer session with one of our other members - - experts Shauna Banner. >> What will it take to demonstrate meaningful use. As you all may know, CMS released the 2015 through 2017 modification final rulemaking for this year. It was published in the Federal Register on October on October 16. Today we are going to discuss the modifications to the objectives and measures on which they will have to successful report to demonstrate meaningful use for Now we have a quick polling question for you. Which I will launch now. Moving on why you guys are answering that. I will give it five more seconds and we will then move on. >> We will let the poll finish. There will be 10 more seconds. Thank you so much for answering. We will go over them. During the Q&A section. This is not me. This is what I felt like when I found out that the final rule was 750 pages. You are not alone. Like this poor person is. Because we are here to help you. At the end of the slide deck we provided a link to the online version of the final role. I found it easier to read diversity because the table of contents is hyperlinked. You can go straight to what you are looking for we provided a list of acronyms we used in the webinar and I apologize for overusing them. We also provided some additional resources. Some quick points about the final rule. For 2015 you must be on EHRs certified 2014 edition what was known as the 2014 flexibility role is no longer an option no need to hold our heads in our hands because the modification leads to better alignment with other incentive programs such as PQRS or the physician quality reporting system. These modifications removed to those redundant to plug it if and topped out measures. We are heading towards a more advanced use of health IT. What we are calling modified stage II for EP is now made up for a single set. These 10 objectives which we will go over soon replaces the previous core in many objectives as we knew them. The final rule consolidates the public health measures into one objective measure. And finally for those EP's scheduled for stage I there are alternate options, exclusions, and specifications for 2015 and we will go through those as well. >> With that let's look at modified page 2. This chart shows how the stages based on when and EP began doing meaningful use is being phased out. You will see that in 2015 through 2016 everyone isn't modified stage II. Again there are exceptions for EPC would've been in stage I. Also you will see that starting in the year 2018 everyone will be in stage III. Here is what you need to know regarding the meaningful use timeline for The reporting period is 90 days. This means any continuous 90 days for all participants of the calendar year EMS - - CMS hasn't opened their attestation portal yet. They don't plan to until January 4 of The deadline is February 29 of As always we encourage you to attest before this last day in February. Now let's go over the 10 objectives for EP's under the final rule. I want to take a minute to mention that all but three objectives manage the previous

3 criteria in the associated proposed rule which we had a webinar on earlier this year. This is a quick overview of the three changed objectives in a nutshell. We will get into more detail and the specific objectives starting on the next slide. So the motto died - - modified objective page which has to do with electronic access measure to was reduced from 5% to one patient. With modified objective nine which has to do with secure messaging, the 5% threshold changed to the capability for patients to send and receive electronic messages. And with modified objective 10 which has to do with the public health reporting measures, there was really no exact correlation to a specific previous stage to measure as we know it. It does what happened here is the public health reporting objective has been consolidated into one objective with three measure options for EPC again we will get into more details only cover the individual objective starting on the next slide. Objective one, protect patients health information. There is no change from [ Indiscernible ] this objective matches the proposed rule. This should be an ongoing process. Any organization with electronic protected health information. The process is to conduct a review and a security risk analysis and implement those security updates as necessary. Security deficiencies need to be identified as part of the EPs risk management process. There are no exceptions and no alternate options for Qualis Health scheduled in stage I. We want to put it out there that this is the number one reason for a failed audit. Security risk analysis must be completed prior to attestation. As mentioned in previous med webinars documentation should be kept up-to-date. We also recommend it should be in the form of something like a PDF meeting you wouldn't want it on an editable document. A document that can be edited. With objectives - - objective two. With objective to which is about clinical deficiencies - - decision-support again there was no change from stage to criteria. It matches the proposed rule. Measure one is to implement five clinical decision support interventions related to for or more TQM had a relevant point in patient care for their entire period. Absent or critical quality measures related to a practice or patient population the clinical decision support intervention must be related to high priority health condition. Measure to is the EP has enabled and implemented the functionality for drug and drug allergy interaction checks for the reporting period. The exclusion is for measure to only. And is for when and EP writes fewer than 100 medication orders. For those scheduled in stage I, in 2015, the alternate option is to implement one clinical decision support rule relevant to the specialty and high clinical priority along with the ability to check - - track with it. They need to be enabled for the entire reporting. And we recommend doing screenshots at the beginning and ending of the reporting period. Objective three is computerized provider order entry or CPOE and again no change from stage to criteria. The objective is to use CPOE for medication and laboratory and radiology orders directly entered by any licensed health care professional who can enter them into the medical record for state local and professional guidelines. The subject it is made up of three measures with more than 50% of medication orders more than 30 of lab orders and more than 30 of reality orders they are all created by the EP during the reporting period and are recorded using CPOE. The exclusions apply to all three measures for this objective and is for any EP writes fewer than 100 for their order type during that recording period. For EPs scheduled in page

4 there are alternate measures and there were no changes from the stage I criteria. So EP's in stage one may use over 30% medication and they may exclude the lab and radiology. Objective four. It's the prescribing. For this objective more than 50% of prescriptions written by the EP are queried for a drug formulary and transmitted electronically using search or certified technology. This is where the drug formulary is turned on and is working. You probably as we mentioned before in a previous webinar need to use a real patient to make sure the administrative settings turned up. Remember to use the audit documentation showing it is turned on and is working. The alternate EP measure for stage I providers is more than 40% of all permissible prescriptions written by the EP or transmitted electronically. We are halfway there. I want to check in and see how you are all doing. I want to remind you that we will have a Q&A at the end of this webinar. In the meantime if you know you have a question would like to type it into the Chatfield, P Lees - - please feel free to do so. Hopefully there is not any more echoing. If you are bothered by it please type it into the chat we will take care of it. >> Let's move on with modified objective five which has a new name of health information exchange. Used to be the summary of care records for this objective [ Indiscernible ] and measure to was simple fight but it is still [ Indiscernible ] for this objective the EP that transitions or refers the patient to another setting of care or provider of care must first use CEHRT to create a summary of care record and to electronically transmit a summary to her receiving provider for more than 10% of transitions. The exclusion for this is any EP who transfers the patient to another setting or refers a patient to another provider less than 100 times doing the reporting period. In stage I EPs may claim an exclusion because stage wanted not have an equivalent core measure. Objective six is patient specific education. No change from stage to criteria. The measure for this objective is more than 10% of unique patients seen by the EP is provided with educational resources identified by the CEHRT technology. Let me add again for this objective the CEHRT must be to identify the patient education resource. This means you should utilize the CEHRT inner matter where technology suggest information that would be stored in it. Problem list medications - - [ Indiscerniblebackground noise] there is a stage to exclusion which is for any EP that has no offices it during the reporting. Period and stage I EPs which is [ Indiscernible ] in reference to page 200. Of the 752 final rule PDF version. Where the rule states CMS acknowledges it may be difficult for a provider to document intent and will not require documentation. >> We are getting a note that we are getting echoes. I want to remind attendees to please mute your line. We can hear echoing and some background noise. It is making it hard for folks to hear. I will do my best to speak up. >> Objective seven is medication reconciliation. Again there was no change from stage to criteria. For this measure, the EP performed medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP. The exclusion for this measure is any EP [ Indiscernible- background noise] as was the case for objective six for those stage I EPs can use the alternate exclusion for the same reason. Now we are going to cover those objectives that were changed that I mentioned at the start of the

5 discussion today. This is objective eight. It is about patient electronic access to health information in VDT which is the acronym for that. There is no change to measure one which is more than 50% of unique patients seen provided online access within four business days. Measure two, instead of the stage to 5% threshold the measure requires that at least one patient during the reporting period use, download, or transmit. Again measure one is about providing online access, and measure two is when the patient actually accesses. This is an objective that you want to establish workflow for patient engagement for using that portal. Remember to document, document, acumen. You can document things like sequential screenshots to show the portal is working. EPs in stage one may use an alternate exclusion for measure two only because stage wanted not have an equivalent or a measure. Objective 90 secure messaging. This objective is changing by your. So for 2015, the 5% threshold had been changed to the capability for patients to send and receive a secure electronic message with the EP and that it was fully enabled during the EHR reporting period. For 2016 it will change to at least one patient and for 2017 it will change again to more than 5% of unique patients. Again, like to remind folks that it's a good idea to do a screen capture for audit documentation. There is an exclusion for this objective. It is for any EPs that has no officer this during the reporting period or any EPs conduct 50% or more of their patient encounters in a county that does not have 50% or more of its housing units with 4 MB per second broadband availability according to the latest information from the FCC on the first day of the EHR reporting period. In those stage I EPs may use the alternate exclusion in stage one did not have an equivalent core measure. Finally we've made it to objective 10 which is public health reporting. Again the public health reporting objective has been consolidated into one objective. With three measured options for EP. For the fifth objective EP's must meet to of this - - two of the three measured options on the screen. For this objective, the EP is and what's in active engagement with the public health agency to submit electronic public health data from CERT except where prohibited in accordance with applicable raw Josh - - law and practice. Measure one is industry reporting measure two, surveillance and measure three is a specialized registry. In all three measures the EP is an active and gave given - - engagement with the public health agency to submit reduction data. Objective 10 also replaces the wording from ongoing submissions to active engagement. So active engagement in this sense means the providers in the process of moving towards production data being sent to a public health agency or clinical data registry. Where is actually sending that production. Here are the options for active engagement. In the final rule CMS noted that these options are meant to be flexible is as we all know states are in varying stages in terms of the registry. For option one if you have already registered you need not do it again. For two from ever you must respond twice during the testing and validation process. And for three UF completed the testing and validation process successfully and your electronically submitting that production data to the public health registry for clinical data registry. So clinical quality measures. There were no changes from stage to - - two. The 2015 through 2017 modified meaningful use program, EPs must report on nine of the 64 CQM from three of the six national

6 domain. The CMS made final the 90 day reporting. In 2015 for CQM's for all EPs that report measures by attestation. Furthermore the event knowledge of provider may choose to a test to a reporting. Of greater than 90 days and up to including one full calendar year of data. CMS noted that EPs seeking diversity in multiple programs with a single electronic submission would be required to submit full calendar year CQM data in the 2014 electronic [ Indiscernible ] for those CQM's which are also known as E CQM's for reporting. In We have covered a lot of ground here. On modifications to the meaningful use program. We discussed battler alignment and better incentive programs but where this modified stage II is heading toward his program consolidation with the transition to a single phase. CMS is not only better aligning the objectives and measures as we continue to advance the use of the HR but they are also simplifying the process. Some of the commenters noted in the role that a believe changes will make it easier for all providers to a test. It will make it easier for providers to know what stage they are in in the transition to a single stage of meaningful use. It will also help CMS to track providers in different reporting years. Some comments made stated the transition to a single stage of meaningful use would drastically reduce the administrative burden provide sympathy that would benefit both the EHR developers and users and facilitate meeting those interoperability goals. Here are some next steps. Make sure you are on a Qualis Health mailing list to receive any meaningful use updates. CMS is expecting to continue to use the 2014 edition in the 2015 three 2017 program years. We would ask that you pull the meaningful use reports for both ReVia stage I and stage II which will have the necessary information to a test. - - Testing. Go ahead and make sure all your EPs are properly registered as well as any circuit uses. Confirm your stage check your national plan and provider enumeration system login information. Making sure your address and payment information are correct. And finally attest between January 4 and February 29. With that I will say thank you again for hanging in there with us. Now I will hand it off to Kelly - - Kelley for the Q&A. Thank you, Lisa. That was a lot of information. I am amazed that so many of you have stuck in their. It was a tough topic to get your head around. I know we are learning about this together. We do have Shauna Banner on the line. Who is another one of our meaningful use experts many of you have worked with her. If you are in the Tri-City Eastern Washington area. >> I'm here. First of all let's go to the polling. I am curious to see what the polling says. Me too. It says are you planning to attest for meaningful use? It looks like most of you are. Some of you are not sure. Hopefully this has helped some of you to decide as far as what the requirements are

7 and whether or not you have been doing what you needed to do in terms of documentation for meeting the meaningful use requirements pick if there are questions than let's get to those now. We will go ahead and move to chat. I apologize I realize there were some problems with the noise in the beginning. Hopefully they have cleared it up. We have a question here. We attest for Medicaid in the state of Washington here my understanding is if we attest before December before December 2015 we can use the oldest speck of meaningful use in my understanding this correctly? The state of Washington is actually excepting attestations until the beginning of December if you are doing AIU or stage I your one. Because those measures were different and they only required a 90 day reporting., But once the state of Washington updates their system you will no longer have the capability of doing that. If you are past stage I, your one, then no. You cannot do your attestation. Until next year. For Thank you. The next question is would you define electronic orders for radiology? E-Send our patients to local hospitals to a local hospital for this but we do not have an interface with our EHR. How would this practice still fulfill the requirement to have an interface with the lab company which is apparently how they are doing it now. I'm not sure what measure this is pointing to it I am assuming it is CPOE for medication lab in radiology. For the radiology piece you only need to use your certified electronic health record. To create the initial order so you can print that order out you can send it electronically or fax it order out. You have to create the order using your EHR. That is what would fulfill the requirement. For example, if you have a provider that orders radiology to the local hospital, you would enter the order into the EHR. You could print it out and hand it to the patient to take over to the hospital for their order. Or you could fax it. That would count - - the actual denominator would be the patient. That would be the patient would be one. In the numerator if you use the certified technology to create the order, that would be one in the numerator. That's how you meet that measure. Hopefully that answers your question. Thank you. We have another one here. What are clinics doing if they are in a community that does not have a lot of clinics that are a lot - - electronic and cannot receive a electronic COC or FOC. The first thing for the transition of care to remember is if you are not doing a lot of referrals pick if you do less than 100 transition of care in your 90 day reporting. You can claim the exclusion. Otherwise there is no exclusion for not meeting the measure. Most providers even primary care don't refer 100 times in the 90 day reporting period. The good thing on that is that moving forward because anyone doing meaningful use is going to have to be doing direct messaging. You will find more and more providers out there being able to do that. The percentages will get higher. I do hear this across the board and it is something that hasn't been specifically addressed. Hopefully it will be. I think you will find more and more providers that will have direct

8 messaging. What I can tell you is in the small organization sometimes it's finding the right person that actually knows what you are talking about. Maybe they are doing it but they don't understand what it is. Sometimes it will be a little more research. If you are working with a Qualis Health representative they are helpful and try to help you get connected to those people if you are not participating in one of our programs I would look into participating in one. So you can get some of the service. Great. That's helpful. There is a clarification someone wanted to make sure whether they heard you correctly. Did you say that after December 31 of 2015 EPs will not be able to attest to stage I. They will not be able to attest to stage I with the old measures one's the state of Washington updates their system with the new measures. They haven't given a cutoff date. They just told us beginning to mid- December. You would have to be watching with the state of Washington to see if they come out with the deadline date as far as attesting for stage when you're one 2015 measures. >> We received a few questions privately. It says my facility is only on the second year of stage one for Medicaid. Do we still report stage I after January 2015 or do report the first year of stage II? I did not hear the first part of the question. >> My facility is only on the second year of stage I. For Medicaid do we still report stage I after January 2015 or do we report the first year of stage II? >> First of all I want to clarify facility versus EP. When you're attesting for meaningful use you are attesting to individual eligible professionals not facilities. I want to make sure that everybody in that facility is in the same stage. Most facilities have a variety of providers that have a variety stages. If that's N you have all of your providers that work for your organization in stage I year two, you'd be attesting for the 2015 measures if you cannot meet the 2015 measures your be able to either doing exclusion if it's a measure that did not have an equal measure for stage I so there is a few things. You can meet the measure you can do the exclusion or you can do the alternate. For example the prescribing for the 2015 measures, is that you meet 50% of all electronic prescriptions. In stage I, it's 40%. If your providers can meet the 50% I say go ahead and attest for them. If they can't meet the 40% because it did not have an equal or in equal measure for stage I, you can do the exclusion. You have to look at each individual measure to see what you can do as far as meeting. To answer your question, if you are in stage one year to you would be expected to attest for the 2015 measure. >> I think that answers the question. >> Probably more than you expected right? It is complicated. Thank you. It's a little different from some of the other federal programs. One of these questions asked us to show the timeline sheet. That shows the attestation. I think that was - - I think we are talking about this. It looks like Kathy had a question. If this was not what you are interested in learning about Libya. There was a question where can we find or information on the broadband you mentioned in objective nine? I have a CMS document let me pull this up and I will give you the link to the document.

9 We can get that link. I will post it in the chat. >> There is the link for the EHR information. >> I posted in chat to all attendees. >> There was another question that came in what documentation should I have in case of an audit? Good question. It's something that comes up all the time there's a long list of documentation. Requirements that you will need. I do want to point out I have worked with several organizations recently when I have asked them to pull up their information from last year no one seems to know where that and not confided. In the case of an audit you have a certain amount of time that you have to be able to produce this information to the auditors. I am hoping everyone goes act to their organization today and finds their audit materials. The first thing you will need is a copy of your security risk analysis for the year you are being audited for. For this year, make sure you have a copy of your completed certification - - security risk analysis along with your mitigation plan. And any changes that you made prior years. You need your yes no attestation screenshots. Any measures that require a yes or no attestation such as clinical decision support and now the patient secure messaging which was previously a percentage based report you need to have screenshots showing that the functionality was in place and functional for the entire reporting. That means you need to take screenshots at the beginning of the reporting period back and the reporting period at the end. Making sure you have the date and time stamp at the bottom right-hand corner. Or some way of showing a date and time that you took these. We need to get a letter from the vendor that the functionality was in place and uninterrupted for the entire reporting. One thing I want to point out for secure messaging for clinical decisions support for any of those measures that are yes/no they have to be in place and uninterrupted and functional for the entire reporting. - - Period. That means if you have not gotten it turned on in the patient Porter - - portal by October 1 of this year you would not be meeting that measure. In the case of an audit you would have to be able to prove that this was uninterrupted for the entire reporting period. The other areas as if you are doing Medicaid program you need to make sure you have your documentation information for your group Roxy or your individual eligibility for the 30% threshold. Anything like that you need to make sure you have in place. I really recommend that you keep spreadsheets and you keep logs and keep it in an electronic folder and a paper folder if possible and that more than one person in your organization is aware of where it is. Especially if you have a process were other people do meaningful use so you have switched employees and this is where I come across a lot of times that employees have left in organization and no one knows where anything was at. It needs to be saved in some kind of central location where people know where to go to get it. Very helpful. Very important information. I know a lot of people get audited. We had a request that the link you sent out does it look like it when to both participants - - all participants. Another question. My certified technology is not working crackly plea. - - Working correctly. Can I claim exclusion?

10 No. But you can do a hardship if there is something in the final rule that came out that if it was due to the delay of the final rule coming out or if the provider is unable to demonstrate meaningful use you can apply for extreme and or uncontrollable circumstance hardship exemptions. They do go through a vetting process and the review for your application as to why you can't mean - - meet meaningful use of your technology isn't working right. If it's due to something within your organization so for example if it's because you didn't want to pay for a component and it doesn't work right, that would more likely not be an uncontrollable circumstance. Or a hardship exemption. If it's something that for example I have a client that their EHR is 2014 certified but they never got it stage to working. So the portal that doesn't work and the direct messaging doesn't work. They have worked on it. But they have the documentation that they have kept from their EHR vendor as well as they have tried to do to support the exemption and they would be able to file and claimant. You would be - - if approved you would not be subject to the payment adjustment in If you are doing this for You also would not be eligible for a payment as well. >> So there was a question on here about a testing with Idaho Medicaid is that something you know about? I am not up on Idaho Medicaid but I know this participant that sent the question and if you want to work with me off-line I would be happy to work with you off-line. Perfect. I will keep going on our slides. The rest of you - - the folks on the phone will have received this live seminar today. You'll see a number of resources that we provided at the end of your slide it. You will see that there are a number of websites that you can go and find additional information. We did include the Idaho Department of Health were you should be able to get additional information. Then of course at the very end we have the contact information for both Shawna and Lisa who spoke today. You can ask additional questions to them as well. We have one final question that came in privately. Can a provider that his switched ES that - - EHR technology vendors apply for a hardship exemption to avoid the Medicare payment adjustment. The answer to that is yes. CMS sent out an FAQ regarding that an if a provider switches EHR vendors during the program year and is unable to demonstrate meaningful use, the provider may apply for an extreme or uncontrollable hardship extension. If approved may be exempt from the payment adjustment. So for example, if an eligible professional switches vendors in 2015, and is unable to demonstrate meaningful use for 2015, they can apply for an EHR vendor issue hardship before the July 1 before the July 1, 2016 submission date and be exempt from the payment adjustment in That's good news. Yes. There are good news. Because people are switching vendors. There are many of you are not satisfied with your vendors.

11 It's a big issue out there. So there is a question here can we get a copy of the questions and answers showing on the media viewers at the end of the webinar. I think you're talking about the chat? We will do our best. Definitely this recording of the event will be on our webinar. - - I'm sorry will be on the website. I think that comes with the audio portion of these answers. If there is this is coming from join if you have a specific question you need an answer to that we may have talked about today. You can feel free to get in touch with Lisa or Shauna and they can answer again what the question was. That is all the questions we have received today. If there are additional questions or comments feel free to enter those into the chat now. You will remember there will be a evaluation form that comes up when you close out of this. Please let us know how we can improve our invents and if there are any topics in the future you would like for us to cover with you. We take it seriously and want to make sure we are addressing topics that are of concern to you guys. With that, I want to thank our speakers Shauna and Lisa thank you so much. It's been a very informative and helpful hour. It's definitely a topic that we are trying to get our heads around. It's not something most of us want to deal with. It's very valuable. >> Kelley it's such exciting reading. It is exciting. [ laughter ] >> So thank you again everyone. The webinar will be offered online so you will be seeing this available online. We will most likely be doing another event in the next few months. Related to meaningful use. This is a big topic and I know a lot of our eligible providers that we work with our - - have this is one of their main priority we will most likely be doing another event about this topic. Again you guys let us know what you want to hear about so we can plan events that are most relevant for you. With that and want to thank you and we will go ahead and sign off. Thank you to everyone for joining. Thank you, Kelley Thank you. [ Event Concluded ]