Make Epic Training Work for You and Watch User Satisfaction and Gold Stars Soar

And I’m excited to emcee today’s webinar with our guest speaker, Dr. Brian Patty. And, uh, in today’s environment, healthcare leaders are facing the challenge of improving clinician satisfaction while meeting the challenges of the changing Epic Gold Stars criteria.

And so, in this webinar, uh, Dr. Patty’s going to present a paradigm shift, treating these not as separate battles, but as unified goals. And so he’s going to share. A proven playbook for using satisfaction data. And utilizing gaps to build a high ROI strategic training program. Creating a sustainable system where user satisfaction becomes the engine for long-term performance.

Before we do that, I want to give a little bit of context about 314e. Uh, so we’ve been around for 20 years. We are, uh, there’s no venture capital backing us, we’re organically grown, which we like to, uh, we’re proud of that, and we’ve got several products that are in the market that integrate with EHRs, uh, especially with Epic, and namely relevant to today’s conversation, is our Jeeves AI-powered just-in-time training platform, which has a place in the strategy for training programs.

So, a little bit of our agenda today, so I’ll do a quick introduction of Dr. Patty. We’ll talk about… he’ll talk about EHR satisfaction and burnout. Um, then he’ll get into practical plans for building a clinical satisfaction program with a focus on training and support, walk through a case study of an academic medical center where he applied these principles and these strategies. And then we’ll have time at the end to get into Q&A and some discussion. So, as I mentioned, our speaker is Dr. Brian Patty. Dr. Patty has practiced emergency medicine for over 20 years. He’s been in medical informatics for over 20 years at multiple organizations that you can see here.

I’ve had the distinct pleasure of working with Brian and knowing Brian for the better part of my career as well, and so I’m pleased to co-present with him today. He currently works with organizations to improve clinical workflows and improve EHR efficiency and satisfaction.

And so with that, I will hand it over to you, Brian

Thanks, Casey and everyone at 314e, for this opportunity. This is a topic that’s near and dear to my heart, and I… I always love an opportunity to share, to kind of pay it forward, if you will, to share what I’ve learned from others and what I’ve learned through my, uh, years of practicing clinical informatics, and so this is a great opportunity, and I appreciate it. Thank you.

So let’s talk a little bit about burnout. You know, people… I’ve seen a lot lately that, oh, the burnout is decreasing in the U.S. You know, and while that’s true, it really is decreasing from a peak. You can see this is from just a couple months ago, in July, Mayo Clinic Proceedings put out another article on burnout. I’m showing the latest statistics.

You know, showing that 45% of physicians have reported at least one manifestation of burnout, which is obviously down from 2014, are down from 2021, the peak after the pandemic. But as you can see, it really hasn’t… we really haven’t done a lot to improve over the last 10 years. Um, other than that… that peak where it got worse during the pandemic. We really haven’t dropped to pre-pandemic levels yet, and so we’re still seeing a significant amount of burnout in both our physician and nurse populations out there. And people say, well, okay, yeah, burnout is burnout. Is that having an impact?

Um, and so this is an even more recent article from the Analysts of Internal Medicine. This just came out last month. Um, showing that, um, physician attrition rates from clinical practice are accelerating at a rather astounding rate… 1.5 percentage points. Uh, really, in the last… in a 6-year time frame. And this is kind of scary, and so I, you know, it really… You know, uh… I think that this should resonate with organizations to say. You need to keep the physicians and nurses that you have. You need to find ways to keep them, reduce burnout, and keep, uh, and reduce this attrition rate. Um, because if you do lose them, it’s going to be harder and harder to find replacements at your organization. Um, and as you can see in this article also showed that there’s a significant predicted shortage of physicians by 2036 and another 10 years. Um, so I think it’s imperative for organizations not only as an ROI, because I think there is an ROI to these projects, but just as a, uh, to sustain your current levels of physicians and nurses. Uh, because it’s gonna be harder and harder to find replacements if you do lose them.

So, what can you do? Um, I compiled this list, um, from multiple sources about what organizations can do to affect and decrease burnout at their organization. Uh, you know, from Mayo Clinic, from the AMA, Cleveland Clinic, AMGA, and others. And, uh, you’ll note, you know, I don’t think any of these is new to anybody, but it is a great… I think it’s a fairly comprehensive list of things you can do.

But I think of note. Well, EHR satisfaction isn’t the be-all, end-all of burnout, although it’s an important factor of it. Putting together a strong EHR satisfaction program impacts 6 of these 7 tasks significantly impacts them. And so I think it’s important for organizations to really take a programmatic approach to EHR satisfaction. Um, now, obviously, there’s a lot here. You’ve got, you know, assessing the level of burnout, optimizing your care model, enhancing clinical workforce management, decreasing administrative burden, increasing clinical efficiency, improving clinical and leadership alignment, and providing comprehensive well-being support to your organization.

That’s a lot. So how do you prioritize? Well, number one on the list is measurement, and you’ve got to measure. You have to understand what’s going on at your organization. Um, so I… I’ve… do this on a regular basis now with organizations. And when I come in, I like to start with 3 areas of measurement and combine these data sets. Um, I encourage organizations to use the Classarch Collaborative Survey. It’s really the only externally benchmarked, validated survey out there for you to understand where you are with end-user satisfaction. It also has a measure of burnout in it, if you utilize those questions, and I encourage organizations to utilize the burnout questions. Um, within the Arch Collaborative Survey. So, great place to start.

Um, I then take a look within the organization at their signal and gold stars data. Epic supplies great tools for organizations to understand where they are, and you need to utilize these. You know, signal. I use Signal on a layered basis. I look at it from a global standpoint. Where are there issues across the organization that are systemic issues? I look at, um… at a specialty-by-specialty basis to break it down to see how there are specific specialties that are struggling more than others. And then take it down a notch further. And look at individual physicians to say, are there individual physicians who are struggling when others around them are? And obviously aren’t, and obviously that’s, you know, a training and support issue. Um, gold stars, um, and I’ll mention this a couple of times now, uh, Epic has markedly improved their gold stars by including not only implementation, but utilization data. And that’s one of the key things we’re going to focus on throughout this talk is looking at that gap. I tell organizations, if you’ve ever been on the underground in London, you always see these signs, mind the gap.

I tell organizations now, when you’re looking at gold stars, mind the gap. If you see a huge gap, um, or even a couple of point gap between your implementation score and your utilization score. That’s a golden opportunity for you know, either people don’t know that it’s been implemented, or they know it’s been implemented, and they don’t know how to use it. So it’s a great opportunity for both communication and education. And so, look at those, uh, look at those gold star gap areas for communication and education opportunities. And then I also interview… I do a lot of interviews with senior operational and clinical leaders, not only to find out what are their areas that they see are um impacting end-user satisfaction, but also to understand. What are some of their strategic initiatives that they’re working on? And… That can help you as you build your program and you start prioritizing projects. If you can tie projects into some of these strategic initiatives, or some of the areas that are important to your senior operational and clinical leaders. You’re gonna have budgetary support going forward for those projects. And so identify those. Validate with those leaders that you heard that from, that this is a project that can help them along their, you know, with their projects or their strategic initiatives. And get that support when you go through the budgeting process for some of those, uh. Uh, uh, projects. So, taking this measurement and really developing an evidence-based action plan based on what you find.

But first… And this is key. One other thing I want to go over, a class released this impact report last year on burnout, and one of the key findings there is. It’s easier to prevent burnout by increasing EHR satisfaction early on than it is to reduce burnout after it’s peaked. So again, focusing on being proactive. Uh, don’t play whack-a-mole. Be very proactive at your organization and develop a strategy and apply that strategy to, to the… to your organization. You know, a couple of years ago, and actually, Casey, when we met, when I was back at Health East. Um, we had a great lean sensei. We were a lean organization, we had a sensei, Didier Rubino. I just, uh, I learned so much from him, and, and, you know, a couple of the key things he taught me is, one, get to the root of the problem. Continue asking why until you get to the root of the problem, and then take a systematic approach to solving that problem. And so, uh, really, uh, rather than seeing an issue and attacking it, seeing an issue and attack it, take a step back and develop a program and make sure that you’re looking at all of these areas. So I developed this, you know, as you know, if you have any exposure to Lean, we love our houses. And so I developed this house of success for EHR satisfaction.

Um, I’ve improved this over the time. At the time, I worked at Health East and through the time I worked at Rush, and as a consultant, but also in working with class, and CLASS has validated a lot of these components. Uh, and actually uses a similar structure now to, uh, to promote, uh, how organizations approach EHR satisfaction. But I developed this house very purposefully. One. Um, at the base, you’ll see EHR speed and reliability. Uh, and we’ll go into that in further detail. But if your foundation isn’t solid, if you know, if you haven’t implemented and kept Epic up to date well, and if you haven’t, if your network and delivery systems aren’t working properly.

No matter what you do in the rest of the house, rest of those pillars, it’s not going to have a huge impact. You have to nail the implementation, speed, and reliability issues first. Um, and then the next most important thing is training and education, and support. And again, we’ll dive into those deeper, um, uh. But, um, I do want to focus… we’re going to focus on those two areas today, but I’m going to quickly review the rest of the house here.

And so, it’s very tempting to jump in right away and solve problems. Um, but let’s make sure we’re solving the right problems and getting to the root of those problems first. And then we can attack it, uh, proactively and get ahead of the game before you start to see peaks in, uh, uh, burnout and turnover at your organization. And so, uh, really getting ahead of the game is critical, and you have to develop a program to do that.

Yeah, so thanks for that, that. That question, Casey, because it is so important, and I see it time and time again.

So, um, I’m gonna briefly go through these. Like I say, we’re gonna spend a lot of time today on speed and reliability and training and support, but I did want to go through, kind of, a few basics on each of these on the foundation and the pillars. And so, again, with EHR speed and reliability, using that latest functionality with Epic, keeping up on upgrades, and making sure your keeping as up-to-date on Epic with all of the latest functionality as possible. And then improving speed and reliability, uh, taking a look at your network, measuring and solving those root problems, and we’ll go, again, we’ll go deeper into that in a little bit. Same thing with training, education, and support. Make sure that you have… I always see that there’s 3 components for this. There’s really that onboarding training, whether you’re implementing Epic for the first time or you’re bringing new people into the organization, making sure you’ve got that onboarding nailed.

We’ll dive deeper into that. Ongoing training is probably the number one thing that I see organizations fail at. They think, oh, we’ve implemented EPIC, we can now let most of our training team go. No. Epic is constantly changing, your organization is constantly changing, you have new people coming in all the time, you have people who have gotten into ruts.

You need to… to really develop a strategy for ongoing training. And you need to have a real-time support team for just-in-time training and get people unstuck. I even see this real-time support piece as even a patient safety issue, because it’s that real-time support team, and we’ll talk more about the, uh, what that looks like in a little bit. Um, but if you have somebody who’s clinically practicing, they’re taking care of a patient, and something gets them stuck. You have to get them unstuck now, and so that they can continue taking care of that patient. You can’t rely on them putting a ticket in and solving it for them in a couple of days or months, when somebody gets around to that ticket. You have to have a way for people to get unstuck now.

And so I really see a need for organizations to develop and maintain a real-time support methodology beyond just the help desk. There’s no way people at the help desk can have the deep knowledge of clinical workflows that you need to solve some of these issues. They can solve some of them.

But, you know, 90-plus percent of calls to the help desk from physicians and nurses are training issues. They’re not something broken. If there is something broken, great. You can put a ticket in, follow it, and get back to them.

But, uh, it’s training, training, training, and we need to understand that. Um, so a little bit more on some of these other pillars, governance and communication. You really need to give your end users a voice. Let them tell you what they need. Um, I like to educate those voices. So, at Rush, our, our physician, um, uh, team, uh, physician governance team. We’re all, um… physician builders. We gave them advanced training in Epic so that they understood how to solve the issues that are coming in front of them. They understood Epic at a deep knowledge of how Epic works. And they understood the best ways of solving these problems. And so, having an educated voice with advanced EHR training on your governance teams, I think, is critical.

Um, workflow is king. Um, I tell my teams this all the time. Uh, if… if the workflow is broken, everything’s broken. And so, engage key voices from key, unique workflows across your organization on your governance teams to make sure that you’re understanding where the issues are arising. And develop a communication cadence. Um, I used to tell my teams, take the… take 5 minutes at the end of every governance meeting to say, what did we decide?

And what do we need to communicate, and to whom do we need to communicate it?

And so that you’re all on board with what that communication strategy is going out of that governance meeting, because I believe peer-to-peer communication is one of your best tactics that you can use. And so, using those peers that are making those government decisions, giving them the tools to go out and communicate those decisions, the why and what’s in it for me.

Back to the organization is critical. So use your governance teams as your first line of communication back to the organization. And make end users feel heard. If an end user brings up an issue, and it comes to the governance committee, and the governance committee makes a decision whether they decide to go forward with that or decide not to communicate back to those people that brought it there. Make people feel heard.

I think that, again, that’s… that’s very so important. So, let’s dive into these a little bit, and again, I’ll go even a little more deep on these, but you know, EHR speed and reliability, you know, keeping up on upgrades, using all that additional available functionality. And utilizing that satisfaction data to kind of prioritize your gold stars.

I’ll dive into this in a little bit more in a little more detail.

Um, voice and AI, this is a whole other talk, and again, we’ll expound on it in a little bit, but take advantage of the AI resources that are out there. And then, uh, speed and reliability. Know where your issues are. Measure and monitor your speed and reliability across the organization. Don’t rely on. Uh, on calls to the help desk. Get tools in place that will help you measure and monitor your speed and reliability in identifying those root causes.

Okay, so let’s dive a little deeper into those.

Um, so I’m going to take a little breath here, Casey, and see if you have any questions or clarification, uh, so far.

And, um, you know, I think you mentioned minding the gap, and I think that’s really kind of how we think about our product development, is where are there gaps in, you know, that we can create solutions that address those gaps, and so that just in time, you know, we need the answer now versus calling the help desk is what we’re trying to focus on here.

So, from a Gold Star standpoint, I really love the Epic Gold Stars program. It really… Epic does a great job of identifying what are the most impact… what’s the most impactful functionality that is out there that people either are using or are not using. And Gold Stars really helps you identify those. I think Epic’s seen who are their most successful organizations, and what are they doing. And through the Gold Stars program, they’re helping other organizations mimic those highly successful organizations. So Epic does a… spends a lot of time trying to help all of its organizations be successful on their platform. And so pay attention to the gold stars you know, try and get to that 8 or 9 or even 10 level, and try and stay there.

Um… So, if you’re not at 8 or 9 gold stars, I think one of the best… there’s a couple of really good sources to say, how do we get there? What do we… what do we do? Well, and one, first and foremost, is your governance teams, you know, expose your governance teams to gold stars, expose them to the functionality that you haven’t implemented, and get their opinions on, um, what are the things that are most important for them, and attack those.

But also your satisfaction surveys. There’s often a lot of alignment between the results of your satisfaction surveys. And where you’re lacking in your gold stars. So look for alignment there. I think it’s critically important, because.

There’s… there… I have yet to come into an organization where I haven’t seen a significant amount of alignment between what people are asking for in the satisfaction surveys and what is lacking from a Gold Star standpoint. And, you know, budget to stay on top. Once you’re there, don’t assume you’re gonna stay there. It’s work staying… keeping up with gold stars. You have quarterly updates, and all of those updates include elements that are going to get added to Gold Stars are likely going to get added to the gold stars. And so, uh, keeping up on those updates, being strategic.

Um, with your upgrade planning. Again, try to align those things that are difficult, uh, with strategic initiatives at your organization, but also align at what you’re hearing from your satisfaction surveys and your governance teams. Um, I like forming SWAT teams, so there’s a lot of quick wins within Gold Stars. And, uh, forming these little SWAT teams can help you attack those quick wins, very, uh, in a very agile way. And so what I mean by a SWAT team, uh, we did this at Rush. We paired a physician builder with an analyst and a trainer, and they would meet on a weekly basis.

Not only to look at what are the irritating things that they’re seeing within their area, let’s say we have a, you know, an ED physician builder, an ASAP analyst, and a trainer that focuses on ASAP. They would meet regularly and understand what are the issues in the emergency department, and what are the things that we need to solve, and those… the things that we empowered those teams to fix the things that they can fix, but also to identify, so those quick wins, but also identify those things that are going to be a bigger project to bring them back to the clinical governance teams to get them prioritized for the next round of budgeting if you don’t have the resources to do those.

So the SWAT teams did two things. They knocked out the quick wins, but they also identified things for larger projects. And then, um, I’ve said this before, but mine the gap, look at the Gold Star’s implementation and utilization scores, and identify those training and communication issues. You’re gonna see, uh, uh, when you see a gap in your Gold Star’s implementation utilization scores.

It’s one of two things, or it could be both.

One, people don’t know that you implemented it, and so it’s a communication issue. Or two, people know that you implemented it, and they don’t know how to use it, and so it’s a training issue.

Uh, and oftentimes, it’s a little bit of both.

So it’s a great way to identify where you need to focus with your ongoing training. And I know that you guys do a lot of work in this area as well, Casey.

Or, it sees that they’re doing something unusual in their workflow, and they can kind of tap them on the shoulder and say, Hey, look at this. This might be helpful for you.

Um, I’m not gonna go deep into AI, that’s a whole other topic. But, excuse me. Excuse me.

As organizations really need to. Focus on not only the… opportunities, but also the risks of AI. And if you don’t have a team specifically focused on this, you need to develop that, because - One, it’s a great way to improve end-user satisfaction. But there are risks, and you have to identify those and you have to mitigate those. And so you have to have a team of experts within your organization analyzing opportunities to use AI, and identifying. Uh, what are the risks, and how do I mitigate those risks?

So things like clinical documentation, optimizing decision support, streamlining medication management, automating and offloading a lot of administrative tasks, things like prior authorization, patient messages, refill protocols, and documentation that isn’t necessarily needed to be. provided directly by a physician. These are all areas where AI can help you, um, and help your clinicians be more efficient and therefore more satisfied with the EHR.

And I know that Jeeves has a lot of AI tools embedded within it, and, you know, obviously, you’d love to talk with folks about those in greater detail. But again, I think that this is an evolving area that organizations need to pay attention to, because there’s a lot of value here.

And then speed and reliability. Don’t rely on the calls to the help desk to identify areas of speed and reliability. Put in tools so you can proactively measure where are we having issues. Uh, and you mentioned earlier, you know, I love an organization called Goliath Technologies. I think that they have an amazing tool. It’s very inexpensive, it’s very lightweight. And it really looks kind of across the board, and gives you the ability to identify the frequency, the duration, and the cause of speed and reliability issues at your organization.

Um, it allows you to have dashboards that you can share with your clinical teams, with your IT, and with your vendors to show them that these issues exist. And it also it looks across. All of the areas that are… that have the potential to cause speed and reliability issues. A lot of times, your Citrix team will say, Oh, Citrix is fine, your infrastructure team says, No, infrastructure’s fine, network team, No, network’s fine. You know, devices on down the line.

But there are interplays between those that oftentimes those individual teams don’t see, and Goliath kind of looks more globally and can see where your organization’s having issues. And it can see it in real time, and you can be proactive. So, again, uh… whether you use Goliath or not, I don’t care, but use a… tool that allows you to be proactive in, um, looking at speed and reliability across your organization.

So, let’s talk about the training component. And I really see this actually as having 3 separate components within it. You know, the ongoing, uh, onboarding training, whether you’re implementing Epic for the first time, or you’re been on Epic for a long time and you’re onboarding new physicians, nurses, or others. You have to have a strategy for that.

Um, ongoing education, uh, making sure that you’re keeping people up-to-date. Epic is constantly evolving, your organization is constantly evolving, ongoing education support is one of the biggest Achilles heels I see at organizations, they fail on this, they fail to adequately budget for it at the time of implementation, or adequately budget for it in an ongoing basis, and so make sure you’re doing that.

And then field support. I talked about field support. Get the ability to get Clinical users unstuck when they get stuck is so important, and you have to have people that understand clinical workflows on that field support team. We’ll talk more about that. So, let’s go into each of these in a little more detail.

Um, ongoing or implementation training. Um, I really encourage organizations to use a mix of modalities, different people learn in different ways, um, and so you have a, you know, make sure you have a mix of classroom and online coursework.

Um, uh, make sure there’s opportunities for both, uh, and again, you’re, you’re… your classrooms can be in-person or virtual. Um, but also have, uh, some, uh, asynchronous materials as well.

Um, and I divide this up into two kind of basic components. One is basic EPIC functionality. People typically nail this when they’re implementing Epic, or when they’re bringing somebody on board. Epic has great training modules, um. They work very well here. They’re, uh, they enable… but also make sure you’re enabling test outs for users who are familiar with Epic. If they’ve used Epic before, allow them to test out in a reasonable way on the Epic functionality. But a lot of organizations fall short on the workflow training. Okay, I’ve now got that functionality training. How do I use that in a day in the life? Walk people through scenarios. This is a great place to utilize your specialist training specialist program.

Um, identifying those key workflows that people are going to do day in and day out, and walk them through that workflow, and show them, okay, here’s how you use that Epic functionality within your workflow, you know, for a clinic physician, here’s. a patient from the time they enter your clinic to the time they’re discharged from your clinic, walk them through that whole process, and how you use the tools to advance the patient through.

Um, inpatient physicians, show them the admission process, show them the rounding process, show them discharge process, proceduralists, show them, you know, pre-op, inter-op, post-op workflows, walk them through those workflows, and show them how those tools that they’ve learned in the initial training are utilized within the workflows that they’re going to be utilizing those tools in. It’s so critical.

And then follow-up. Make sure you’re following up with people. This is just an example of what a follow-up process might look like at your organization. Um, but quite frankly, adult learners. retain, you know, 30 to 40% of what you taught them, right? Um, and so, the follow-up is important to, one, go back over some of those things that they may have forgotten or aren’t using properly, but also to introduce some new stuff that you may have not covered, and making sure that, you know, that they’re their mobile… their devices are set up properly. Um, that they’ve, you know, they’ve customized their schedule, customized their toolbars, uh, looking at their charting tools and orders tools and customize those. You know, how do an open encounter, how to do an addendum, those types of things that they may have forgotten because they had information overload during training, make sure that they understand those, because those are critical tasks for them to get through their day.

Then follow up, uh, at a period 30, 45 days afterwards, you know, focus on things that… a little more minutiae. In basking, uh, trainings, activity trees, navigators, chart reviews, filters, smart phrases. Go over some of those in more detail at a later… at a, you know, 30, 45 days after they’ve been using Epic for a while, and they understand how to… what they need to do to personalize it.

And then, um, some follow-up sessions later on. kind of a catch-all for all those topics that, you know, weren’t covered in the first two sessions, or now that you’ve seen some signal data on this person, you obviously see, oh, they don’t get this. Let’s go back and re-emphasize this piece for them. And so… but being… You know, whether you follow this game plan or you develop your own, make sure that you’re following up with people after they… after your implementation, or after you’ve onboarded them, and make sure that they’re, uh, you’re giving them additional opportunities for… for training.

So, ongoing education. Again, this is an area where a lot of organizations fall flat. They don’t fund this well enough. Um, and they, um, uh, they… they don’t… oftentimes, this is one of the key Achilles heels for end user satisfaction at organizations.

Epic recommends 4 hours of ongoing training. KLAS data has shown that 3 to 5 hours of contact per year is kind of that sweet spot. If you will. And so, really figure out how you can deliver that. And again, using multiple modalities, accommodate different learning styles. But also accommodate different ways of. accessing educational materials. You know, classroom, whether it’s a virtual classroom or on-site, you know, utilizing those Epic Thrive materials and, uh, walking people through purposeful classroom events. You know, lunch and learn sessions. What are some focus topics that you’ve been hearing a lot about lately that people might be interested on?

Go to department meetings. When I look at class data for organizations, I consistently see this as one of the top ways that physicians want to learn more about Epic: come to our department meetings. We’re going there anyway. Come there, we’ll give you 15, 20 minutes out of every department meeting to tell us what’s going on, what’s new, what could we learn, give us some tips and tricks, come to our department meetings. Same thing with nurses. Go to your nursing unit meetings. People, again, are coming there anyway. It’s a great opportunity to give them some tips and tricks, and to take some feedback back to your governance teams on what’s not working.

Um, one-on-one sessions. Uh, these can be both on-demand or targeted based on signal data. Uh, but obviously, a great way to do some of the personalization tools.

And then, embed your trainers in clinics. Embed them on care team rounds, embed them in the operative workflow. So that they can observe. what’s, uh what’s working and what’s not working, you know, based on how things are designed in Epic, and they can also give people some quick tips and tricks to say, hey, listen, uh, this is… let me show you a quick way to do this a little more efficiently. But also, another opportunity to take some feedback back to your governance teams to say, Hey, this isn’t working. We designed it, they’re using it as designed, and it still doesn’t work for them. We gotta figure this out. So… getting those trainers out, doing some rounding, and getting them out in the field is, again, critically important for your ongoing, uh, education program. You know, like I said, you can have some… a different modality… oh, go ahead, Casey, you had…

So, in the absence of in-person or on-site, what do you consider to be kind of good self-directed alternative approaches to that ongoing education, or even that follow-up from the initial onboarding education.