February 25, 2010
Dr. Dougherty: Good morning. Welcome back. I see it's a bright and sunny day. I have just a couple of reminders about the agenda for the day. We are hoping to be able to do three breakout groups, one on feasibility criteria, one on criteria specific to children that would bring together the previous criteria and see if there's anything to specific to children, and the third one would be on racial and ethnic disparities, again bringing the other criteria together and seeing what is specific to identifying racial and ethnic disparities. And so disparities affecting children with special health care needs will be in the children's group.
So we're going to start. Just a couple of reminders—if you are asking questions, making comments, could you please say your name for the benefit of the transcriptionist?
Another reminder—I understand and not surprisingly by the end of the day yesterday, some folks had kind of lost track of who our target audiences are. The target audiences for these criteria are going to be the awardees for the Children's Health Insurance Program Reauthorization Act (CHIPRA) Pediatric Quality Measures Program, which is described—well, there is a section of the law for the Pediatric Quality Measures Program.
Unfortunately, that announcement is not out yet, so I can't say too much about what that is except for what was on the Web site and in the grants.gov guide back in November when we had hoped to release the announcement, which is that these will be cooperative agreements, which means for-profit entities are welcome to apply. It also means that the awardees will work very, very closely with each other and with the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS).
So that's our opportunity for future development of criteria that we don't quite get to the, you know, really nitty-gritty of specifics at this meeting. So your effort here will not be wasted.
And the users will be the awardees of the CMS Quality Demonstration grants in their quality measurement efforts that they have said they are going to do. One of the foci is school-based health centers, so—of one of the States. But it is very diverse and good group of awardees.
The other reminder is that when we talk about what levels we are measuring, who is going to be doing the reporting, and it's the State level. Of most interest to CMS is the States have to report. That's in the legislative language.
And also in order—there is the American Recovery and Reinvestment Act (ARRA) language that is going to be closely connected to CHIPRA somehow, that Michele Mills is going to explain today and Jon White. So we're interested in the electronic health record (EHR) and how far you can get with that.
So the focus of our first breakout is feasibility, with a heavy emphasis on the health information technology (health IT) and EHR components. And so this morning we have to give you some background on that because it can be hard to keep track of what's happening with health IT and EHRs, we are going to ask Michele Mills from CMS to give us a little background on that.
And then Jon White, who is the health IT lead here at AHRQ, he is also going to give a little background on that on the overall picture as well as the AHRQ and CMS partnership on creating a model template for EHRs.
Dr. White: Thank you and good morning. My name is Jon White. My official title is Health IT Portfolio Director here at AHRQ. I've been here for 5 years now.
I want to start off by saluting those of you who stared in the face of impending doom from snow, only to see the threat fade in the face of your strengths. So, well done.
I also want to say it is a pleasure to see some friends here, Denni McColm, a long-time AHRQ grantee, and expert health IT user. And on just a very personal note, I want to welcome Kevin Lorah to AHRQ. It was completely unexpected when I walked in yesterday.
So 5 years ago, I was a family doctor. And I was delivering babies in Lancaster, PA. And Kevin is a neonatologist in Lancaster, PA. So I would catch them, and I'd hand them to Kevin. And Kevin would buff them up and hand them back to mom. Or he'd say I'm going to take this one back to the workshop for a little bit, and kind of go back and buff him up a little bit, and then bring him back and hand him to mom. So it was a delight to see him. And Kevin and I still haven't had a chance to talk and say hi. But we will.
So thank you for coming. Let me just give you a little sense for what's happening in health IT, especially with the Recovery Act. And then Michele will connect the dots for you.
So health IT has long been of interest. AHRQ has actually funded health IT—AHRQ and its predecessors for 30-plus years, research in a lot of difference places, whether it's Intermountain Health or the Regenstrief Institute, the Partners Healthcare—what is now Partners Healthcare up in Boston. So it's been of interest to the Agency as a means to improving health care quality.
And for the past 5 years, Congress has set aside part of AHRQ's budget to be able to fund research and synthesize the best evidence about how you do that, improving quality using health IT.
For a long time, it's been talked about, the interest has been mounting. And then 1 year ago, the world changes because the Recovery Act passes. And of the 400 pages of the Recovery Act, 100 of them are dedicated to health IT and establishing the Office of National Coordinator (ONC) and setting up all sorts of advisory councils and, most importantly, setting up an incentive program, okay, where for the first time, the Federal Government, in a very substantive way, will pay doctors and hospitals and some other folks to adopt and—this wonderful phrase of art, meaningfully use, health IT. You know as opposed to the meaningless use, which has happened previous to this. Now it is meaningful.
So—which has been a really fascinating concept and it's been, you know, this was not in the plan when I went to medical school, but it has been a really fascinating time to be in the Federal Government and watch all this unfold.
In essence—and the meaningful use component is what I really want you to be able to pick up on because it's not just that, you know, the doctor buys the equipment and bitches about it for a while and then eventually gets back up to speed with productivity. They have to also then be able to do certain things with that and demonstrate that they can do certain things with that to get their money from CMS.
And when we talk about their money, it's for doctors and hospitals. It is through Medicare and Medicaid, okay. And the estimates are that it is on the order or $20, $30, $40 billion. It's not specified. It's formulaic, okay, but it authorizes CMS to make those payments out. So nobody knows exactly how much.
But there is a regulation out on the street now, notice of proposed rulemaking, a draft regulation that specifies what the incentive program looks like. The comment period is up until March 15th. There will be a period of time. And then a final regulation will happen. And that regulation will specify the payment rules for 2011, when the program starts, and to a limited degree, 2012—not completely. I think there will be some tweaks in the payment regulation for 2012.
So it is still forming. It's not set yet. But it's on its way. A key part of the definition of meaningful use, as established by Congress and then further promulgated out in this regulation, is the reporting of quality measurement data through these systems.
The way it is set up right now in the proposed rule, a number of specialties are called out specifically. Pediatrics is definitely one of them. A number of measures are put in there for 2011, with a proviso that A, that may change, and B, it can definitely change in future years.
Let me tell you what the reality is. The reality is that most of the systems that exist right now currently cannot do this. I'll just, you know, tell you that.
Denni is working on the grant, and she can probably tell you very explicitly the challenges that go along with actually doing this. It is a real challenge.
For the first year in the rule as proposed right now, providers are asked to attest to the fact that they have gathered these data. And then in 2012, provided the Secretary can accept it, the providers are going to be asked to send the data in. Where, how, don't know yet. Still working on that, okay, so it's still under development.
So the key thing that you need to know as you move forward with this terribly important work that you are about today—yesterday and today—is that maybe not in 2011, maybe not in 2012, but in 2013 and in years subsequent to that, there likely will be an expectation that the measures that are decided upon get baked into the information systems. And a means to gather that data, aggregate it, interpret it, report it out is going to be baked into these systems.
So as you go about this work, I know you're going to spend some time doing this, and I'll stop mostly on that and just talk briefly about the pediatric formats that are going to be a key part of that. So as you go about the work that you do, that's the background that you're working on.
Just very briefly, part of the CHIPRA legislation was a demonstration or, you know, the requirement to define—I'm sorry. Erin Grace is in the back. She is part of the health IT team. Erin has been the Project Officer and what I genuinely consider a shining example of good intergovernmental working relationships has been just a paragon of virtue working with CMS around the establishment of this task order.
CMS and AHRQ have partnered up to compete and award a task order to establish pediatric EHR formats as required by the CHIPRA legislation through one of our contract mechanisms. So that project has been solicited for, but it is not yet awarded. They're still going back and forth in negotiating.
But there are two key things to understand about that. Number one, over a period of time, these folks are going to develop not a new EHR, okay, but formats that will be expected to be able to be used by pediatricians using EHRs, and that they will meet the needs as laid out in the CHIPRA legislation. And quality measurement is definitely going to be a part of this.
The other thing to note about that is that you are aware of the Medicaid demonstration grants that were awarded recently. Those folks are expected to interact with the development of those pediatric EHR formats.
So just very briefly that's a touch on that. And you've plumbed the depth of my knowledge. If you want to know more, talk to Erin.
So thank you very much. I hope I didn't overextend my time. And I will relinquish to Michele.
Ms. Mills: Thanks, Jon. I'm excited to come and talk to folks here today about this. And I'm going to extend what Jon was talking about and tie it back to the overlap with CHIPRA. I've been one of the folks working on the Notice of Proposed Rulemaking at CMS. And also I came out almost exactly a year ago to help implement both CHIPRA and the Health Information Technology for Economic and Clinical Health (HITECH) Act.
I came out from the Chicago Regional Office for the purpose of making sure that the Health IT parts of both the Recovery Act and CHIPRA didn't fall through the cracks because there were parts of both. And our interim center director thought we needed one person to make sure that we didn't have elements—the overlap elements falling through the cracks.
So I've been working on this specific issue for about a year now. And so I'm excited to talk to you about this today. Taking a step back, we had this pediatric core measure set that everyone here has been working on now for the last 6 months or so. And we had the pediatric measures that were proposed in the Recovery Act under the HITECH Notice of Proposed Rulemaking that was just published about the same time.
So if we look at this as a Venn diagram, we had about four measures that were overlapping in the middle. For the voluntary measure set that you folks have been working on, we have measures that States can't pay for—or maybe they are paying or proposing incentives under managed care or some other activities in their States now—but we're hearing from States that they don't know how they are going to implement or pay for these programs in their States.
So we're looking for ways to help leverage HITECH with the CHIPRA core measure sets, since it is a voluntary program. We have right now four measures in that interim space in the middle. So we want to look out on the horizon for how we can extend that electronic set of derivable measures for the long run.
I think what we want to talk to you about today is how we can continue to think strategically from what we're doing now—the activities this week and what we will be doing with the rest of the measure activities going forward.
I think that with what Jon was just saying, the program going forward will be—we want to look at alignment where possible and—let's see here—
Dr. Dougherty: We can just have people ask you questions.
Ms. Mills: So I had a couple of things I wanted to say, and Jon said about four of them. So let's do that. Let's just go to questions. The idea that I was just trying to get across was that we want to make sure that as many of the measures that we began to look at are going to be electronically derivable as possible. We know that many of the measures are going to be survey-based. And that's necessary to cover a number of the populations and components of the program that you are looking at.
But going forward, we need to continue to have overlap with HITECH as much as possible because we need to leverage the program or otherwise the CHIPRA measures won't be successful and States won't be able to implement them.
Dr. White: I just can't emphasize enough how bureaucratically important it is to—and I say that, you know, without smiling, which is something—how bureaucratically important it is to have somebody like Michele do exactly what she just described, which is keep their eye on both things.
It is not hard at all for trains like that to uncouple, you know, with the result being a collision down in the stockyard much later. So you've just described a terribly important function.
Dr. Dougherty: Yes, Barbara?
Ms. Dailey: I just wanted to add two more points. Thank you very much, Michele, for that.
One of the other points I wanted to highlight in terms of the work that Michele has also done, we've mentioned the partnership that we've had between CMS and AHRQ as being very successful.
One of the things we found between ARRA and CHIPRA is we've actually had to talk to a lot of Federal agencies. And we've had so many interesting discussions and successes. And our work with the Office of the National Coordinator has also been one of those significant successes because they also were working on a regulation at the same time in terms of the certification technology.
All of that intermingles. And as Jon was just pointing to, we all have to make sure that we are aligning all of these efforts in order for providers and States to be successful with these efforts.
One of the points I wanted to make when you go into your breakout groups is specifically for Medicaid, there are five eligible provider types. And this is why it is significant because it goes beyond physicians.
We have physicians, but there is a focus on pediatrics, as was mentioned. Dentists are eligible for incentives. Certified nurse midwives are eligible for incentives, as are nurse practitioners and physician assistants.
This is significant for Medicaid because of the types of complex needs that these children have. We've been talking about medical home alternate care settings, all of this comes into play in how we are going to utilize exchange of information, electronic health records, and interoperability of these systems in various care settings.
There could be telemedicine to a rural area that may even—how are we going to collate this information and demonstrate that these children are getting quality care? So I just wanted to put those thoughts to you when you are brainstorming that, you know, there are acute care hospitals, there's children's hospitals. But we are looking at how this is also going to interplay with alternate care settings. So I just wanted to mention that.
Dr. Dougherty: Thank you, Barbara. Okay, questions?
Mr. Young: John Young at CMS—this is more of a point than a question. Just a couple of things piggybacking on what Barb has had to say. For the medical home also, the interfaces that sort of work beyond just medical care but looking at the interfaces of public health, looking at the interfaces with other activities, I mean in terms of school-based health centers and so forth, so that's part of the equation as well.
And I've got to admit, one of the things that I thought would be very difficult early on was this sort of fusion between ARRA and CHIPRA because the intent is a little bit different. CHIPRA is in a developmental stage where we're looking at experimenting and assessing activities that States can do and can't do within their programs, whereas HITECH and ARRA are a little bit more mature in that sense.
So I think going back to what Michele was saying, that whole fusion between the two becomes critically important. How do we work down that path without extra burden on our providers and managed care plans and States as well? So that's what makes that exercise I think that much more important.
Dr. Dougherty: Well, can I start with one question that I've continued to ask my CMS colleagues? And tell me if you can't answer me. The fact that there are four measures in the middle of those Venn diagrams, CHIPRA and ARRA, does that mean that when we're really talking about what core measures you want States to choose to voluntarily use, we're only talking about those four? Or are you talking about the whole CHIPRA core measures set?
Ms. Mills: And could you tell us what those four are?
Ms. Dailey: Sure. The four measures that overlap are body mass index (BMI) for children 2 to 18 years of age. It is a National Committee for Quality Assurance (NCQA) measure.
Dr. Dougherty: Is that BMI documentation? The same as the CHIPRA core measure?
Ms. Dailey: These are the ones that overlap, yes. Followup care for children prescribed medication for attention-deficit/hyperactivity disorder (ADHD), annual hemoglobin A1c (HA1c) testing, but for CHIPRA, and this is where we get into the specifications, it's targeted obviously for children and adolescents with diabetes versus the NCQA measure, which focuses on adults. Is that right, Sarah?
Dr. Scholle: Yes.
Ms. Dailey: That one is for adults specifically?
Dr. Scholle: I believe that it—the endorsed measure is for children. We have both.
Ms. Dailey: Oh, thank you. Okay. And then the last one is appropriate testing for pharyngitis. Okay. So those are the four measures.
To answer Denise's question, for CHIPRA, the intent is for voluntary State reporting for as many of the core measures as possible. Obviously, the four—we wanted to have some overlap, as mentioned by Michele, because we want to have some financial support for States to be able to at least pursue those measures, if possible.
One of the things that we're really curious to see is how the final comments come in. We're in the last week now of public comments for the initial core measure set in terms of what the States and various users anticipate as being problematic.
We have until next February to release the procedures and the approaches that we're going to be recommending to States to use in voluntarily using these measures. But this is new territory for us. I mean Medicaid is in its infancy in terms of fully utilizing the full quality improvement (QI) and management cycles.
So we have a lot to learn, and these are complex kids. It's all kinds of populations. They utilize all kinds of care settings. And so it is a learning process.
And we wanted to start somewhere. And that was the purpose of the Subcommittee on Quality Measures for Children's Healthcare in Medicaid and CHIP (SNAC) this summer by trying to use what we called the grounded measures, you know that there had been some experience, some—like a scientific evidence base to show the meaningfulness of those measures.
But it is new ground. And we recognize, again, for States and the position that they're in in terms of serving their beneficiaries, how are they going to be able to apply resources to this?
So my final note on this to move the quality agenda forward is we're also—this is the year we're finalizing a report—our first report to Congress on quality. And we're going to be having a couple of sessions with State and Medicaid CHIP directors and then a separate one with national stakeholders to get their input. What do we want to tell Congress we need to move the quality agenda forward?
And obviously resources is a big one. But we need to be specific. If you were given resources, how would you use them? And so that is—you know how we tie this into EHRs and health IT, this administration has been extremely focused in having this be a successful endeavor. And it's moving—it's helping us to move our quality agenda.
But maybe the need for resources hasn't been put in the right place. And so here is our chance to use our voice. And so we'll be looking forward to talking to you more about that in the next couple of months.
Dr. Dougherty: And you did mention to me that what's happening here and your suggestions or recommendations will be fed into, you know, information or requests for resources about specific different criteria building.
So, Colleen, you had your hand up? We'll do only—sorry—only do about 5 minutes for questions since we're already 15 minutes behind. And then go into our breakout groups which, Michele and Jon, you are welcome to join, and Erin as well. So go ahead, Colleen.
Ms. Reuland: I was wondering in the CHIPRA legislation it talks about having the measures stratified by groups, raised up in the city, children with special health care needs, are you guys exploring in the model EHR format methods by which patient-reported data can be implemented in the EHR?
So, for example, children with special health care needs, there has been a lot of work to develop a non-condition-based approach. But it is a parent-reported or patient-reported measure. If it could be inserted into the EHR, it could be used to stratify the data.
So are you guys looking at those elements in trying to keep coordination in considering that important avenue?
Ms. Dailey: Yes, we're very early in this phase. So we're exploring all kinds of options. And I know that there has been discussion about that.
I don't know, Erin, did you want to say anything to that point? I mean it's basically too early to really have any specifics that we can provide.
Ms. Grace: Erin Grace with AHRQ. In the solicitation that we put out to the offerors, we referred them back to the CHIPRA legislation and the import of the kinds of things that CHIPRA referred to. So as Barbara said, we're early in the process. And so we haven't, you know, finalized who is going to get this. But this is certainly something that we're trying to be aware of as we work with the contractors.
Ms. Reuland: And are you guys, when you are coming up with the model format, are you—is there going to be a separate process in which you work with the major makers of EHRs to try to incorporate that? Because just in working with Kaiser, it's been—one region of Kaiser can't share what they do in their EHR with another region of Kaiser.
So is that—given that they are normally for for-profit entities, how do you guys see that working?
Ms. Grace: Most of the proposers have in their proposals ways to work with vendors. And those that didn't—and when we're doing the negotiations, we're certainly aware as we are selecting the contractor of how are they going to be incorporating vendors.
And also the CHIPRA legislation and then hence the solicitation was very specific on a dissemination plan of the model format, and obviously vendors are a key audience in that.
Ms. Dailey: And under the CHIPRA provision, for the EHR format, it's actually an EHR program which CMS is still fleshing out. So we'll be providing more information.
But as an example, one of the components that we're pursuing as part of that program is how we're going to have outreach to parents and caretakers to educate and encourage them to use EHRs. So the point in terms of how patients can actually have their information included is being evaluated.
Dr. Dougherty: Nora, you had you hand up?
Ms. Wells: My name is Nora Wells, and I'm from Family Voices, a national organization that speaks on behalf of children with special health care needs and their families.
And I would just like to encourage—kind of building on Jon, your point, and a couple of points that have been made here, definitely now is the time to get people involved in the thinking about how consumers are going to have a role here.
We've had a little teeny tiny input in some of the HER pieces and the health IT. And we know there's a lot of issues and concerns. And there are clearly, I think, avenues for us to start—you know, this is an opportunity, as was said yesterday, and I think we have to start at all levels to include those voices in the thinking and the discussions.
So I just want to applaud what I heard about this morning, which was the opportunities that these grants are giving for youth, a project that has just been funded, right, for youth to actually report on their own care. It has nothing to do with EHRs, but it is the principle of it.
So you have awarded one of these grants. I think we need a huge push—this is what the legislation says really—and I think all the history has been in a different direction. So it's kind of like a change of direction.
Dr. White: I just want to say one or two or three things about that. The legislation is obviously very, you know, doctor and hospital focused.
Dr. Dougherty: Which legislation? Not CHIPRA?
Dr. White: Not CHIPRA. The Recovery Act and the HITECH stuff in particular. Here's my expectation over the next 5 years, okay? There is going to be a lot of angst and, you know, blood in the streets, and by the end of that period of time—there will be a reasonably broad installed base of these tools in the health care system. Okay?
We have some lead time here to be able to look at what those needs are. And at least at AHRQ, we've already started looking at that.
If you go to healthit.ahrq.gov, there is actually a nice report on a series of 20 or 30 focus groups that we held around the country asking consumers about health IT and what their attitudes were about it and really what they wanted from their health information. As you know, that's a woefully under-explored issue.
What I would love to be able to do is start things in motion now so that 5 years from now, when these projects are ready to bear fruit, we are in a place to answer the questions now that we've got this installed base about how it should be used to be able to address exactly those needs and those issues that you want.
So yes, I completely agree. And there are things moving in that way.
Ms. Mills: Additionally, in our Notice of Proposed Rulemaking we identified a number of places where Cindy Mann, our Medicaid Center Director at CMS had asked us to point out areas where we will look at duals and children and children with special needs and CHIPRA. These are areas of priority for us for health IT. And we will continue to look at these things.
We're hoping to get a lot of feedback and comments and places where folks have provided data for us for the final rule so that we can continue to consider these issues. But these are areas of priority, especially when they have an impact on the consumer population.
Dr. Dougherty: And your comments on the final rule are due?
Ms. Mills: March 15th. And then we do expect to have a final rule on the street by the early summer, June.
Dr. Dougherty: Okay. And the comments on the CHIPRA measures are due March 1st. So you have the Federal Register notice, at least one copy on your table. Yes? One more question.
Ms. Hess: Cathy Hess, National Academy for State Health Policy. And I'm sorry, I missed the presentations. But I'd be surprised if you touched on this.
Just a question, and also I guess a plea, and Cindy Mann may have raised this also, that as we work on health IT and health information exchange (HIE) that we think about enrollment and retention needs as well. There is a whole movement going on to try and use technology more effectively for that purpose.
And having kids enrolled, as we know, is essential to the ability to implement—to have them access quality care and to be able to measure that care. So I don't think there has been a lot of connection going on between those. I don't know if you can speak to that a little bit.
Dr. White: Yes, you know, one of the neat things about the legislation, there's a lot of provisions in there. There is a provision for State grants. And ONC had to decide where to put down their chips. They had about $2 billion in discretionary funds to put down. And they put down $600, $700 million into grants to States to develop HIE, in particular.
Now that's key both—you know, it was established in the legislation also on how they rolled it out—just a couple of weeks ago, ONC awarded 40 State grants. And those groups are going to be key. Absolutely key.
Erin—I'll let the cat out of the bag, you were one of the reviewers—and actually Erin was also in a nice confluence of events, was a project officer for contracts that we had running for the past 5 years called State and Regional Demonstrations, which really, in many ways, are prototypes of what has rolled out subsequently.
So those folks are going to be focused on it. And I promise you the State governments are involved. And the State Medicaid programs, I'm pretty sure are extensively involved in the applications. Is that fair to say?
Ms. Grace: Yes, they are. The State applicants had to have a letter of support from the State Medicaid Director. And there has been a lot of overlap between CMS and ONC in terms of reviewing the State Medicaid health IT plans and also CMS staff reviewing the State HIE plans, which were required for the grant applications.
So that goes back to what Barbara was saying in terms of a really successful and strong overlap in collaboration between the ONC and CMS.
Ms. Dailey: And right now CMS has had a total of 43 States that they've been working with on those plans. So—
Dr. Dougherty: So we could talk about this.
Dr. White: Yes, as the life blood of money pumps out from the Federal aorta and diffuses out to the capillary beds, that's where that diffusion exchange is going to happen. And that's going to be a key place to monitor it.
Dr. Dougherty: So thank you very much. And we will take your wisdom. Obviously there is a meeting at least every week, right, on this topic that goes on for days. So children aren't always the focus of the meeting, but they are definitely in there.
Ms. Dailey: And one of the things that I think shows Cindy Mann's dedication to this is within 3 months of her starting at CMS in June, she had a new Deputy Director specifically brought on to focus on quality and health information systems. So she is very focused on this.
Dr. Dougherty: Next we'll turn our attention to the OPM, Office of Personnel Management, and health IT.
Ms. Mills: And she is going to be talking about this to the National Governors' Association (NGA) today, too—this issue.
Dr. Dougherty: Great. So—and I'm sure she'll bring up children and CHIPRA. So—
Ms. Mills: Yes, she's talking about the CHIPRA HITECH overlap.
Dr. Dougherty: Okay, great. Well, thank you very much. And feel free to stay and offer what wisdom you can. People are going into their breakout groups to—now—yes, Patrick?
Dr. Romano: I just—on the agenda, it says that we're supposed to do application to examples.
Dr. Dougherty: Yes.
Dr. Romano: I'm wondering what that means, did you had specific examples in mind?
Dr. Dougherty: Yes, the examples are the measurement topics. And they are the same that we had yesterday. So—and here are the room assignments. And I have the thumb drives up here if you want to come and get them.
And do people still have a sheet saying where they should go? Actually, unless you've been asked to be a facilitator or a reporter, you can go wherever you'd like. So—if you have any questions, come up and ask. And, again, this feasibility list is a very long list. So I would encourage you, since we only have 40 minutes for this, to—somebody still has a thumb drive out so please go into a group and share it.
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