Promoting a healthy workplace culture is one of the key components of any successful health system. However, defining and understanding that culture can be a real challenge, especially in a hospital's fast-paced environment. A strong workplace culture can have exponentially positive downstream effects, from improving clinician morale to enhancing hospital safety and ultimately improving patient outcomes.
On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, sits down with David Berger, MD, CEO of SUNY Downstate Medical Center. They talk about what it was like for Dr. Berger to take over a hospital swamped with COVID-19 in the summer of 2020, how he began to understand and change the clinical culture, and the path to becoming designated a high-reliability organization (HRO). They also discuss the timeline for incorporating artificial intelligence (AI) into health system operations, implementing decision support tools into clinical workflows, and the power of huddles in healthcare.
Listen here:
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Want to hear more from Dr. Joseph? Order a copy of his book, Designing for Health.
Show Notes:
[00:00] Intros
[01:00] Dr. Berger’s background
[05:39] Taking over a hospital during the pandemic
[13:09] The path to becoming a high-reliability organization
[22:15] Implementing workplace culture change
[26:10] The power of daily huddles
[30:59] The path forward for AI in healthcare
[35:14] The complexity of running an academic medical center
[40:34] Dr. Berger’s favorite well-designed thing
[42:19] Outros
Transcript:
Dr. Craig Joseph: Dr. Berger, welcome to the pod.
Dr. David Berger: Thanks, Craig.
Dr. Craig Joseph: So you started your career as a general surgeon and a surgical oncologist. You've taken on progressively more leadership and administrative duties. Meanwhile, you earned a Harvard master's degree in healthcare management. Can you give us some sense how you went from being a surgeon to being the CEO of an academic hospital? How's that work?
Dr. David Berger: So I started out my medical career. I actually thought I was going to be the pediatrician, and then ended up doing a surgical residency and residency in surgical oncology.
Dr. Craig Joseph: Let me stop you right there. How does one go from pediatrician to surgery residency? As a pediatrician, I have some sense of what pediatricians kind of like to do and don't like to do. And a lot of us don't like to operate on people. So that's a big difference. Give me a little insight there.
Dr. David Berger: Yeah. So the reason I thought I was going to be a pediatrician is when I was a kid, I had asthma and I was sick a lot, and I was in the pediatrician’s office all the time. So he really became a role model for me, and that's why I went to medical school. But during my third year of medical school, what I found is that I really liked most in terms of the clinical rotations was when I did OB and then when I did surgery. And what I really loved about both of those was the procedural aspects of those two specialties, and especially surgery. What I loved about surgery and I still love about surgery is you identify a problem, you treat the problem, and the patient gets better. And so that's sort of how I'm wired. I like to see immediate results in terms of when I thinking about problems. I want to be able to fix those problems.
Dr. Craig Joseph: All right. That makes sense.
Dr. David Berger: And then I had an amazing preceptor on surgery, a guy by the name of Mike Zinner, who went on to be the chair of surgery at Harvard and Brigham. And he was just amazing. And I wanted to be like Mike. So that was really how I became a surgeon. And then I thought I was going to be an academic surgeon. I was going to do a fellowship to research, be a division chief, the chair, and then maybe someday be a dean. But really pretty early on in my career, I had the opportunity to take a management role. And that was when I was the operating care line executive at the VA in Houston. And I realized I really enjoyed making the trains run on time. So I really liked the operational aspects of being in management and being on the administrative side of medicine. And based on those opportunities, I gradually progressed. I realized I needed additional training, which is why I got a master's in healthcare management at Harvard. And then because of successes, I got asked to do progressively higher level, leadership roles. So I went from operative care line at the VA to being a chief medical officer and a chief operating officer. And then I knew it by that point that I really wanted to be a hospital or healthcare CEO. And in 2020, around the time of the pandemic, I had the opportunity to come back to where I actually went to medical school and where I did my general surgery training in order to be the CEO of University Hospital.
Dr. Craig Joseph: Okay. So that yeah, I guess the life lesson there is, don't be successful at progressively more difficult tasks if you don't want to go down that road. And that is why I'm really bad at doing laundry, so that I convince my wife that I'm not able to do that.
Dr. David Berger: Yeah. So, there's, that reminds me, I really like the show Everybody Loves Raymond. Yeah. And there's an episode on that show specifically that Raymond doesn't do things well. So his wife won't ask him to do it so that really resonates.
Dr. Craig Joseph: Was this the episode with the wedding? Yeah, I saw that. I recall that one. And, it didn't turn out quite the way we thought it would, but that's, I guess, the formula for a successful sitcom. Yeah. I feel like I'm diverging now on the on the conversation. Let's get back to you, you became the CEO of University Hospital, at Downstate part of the SUNY system. I understand this isn't Brooklyn, and this was September of 2020. So was there anything going on then, or was it just pretty calm waters? Everything was great and you just kind of snuck in and no one noticed?
Dr. David Berger: So this was just after the first wave of the pandemic, and our area in Brooklyn was really ground zero. We take care of a patient population that's 80% African-American and Afro-Caribbean. So really severely impacted by the COVID pandemic, high incidence of COVID, high mortality and morbidity. And our hospital was actually designated a COVID-only hospital from March of 2020 until July of 2020. So, all other services had to be transferred out and stopped so we could only take care of COVID patients. And then obviously, when the first wave of the pandemic dissipated in central Brooklyn, we were left without any patients in the hospital. Take care. Of course, all our services had been stopped and all our patients transferred out. So when I came in, our volume was about 60-70% off. We had lost about $250 million that year, and we were having significant quality problems. Two of our big programs were on hold because of quality issues. One, our renal transplant program, which had a long, long history dating back 50 years, and our Open-Heart program also was on hold because of quality issues. And when I interviewed for the job, the president of Downstate actually said to me, David, this place is a hot mess. So I sort of knew that there were a lot of problems coming in, but I didn't realize how hot and how messy all the things were.
Dr. Craig Joseph: So when your boss, before they became your boss, says it's a hot mess, you should take them at their word. Another life lesson?
Dr. David Berger: Yes. You should definitely take them at their word. And not only take them at the word, but if they're willing to tell you that, it's probably worse than that.
Dr. Craig Joseph: All right. So, when you when you joined, had they started back? They were no longer a COVID-only hospital. Or were you right in the middle of that?
Dr. David Berger: So we were not COVID-only any longer.
Dr. Craig Joseph: Okay.
Dr. David Berger: That stopped in July, but there was a significant hangover that has lasted almost three years.
Dr. Craig Joseph: Before we get into some of the things that you've been doing to fix the problems, I'm curious if there was, I'm trying to look for the good side of being a COVID-only hospital in the middle of a global pandemic. And the one thing I could imagine is that you got, and I understand this precedes you a little bit, but your hospital probably got very, very, very good at taking care of COVID patients. Is that true, or was pretty much everyone had enough COVID that they all were experts, and a follow-up question is, were there any benefits in terms of like long COVID and in terms of, hey, we're really good at treating that, or is that not kind of been fruitful?
Dr. David Berger: Yeah. So I think the hospital did get really good at treating COVID. I think the people who went through it, and obviously I came in after I think there was a lot of camaraderie and the fact that, hey, we made it through this. And in terms of the quality of care, despite the fact that we were COVID-only, and also that this was really the ground zero, we had a lot of patients with significant comorbidities. The mortality at University Hospital was no worse than anywhere else in New York City. So I think the institution did do well during that first wave. And I think it helped us for the subsequent waves. Right. So that was the first wave. It's been at least two or three waves, subsequent to that. And I think we've done extremely well and taking care of the patients after that.
Dr. Craig Joseph: Okay. All right. Well, that is good to hear. So what are some of the things that you know, what did you do, when you get to this hospital that's kind of been devastated. As, many hospitals were, but yours in particular. It was hotter and messier than you could have even imagined. What does one do besides, panic?
Dr. David Berger: So, besides panic, I'm not one to panic. So I've dealt with difficult situations before, but this was certainly a challenging situation. So what I wanted to do was I wanted to understand the culture of the institution. And the way I went about doing that is basically threefold. So I wanted to understand why people worked at Downstate, despite all the challenges that we have and why they felt Downstate was important to me. Those were the questions I wanted answers. So I think, as I mentioned, three things. First thing I did was answer to what we call bagels with Berger. And once a week I would go to a different department within the hospital. I would bring breakfast, and then I would just have an informal conversation with the staff members on that particular unit or in that particular department. And I asked them the two questions: why do you work? Why is this institution important? I then had focus groups with other members that didn't necessarily touch with bagels with Berger. And then the third thing I did, I sent out a simple survey with just those two questions. And the answer I got back over 80% of the time was actually one word, and that was community. The people who worked at Downstate, a majority of them, actually live in this community or grew up in this community. And the reason they thought it was important was because we serve a community that suffers from significant disparity in terms of their healthcare and their healthcare access. So understanding the culture, then allow us to move forward and in terms of moving the culture in a positive direction in healthcare, there's one thing that people cannot argue with you about. That's the issues around quality and patient safety. So we decided to go on a high-reliability journey to address the culture focused around improving our quality and improving our patient safety. And that was that really allowed us to move forward.
Dr. Craig Joseph: Okay. So let me back up a second and then talk or let you talk about a high-reliability organization. It sounds pretty straightforward. It's an organization that's reliable, but I suspect it's deeper than that. So, yeah. Can you give us a little bit of background about HRO and you know, where did you first learn about this and why is it important?
Dr. David Berger: So, the I first learned about HRO, actually, when I was running with care line at the VA. The VA really has done a great job in terms of trying to move forward on the quality within their healthcare, their hospitals, as well as the rest of the healthcare system. And one of the principles that they have used is HRO. I also used HRO when I moved over to Baylor St. Luke's as the CMO to try to move the needle forward. So what does it mean to be a highly reliable organization? It means that you have processes in place to mitigate errors and try to catch them actually before they occur. And you're empowering the frontline people to be able to identify issues and improve their own work. It's come from the Toyota Production System, where frontline workers can essentially stop the line if they see something that is potentially going wrong and may cause a defect. It doesn't even have to cause a defect for them to be able to stop the line. And when I think about highly reliable organizations, the first thing I think about is a United States aircraft carrier. So, you have to realize a United States aircraft carrier is essentially a nuclear reactor. With an airport that functions 24/7/365 and is loaded with a huge amount of weapons, and the average age of the crew of a USS aircraft carrier is 19 years old. So if a bunch of 19-year-olds can make sure that planes take off safely around the clock, the nuclear reactor doesn't blow up and all the munitions are handled safely, why can't a hospital or other healthcare entities run similarly?
Dr. Craig Joseph: So that is an excellent, metaphor there. So that makes sense. So every hospital really, in fact, every organization, that one thinks is important should strive to be a highly reliable one. That makes sense. And you had said when you came in, the message was clear from 4/5ths of your staff. Community is the most important thing. And so one of the things or I guess the main thing that you started working on was creating the culture of a highly reliable organization. So how does one do that, presuming that, first of all, I guess every organization could become better and more reliable. So it doesn't really matter where you start. I think as long as you're finishing in a better place than you started, you're at least somewhat successful. So, what did you do? What's the magic?
Dr. David Berger: Yeah. So since when I got there, we were clearly not highly reliable, and we had a culture that was depressed because of the issues I raised before, I felt it was really important to engage with an outside organization that had expertise in building culture around high-reliability. So issued an RFP or a request for proposals. And we eventually decided to partner with Press Ganey on our highly reliable culture.
Dr. Craig Joseph: Okay. And many of our listeners will know Press Ganey as the group that does surveys for patient satisfaction. And in fact, I didn't realize that they did very much more than that. But apparently they've got some consulting as well, and that makes sense. They certainly handle a lot of, quality and safety and satisfaction data from patients and healthcare systems. And so, so how does that engagement work? Do they kind of come in and sniff around or, are they able to kind of just bring some recommendations?
Dr. David Berger: Yeah. So they did a pretty detailed analysis of where we stood. They did a lot of interviews. They looked at our patient safety data as well as our patient safety reporting. And then based on their analysis, it worked with my quality leadership to come up with a clear plan for how we could move forward.
Dr. Craig Joseph: Okay, and can you tell us some of the details of that plan and how do you execute it?
Dr. David Berger: So one of the big things that we did was we did leadership skills training. So first we need to teach our leaders what it meant to be highly reliable and what the skills were necessary to be able to coach their reports on terms of what a high-reliability organization looks like. The other thing we did was we put in just culture principles, which doesn't mean necessarily no blame, but when errors do occur, we try to look at the root cause and determine if there are people issues versus systems issues, and we treat employees with respect.
When I first got here, if any employee was perceived to do something wrong, they immediately got triaged to labor relations, which caused a significant amount of friction between management and the employees. And then the third thing that we have done as part of our high-reliability journey is train all our frontline staff in performance, improve being highly reliable means that everyone, especially those people at the point of service, are capable of improving their own work.
Dr. Craig Joseph: And this kind of goes back to your reference to the Toyota Production System, where a frontline factory worker who might have been there for two, two days or two weeks, is able to stop the entire line, if they see or perceive that there is a quality issue. And so it makes sense that your front line folks, I'm assuming that includes everyone from, of course, nurses who are taking care of patients, but also, folks that are cleaning the rooms and the and the operating room and, and perchance the cafeteria folks.
Dr. David Berger: Yeah. So one of the, speaking to that specific issue that trying to get it through the whole entire organization, we built in on our floors what is called the no-pass zone. So anyone on any floor, if the patient call light goes on, they are responsible for going into the room and seeing what the patient's need is and then escalating it to the person who can best take care. So rather than having, I'm sure you've walked into hospitals where every patient's call light is going on and people are running around and doing their jobs and it's being ignored, that was really one of the most important things. And that involved everyone from, you know, VP level to my level down to the people who are responsible for cleaning the room.
Dr. Craig Joseph: You know, it sounds, I know I'm going to get this reference wrong, but one of the expensive hotel chains was the Ritz-Carlton. I'm making this up, but they permitted, actually demanded, that all of their staff be able to comp a night. And so if a housekeeper learns that something didn't go the way it was supposed to go or, you know, there was some sort of problem, that the housekeeper doesn't need to get anyone's permission and can simply say, yeah, you're not paying the thousand dollars a night fee because we didn't meet our very high, you know, levels. And that kind of attitude really gets through to people and lets them, you know, take the kind of the eight levels of management and squeeze it down to almost nothing. And so did you see kind of a rapid change at least in the culture of the folks that work with you?
Dr. David Berger: Rapid change, I would say not as rapid as I would like, but, when we started this journey, we felt it was at least a three-to-five-year journey. So, I think we've moved the needle significantly over the course of three years. The thing that's been hardest is around the issue of accountability and escalation. So because the culture was very laissez-faire and when things didn't get done, oh, it's Downstate. This is the way it gets done. This is the way it works. So teaching people that if you don't get a response to something after asking twice to escalate to the next level and then to continue to escalate until it's answered, that was probably the biggest challenge.
Dr. Craig Joseph: Okay, so un-training, you know, breaking bad habits. I can imagine, it certainly takes me a long time. So I think that's a reasonable statement. So, some of the things that you instituted, when we were preparing for this call, you mentioned something called a, culture matrix. And, I, I'd like to hear more about that. You know, what problems does it solve? How does it how does it get developed?
Dr. David Berger: Yeah. So, this is, I think, what you're referring to is our just culture matrix.
Dr. Craig Joseph: I'm so sorry. A just culture matrix.
Dr. David Berger: Yeah, and as I indicated when I first got here, there was a very punitive culture in terms of dealing with staff behaviors that fell out of the norm. So what we've done is created a pretty detailed matrix based on intent, the degree of what the problem is, and how the person acted. And if they acted in the best interest of the patient and didn't really intend to cause harm, because most of the time I don't know too many healthcare workers that come to work intending to do things wrong and to cause harm. They’re usually well-intentioned. So the question is, and the matrix helps us, to get to what the root cause of why what was done was actually done, and try to avoid blaming the individual if there was clearly not intent.
Dr. Craig Joseph: Okay, okay. And again, I would assume that that that's more of a kind of a management endeavor, process. The staff were kind of on the receiving end of that and appreciative, I would presume.
Dr. David Berger: Yeah. So, this is teaching managers how to deal with staff in a positive manner without, as I mentioned, being extremely punitive. And it actually allows management to develop better relationships and closer relationships with their staff because the previous responses, oh, they did something wrong. Not my problem. I'm going to send them over to labor relations, and then we'll write them up and reprimand them. And I don't have to do that. But when you push it down and you require the managers to be directly involved, they get to understand from their staff’s point of view, some of the things that are going on that caused things to potentially go wrong.
Dr. Craig Joseph: Yeah, sometimes the details are important. Another part of, I think, process improvement that you've been focused on our huddles and I've heard you speak about the huddle board. What is that? How does it work? And, you know, what kind of changes can it affect?
Dr. David Berger: So using the analogy, you mentioned huddles, use the analogy of the National Football League or college football. Everyone gets in a circle. They talk about the play and then they go execute the play. If people just ran up to the line of scrimmage and tried to execute the play, things don't necessarily turn out very well. So essentially the huddle is when everyone gets together before their shift and then at the end of the shift and it causes situational awareness. What are the challenges we have? What do we need to do today? What were the patients were seeing that any of them have any problem? So those issues are all discussed at the huddle. So you can anticipate ahead of time issues that may arise and then huddle boards, basically a way to formalize and make sure that the things you want covered in the huddle are actually covered. And it gives the manager of the unit the opportunity to highlight the accomplishments of the unit. And it also gives the frontline staff the opportunity to make suggestions of how to improve things. One of the main huddles we have at the C-suite level is we have a daily safety huddle. So this happens every single morning. All the leaders of every department, and we do it virtually, gets on the virtual meeting, and each department discusses the challenges that they may have during the day, so that situational awareness across the entire institution, okay.
Dr. Craig Joseph: And that goes from every level. So no matter what we're talking about, you're aware of all safety concerns, as are all of your staff. And so, how's it going? What are the results with respect to quality or finances or patient satisfaction and employee satisfaction?
Dr. David Berger: Yeah. So I wouldn't say that we're highly reliable yet. Are we better than we were three years ago? Absolutely. We went from a Leapfrog D to just a hair below a B right now. And data lags in terms of Leapfrog measurements. And we believe when it's updated in the fall, we'll be getting to a B. Our kidney transplant program which was on hold because of poor outcomes when I got here, was declared a center of excellence. We passed a joint commission survey without a single condition of participation level finding, whereas a previous survey three years before we had four condition level findings, which are the most severe. We've improved our finances, and actually in 2023 we had $24 million operating deficit. But a $27 million positive a bottom line. So we've gone two quarters now without a catheter associated urinary tract infection, a central line associated bloodstream infection, and we had ESI 90s, which is a roll up of all patient safety incidents. Went from an observed to expected of 1.74 to 0.6. It’s sort of like, think about playing golf. You want to shoot below par not above par with par in this instance being one. So you want to be below one. And previously we were significantly above one.
Dr. Craig Joseph: So all of that sounds awesome, congratulations on the journey. As you say, it's not done, but certainly going in the right direction. Let me pivot a little bit to something that I wouldn't expect to have this conversation with the CEO of a hospital, but, this artificial intelligence thingy that I keep hearing about, I know that you're interested in how to apply and leverage AI in the hospital today, not in five years. And so talk to me a little bit about, you know, what you're thinking is what you all are doing, what you see others doing. But, basically just, you know, predict accurately where AI is going in the the next couple of years.
Dr. David Berger: So I'm really excited about artificial intelligence. I believe it will have a significant impact on healthcare. And actually, it will transform form how we deliver care. The timeline for it, I think, can be argued. I think it's going to be a 5-to-10-year transition for various reasons. The way I look at it, I break it down and do my daily work in four different aspects of healthcare and running a hospital. So there's the back office functions like coding, billing, revenue cycle, all of those issues. That's one. Then there's the front end, which is access scheduling patients and prior authorization. Those are really administrative functions. And then there were two related to care and care delivery. One is how we operate, analyze and sequence and provide care like how we schedule an X-ray. Who gets a different lab test. Then there's the actual provision of clinical care reading X-rays, reading pathology reports, helping with decision support. So that's how I sort of look at the different aspects of AI within healthcare. So it's furthest along, I believe. And the strongest use case currently is on the back end in terms of revenue cycle. Secondly, probably on the front end in terms of access scheduling, getting people into the system where it's the biggest challenge is probably the actual delivery of care. And I think there's a lot of reasons for it, especially and potentially resistance amongst clinicians, as well as the issue of how accurate does AI have to be. And I sort of compare it to self-driving cars, a self-driving car is probably better and safer than a drunk driver. Somewhat less likely to get into an accident. However, if a self-driving car does get into an accident, that's basically front-page news. So the expectation, rightly or wrongly, is that self-driving cars need to be 100% safe. It's the same thing with using AI in medical care. Yes, you can demonstrate potentially that it's better than a doctor at doing some things, but if AI is not perfect, then the question comes up who's the responsible person? Regarding that issue? So I think it's going to be a little longer to be able to incorporate AI completely in the delivery of medical care. But the one thing that's really important to remember about medical care and incorporation of AI is the number one source of medical error is diagnostic error. So if you can use AI to enhance the diagnostic ability of a clinician and help them make the correct diagnosis, there's a lot you can do to solve the issues around adaptation of artificial intelligence in terms of moving it forward into an organization, you have to educate your entire staff about artificial intelligence, because there's a lot of disinformation and a lot of concern. Especially people have concerns around their own job and whether artificial intelligence will actually eliminate their specific position.
Dr. Craig Joseph: So, you know, incorporating AI, incorporating AI into workflows and diagnostics at a hospital is complicated and no one really knows how to do it yet. However, your situation as an academic medical center seems to me even more complicated because you have trainees, right? You have medical students and residents and fellows kind of floating in and out. And part of the job of those folks is to learn how to, you know, how to diagnose what's important. What's, unimportant, actually. And so, you know, how do you, how do you kind of walk that line between not, and not allowing your trainees, I know I realize you're not the dean. That was that was a potential future of yours. But, for folks that are that you're responsible for to some extent, you know, how do you make sure they learn how to become doctors and nurses who can, who can have that sixth sense that something's wrong even if they don't know exactly what it is?
Dr. David Berger: Yeah. So we ran into a problem. We were implementing a decision support tool that helped with various pathways regarding, certain diseases. And we had rolled it out to internal medicine, and we noticed that no one was using it. So we went to the medical chief residents and we said, this is to help you guys, what's going on? And they said, well, our junior residents need to be able to learn to think through and make decisions on their own. That is a fallacy. And I think it goes back to when I trained, it was see one, do one, teach one. Right. So I would watch something and then I would do it. Was that the best thing for the patient? Probably not. So learning by trial and error like the chief resident was proposing, it's probably not the best thing either. And we need to teach our medical students, our nursing students, all healthcare providers how to incorporate digital tools and artificial intelligence to enhance how they take care of patients in order to prevent bad outcomes, prevent disease progression, and provide the best possible care. So stop teaching medical students to memorize the Krebs cycle, because they can pick it up on their phone and get the answer in less than 30 seconds. They need to understand how best to use all the tools at their disposal to take the best care of the person that's actually sitting right in front of them. And that's going to take a while to be able to train the entire generation of healthcare providers.
Dr. Craig Joseph: David, this reminds me of when I was an intern and was called by a nurse for a patient with a high potassium, so they had drawn some blood. The potassium was very high, which is very dangerous and can cause, your heart to stop beating. And if you're only data driven, like I think most AIs naturally would be, you'd want to start treating that. And in doing lots of other things. And what I was taught was, hey, whenever anything's, dangerous, like, at a code, at a code blue, the first thing you should do is check your own pulse. Right? So, think about what's going on. And as it turned out, it was this. This anomalous result was actually an anomalous result. This was the way they collected the blood for some hemolysis. And that caused an artificially high level of potassium. It was repeated and it was normal. And that was the that was the right response. And that's the fear I think I have is that a logical kind of Spock-like creature will simply, you know, see data and, and react to it, not taking into the full context of the patient, the patient's condition.
Dr. David Berger: Yeah. I don't think that you're going to have AI, autonomous AI think you're a patient. I think you can have, augmented AI in combination with physicians or other providers taking care of patients because you're going to need that filter. Right. So you can't get that from artificial intelligence.
Dr. Craig Joseph: Yeah. Okay. Well, we are running short on time. I thank you, Dr. Berger, for the excellent and interesting conversation that you've given us. One thing we always try to ask at the end, since we like to talk about design and healthcare, is if there's something that's so well-designed in your life, it can have to do with healthcare or not. That's so well-designed it brings you joy and happiness, just kind of interacting with it. So, what would be that, that workflow or that product or that tool? What do you think?
Dr. David Berger: So my wife and I love to snow ski, and therefore the thing I really like and admire, and does an amazing job for making my life easier, is what's called the Epic Pass. It's issued by Vail Resorts and Vail Resorts now owns, ski places throughout the world. And you can use the Epic Pass at any place that is a Vail Resort. So we ski in the Northeast, we ski in New York, in Vermont, and then we go out to Utah, once a year to also ski. And we have our Epic Pass, the Epic Pass also lets you rent lodging. It's used in all the restaurants, at all the ski slopes. So it's really an incredible tool. And the other thing that I really like is it tracks how much you've done each day. So your verticality, how many lifts you, you've ridden so you can actually track the amount of skiing you've done within any year. So it's really, a really elegant app. And they make improvements on it almost every year.
Dr. Craig Joseph: That's awesome. It does not give you access to an electronic health record, though?
Dr. David Berger: Not yet
Dr. Craig Joseph: Okay, okay. Because it might be more expensive if they were to add that feature. That's awesome. The Epic Pass. All right. Well, for skiers out there, now you're aware if you weren't aware before. Well, thank you so much. David, it's been great talking to you and look forward to your success in the future and having you back to tell us, how much more reliable your organization then than it is now.
Dr. David Berger: Well, thanks, Craig, for hosting me. It was really a lot of fun.