**Cyberseminar Transcript**

**PACT Series**

**Veterans’ Perceptions of Full Access to Their Health Records Through the My Health*e*Vet Pilot Program**

**Susan Woods, MD, MPH**

**Erin Schwartz, PhD**

**June 20, 2012**

Moderator: We are just at the top of the hour. So I want to introduce our presenters. Our first presenter is Susan Woods, MD, MPH. She is a part of the VHA Health Informatics Initiative at the Portland VA Medical Center. We also have Erin Schwartz, PhD, also at the VHA Health Informatics Initiative at the Portland VA Medical Center. And I believe we will also have Maher Roman, MD, MBA who is a part of the VISN 22 PACT Demonstration Lab at the VA Loma Linda Health Care System. Ladies, I am going to turn it over to you now.

Susan Woods: Hi everyone. My name is Sue Woods. Welcome. The session is focused on My HealtheVet enrollment and engagement. I am going to tag team also with Erin Schwartz, Co-Investigator on this particular presentation. We are not going to focus so much on enrollment of the current My HealtheVet but on the early lessons, and really talk about a study that we did with the My HealtheVet Pilot, which is the very first prototype of My HealtheVet that was started over ten years ago where Veterans had full access to the electronic records. We are going to talk about a qualitative study that we did. What we really want to focus on is patients getting full electronic access to their records, meaning all the information that is in the record, in particular the clinical notes. And this is not a new idea. It was actually a proposal 40 years ago. 

In the *New England Journal* in 1973, there was a very short paper by Shenkin and Warner, *Giving The Patient His Medical Record: A Proposal To Improve The System*. And in 1973 they theorized that full access to electronic records would give patients all their information and their complete information. That alone would be a source of increased satisfaction. They also postulated that having the information in hand; patients and family members would not have to rely on the memory of what happened in that short visit when you can only remember so much. There would be in their terms “high compliance.” And then lastly, the patient would actually be a source of improving the record for things like noticing errors and mistakes.

So where are we today? Patients have access to records more in policy and in theory, but the actual sharing of that is not very robust. I will talk about the Open Notes Study shortly, but this is a figure that was recently in the *Annals of Internal Medicine*. Jan Walker and Tom Delbanco, the primary investigators, put this wonderful figure into their paper. In one image it shows how many people have access to this information, providers, payers, quality improvement monitors, administrators, care teams, support of physicians, and then there are some additional access that is available in certain circumstances, including the patient. So the patients have access. We had laws in 1996 that established the right of patients to review their medical records. Many people might not know in that law it also states that they have the right to request amendments. Most people are not aware of that, both the patients and a lot of health professionals. And because the process is so cumbersome, few people actually do that. However, many national surveys, including the Pew American Internet Survey, shows that overwhelmingly people are interested again in theory. 

On the health system side, there is a lot more controversy in terms of whether this is a good thing, whether this is the right thing, particularly in the era of electronic records, and potentially technology allowing that kind of access to happen in a much more ready and robust way. There are views that it will cause harm to the patient with specific diagnoses, and that the information will be too hard to understand and will cause a lot of confusion. Because of that confusion, it will put an unnecessary additional burden on clinical and health care team workflows. Then the worst scenario is that the harm really is to the health care system and the providers being questioned and legal issues being brought up as their concerns.

There is a modest, but growing literature about full access to clinical information and clinical notes. Some of the early work came out of the UK. This is a fairly recent and small study from a clinic in London that has actually been giving access, initially copies, and now with a personal health record with electronic access. They have a Kiosk in their clinic that patients can access their records, and they did an observational study with 231 patients. The results are summarized here. Almost all of them, 86% access the records. Data that is similar to what we see with consumer access to health care information is that folks who have poor health actually accessed it more frequently. This particular study did not find age or ethnicity to be associated with the frequency of patients accessing the information. A little over a third found errors, but interesting only half of those who found errors took action. The majority said that they were more involved in their care, and a small amount said that they were more worried about their health, which actually is not a negative outcome. It could potentially be a positive one as well. I find one of the most interesting results of this study is that three quarters felt more confident in their general practioner, and only three percent felt less confident.

There is a very large ongoing study called Open Notes. Tom Delbanco and Jan Walker are the lead investigators. The RWJF Pioneer Portfolio funds it. There are a hundred providers and over twenty thousands patients in three health systems. The hospitals are Beth Israel, Harborview, and Geisinger. Patients have full access to the notes. They get a notification with there is a new note, and they are doing baseline and follow-up surveys. This study has garnered tremendous attention, including outside the health care and research arena, and made it to *The Wall Street Journal*.  When they published their baseline study, which I am going to show you one graph from. This is what the primary care providers and the patients, how many agreed somewhat or agreed that it was a potential benefit to open all the notes at the three sites. Beth Israel is at the top, and Geisinger is in the middle. Harborview in the Seattle area is down at the bottom, and primary care providers are on the left with how many agreed. Also at two of the three sites they interviewed providers who were not participating. That is in the open circles, and you can those providers thought that this was not as good an idea as the providers who were participating in the dark circles. Over on the right is the patient baseline view, how many agreed. And patients who were participating obviously thought is was a good idea for a variety of reasons.

So we had an opportunity with the VA with the My HealtheVet Pilot. This is the first version of My HealtheVet. It is currently no longer available to patients. It ran from 2000 to about the middle of 2010. It was piloted in nine sites. Portland, Oregon enrolled over 70% of those. We had a wonderful opportunity here in Portland to learn about patient experience with that access. This is a snapshot of what the patient viewed when they log into the My HealtheVet Pilot. On the left side you can see the tabs. In the middle it says VA Patient Record. And they had access into pretty much what was a window into what we see. In additional allergies and prescriptions, they saw the problem list. Underneath the problem list you can see progress notes. They also saw discharge summaries of admissions as well as the results of their testing in their radiology and imaging results. I am going to turn it over to Erin, and she is going to talk about the study.

Erin Schwartz: Okay, thanks Dr. Woods. I will be describing rather quickly is the study we did here in Portland with Veterans who were a part of the My HealtheVet Pilot. The purpose of our study was really to describe the patients’ experience of being able to view their full medical record, especially and including the progress notes through the use of a PHR. To do this, we undertook a qualitative approach. We purposely selected patients who had accessed their records. We ran five focus groups between November 2009 and January 2011. Our first group was comprised of Veterans who had accessed their records somewhere between one to three times. The other four focus groups were made up of Veterans who had accessed their records ten or more times.

We used a semi-structured focus group guide. The questions were designed to find out more about what Veterans expectations were when they first signed up for the MHV Pilot, how they used their health information that they had access to through the MHV Pilot, and their perceptions about having access to their records and how that might have impacted their health and their healthcare. Our themes emerged inductively. We had two researchers who independently coded the data, and our team met regularly to reach consensus around themes and codes.

This gives a break down of what our sample looked like. We had a total of thirty Veterans and six family members. They ranged in age from 49 years to 82 years. Four of our Veterans were women, and five of the six family members who were a part of our focus groups were women. We found that three broad themes emerged that characterized the patient experience. Theme One really had to do with communication between patients and providers. We found that having that access had an effect on communication both during visits and between visits. Theme Two was that patients reported that they felt like they knew more about their own health, and that they were better able to make decisions about their health. And then our final theme was that our participants felt like electronic access improved the quality of their care. We approached this as being quality of care not only for them personally, but also from a more global or macro level as well. We will just go through each theme quickly, and also provide a sample quote that illustrates each of these. 

In Theme One where we are really talking about communication between patients and providers, we found that patients in our focus groups were using their access as a reminder tool, so helping them to remember appointments and scheduling as a communication tool to help supplement visits and calls to their clinical teams. There was also a health information exchange, coordination of care between the VA and non-VA providers. We heard a lot about them using the information to prepare for encounters. A lot of our participants talked about knowing what questions to ask when they would have to come in for a visit. Here are a couple of quotes. The first quote refers to the patient using their access both as a reminder of what happened during the appointment and verification. The second quote talks about preparing for appointments and having improved communications with the provider. 

The next theme encompassed patients feeling like they had enhanced knowledge, self-care, and participation in their care. Our participants felt like they had more insight into their health conditions and the reasoning of their providers. They used the information in their record to do their own self-directed research. Many, many participants talked about using the Internet to look up health related information, especially when they came across terms they did not understand. Several of our participants talked about making lifestyle changes. And a lot of them made comments about seeing the information in black and white really helped to motivate change. The last one is participatory decision-making. Patients used that knowledge to make decisions about their care. Again with a couple of quotes, we heard time and time again that participants would use Google or WebMD or other search engines to look up information that they had found in their record, or to find out more information. In the second quote the patient is talking about feeling more responsible based on having that information.

Our third theme is the patient contribution to care and quality of care. It was comprised of this kind of monitoring care, so patients having input on decision-making and their services. Advocating for care, so reminding providers about follow-ups. There was some discussion around patients finding discrepancies between what was said during a face-to-face visit versus what they found in their record. And then there were observations about the records themselves. We had several Veterans who said they wanted thorough notes, or that they did not want to see the same information in notes over and over again. They found that less helpful. Again with another quote, this is an example of a patient acting as his own reminder based on the information in his record. He was able to look in his record and see he needed to have a procedure redone in six months, and did not hear from the provider or from the clinic. So he initiated the contact with his provider. With this quote, this is somebody who said I did not feel like I had to go in as often, so having fewer face-to-face encounters because he or she had access to the results. There is a quote with a patient acting as an advocate based on what they were seeing in their record, so possibly wanting to change providers based on what he or she is reading.

One of the things we asked very directly in all of the groups about what we found in the literature around clinician concerns that patients could be harmed if they had access to their full record including the notes electronically. We asked very directly about that in all of the groups. There was no explicit declaration of harm in our groups. We did have one woman who was the wife of a Veteran diagnosed with cancer who made a comment about having access to surgical notes. In her case she said, “I would rather not have known. There were a lot of little things step-by-step about what happened in the operation.”  That was the one instance of somebody saying that is something I would rather not have seen. What we saw more often is something similar to the second quote. This individual was talking about the perception that seeing the notes might upset patients. This person says, “That is a lot of bull. I want to know.” 

So just to wrap up, evidence shows that activated patients achieve higher levels of self-care and satisfaction. And this seemed to bear out in our study. So sharing all clinical notes with patients may be an important component of the meaningful use of electronic health records and health information exchange. At this point, I am actually going to turn it back over to Dr. Woods.

Susan Woods: There are some limitations to the study. There were nine pilot sites, and this is just a sample at the Portland VA. We used an eighteen-month timeframe prior to this study that was done. Patients likely had access earlier than that time period. There might have been people who accessed their information and had a different experience and did not come back in. So it could have been a group of people who had less positive things to say. However, we really wanted to meet with people who had been looking at their record in a relatively recent time period so we would not have recall bias. 

As I said, the primary goal of this study was to talk with people and really learn their experience of Open Notes. We found overwhelmingly a positive experience. We did not find significant harm according to what they told us. The primary results of the active participation and decision-making are what we found. Having access to notes was an avenue for more participatory care for participatory medicines where the patient is using the information to help make decisions about communication, follow-up, and the type of communication. We do not obviously know very much about the clinical workflow. We had comments from one participant who did say that they went in and asked for a different provider, but we cannot really say what the impact on the clinical side is with this study. 

As we move towards a journey at the VA in prototyping new tools, mobile apps for example, and point of care services, we want to move towards a model where patients have a greater access to the information in their records. The current My HealtheVet Program does not have this functionality yet. But it is important to understand the information that is available. We have lab results for example, wellness reminders. We have of course secure messaging and a way to communicate other alternative ways to communicate have significant potential impact. I think we are out of time. I want to thank all of the study investigators on this study who are listed here including some of our national partners, Dr. Turvey, Dr. Nicol, Dr. Nazi. I appreciate everybody’s participation.

Moderator:Ladies, would you be okay with taking a question while we are waiting?

Susan Woods: Sure.

Moderator:That would be great. Let me start off at the top here. This is probably premature, but did you find any evidence of improved patient outcomes for those that had access to their health records?

Susan Woods:Good question. We did focus groups with people for an hour. We focused on the experience. We did have people self-report that they changed some of their behaviors. They reported about trying to focus on diet changes and exercise. Obviously because of the design of this study, we do not know whether that is as a result of actually having access to the records, but we did have people state on more then just a few occasions about things like that. Erin, do you have any other comments?

Erin Schwartz: We did have a couple of people, one that I remember in particular who made the statement that he felt like having access to his records added years onto his life. And that is a pretty dramatic statement. 

Moderator:Great. Thank you. Lisa, do we have you on the line here?

Lisa Rubenstein:Yes we do.

Moderator:Perfect. Fantastic.

Lisa Rubenstein:Do I have control of the slides or do you?

Moderator:I have control of the slides. So when you need to go forward, just say “next slide,” and I will move through them.

Lisa Rubenstein:Okay. I am doing this for Maher Roman who was the spearhead for this lab project. Maher wanted to do groups on My HealtheVet and he had a proposal for that. But he found that relatively few people were registered on My HealtheVet. And it was going to be hard for a teamlet to work with this new modality without figuring out a way to get more people actually on the system. Originally I think he thought that was going to be fairly simple. But experience has shown that this is actually a somewhat difficult problem. 

First he reviewed the evidence. We did a rapid evidence review with our evidence-based practice center. Some key findings were that users were more likely to be female than male, which does not help us. They had more complex illnesses and they tended to be a bit younger. But the key thing for figuring out how to move ahead was that they were much more likely to belong to a primary care provider who used securing messaging with other patients. So that was a signal that perhaps the teamlet was a place to look. People in the prior My HealtheVet studies had said that pharmacy and appointments had been the thing that they have used the most, but what they really wanted was to communicate with their physicians or nurse practioners. 

The aim of the project became to enhance teamlet enrollment of patients in My HealtheVet, with the ability to discuss patient concerns and increase provider awareness, and also to assess how often lack of computer access was preventing enrollment so that we would have idea of what our targets could be. We were thinking of goals that are pretty ambitious for a VA. If you think about the experience of other places like Geisinger and Kaiser and Group Health and so on, really the way they have been able to implement PACT, or Patient Center and Medical Home, is significantly through non face-to-face care. And a lot of that is through electronic means. So our ambitious goals are probably warranted. But even goals of having 25% of patients authenticated and 15% opted-in, which are our current goals, is being relatively hard to achieve. 

Just to make sure that everybody understands the terminology, In-Person Authentication is what IPA stands for. It is basically a release of information that is often done by the My HealtheVet coordinator or somewhere else. Opting In can be done at home or on the My HealtheVet website. People often have problems, because there are problems with the authentication form and the way the name is in the system versus what the patient thinks their name is under ordinary circumstances. A test message has to be sent. One problem with that is that there is not an instant reply to that, so the patient tries to do this and then may not realize immediately whether they have actually gotten on.

Overall, there is a big drop in voltage from the IPA process to getting an actual secure message. Secure message is the only part of the whole thing that is really going to impact non face-to-face care, which in turn is going to impact whether we can serve Veterans effectively through PACT. Providers and teamlets are probably the best marketers for patients. That was the result of local investigation and mirrors some of the other information on My HealtheVet. But the providers and teamlets under the initial method of enrollment at least locally, were disconnected from the enrollment process. The people were sent to My HealtheVet coordinators or other clerical support without being engaged by their teamlets. The result was little follow through from the brochures that were passed out getting all the way down to secure messaging.

The initial pilot for this was carried out at Loma Linda VA Redlands Boulevard Clinic. And the concept was to try to make more of a Point of Care Enrollment. The Loma Linda Redlands Clinic created a toolkit that includes three physical elements: a reminder that is template in CPRS, an IPA form, and a brochure. Those are the three things that need to come together physically at the visit. And then there are three functional elements. One is education, which the plan called for coming from the teamlet LVN or from the provider, but particularly emphasized the LVN, the authentication and the registration. 

This slide shows the results of the initial Plan-Do-Study-Act Cycle of this process. So you can see that with one LVN who was trained to do this, you see at the far left in February of 2011, it took a little while to warm that process up on the teamlet. But then in March, the following month, things started to increase rapidly and got as high as 65 IPA people in late March. The initial teamlet began training other teamlets, and again pretty high numbers of enrollment was continuing on. And then going towards the far left; the champion became unavailable for a period of time. You can see what that did. So this was a little bit champion dependent. 

This shows what happened to the first 1600 patients who had never been enrolled that were seen between March and September of 2011. This includes those periods where the champion was not available. Things were tweaked, and things were improved. Overall, of the patients who had never been enrolled during that period of time, 44% got authenticated on the spot through the teamlets. 29% had no computer or Internet access, 13% were not interested, and 14% had another reason.

The enrollment was spreading some across modules, but the Module 5, which was the original Pilot site where the LVN began this process, was clearly moving more rapidly than the other modules. At that point, the toolkit began being spread initially to my teamlet, which has really been a pleasure for me, because it has worked much better than the prior process. Then it spread to all of the Loma Linda teamlets in January of 2012, and then all of the GLA sites. It is now starting in San Diego at Oceanside and Long Beach. 

This is what it looks like for In-Person Authentication numbers across all of these sites. You can see that at Loma Linda Module 1, things have been kind of perking along. That is the next to the bottom one. If you compare Module 3, which is the lavender one at the bottom, to the RBOC, which is at the top, the line that goes up the most steeply, RBOC was the module in which the first teamlet and then the subsequent teamlets were in the RBOC. If you look at the goal in the green, that shows the VA target and even Module 1 still is not quite there yet. 

If you look at Opted-In, that also has been increasing. Looking at the Redlands Boulevard in the upper line and then the remaining modules in the black line, those have been continuing to rise. And the less effected teams and teamlets are not so fast.

If you look at the Sepulveda Green Team, which was the next spread site that began going up pretty soon after the reminder and the toolkit were turned on. And then GLA itself has sort of boosted its slope since that time. Downtown LA in the black line is another GLA site that is there for comparison. So their line is also going up, but not quite as steeply.

This is a quality improvement project. It is not proving that this enrollment method works. But I think it does show that attention to the enrollment process probably enhances the ability to achieve some of the things our Portland colleagues have been discussing earlier in this session. We do not know whether or not it is the point of care aspect that the patient can do something all at once. We do not know if it is the teamlet. I think having the LVN in an educational role across all of the spread sites, that seems to be something that at least the spread sites agree is really helpful and critical, because it means that the patient can get a sense that this is all connected to their source of care. But there have been a variety of different approaches across the spread sites to the actual authentication process and who does that. So that is something that is still in exploration. Is it the reminder? We are going to be able to have a chance to check on that, because we have one new site at Long Beach that just so far has the reminder and not the rest of the educational approach. There is a patient brochure that has been simplified. But in any case, we hope that this gives you all new ideas and we are happy to answer any questions or help. Okay, that may be the end. Yes. Okay, thank you very much. And again any questions or comments are welcomed.

Moderator:Thank you so much Dr. Rubenstein. We really appreciate you stepping in at that moment. That was very, very appreciated. Dr. Roman has called my cell phone several phone several times. He is definetely trying to get through to the line here. Dr. Roman, have you been able to get through yet? Okay, I am going to take that as a no. So we are going to start working through some of these questions here. We will start from the top and work our way down. The first question we have here is was secure online messaging available through My HealtheVet during the study? And if so, did you look at patient and provider satisfaction with that?

Lisa Rubenstein:Was this directed to me?

Moderator:This came on a little bit before you. I think this is for Sue Woods.

Susan Woods:Yeah, the My HealtheVet Pilot did not have any of the functionalities of the current My HealtheVet portal. So the answer is no.

Moderator:Okay. Thank you. The next question is what was the thinking behind restricting access to progress notes in the current rollout of My HealtheVets?

Susan Woods:This is Sue. I do not know the answer to that. That is a good question. The plan is that progress notes and all notes are on the jet way. The VA is currently committed to move towards having that functionality and open access. I cannot answer the timeframe for that, but I can tell you that there are current projects including mobile app efforts, that are working through the issues of greater access to the notes.

Moderator:Great. Thank you. And for the audience once again, please take this opportunity to send in any questions that you have. You can use the Q&A screen located on the right hand side of your monitor. Just click on that orange arrow to open or close it. The Q&A screen is located near the bottom of that. The next question that we have here is what process is being used to educate Veterans about secure messaging? We have concerns with Veterans incorrectly using the secure messaging.

Lisa Rubenstein:This is Lisa Rubenstein. I will welcome other comments, but I think currently we are using brochures and not a lot else. And there is not a sense of where to go if something does not work. We are putting a significant burden on the patient. I think with my own experience with having the LVN be the educator, it is pretty easy to get LVN’s up to speed on this really helps, because if the person has a problem they can call their usual source of care back again and say, “I have a problem. Can you help me?” And then if the LVN needs to go to the My HealtheVet coordinator, then it still feels to the patient like one stop shopping.

Moderator:Okay. Thank you. The next question is a lot of the info that was reported in the previous segment seems anecdotal. Was there quantitative information, or was the study qualitative?

Lisa Rubenstein:This was a quality improvement project. We will have quantitative information through a couple of sources over time. We will have information from a provider survey. We will have information from patients from the Patient Satisfaction Survey in which they will now be asked about their secure messaging. And we have many reports done in many ways on the rates at which people are enrolled. So I did present qualitative information on the PDSA cycles for this project in terms of whether we think that this improvement looked like it was an improvement. But at this point, it is a QI project, not a research project. It is formative information rather than summative. But why go ahead with something if it does not look like there is a balance. I think we have found a balance.

Moderator:Good. Great. Thank you. The next question is can patients access all records including mental health progress notes?

Erin Schwartz: I assume that is for the My HealtheVet Pilot question. They could. They currently cannot. That project is over. They could see all of the notes, including the mental health notes.

Moderator:Okay. Thank you. The next question is in terms of getting patients enrolled, can you speak more about getting them enrolled/registered?

Susan Woods:That must be for me. The way this tool is working is that there is a reminder for a patient who is not enrolled that comes up for the provider that asks whether the person has Internet access. And if they have Internet access, can they be enrolled on the spot? Or if not, can they be given a subsequent enrollment plan? And then there is a part of it that you can ask for, “Please remind me.” If you cannot deal with it then, you can ask to be reminded in three or six months. Or if you think the patient is waffling, “Well I do not have a computer now, but I think that I am going to get a computer,” then you can be re-reminded that way. When the LVN or the provider sees that reminder, then the patient gets a brochure. The LVN can complete the entire enrollment process with the patient, and having the patient go home and do the final sending of a secure message. Or, other people can be involved. In some sites, there are volunteers who have been trained who assist with this process and who can be available in waiting rooms and so on. In other sites there is a My HealtheVet coordinator who can sit there and finish the process for patients who want to do it that way right on the spot. But I think that from a qualitative point of view, one of the learnings in the project has been that without that teamlet connection, it is much harder to get patients enrolled in whatever other help you give.

Moderator:Great. Thank you. I just want to make sure people know we are aware of what time it is. It is now the top of the hour. I know that we do still have a lot of pending questions. I want to check with our presenters Sue, Erin, and Lisa. I do not know if you all are able to stay on to handle these questions, or if we want to deal with them of these offline? I just wanted to check in with you three. 

Lisa Rubenstein:For me, I have to go to a meeting.

Susan Woods:This is Sue, and I am going to a VA meeting that I need to attend.

Moderator:Okay. Erin?

Erin Schwartz: I am supposed to be on another call in one minute.

Moderator:I am sure that we all understand that schedules are tight. Just so our audience knows, I am going to take these remaining questions and I am going to give them over to our presenters. We will be able to get responses back to you. I know it is not immediate and it would be great to have some discussion on it.

Susan Woods:This is Sue. Can I just make one additional comment with Lisa? I know people may have expected to hear more about how do we increase our numbers of enrollment and go out and get a qualitative study of the portal that does not exist anymore, and a formative evaluation in the field. I think there are two components. One is I will say the logistical component of physically getting people these resources and having boots on the ground. But I think the other learning point here across all this information from a qualitative standpoint is to try and help people understand that the value is there. The patients and the family do not necessarily understand what it is. I think a lot of people think of this as a black box, and do not really understand. So we asked people what they thought that they would get out of seeing their records including the notes. And I think people did not really know. But the stories of what they told us were pretty profound, pretty important, and it resonated with them. So figuring out ways that we can almost socially market these tools in a way that they understand what the value is I think is really one of the things we need to continuously work on.

Lisa Rubenstein:I think that is very well put, and I would just add that again, this is anecdotal. But I have nearly half of my panel enrolled and the selling point over and over again is the ability to contact your provider. Maybe they will progress to wanting to know their medical record, but I think it is a big selling point. And that selling point is not really getting there if only the My HealtheVet coordinator is the marketer.

Moderator:Great. Fantastic. Thank you so much for those comments. I am sure the audience will hopefully be able to use that information there. I want to thank our presenters very much for putting the time into preparing and presenting for today’s session. We very much appreciate it. Thank you to our audience for bearing with us, and we will get responses to your questions out as soon as they are available. I believe that is it. Thank you everyone for joining us for today’s Cyber Seminar.

Page 1 of 11