Holy MACRA! Patient Engagement rides again!

“What was that masked legislation? Why that, my boy was CMS! The greatest regulator in the west!” (Cue The March of the Swiss Soldiers in the William Tell Overture aka, theme song for one of my childhood heroes, The Lone Ranger).

What is MACRA?

MACRA is the abbreviated version of the “Medicare Access and CHIP Reauthorization Act of 2015” which was signed by President Obama on April 16th of this year. (Healthcare and CMS sometimes really can’t help it’s communication to the public when they make these abbreviations something that only so called “healthcare insiders” will understand).

The new law repeals Medicare’s sustainable growth rate (SGR) formula and creates a way to increased Medicare payments. At HIMSS16 this year, there was a focus was on “MIPS” or Merit Based Incentive Payment System which is the program that the SGR will be replaced with.

Physician rates are understood to be increased by 0.5% starting in July and each January through 2019 and then, bonuses could reach 12% and then 27% by 2022 (physicians could also face penalties for not meeting quality targets down the road).

On the CMS site, it asks the question, “How does the Medicare Access & CHIP Reauthorization Act of 22015 (MACRA) reform Medicare payment?”

Apparently, in a couple of ways:

It makes 3 changes to how Medicare pays those who give care to Medicare beneficiaries. The changes create a Quality Payment Program (Abbreviated to ‘QPP’).

1. Ending the SGR formula for determining Medicare payments for health care providers services.
2. Making a new framework for rewarding heal care providers for giving better care not just more care.
3. Combining CMS’ existing quality reporting programs into one system.

The changes have been named QPP and replace other Medicare reporting programs with a flexible system that allows providers to choose from 2 paths that link quality to payments either MIPS or something called Alternative Payment Models (APMs)

MIPS – This combines parts of the PQRS (Physician Quality Reporting System), the Value Modifier (VM or Value Based Payment Modifier) and the Medicare Electronic Health Record (EHR) incentive program in which EPs (Eligible Professionals) will be measured on:

1. Quality
2. Resource Use
3. Clinical Practice Improvement
4. Meaningful Use of Certified EHR technology.

APMs – Alternative Payment Models give new methods to pay healthcare providers for the care they give to Medicare recipients as from the year 2019 to 2024, CMS will pay some participating healthcare providers an incentive lump sum; increase transparency of physician focused payment models and starting in 2026, offer some participating healthcare providers higher annual payments.

 

 

 

 

 

We don’t “Lobby” in Healthcare IT, we “Advocate”

As someone who grew up in other countries before becoming a naturalized American, there’s always been some kind of fascination when it comes to what is called “lobbying” in the United States. I’ve never been able to understand it as it always seems that it goes against the grain of what I’ve always thought of the United States through history books and the Founding Fathers, whom I so admire for their simple vision that has overcome the tests of time. Yet, hiring professional lobbyists in the United States is perfectly legal and healthcare has been leveraging this legal loophole for sometime now. Just this year as an example, lobbying has come into the news through the change in the regulatory date for ICD-10 from October 1st, 2014 to October 1st, 2015. Most believe that this was the result of pressure from care delivery professionals that wanted more time to get their act together (I for one was against this).

Recently, it was reported in “Modern Healthcare” (September 10th, 2014) that Epic retained a lobbyist and as it was reported the filing said that it was “to educate members of Congress on the interoperability of Epic’s healthcare information technology.”

Last week, HIMSS delegates from across the country had their yearly visit to Washington D.C. for their HIMSS Policy Summit, held during National Health IT week where (as reported by Healthcare IT News) HIMSS had certain asks of the nation’s representatives, which were:

• Minimize disruption in our nation’s health delivery system emanating from federally mandated health IT program changes.
• Fund the National Coordinator for Health IT to achieve interoperability, improve clinical quality and ensure patient privacy and safety.
• Expand telehealth services to improve patient access and outcomes and decrease healthcare costs.

The role of politics and healthcare will remain inextricably tied to one another. As we continue to move through this paradigm shift, these areas will ultimately focus on the future of our country’s care delivery and outcomes and the way that we, the patient, will receive our care.

Physicians are people too…right?

When it comes to working with physicians,  we’ve seen their involvement in this healthcare technology world at opposite ends of the spectrum.

The younger,  more technologically savvier physicians who have been used to technology from the early 80s to now, seem to somewhat adapt to using EMRs. They are characterized by their comfort with all things digital and their disdain for a paper process and being eco-friendly. While this isn’t always the case, this is mostly attributed to younger, 45/50 and under physicians.

The older,  more experienced physicians who have been around practicing for 3 decades or more have generally been extremely resistant to the current change and have at times,  even retired rather than continue to use EMRs on the grounds that it takes away from their focus on the patient, which can make for an good debate. I’ve also heard that some of the older physicians don’t feel like they need to be “engaged with their patients” as “the way they have been practicing medicine all these years is fine”. Millennial physicians,  early to mid 30s take to technology as if they were born with it. As digital natives,  they have the ability to be the most productive and efficient when it comes to EMR usage.

Also, their has been a divide when it comes to adoption by small and large practices. Smaller practices have had to think about how they can deal with the process of purchasing EMR capabilities and this has not always been easy. During a project in California, we studied how we can get pediatricians to refer patients to the hospital I was working at and how to make sure the referral process was smooth for them; whether it was directly from their PC and their own EMR system or if they needed to login to a portal with their credentials and how it would then go to the correct clinic at the specialty pediatric facility I was working at the time.

For anyone in the care delivery IT arena, this is old news, but really needed to be said. The question is whether if the digital divide has an impact on the quality of your care and if this trend continues, will we lose our senior, experienced physicians to Meaningful Use?

According to an article out by USA Today (dated 6/30/2014), the United States is expected to need 52,000 more primary care physicians by the year 2025 based on research by the Robert Graham Center and funding for teaching hospitals expires in the latter part of 2015. Due to the Affordable Care Act, the need for family physicians to 8000. As a nation, we cannot afford to lose these experienced physicians at a juncture when more physicians are required than ever before.

Thought Leadership – Empathy’s involvement in Patient Engagement

 

Earlier this year, I had introduced you to “lifestyle philosopher” and Oxford University Professor, Roman Krznaric and his work on empathy’s role in our world today. He has released a new animation which is an amazing video that is part of this post. Hopefully, it is as insightful for you as it was for me. I interviewed Roman on some of his thoughts about empathy and it’s role in healthcare as well as other areas that were relevant to our world today. Here, below is that interview.

Roman, thanks for your time to answer some of my questions. How did you get involved with the concept of empathy?

I used to be an academic teaching and researching political science. But about a dozen years ago I had an intellectual awakening when I came to realize that societies and politics didn’t simply change through new laws, institutions and policies but through changes in the way people treated each other at the individual level, especially through empathy. I define empathy as the art of stepping imaginatively into the shoes of another person, understanding the feelings and perspectives, and using that understanding to guide your actions. It’s a fundamental skill that almost all of us have, but we rarely fulfill our empathic potential, or work hard enough to harness the power of empathy to create social transformation. 

How do you think that empathy can help healthcare, both there in Britain and here in the US, where healthcare is a very politically charged topic?

It’s interesting to me that the origins of public healthcare in Britain can be traced back to an important empathic shift during the Second World War. Over a million children were evacuated from big cities to rural foster homes to escape the German bombs. And one of the unintended results was that relatively well-off rural folk suddenly had relatively poor city children thrust into their homes, and they could see the extremes of urban poverty with their own eyes: it was a moment of empathic understanding and awakening. There was huge public outcry and the government took immediate action, improving public health care for children, giving free meals in schools, vitamin supplements and other health care. This mass meeting of strangers was, in effect, the beginnings of the British welfare state – and it happened right in the middle of the war when resources were extremely scarce. There is a lesson here: that empathy sensitizes us to health care inequalities, and can spur social and political action to alleviate it.

Of course, healthcare reform is a very politically charged topic in the US, since it is so closely associated with the Obama administration. It was also Obama who started talking about America’s ’empathy deficit’ in the lead up to the 2008 Presidential Election. The American right then started critiquing the concept of empathy because of its links to Obama. Despite all this political complexity, I think empathy remains essential to the issue of healthcare. Why? The historical evidence points to the fact that empathy opens the door of our moral concern for neglected or marginalized social groups, and laws, rights and public policy wedge that door open, helping to universalize that moral concern. Healthcare, like other key areas of public policy, is one where we should be shining the light of empathy, trying to understand how different parts of society experience the public health system (or lack of it), and equally how they are impacted by the structure of private health care. It is only through empathising that we gather enough evidence, from enough points of views of different citizens, to design truly effective and socially just health care systems. Otherwise good healthcare becomes the privilege of a few, rather than the right of the many. 

The US is undergoing a sort of renaissance in healthcare information and technology. What do you see as the role of empathy in this area (more usage of smartphones, tablets and laptops vs. human interaction)?

 

One way to think about this issue is to look at the new wave of ’empathy skills training’ for doctors that has become popular in the last few years. Doctors are often criticized for being too clinical and emotionally detached from their patients. In 2010, doctors at a Boston hospital took part in an empathy skills program in which they were advised to pay greater attention to the changing expressions on their patients’ faces (for instance whether they showed anger, contempt, fear or sadness), to take note of voice modulations, and to make simple changes such as facing the patient rather than their computer screens during a consultation. After just three one-hour training sessions, doctors who went through the program showed vastly improved empathy levels. Their patients said these doctors made them feel more at ease, showed greater care and compassion towards them, and had a better understanding of their concerns. The doctors too could see the benefits. After spending a day putting the program’s methods into practice, one hospital doctor reported that while it was initially difficult to empathize with the patient while simultaneously making her diagnosis, eventually it ‘became fun’ and embodied the kind of personal interaction that had initially drawn her into medicine.

Now, what does this tell us? It would seem to suggest that it is person-to-person interaction that patients are after more than anything, and that this is the key to bringing more empathy into the sphere of healthcare. All the technology in the world doesn’t substitute for having a real human being treat you, look you in the eye, and hear your personal story.

 

That might make me sound pessimistic about the possible role that technology might play in empathic healthcare. Yet I also believe that if we get smart about using technology, it can help bring about an empathy revolution in healthcare. OK, almost everyone would rather have the doctor look at them rather than at their computer screen during a consultation. Yet just imagine if basic video technologies like Skype became a standard way for your doctor to visit you in your home to give post-treatment or post-operation check ups and advice. We need to learn to bring a little more intimacy into the way we use technology, especially social networks.

 

Do you foresee any upcoming empathy deficits?

 

The evidence is pretty clear that the US in a period of long-term empathy decline. A well-known study (Scientific American, December 23rd, 2010) revealed that US empathy levels are down nearly 50% in the last 40 years, with the steepest decline occurring in the past decade. So the empathy deficit is growing. At the same time we see rising levels of narcissism – around 1 in 10 Americans now exhibit narcissistic personality traits. There is also growing evidence that social networking technologies are exacerbating narcissism and contributing to empathy decline. There is a question about whether these trends are going to continue. I’m glad to say that there is a growing movement trying to address these problems by teaching empathy in schools. The most effective program, called Roots of Empathy, began in Canada and has now reached over half a million children worldwide.

 

Will we see more of these animations in the future? I think it is a great tool to get your message  across in a simple, entertaining and informative way.

My animation about empathy, The Power of Outrospection (produced by the Royal Society of the Arts in London) makes the case that empathy can be a powerful tool for social change. It’s fascinating how popular the animation form has become – this particular one has had over half a million views – and is evidence of the shift towards visual learning. I think we need to tap into our multiple intelligences when communicating ideas. For some people books are the most powerful, for others it will be animations, blogs or going to talk with a real live human being! Personally I plan to pursue all these communication routes in the future, including the animations – luckily for the world someone else does the drawing, since my drawing skills are in need of serious work!

Thanks for your time on this interview. Hopefully we see a much more empathetic world as we move forward in the 21st Century.

Roman Krznaric, PhD, is a writer on empathy and social change based in the UK. His latest book is Empathy: A Handbook for Revolution (to be published in the US by Penguin in November 2014). He advizes organizations including Oxfam and the United Nations on using empathy as a tool for social transformation and public policy. He is a founding faculty member of The School of Life, and founder of the world’s first digital Empathy Library. Website: www.romankrznaric.com Twitter: @romankrznaric

The Tide is HIE, but we’re moving on…

CCD Example found online

Ok, so I was a “Blondie” fan in the 80s, I mean, who wasn’t really? During a breakfast meeting with some healthcare leaders on Friday, we discussed the need for an HIE and what it would mean to executive leaders in the region if they pulled out of the local healthcare information exchange when Meaningful Use requires that not only do you need to be interoperable with another healthcare provider organization that has the same electronic health record you have installed, but one that is different from your EHR as well that you can interface with. What is the need for an HIE then if CMS stipulates that you need to do this in order to attest to MU 2 anyway? In a HIMSS document, they mention that while working with Stage 1 objectives and measures, “an organization should keep in mind that future rule making around Stage 2 and Stage 3 requirements will include HIE capabilities”.

Many healthcare IT executives wonder whether it is worth the money to pay an HIE to follow their patients and make sure that CCDs or Continuity of Care Documents can initiate (see the generic example I found on the left). As of now, if my healthcare provider wants me to go to get a blood test, and the lab that I have gone to is the same one close to my house for the last 12 years (currently owned by a different provider in this day and age of acquisitions and integrations), I am happy that half a day after I get my blood drawn, I have the results on my smartphone app. A far cry from when I had to wait for days without knowing the result and that too, if my provider got it, saw it and then mailed it or faxed it to me (or I asked to come in to meet him for an appointment, pay co-pay, review the result with him, he makes a copy and then I took that copy home and filed it in my healthcare folder). Fewer trees cut down, less wait, less suspense. Patient Engagement at it’s finest.

As was noted in a Government Health IT News article, many of the measures in MU stage 3, such as sharing care summaries and care plans, rely on health information exchanges and while exchanging data remains expensive, with the core problem being standards, for data, transport and identification of patients. With underlying costs for long term interface development, support and maintenance remaining high, not to mention safety issues and the inability to have secure data when moving between different standards and processes at each care delivery provider.

We are getting to be more educated about our healthcare as patients and consumers of healthcare and we want to be. I watched CNN’s GPS with Fareed Zakaria on the April 20th episode and he discussed the study in which the US was found to be ranked #16 in terms of Social Progress by noted Harvard scholar (and committed Capitalist Michael Porter). America ranks poorly by a team that Porter has put together. Fascinating GPS episode and a must watch. It takes social aspects, community and your quality of life in a country and captures it in a framework that measures social progress in quantitative terms. In Health and wellness, the US ranks 70th and we spend more money in the world than many other countries. Access to information and communication, we are behind Jamaica at 23. These numbers surprised me. The penetration and access to information (like the mobile telephone subscriptions, we are 83rd) and we do better at access to basic knowledge at 39th (behind Cuba). Something to think about.

 

Healthcare’s sign of the times – Big Data, Analytics and Patient Profiling.

Analytics and Big Data are in everything now. They are used for online couponing to analyze your buying patterns, in your (sic) email  and what your likes and dislikes are, in your browser with pop ups and in your social media. It has been in healthcare by the industry leaders, but was going to get more penetration as soon as the industry realized that they would have to get to know their patients through Patient Engagement initiatives as part of Meaningful Use Stage 2 where it is mandated that 5% of patients view, download and transmit their own health data, healthcare provider organizations who are concerned about that percentage of their patient population, can leverage analytics to help drive that engagement. Now that predictive modeling is the hot button topic of our healthcare IT times, I have given a lot of thought towards patient profiling and how that will progress over the years through better ways to collect, transform and present patient engagement data.

Building an enterprise data warehouse within a healthcare delivery organization brings together the many disparate systems that hold data become integrated into a single source of truth for operations, clinicians and the consumers of the data or analytics. The ability and focus now by many in the healthcare ecosystem that the way to progress is through the process of integration of disparate data, much also from legacy systems where the data was never was never clean and easy, but organizations now think that having this data will give them an edge in a newer, more cost conscious care delivery ecosystem

How much of a risk are you really and how effectively can a care dlivery organiation manage their costs and quality of care when dealing with a patient that may have the likelihood of hospitalization and possibly be re-admitted in the near future and a risk to the organization, especially for an ACO?

Physicians have the opportunity to prevent these patient readmissions utilizing profiling techniques that currently, may be exactly what large CPG or retail organizations already do well. Making sure that the ED (Emergency Department) as one of the most expensive locations for care that an organization has the ability to be increasingly efficient without losing the high quality of care that it requires to be for the community. Being able to keep patients away from using the ED’s facilities and be able to have regular ambulatory visits by identifying their conditions or health characterists early on and leverage newer technologies such as tele-health (Ohio HB 123 was recently passed here in Ohio covering just that topic and effective 5.20.2014) can lower the costs for an ED and make the delivery of care more efficient and target care for specific, previously identified patients more pro-actively.

Profiling can allow a physician to help lower the cost of medications that a patient is prescribed by reviewing and substituting equivalent, lower costs medications for the patient based on the information at hand. Medications account for one of the highest areas of healthcare costs today.

I sum up today’s blog post by reminding everyone that whether you work for or are a healthcare provider, a vendor, a professional services firm or a consumer of healthcare services, you have your work cut out for you. My encouragement goes out to everyone as I know and have seen how busy your day to day lives are and I have also seen how EMR teams, reporting and analytics teams and functional managers are tasked with many times doing the seemingly improbable tasks of getting all of the work effort completed in the short time frames that they have and somehow, it all comes together. For those of you in a state (clue, NC) the South East coast, United States who I know have gone Big Bang at all locations with everything live this past Friday morning with your EMR, my hats off to you, for you are one of those teams that have worked countless hours to make the seemingly impossible, seem doable. Collaboration and good team dynamics is the key. Don’t forget that!

Oh, and if you are viewing this from an XP machine after April 8th, well, you better unplug your computer from the internet because Microsoft has stopped supporting XP. Talk to your IS&T team if you are in an organization and think about options for a different platform.

Did your Provider bill you extra due to Daylight Savings Time?

Healthcare providers across the country have been busy with recurring yearly work effort this past weekend. If you or anyone you know were in the hospital over this past couple of days, you may want to double check your hospital charges to make sure that you that if you were charged hourly during this past weekend for a hospital stay, you may want to take a second look at your bill just in case you were charged extra for your overnight stay due to the time change.

If the care provider’s system is configured to bill you hourly for bed charges, some systems may not have taken the Daylight Savings Time changes into account so the organization may have had to update or configure these settings manually during that time (and all said and done, they’re only human, so it might be better to validate with the billing office when you get your bill).

Most, if not all organizations have a plan for this time change, but it never hurts to double check. Another one of those operational necessities in the healthcare delivery systems world.

I

MU gets a Breather! Healthcare Providers heave a sigh of relief!

 Marilyn Tavenner, the CMS Adminstrator announced last Thursday at HIMSS ’14 in Orlando that CMS would be flexible on “hardship exemptions” for meaningful use requirements, which I am sure the healthcare industry heaved a collective sigh of relief.

Expectations were high for this to happen as it had been suggested earlier that this was to come.

In reviewing the CMS document titled “Payment Adjustments & Hardship Exceptions Tipsheet for Eligible Professionals” that was last updated in  October 2013 has hardship exemptions for eligible professionals with the following information:

EPs can apply for hardship exceptions in the following categories:

*Infrastructure — EPs must demonstrate that they are in an area without sufficient internet

access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).

 New EPs

— Newly practicing EPs who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. Thus EPs who begin practice in calendar year 2015 would receive an exception to the penalties in 2015 and 2016, but would have to begin demonstrating meaningful use in calendar year 2016 to avoid payment adjustments in 2017.

Unforeseen Circumstances

—Examples may include a natural disaster or other unforeseeable barrier

Patient Interaction:

1.  Lack of face-to-face or telemedicine interaction with patients

2.  Lack of follow-up need with patients

Practice at Multiple Locations:  Lack of control over availability of CEHRT for more than 50% of patient encounters 

With the number of initiatives currently under way at every single care delivery organization, ICD-10, optimization, Patient Portals, Patient Engagement, workflow optimization and so on, we continue to move at, what can only be considered, lightening pace through this decade as we regain American dominance in the healthcare technology sector and then shift our focus to lowering the cost of care delivery and leverage process improvements, better preventative care options.

With current clinician retirement trends the way that they are, I also foresee a great need for qualified physicians and clinicians over the next few years and migration to the United States for technology savvy medical professionals from other countries could assist with this demand in major population centers across the country.

Patience with patients! A CEO that gets it!

At a recent meeting of the local Indian American Chamber of Commerce this past January, the new President & CEO of Mercy Health Partners, Dr. Yousuf Ahmad (who was the keynote speaker for the evening) spoke about his journey to the CEO spot at Mercy; from arriving in the United States in his teens and adapting culturally through the years in Kentucky and south western Ohio, to his focus on being able to leverage data during his time as CIO, and move Mercy Health deftly through the challenges of MU 1 and now navigate through MU Stage 2; the topic of patient engagement arose and how Mercy has towards being an ACO and how he places a high degree of value on physician empathy towards their patients in today’s continuum of care.

Listening to his keynote, I realized how now, more than ever it was even more important to share clinical and operational best practices across the healthcare community and for care provider leaders to share their experiences on implementing different elements of technology necessary for their initiatives, such as building and supporting a successful ACO. I was recently privileged to have that opportunity during the ICD-10 project I managed last year and have seen our care provider IT departments collaborating to help make sure that they can assist their fellow care delivery organizations meet their project and regulatory objectives.

Yousuf spoke about the need to understand the data requirements needed to support care, such as the 91% patient experience quality metric he mentioned that Mercy Health is able to derive from their physicians showing empathy towards their patients and the success he mentioned to a question I posed of his patient engagement initiatives for MU Stage 2. In short, he is able to tie his metrics with the quality of care the patient population his organization serves. What are the challenges they have with interoperability, especially with other care provider organizations, both urban & rural and health information exchanges in order to better and more efficiently coordinate care?

The role of, and need for empathy within the care delivery environment was described was evident to all during his talk and he was an amazing evangelist for his organization’s mission, both operationally and for information technology and the positive initiatives he has spearheaded over the short time he has been it’s operational leader.

During the Q&A session afterward, I made a comment that I applauded the fact that he had tied bonus incentives for Mercy’s physicians and making sure they focused on a better patient experience for the organization meeting it’s regulatory MU goals even though they would have had challenges in culturally changing the way in which some physicians may be working and relating to their patients now, but ultimately, through great patient care and compassion, his organization will march on towards their plans of expansion and as an excellent regional healthcare provider. I had the chance later that evening, to take a poll from some of the physicians that were present during the keynote and they all concurred that while they were inundated with all of the regulatory challenges currently, their ability to interact and positively connect with their patients was paramount for their initiatives to succeed.

With the news coming out over the last few days that interoperability will be the focus for the newly appointed national coordinator for health information technology, Karen DeSalvo, MD, the focus on better health through information technology assumes so much more significance as we transition towards a technology prevalent care provider environment where the patient is, and will remain, the center of attention.

Empathy and the Patient Experience

How is the experience of patients tied to the overall empathy index of an individual? As healthcare provider organizations move forward with their Patient Engagement initiatives, where does empathy play a part in this overall initiative? How will the interaction between a physician and a patient affect the overall patient experience with technology such as portals and smartphone apps. You will see this theme over a series of blog postings that will post soon. I am fortunate to have the opportunity to know an expert in the field of empathy.

Roman Krznaric is a cultural thinker and writer on the art of living. He is a founding faculty member of The School of Life in London, which offers instruction and inspiration on the important questions of everyday life, and advises organisations including Oxfam and the United Nations on using empathy and conversation to create social change. He has been named by The Observer as one of Britain’s leading lifestyle philosophers.

He regularly speaks at public events on topics such as empathy, the history of love, the future of work, and the art of living. Recent appearances include the Edinburgh International Festival, the Latitude Arts Festival and the London Design Festival. His media work ranges from articles in the Guardian and Wall Street Journal to interviews on BBC Radio 4’s ‘Today Programme’, Channel 4 and PBS television in the United States.

During this year, I’ll collaborate with Roman and get his thoughts to share with you, about empathy’s influence and footprint within the healthcare technology landscape with some insights from him and his musings of the state of the world we have been living through and what he sees are technology’s effects on healthcare delivery both nationally and internationally from his home in the U.K. He has also just launched the world’s first online Empathy Library .

How will patients deal with both their providers and technology in the 21st Century? Britain’s experience with healthcare technology has been mixed and there the patient population is much smaller and there is only one payer in that nation, unlike in the United States.

With Meaningful Use initiatives in Stage 2 for many organizations, the country is set for a new wave of healthcare patient care and technology adoption culture that continues the initiatives started earlier and gains momentum in 2014 with paradigm shifting healthcare organizations. Get yourself ready for a new state of mind.