My name is Paul Bruning. I am the Director for the Neuromusculoskeletal Service Line for Sutter Health in San Francisco. I specifically have the Silicon Valley market. So I've been working in PROMS for quite a while now. Oh, check-in code, 475259. So with that, I do have one disclosure. Code Technologies, I do some consulting for them. And they are a PROMS collection company. And this will be the only time I mention them, unless you ask me for questions on some stuff afterwards. So we don't need to go over the objectives and stuff. You already are here, so you know kind of why you're here. Where did patient-reported outcomes start? They started back in 1914 with Ernest Codman. And much like a lot of people that are ahead of their time, he brought up a lot of thoughts that were not well-accepted by the general medical community. Patient-reported outcomes, what did it matter what the patient thought of how I did the cases and how I took care of my patients? They don't know what they're talking about. He was run out of Mass General Hospital. And now his efforts are becoming the standard of care for value-based care and really looking at what is quality in medical care. Because remember value in value-based care, what is value? It's quality over cost. How do we measure quality in health care? That's the challenge. It depends on who you ask, all right? What is important in that value-based equation to an insurance company? The cost. What's a value to a patient? Well, cost can be, but they also want quality care. But can a patient really determine the quality of their care? Maybe if they feel better and they can have more function and they can ambulate better. But I think back to an article out of the British Journal of Medicine where they did for meniscal cases, degenerative meniscal cases, they did a regular meniscectomy and they did a sham surgery. And the sham surgery, the patients got better just as much as with real surgery. So could the patients really determine quality? I mean, it depends on how you define that, right? I mean, the surgeon is going to say they did the best, most tech, what's quality to a surgeon? The angle of the screw, how the tunnel was, was it deep enough? Did they take off the least amount of bone? The technical component. So value and where we're moving in value-based care now is really about the patient because that's what we're there about to begin with, right? It's taking care of patients. So patient-reported outcomes, they measure a few different things. Quality of life. Maybe you've heard of the PROMIS-10. PROMIS-10 is CMS's preferred measure for a person's quality of life. There's mental health status that gets combined in the PROMIS-10, but there's specific tests that you can use also for mental health. Joint-specific, you've heard of HOOS, COOS, ASES, those. And then you can assess pretreatment and post-treatment with all of those surveys to see where did they start, where are they at now. So PROMS, quality in surgical care. I don't want to read all these things off to you. You can read them. But what have we improved with the care we've given them? We want to be able to apply a quantitative number to it, because that's easier for us than the subjective, my knee bends better. If we can measure things, if we can take what they're providing us as their symptoms and create a quantitative value, we can look at that and say, yes, they're getting better. Anybody know what the magic number is, the delta for the HOOS for the new CMS mandate? What is that delta number you have to hit to be in the positive for CMS? It's 22. There is a vendor that did a little bit of a study that looked at all the outcomes for thousands and thousands and thousands of cases. And what they said was the range that they would have projected was between 20 and 24 for the delta from the pre to the post. So they improved by those 20 to 24 points. CMS picked right in the middle of that. So it's a valid number. One year. One year. Yep. Now, they should probably be at that at six, but CMS wants it at one year. So that's the time frame for that. So I just put this little quote at the bottom. 99% of people in America, when they have surgery, the outcome is not measured. How many of you have had surgery? I've had several. I've never gotten anything except the patient satisfaction survey. No outcomes, nothing. Outcomes are getting to be very popular in a lot of different areas, not just in orthopedics. Sorry, I might have to stand up here after all. So why do we collect PROMs? There's a lot of different things that we can do with it. Not just about function, quality of life, and pain. We can use it for benchmarking between what your organization does and how other organizations do. What's your average delta on a hoose? What's your average on a coose at different timeframes? What that can do is that can then lead to why is surgeon X's patients less mobile at three months than surgeon Z and surgeon W? What's the difference with them? We use that actually, kind of the research thing, kind of the benchmarking quality in a case to keep Xpiril in the hospital. The hospital wanted to get rid of Xpiril because of the cost, but we were able to look at outcomes data and be able to show that at three months, our providers that use Xpiril, their patients had better function and lower pain scores than the ones that didn't. Why? We don't know for sure, but we use, thank you very much. Correlatively, we looked at it and said, the patients with Xpiril were moving quicker. They were on the bike quicker. They were more functional quicker so that that recovery was a little bit faster for them than some of the other docs. If that was the case, why not use it? All right, why would we get rid of something that was giving them a little bit of a benefit? This is kind of typical when we start to talk first about problems in orthopedics, this is kind of what I think of. Think about all the articles you read about in the journals, if you read journals, on orthopedic cases. We had over 1,200 oncologic patients randomized to two treatment arms. We had 22,000 cardiac patients that we followed for a minimum of 10 years. Well, I had two patients that I did this orthopedic surgery on and they were both doing pretty well in the PACU. Is this peer reviewed? Hard to be peer reviewed when you don't have any peers, so I'm like, am I right or am I right? Have any of them had any complications? Well, they were all complicated surgeries. What were your outcome measures? Well, they're out of the OR and I think they might come back. I found this kind of interesting because I also do peer review for the Journal of Orthopedic Excellence and Innovation. And when I do those, I see some of the articles where the end size is 10 and they're case studies or things like that. So that's okay, but still, when you have a size of N, how are you able to generalize that to larger populations? How can you use outcomes to help generalize that to larger populations if you're not keeping track? And if you're only keeping track for a short period of time? I worked with a group that, yes, we collect outcomes. We've been doing this for years. We have like 95% of our patients response rate. Yes, they do pre-surgical. After surgical, their response rate, zero. How much help is that outcome tracking? It's worth nothing because you have no outcomes. You just have pre-comes, right? Nothing afterwards to compare it to. So PROMS currently is not tied to any value-based payment model. It will be next year, all right? For those of you that are tied to hospitals, you know that the hospitals have to be tracking outcomes now and you need 50% response rate pre and at one year. So if you're not starting to collect now, you're already getting behind the eight ball. That's a great issue that you need to talk to your hospital about. Well, sell it to them. I like your business acumen. Correct, yeah, yeah, yeah. Because what we're dealing with is some of our hospitals have a lot of independent practitioners, like two or three surgeon practices that come in and do cases at the hospital. They have to collect for all of them. And then, yes, some of those practices are collecting PROMS for their own use. So it's kind of a mess in a way, but you've got a little bit of time left to figure it out, like till the end of 24. By 25, you better start having collected, especially the beginning ones, because you'll need to, at a year, be collecting the follow-ups. The CMS, they want it at pre, six months, and a year. Why six months? It's kind of that 90-day, somewhat, time frame that they used to use for BPCI, CJR, which is really three months, but they like six months, and then the one year. They really are going to score you on the pre and the one year point. This is just joints right now. These are initial, total knees, total hips. Fractures are not included, just primaries. Not shoulders, just knees and hips right now. It'll come to that. It'll move that way. In 26, it moves to the HOPD. The first year is inpatient only, HOPD, and then the ASC. If your office is collecting, which is good, we collect on everybody now. We decided we were going to start collecting on everybody, and we set it up with IT. We told them to start on April 1st, and March 15th, they turned it on. So, all of a sudden, all our patients were getting it. We weren't quite ready, but we went through the process, and we're collecting them all now. The interesting thing is, if you look at an AOS, patient-reported outcome measures, survey, where they ask their surgeons how many of you are collecting PROMs? First, it's vast majority of survey respondents identified PROMs as moderate to highly important. So, 89% of the surgeons that took this survey said, yes, PROMs are important, we need to be doing it. How many of them had completed PROMs? Nearly half of the respondents collect PROMs in the practice, with over one-third utilizing them. So, only 46% actually do anything with it. So, they know it's important, they know they need to be collecting it, a bunch of them are collecting it, but what are they doing with it? Nothing, they're just collecting for collection's sake. What do you think the response rate is on those types of practices? Terrible, all right? Right now, we started, like I said, collecting for collection rate's sake. Our collection rate isn't even 30%, and that's initial, all right? We need to be at 50% at one year in a year. So, now, they had the whole IT team, all the docs that were saying, we need to do this, we need to do this, let's develop this in Epic. I came on board, they put me on the PROMs committee and said, oh, now it's time to operationalize it, fix our recovery, or our response rate. How do we do that? We'll talk a little bit more about that. But, that is where I come to this little thing. I think you should be more explicit here in step two. So, the first step is, okay, we've now developed a way to capture PROMs. We know it's important, we're going to start capturing it. We've got it built in Epic. They have all these nice little graphs that'll be formed in Epic, and the doc can look at and pull the surveys out. And then, at the end, it's, we can now report this to AJRR, and we can report it to CMS out of Epic. But, in the middle, then the magic occurs. So, you got this complex processing equation, and the magic occurs. That's the response rate collection. How do we collect this from our patients? If you're sending it out, and the hospital is sending it out, which one does the patient complete? Because they're going to get survey fatigue, and they're going to quit filling out any of them. Yep, yep, because they're going to get patient satisfaction surveys. So, it's going to be a challenge. CMS knows it's important. AOS knows this is important. We need to prioritize that patient voice in how we're doing care, and that's outcome surveys. It can tell us a ton about how we're doing our cases. Because if we see those differences, like on the Expirel thing, we also saw some differences on infection rates. And we were able to go back and see that there was actually one of the sterilizing processors who had more infections than some of the other sterilizing processors. Why? Because they were puncturing the wrap, all right? And there were issues related to that process, and how they were undraping, or whatever that's called, in the OR when they're opening up the trays and stuff, that they counted the one day, they had 13 door openings and closings while they were prepping that patient before they even cut the patient. But trays are open. So, those are some of the things that can be looked at if you're tracking some of those outcomes and seeing where differences are so you can kind of delve into them a little bit more. Okay, I must have done something, because, ah, it's finicky again. That's, let's see here, there we go. So, this is what we were talking about with the total hip, total knee PROMS collection. So, 50%. Here's one thing that you have to think about, too, with your pre and your one year. Pre means within 90 days of surgery. So, how far out are you booking surgery? Let's say you're booking surgery 40 days out. Do they get that survey before they come in and see you? Our patients are getting the surveys as soon as they get registered. It goes to them through our patient portal, MyHealthOnline, and they can fill out the surveys before they even come in. Let's say they fill it out 15 days before they come in. That surgeon is booking out 30 days. We're at 45 days. Now, they get scared, they cancel surgery, or prior authorization doesn't come in, and it has to move back another 30 days. We're getting awful close to 90 days. Most surgeons, from what we've seen, the quickest they'll get into surgery, on average, is about 27 days, so 30 days. And it's often rescheduled about 35% of the time. So, if you're not within 90 days, that pre now is gone, and you have to redo it. So, don't forget that part. So, that's gonna take some of your 50 away, 50% of your respondents. This is Medicare. Yep, this is Medicare. So, this is only a Medicare mandate at this time. But what did, where was that, Maine? Massachusetts? It was somewhere in the Northeast, where to get a total hip or knee prior authorized, you had to have PROMS done, the pre PROMS, to get authorized. Okay. Yep. Exactly. Or, well, this number here, two functional, and average, sir. Exactly. That's part of what you can do with outcomes, too. It's shared decision-making, and there's certain blogs out there you can look at, where they actually have looked at that related to smoking and BMI, and their functional scores. And there's a certain point where it's that tipping point where now surgery's gonna be more beneficial, because they, if with the outcomes measures later, they have a bigger delta, and they do better. Because there's certain points where the BMI is too high, or the smoking, and the comorbidities, and their functional score is relatively decent, and they're like, wait. So, you can use outcomes for shared decision-making that way. That's what they were looking at, but they were looking at it not from shared decision-making, they were looking at it to say, I'm not gonna prior authorize this, because you're not bad enough off. But remember, it's not just pain level. There's the functional questions in there that push it in that direction. So, and what's nice about them, though, is they're very reliable, very valid tests. There's hundreds of thousands of these that have been done. And so, the fact that the insurance companies took it to that point, means that they're looking at these, all right? So, it's important to look at, because if you're part of that hospital, your APU is that annual percentage that you're adjusted on your Medicare payment, will get dinged. We looked at this at Sutter, and we're close to $16 million on the line, if we're not collecting 50% of these for our Medicare patients. Remember right now, what we were at? Less than 30. So, once we start putting that number out there, we get the attention of some people that are much higher on the pay grade scale than me, because that is what can change how are we gonna try and capture these, and how much effort are we gonna put into capturing these. There are some providers out there that do extremely well at capturing the data. They make sure they get it when that patient comes in. It's three months, or six months, or one year. They're collecting their data. They have like 90% response rate. They're committed. They're the ones that really get it. They're committed, and they want that data to improve their practices. But that's not that many of them, because remember the AOS survey, all right? Around 46%, I think it is. They didn't actually do anything with the data, while over 60% collected. But the hospitals now know this is gonna be important. If your hospital hasn't looked at this, there is a way you can find that APU number on the CMS website. So, and it'll tell you just about how much you might lose. All right, so some of the things we've talked a little bit about, shared decision making, comparing outcomes between providers, site of service. Right now, we're looking at doing recovery care, where instead of them going home-home, they stay in a hotel for two or three nights. Why would we do that? Because they might end up back in the emergency department, because they don't have somebody at home with them. If I had to have a total knee right now, I don't have anybody that would stay with me. And I have a dog that would like to trip me, because she likes to trip me and sneak around behind my feet. Little Yorkie, 17 years old, so she can keep up with me though. But if you have an animal that you could be a tripping factor, what about stairs? What about getting in and out of bed? All right, then they say, well, let's just use home health. How often does a home health nurse go there? Three times a week. And are they going to be there when they need to get up out of bed? Are they gonna be there in the middle of the night when they roll over and squishes, and they look down and they're seeping a little bit? And then their loved one panics. We were doing this when I was down in Florida, and one of the case managers was really concerned about this one patient. So we Googled their address, and we looked at it from the outside, you know, street view, and we saw the husband and wife sitting in the front yard on lawn chairs, drinking a beer with a little bucket of KFC next to them. Now, if that's happening when the Google car goes by, how often must they be out there? But we were also able to see that they're in a trailer, and the stairs to it are cinder blocks with a piece of wood over it. And we're gonna be doing a total knee on this person. We said to the doctor, we need to do some kind of recovery care type thing with them, no, no, she wants to go home. The ambulance was called to her house twice the first week she was out. What does that do to you if you're BPCI, CJR? All right, so why does that matter to outcomes? Because we could have looked at that individual's score, their comorbidities, lifestyle, the house, different things that way, and predicted that outcome. We could have avoided it by putting them somewhere for the first couple of nights, giving them PT, some general nursing care. And what's nice about that is they can pay for it themselves. How many insurance companies want to prior authorize home health? They're already pushing people into the ASC to have the surgeries done. Cheaper cost of care. How do they know it can be done? Because they have the data. And how does CMS know BPCI worked? Now they're doing outcomes. They're going to use this also then to benchmark surgeons for pay rate changes. That will probably, I think the first adjustment in payment is based solely on the 50% and then the delta. And that would be, the first adjustment there would be in 27, because 26 is reporting, 27 would be when the first change comes in. It's always about a year after. So HOPD, it'd be 27, 28, and then by 29 for the ASCs. And we're going to start to see this with other surgical cases as well. Maybe elbow surgery is going to be the next one. And looking at outcomes. There's enough data that we're collecting on it out there that they're going to be able to adjust for that delta. What are they doing for those organizations that voluntarily report right now? They're making all of this information public. So would that be good for you? It'd be great if you have good outcomes. In San Francisco where we are, we have UCSF, Stanford, and Kaiser competing with us. It's kind of like when I was in Minnesota, we had Mayo. So everybody wants to go to Mayo, right, because it's Mayo. Are their outcomes any better than where I was? Back then, I don't know. I'm going to guess probably not. But our outcomes at Sutter are just as good as at Stanford. Actually they're a little bit better on knees. We know that because they do outcomes, we do outcomes. We have some of that data. Would that be good to be able to publicly state and mark it? Absolutely. All right. Would that help you in contracting with your payers? Do you think that they pay Stanford or Mayo a little bit more than they would you? Why? Hey, we'd love to get paid what Stanford does, plus our outcomes are better. So you should pay us a little bit more. They do. They'll do it right now, but when you start to have patients that see that and want to come see you, they're going to start changing their mind. When their premium dollars incoming start to go away because they say no and then maybe a patient changes insurance companies and wants to come to you, we've also found that if there's a bunch of patients that contact their insurance carrier on your behalf, they can sway it too because they want to keep those premium dollars coming in. So it's nice and you'll get past that person though. Keep pushing it. You'll get past that person. Yeah, I probably wouldn't voluntarily offer it to the insurance companies at this point until you understand it and know how you're doing. Because if you're doing well and better than the average, absolutely give that to them and say, hey, look, we're doing better than a lot of other organizations. We're above the national average at one year on knees, on hips. You should be paying us more. The data shows so. There's different ways you can benchmark. Some insurance companies have theirs because they may require certain things. CMS will be able to put this all out on the market as they start collecting this. If you use a collection company, a vendor, they can collect it and they will benchmark it against all of those that they collect the data for. So you can benchmark it that way. Or like AJRR. AJRR is one of the easier ones if you're collecting it yourself to be able to submit it to because you don't have to submit all of the stuff to AJRR. You can submit just your pros and some of a few other things about the surgery and still qualify for the registry. But yeah, a lot of places use like a third party vendor and they'll give you reports. They'll benchmark it against different locations, different physicians. Actually I used a vendor when I was down in Florida. Surgeons didn't even know we did it. All of a sudden at six months, they started to get these little graphs of how they're doing compared to others and against the national average and they had it by state with how many other organizations in the state they're running the data for like, wow, this is great. We use it for the expiral thing. We found out a little bit about infection. It was wonderful. A lot of surgeons loved it and what they loved most is they didn't do anything to do it. The magic happened in the middle there and they didn't have to be involved. It's a nice trial period for you because when they get to HOPD, that's probably where you're doing most of them and that's in a year. So inpatient, you have a captive audience in that hospital bed to make sure you get it done first. And then you've got your timeframes after that and it's a smaller number. So it's a nice trial, honestly. No, revisions do not go in. Just initial. Yep. Just primary initial. Which is nice. It's going to keep that size down a little bit. But once again, HOPD, you're probably going to five times as many cases. You start looking at the ASC, you're probably on another five times that many cases. So you have time to build the process and how to collect it. How to collect it is actually the hardest part because you've got to get the patients involved and you have to have them fill out at certain timeframes. And it's within a certain window of time too. There's a certain number of days that you have to collect that six months. It's usually like a two, three week period. Because what you don't want is to have Terrence over here collecting his six months at actually four months. And then you're collecting your six months at actually eight months. That's a big difference. You might look like you're doing great at six months, but you're four months after him. So there's specific windows that you have to capture that data within too. Yeah, it's around there. I don't want to say for sure. I'd have to go back and look because as you know, 80% of stats are made up on the spot. But it's somewhere around there. It's in the slide deck. We can go back and take a look. But yeah, our hit was probably going to be close to 16 million, like I said. So if you're a small hospital and you're thinking, oh, we're not going to get hit that much. Think about it, run the numbers, find out because you'll probably be surprised. And it's important, I think, for the individual practices that work with the hospital to cooperate and work with the hospitals. Because we need the hospitals. The hospitals need us. It's kind of a joint effort. So I get selling them the data. It makes sense. But at the same time, it puts them in an awkward position. Because it just does. You really need to sit down with them and talk through it and say, if you want us, we're collecting it. We'll give you the data. But give us better surgical block time. Give us a swing room. Negotiate it that way. Use the leverage outside of cash. Because the hospitals are strapped on that. And to leverage that might not put you in a good light. Well all the systems have to collect. So every hospital has to be collecting this. Oh, yeah, don't send them broadly. And I don't think they're going to do that. They're just going to say, at this hospital, this is the average delta. But they can still break it down. But at the first round, my understanding is that they're just looking at it to say, are you collecting 50%? So it's just a number, a randomized number. Here's 50%. Yep, we hit 50%. We're hitting the delta. Checkmark. You're good. And that's the hard part, is you need to get to the right person. So if there's a quality director for the hospital, that's the person you need to try and hit up. They can be. Yep. And why the patient satisfaction? Because they're going to worry about survey fatigue and people not filling out their surveys. So they may be able to tie them together, where they get a bundle of surveys. That's what ours is, is they get a bundle of surveys through the My Health Online portal. And so when they check in, the registration people see, oh, you have surveys due. Can you please fill out your surveys? And sometimes they do, sometimes they don't. We need to be more dogged on it. We need them to, when they're getting back, they may say, well, it looks like you still have surveys. This is a great time for you to do your surveys while you're in the little waiting room, and the doc will be in in a couple minutes. You get a little done in the big waiting room, you get a little more done in the little waiting room, and by the time you're going, your surveys are done. The problem is, is they're probably trying to do it on their phone, and I don't know how many of you have tried to do some of these surveys on your phone. It's pretty small, and I have fat finger syndrome, where you're hitting the wrong button. Your population's pretty rural, especially your base population, not your influx population. But your base population is rural, very remote, and for a year, I was up north of them for about an hour up in the Sierras, and so many of them didn't know what the internet was, really. They just didn't even have it. Yeah, yeah, because they just don't have access to it. They're starting to get access to it, but they don't. So that makes it really hard to do. But having people that are dedicated to it costs money. How do you get the money to do it? They show them the APU potential loss, but it's still added cost just to avoid loss. So you have to think of other possibilities, too. The reminders, having iPads available for those that have a harder time seeing. I'm starting to use my little light on my phone at restaurants now, so I can see the menu. How many of you remember your password on your portal? If my phone didn't have, and it didn't allow facial ID, I'd have to be filling out the little forms to get a new password every single time, because I can't remember passwords. And I'm trying not to use the same one for everything. But you need somebody that's going to get those response rates, and that's going to be, honestly, your biggest challenge, is going to be collecting it and how to do it. I don't have a solid answer for you. You need to look at the culture of your organization. You need to look at the APU potential loss and say, can we hire a third-party vendor to do it? Do we need to hire individual people to come in and do this? Do we have volunteer capability? Or are we going to make this a requirement for the front desk and the MAs to capture this? And if they hit certain capture rates, we'll bonus them. I mean, our managers, are you guys on a bonus structure of some kind? Yeah, but, you know, if you could give them a little bonus, make it a competition, and say, hey, you guys help us with this. We hit this threshold, we'll give everybody this amount. We hit this threshold, we'll give everybody this amount, all right? It's better, I think, than the annual Christmas bonus, because everybody expects that then, right? It becomes an expectation and entitlement. Every year at Christmas, we get 100 bucks, right? It's in our little Christmas card. What happens when you don't do it? They go Christmas vacation on you, right? They can't buy the pool, and you get the jelly of the month club, and you're terrible, right? So instead of that, take some of that and put it into a bonus program where if they hit metrics, and one of those metrics is your response rate. This is not far behind for all of the clinics. It isn't. Hospitals take the hit first, but then it's the HOPD, it's the ASC, the payers are going to be getting this data, and they're going to be right behind them, and then you're going to start seeing them pay attention to outcomes and use that for contracting purposes. If you're not collecting it now, you're behind, because you need two years' worth of data to have anything. Because you need to have the benchmark, you need to have the one year, and you need to have the follow-up. Because the first year, your response rate's not going to be that good. It's going to take time to build up your end size. An end size of two is not going to convince a payer that your outcomes are any better than anybody else's. You have to be a painkiller, you have to be an anesthesiologist, you have to be an anesthesiologist to go over. Facial poring out rounds is one of those matters for lower extremity, and you have to have a year's worth of data and assistance to get on that with people, that matter. So if you're thinking about doing that, you should be having that patient assistance now. The California America student that started, it was funded by a business person, they wanted to know if their patient had a good outcome. It was so large, and I thought, these are large insurers. Absolutely. All of the insurers are going to be expecting this, absolutely. And like you said, that was one thing we hadn't really talked about, but is huge, is direct to employer contracting. Where if you can show them your outcomes, and you can say, these are our outcomes, this is how well our patients do. Here's our program. Here's what we'll give you for a price to do that total joint. And you go right to the employer, because so many of those big, big, big companies now are self-insured. So in Silicon Valley, Facebook, what is it now, Meta? All those companies, big high-tech companies, they're all self-insured. Yep, you've got companies in your area that you could go to. Another thing is municipalities is a good one. Municipalities is huge. If you can get to them, especially fire and police, those guys will need joints later on in their life, all right? And can show your outcomes. The other one is spine is not far behind, because we're starting to see more and more spine moving into the ASC too, all right? You can show that your ASC is just as safe as the hospital through outcomes also. So it's here, it's staying, it is describing value. And you need to be collecting. Question, it's not necessarily mine, but you're asking me somewhere, you know, is there any relief associated with, you know, showing the payer that you've done? Yeah. No, not on PROMS. Nope. There aren't codes for that. Yeah. Yeah. No. It'd be nice, but no. Well, I know like in Michigan, they have a marquee. They've been doing PROMS like forever. And I think we just had, was it the AME that just had a webinar where like less than the consumption practices were even doing any? Yeah. Yep. Yeah. It, that's what we brought up, like Boesig's dream is to have everybody doing PROMS in the AOS, but 60% are doing something and 40% do anything with it. Probably not, but out of the people that they surveyed and actually responded to a survey, 60% maybe. So that's the other thing you have to think about is who responded to that survey. Probably the more active ones and that would do PROMS. So I think we're out of time, but I'm happy to talk about it more. But the benchmarking, that's why you need such a large volume. So you can get rid of the outliers. So you need, that's where the end size is really important. So it's going to be small to start with, with the hospitals, inpatient. Then it's going to get bigger with the HOPDs, bigger yet with the ASCs. And as that number grows, we're going to see more contracting based on it, more value-based care programs based on it. And it's going to be a marketing tool for you.

Patient-reported outcomes

PROMs

Value-based care

CMS-preferred PROMIS-10 measure

Surgical care

Quality improvement

Provider performance

Healthcare decision-making