By Steve Forcum, cloud solutions engineering leader, Avaya.
A recent report on hybrid cloud in the healthcare industry predicts that hybrid cloud is set to jump from 19% penetration to 37% by 2021. In an industry historically slow to adapt in the world of IT, why is hybrid cloud becoming healthcare’s primary choice?
To be fair, there was hesitancy in most major markets when it came to cloud services, many questioning the security of it all and even how it functions on a basic level. Cloud-based data centers that can either be run by third parties (public) or built and maintained internally (private).
And now that the mystery of the cloud has been de-stigmatized in the workplace, more and more organizations are turning to the cloud as its primary servers, but don’t want to give up control completely. This is where hybrid cloud comes into play.
A hybrid cloud serves as the best of both worlds. With a hybrid model, there is a channel that links an established, private computing system with a public cloud, providing access to unlimited processing power.
Both the private cloud and public cloud work in tandem to run applications, depending on decreased and increased workloads. Here’s why this is important for healthcare professionals:
The Data Storing Problem
The healthcare industry more than most, has immense amounts of data stored on its legacy servers filled with Electronic Health Records (EHRs). Although a private cloud helps keep this information safe with a firewall, the flooding of medical records may cause other applications to slow or even crash, forcing providers to buy and install more servers just to keep the system running.
This costs money and time — both crucial and limited in a healthcare environment. The hybrid cloud serves to remedy this problem as it allows applications to run from both the largely scalable public and secure private cloud, depending on demand.
The hybrid cloud model is set to save the cumbersome task of troubleshooting. Often, hospitals and clinics have to undergo a long approval process that is HIPAA compliant before they are granted the permission and resources to update and install its outdated or outgrown software. Because the public part of the hybrid cloud is maintained by a third-party, it is constantly being updated, relieving the healthcare employees of software upkeep and maintenance.
No Compromise on Security
When it comes to a hybrid cloud, there is no need to compromise on customization. Healthcare IT professionals have full control over what assets are kept on the private data center and what gets moved to the public cloud. Privacy is not jeopardized when sensitive information can still remain behind the internal firewall. For example, while less sensitive data such as appointment requests can run on the public cloud, EHRs can stay protected by the private system’s firewall.
As we look towards 2020, it’s the perfect time to migrate your health IT infrastructure to the hybrid cloud.
Of the nation’s $3.5 trillion in annual healthcare spending, 90 percent is for people with chronic and mental health conditions. Can healthcare institutes afford not to engage in the 2020 wave of preventative care healthcare disruption? While healers are not prognosticators, savvy healthcare CEOs have their eye on 2020.
For those riding the disruption wave, the answer is simple. CMS alone is providing more than $80 billion in reimbursements for preventive care initiatives. This calculation alone does not count on complex chronic care conditions and other follow-ups from preventive care engagements.
Also, CMS aims at containing the growth of acute care reimbursement. It has almost the same “carrot and stick” model used for the evolution from paper to electronic. Stay on the paper train and get penalized or get on the preventative care train and receive financial incentives.
Earthquake or Hurricane?
Both natural disasters are simply disasters. We do not use this analogy from a disaster standpoint, but from our ability to monitor the progress towards controlling the impact. Earthquakes cannot be foreseen. A hurricane cannot be monitored to the exact point of where it will hit, but at least it can be monitored to approximately when it will hit and its potential impact.
The paper evolution is like an earthquake to healthcare with its aftershocks still being felt today without the ability to plan much upfront. The preventive care evolution is more like an imminent hurricane. We know it is coming, we know when it lands, but we don’t know where it is going. We need to deal with it and manage where it will take us. Those unprepared will suffer the most negative impacts. Would your healthcare facility take this risk?
Most healthcare institutes have deployed an EHR system, almost completing the evolution from paper to electronic medical records. This was the first wave of healthcare disruption. However, we are now realizing that this was much more of a disruptive process in healthcare than anyone realized, as its impact has gone way beyond how patient medical data is recorded.
Power vs. Paper
It began with requirements for care providers to use an electronic system in place of the traditional paper approach, opening for a potential patient medical information exchange, improving care quality and efficiency. CMS rolled out preventive care reimbursements starting with the Annual Wellness Visit (AWV) in 2015.
CMS then continued to invest in preventive care through additional reimbursements, such as chronic care management, remote patient monitoring, behavioral health integration and transitional care management.
Every year, CMS has either expanding current reimbursements or deployed new preventive care services. This strategy is based on the patient centered medical home with the objective to curb healthcare cost with preventive care measures, a 6:1 ROI versus acute care.
Reimbursements as incentives led to the next wave of healthcare disruption in which care providers’ workflows were impacted on how to record patient medical records. These preventive care initiatives created fundamental changes impacting almost every operational aspect of a care provider’s workflow.
Today, it is all about preventive care: simply put, the patient is not yet a patient until he or she encounters pain. The patient is not yet sick. The operational model is not reactive. The demand is to anticipate and monitor conditions so care providers can act before the patient encounters a serious medical problem. This causes changes in the operational workflows for healthcare institutes and their workflow.
In the patient engagement model, there is the acute care model in which it is the patient who makes an appointment or visit. For preventive care, it is care providers and healthcare institutes conducting the outreach. However, without the patient outreach model, healthcare institutes cannot realize the full financial incentives offered by CMS.
In non-face-to-face engagements, patients contact their primary care providers for consultation, but that model is different from the preventive care one. In the acute care environment, care providers cannot bill for the engagements, but can bill for visits and appointments. In the preventive care environment, care providers can bill for services, but it is up to care providers (and their staff) to reach out, monitor patient conditions and meet the time required for billing.
Since 2011, interest and investment in insurtech has exploded exponentially. In 2011, $140 million was invested. By 2015, it was $2.5 billion, according to McKinsey’s article, Insurtech: The Threat That Inspires.
By the end of the first quarter in 2019, investment records had already broken new records, and went on to surpass $3 billion, coming second only to the fintech revolution.
While there are still very valid concerns about sharing health data online, the use of such technology can present some useful employee wellness solutions faced by businesses. Considering health-related issues cost US companies more than $260 billion each year, it makes sense that businesses would be eager to support technological innovations that can play a large role in helping to protect and maintain their workforce’s health — and their bottom line.
Policies Personalized To Employee, Company And Industry-Specific Risks
For both businesses and consumers, insurtech delivers that, thanks to the employment of artificial intelligence and machine learning that comes with it. Traditional insurance policies are formed using overall industry averages, which are sometimes inaccurate in terms of business size, employee behavior or the health and safety stance of the business.
This means entities including small businesses often find themselves presented with inaccurate constructed and priced insurance policies. The use and continuous monitoring of employee data mean companies can shed unnecessary policy costs and access coverage unique to their organizational needs.
A simpler customer experience means less time and resources are spent on acquiring and renewing insurance policies by businesses. With the use of real data, insurers and platforms are now able to accurately predict employee and business preferences, significantly cutting down on the time taken to include market risks.
As HR departments spend less time and money collecting, collating and analyzing employee data for the insurance process, they can focus on more internal measures of boosting employee health, such as implementing employee fitness initiatives or offering company-wide mental health resources. Underwriting, claims processing and even policy research is significantly changed for the better, leaving more time and space to focus on employees and not legalities.
Continuous Monitoring Means Regularly Updated Tailored Coverage
Another argument supporting the role of insurtech in preserving employee health is that it provides more data that is continuously updated. With health and behavioral information that is regularly refreshed, the decision-making process is also improved, both within the business and on the insurer’s end.
Policies can be updated to reflect changing risks, and more importantly, up to date policy recommendations are fed to management on an ongoing basis, helping them to play a proactive role in maintaining employee health instead of a reactive one. Policies can be auditable, according to Cerity.com which means the final premium paid by businesses is adjusted for any changes over the insurance period, allowing more accurate pricing.
Want to rapidly improve your hospital’s brand, reputation and financial prospects? Look no further than patient access (PA), typically the front-line “face” of a healthcare provider and instrumental to an organization’s clinical, financial and reputational success.
While the definition of “patient access” may vary from organization to organization, generally it means the department responsible for handling new patient intake, including registration, insurance verification, billing, admissions, cash collection and more. According to the National Association of Healthcare Access Management (NAHAM), PA representatives handle access for “patients, providers and payors into, through and out of their healthcare experience.”
PA also significantly impacts a healthcare facility’s revenue cycle and finances, due to its role in benefit verification, pre-certification and even financial counseling. NAHAM estimates that about 80 cents of every dollar collected by a healthcare facility is handled by PA representatives. Considering the significant shift in health insurance toward high-deductible health plans, and the likelihood that patients will have an ever-larger portion of their overall bill to pay, the importance of PA has never been greater.
You would think a department and function as critical as PA would be considered a healthcare facility’s crown jewel and receive sufficient resources and internal approval accordingly. Yet too often, some in healthcare view PA as a necessary expense – a transactional, high-cost center often faulted for bad debt, claims denials, administrative delays and sub-optimal patient experiences. While that may be the case in some PA departments, high-performing healthcare providers know differently, and ensure that their PA staff members receive all that they need to succeed. Following are the most common characteristics of high-performing PA departments.
It Starts at the Top
A PA department is only as good as the system it supports, and most of that system is beyond PA’s direct control. For example, if a healthcare system lacks sufficient providers to meet the demand for care, or the right mix of specialists, PA will bear the patient-facing brunt of these issues. Similarly, if a facility doesn’t offer the time availability or convenient location to meet local patients’ needs, PA will suffer.
Operationally, healthcare organizations need to be sure they have in place the right care delivery strategy and resources to meet patient requirements – and allow their PA team to correspondingly perform well. That’s especially important in today’s era of healthcare, with patient experience increasingly affected by factors like access, convenience and cordiality, in addition to patients’ baseline expectations of caregiving competence.
Support from the top for PA is not only strategic and philosophical, but also practical. This includes making sure that PA has the latest technological tools necessary to deliver quality PA workflow. This could mean providing PA staff members with improved visibility tools into ED and inpatient unit availability, allowing for better and more productive PA decision-making. For patients, this might entail offering a high-quality, 24/7 online patient portal, providing information on lab results, discharge summaries and billing and scheduling information.
Rising healthcare promises have been tied to cloud technology in the most recent tech-talks of the town. While the majority of care providers are not holding their breath due to previous disappointments, we wanted to translate the often vague statements made into discrete simplified processes for healthcare.
Healthcare is riding a wave of digital transformation that has brought about revolutionary processes of data management and care delivery. Moving from paper-based records to a digital format, the first wave took us from disconnected facility-based care to integrated smart care with increased coordination and population health activity.
The second wave enabled better patient experience with omnichannel communications and interoperable data sharing applications. Empowering patients and clinicians with analytics, the recent wave has health organizations leveraging real-time data-driven solutions, artificial intelligence, and cloud services to align with the culture of preventive and wellness-centric care.
The cloud will be central to future digital transformations in healthcare. What is uncertain for many is what specific, new cloud services will be developed and why are healthcare organizations now – and foreseeable future continuing – to opt for cloud-based technologies.
Why are health organizations leveraging the cloud?
We have been in the process of transitioning from fee-for-service to value-based care over the past decade. The industry is further planning to move from disease-based episodic care to preventive care in future years. To achieve that goal, several additional factors need to progress.
The healthcare system of the future will be more consumer-centric and value-driven. It will use real-time data to generate actionable insights, and data technology will play a crucial role. Cloud technology promises to improve performance enhancement and healthcare data analytics overall.
Health systems have a need for increased data capacity, and the cloud promises almost unlimited data storage, easy accessibility, and enhanced cybersecurity. As health organizations are expanding into a variety of digitized services such as virtual care, wearable devices, telemedicine, and smart AI assistance, the data per patient expands.
The cloud is a single point of access to patient information, to multiple doctors and medical services at the same time, that boosts not only real-time coordination but also ensures data security for hospitals and patients.
Gartner, in a recent healthcare cloud services report, highlighted how provider leadership has moved from skepticism to acceptance of the cloud as a service delivery model. In what ways is the cloud benefiting the healthcare industry?
According to the Centers for Disease Control and Prevention, the flu season is going to be bad this year. There have already been more than 7 million Americans sick with the flu, and we’re still only in January.
Do you want to avoid getting the flu and steer clear of other health conditions as well? Then you should learn how to improve physical health to lower your chances of getting sick this winter.
There are a series of simple steps that you can (and should!) take to turn yourself into a healthier person overall. You won’t have to worry about getting sidelined by sickness this flu season when you take the right approach to staying healthy.
Find out how to do it below.
Eat More Fruits and Vegetables
When you sit down for a meal, health experts recommend that about 50% of your plate be made up of fruits and vegetables. Are you getting even close to that amount of fruits and vegetables with your meals?
If not, there won’t be much of a point in trying to figure out how to improve physical health in other areas of your life.
You’re not going to be giving your body the nutrients that it needs to fight off illnesses.
Some people attempt to work more fruits and vegetables and other healthy foods into their diets after they get sick. But you’re much better off making room for these foods in your diet when you’re healthy so that you can keep it that way.
Commit to Getting the Right Amount of Exercise
Studies have suggested that every time you work out, you put a little bit of stress on your body’s immune system. By doing this, research shows that you may be able to build your immune system up and make it very strong over time.
But unfortunately, most people don’t take advantage of this big benefit that comes along with exercising. More than 80% of Americans don’t get enough exercise day in and day out.
If you fall into this category and you find that you’re always getting sick, you should do something about it.
Start exercising more often and see what a difference it makes in terms of your body’s ability to stay healthy.
Get More Than Enough Sleep at Night
The state of sleep in the U.S. is, in a word, sad. There are so many people who aren’t getting the recommended 7 or 8 hours of sleep every night.
Some people aren’t sleeping enough because they have an untreated sleep condition. Others aren’t sleeping enough because they’re too stressed out to fall asleep at night.
And then, there are those who are staying up until all hours of the night binge-watching Netflix shows and depriving themselves of sleep for no real reason. It’s making America a very tired nation as a whole.
It’s also putting people at risk to get sick more often. When you don’t get enough sleep, your body doesn’t get the time it needs to recover from everything that you put it through each day.
This can leave you susceptible to the flu and other illnesses. It can also affect your mental health in ways you might not have imagined.
Take Your Vitamins
Do you expect the foods that you eat to provide you with the vitamins that your body needs? If so, you’re likely doing your body a huge disservice.
The foods that you’re eating likely don’t contain enough vitamins and minerals for your body to use. This is leading to a shortage of essential vitamins and minerals in your system.
Change this by talking to your doctor about taking multivitamins or other supplements for your health. You can place an order online and have these things shipped right to your front door so that you can begin taking advantage of them.
Keep Your Stress Levels to a Minimum
As we mentioned earlier, stress can hurt a person by preventing them from getting enough sleep at night. It can also wreak havoc on their lives in a variety of ways.
For example, stress can have a huge impact on your mental health. It can make it difficult for you to cope with everyday life.
Stress can also cause you to gain or lose a bunch of weight in a short amount of time in some cases. It can leave you feeling lethargic as well.
And if you don’t learn how to manage stress, it could even make you sick. There are a number of illnesses that people might be forced to deal with if stress gets the better of them.
It’s why you should make it a point to get rid of as much stress as you can from your life. You’ll feel better physically and mentally once you remove the majority of the stress that you’re dealing with now from your life.
Wash Your Hands on a Regular Basis (and Do It the Right Way!)
At the height of the flu season, you should work on washing your hands at least a few times every day. Any time you touch any person’s hand or touch something that someone else touched, think about washing your hands.
Maybe, more importantly, think about washing them the right way. Amazingly, the U.S. Department of Agriculture reported that about 97% of people don’t wash their hands the right way in a recent study.
Washing your hands can stop germs from making their way into your system. You should wash them early and often both during flu season and all year round.
Learn How to Improve Physical Health to Avoid Getting Sick
Now that you know how to improve physical health and keep from getting sick, start doing it. Follow the steps laid out here to make yourself a much healthier person in 2020.
You’ll be surprised by how much better you feel when you eat right, exercise, sleep enough, and take your vitamins. You might even feel like a brand-new person in just a few months.
Read the articles on our blog to find other tips for staying healthy.
Kristin Simonini, vice president of product, Applause
Healthcare has long been looked at as a laggard when it comes to adopting digital services. Part of that is due to the stringent regulations of the industry and the sensitivity surrounding personally identifiable information. Part of the blame, however, falls on healthcare providers themselves. As more and more providers in the industry start to embrace digital innovation, a number of key trends emerged over the past decade including:
The embrace of mobile technology for scheduling appointments and other routine tasks
Telehealth patients accessing doctors for consults, education, and certain outpatient treatments across a variety of fields
The IoT explosion (Fitbits and other wearables) providing customers health information to drive the healthcare they receive
Healthcare’s focus on patient experience means bringing a critical eye to current digital experiences. Ease-of-use and inclusivity must be considered in order to ensure high-quality digital experiences across all touchpoints, particularly on smartwatches, tablets, and smart speakers
In terms of predictions for 2020, we expect use of voice technology will continue to grow and will empower the healthcare industry in new ways, including supporting patients. The benefits that voice brings to healthcare can be seen in medical record transcriptions, chatbots sharing the work, sharing knowledge, voice-user interface, and connecting clinics to customers.
In addition, AI will continue to impact the healthcare industry in numerous ways. As healthcare embraces AI, it will also need to address issues of bias. All types of AI – from virtual assistants learning how different users ask for the same thing, to healthcare apps identifying potential health issues from uploaded photos – have been hampered by the same challenge: sourcing enough data to teach the machine how to interpret and respond, and then testing the output at scale to ensure the results are accurate and human-like when necessary. To mitigate bias concerns, healthcare will need to make AI more representative of patients
Today, healthcare payers and providers are spending nearly $30 billion every year on analytics and using over 415 different vendors for their analytics needs. This is a tremendous waste of resources and time. We’ll see an accelerating trend toward converged analytics solutions that cross clinical, financial and operational boundaries to enterprise analytics solutions.
Enterprise analytics will dramatically increase the speed and efficacy of population health programs because when you have both fresh claims-based data and clinical analytics you can diagnosis, intervene and engage in care management programs far faster and with much greater confidence in the data and results. This is where healthcare will be moving in 2020.
In the year ahead the health care sector is going to continue to see investment in Artificial Intelligence (AI) and Machine Learning. That dimension of innovation in hi-tech will continue to evolve and emerge and markets will slowly open and mature.
I believe health information exchange or HIE – once known to most of us as regional health information organizations or RHIOs – will be back in vogue. What began more than a decade ago went underground for a while but ACOs and other initiatives have resurrected HIE infrastructure and made it abundantly clear that HIE is vital to care coordination, outcomes and value-based reimbursement (VBR). All-provider clinical messaging, outcomes measure, quality assurance, transitions in care, cost and utilization management, and referral management absolutely must be supported by HIE infrastructure.
Biometrics will continue their spread and companies such as Apple and Google (for better or for worse) are making it clear they see the future and are investing accordingly.
Lastly, population health management platforms that enable functions like risk stratification will see tremendous growth.
Tim O’Malley, president and chief growth officer, EarlySense
Technology advancements over the past decade have enabled us to accurately track millions of physiological patient parameters in real time. As we head into 2020, the industry will continue to leverage the incredible power of AI-driven “smart data” and analytics to not only predict potential adverse patient events, but also prevent them.
Patient care will continue to become even more personalized and new standards for patient safety will emerge. Predictive analytics will be used across the continuum of care- from hospitals to skilled nursing facilities and homes- to support health staff and patients, improving clinical outcomes while also creating a potential for significant financial savings.
Last month saw the rollout of the latest upgrades to Amazon’s Echo speaker line: earbuds, glasses, and a ring that connect to Amazon’s personal assistant Alexa. These new products are just three examples of a growing trend to incorporate technology seamlessly into our human experience, representing the ever-expanding frontiers for technology that have moved far past the smartphone.
These trends and others are going to make a big impact in the healthcare space, especially as providers, payers and consumers alike slowly but surely recognize the need to incorporate tech into their workflows to meet the growing consumer demand for digital health tools. At the same time, the data-hungry nature of these innovations is creating its own problems, driving a discussion around privacy and security that is louder and more urgent than ever.
Here are three trends to look out for in the coming year:
Artificial Intelligence (AI) and Machine Learning are growing into themselves
In 2020, we will continue to see AI and machine learning push boundaries, while at the same time mature and settle into more defined patterns.
With the adoption of technologies like FaceID, facial recognition technology will be an important player in privacy and security. It can be leveraged to simplify the security requirements that make multi-factor authentication a time-consuming process for healthcare professionals — on average, doctors spend fifty-two hours a year just logging in to EHR systems. On the patient end, this same technology has the ability to detect emotional states of patients and anticipate needs based upon them, and the success of startups like Affectiva, the brainchild of MIT graduates, shows its tremendous promise..
Meanwhile, FDA-approved innovations from Microsoft and others claim the ability of computer vision for assisting radiologists and pathologists in identifying tumors and abnormalities in the heart. While robotic primary care is a long way off, some view AI as a rival to more niche clinical positions.
Although Google first gained prominence as a search engine, it quickly moved into other sectors, like smart home tech and cloud computing. One of the latest projects associated with the brand relates to health care, or, more specifically, electronic health records (EHR).
In early 2019, rumors began circulating about Google’s plans to develop an EHR tool. In late November, the company confirmed with an official blog post discussing the project. It centered on the challenges associated with health data, such as the variety of formats and number of people contributing to files.
Accessible Health Records
In the blog entry, Dr. David Feinberg, the head of health, claims the Google EHR solution will put all health records into a single, search-friendly database. This setup will reduce the time providers spend hunting for information.
A product video accompanying the post featured Dr. Alvin Rajkomar, a product manager and practicing physician. He discussed how providers spend half their days working with EHR interfaces and often need to log into several systems to acquire necessary materials. While Google’s product is still in the pilot phase, it’s available for widespread clinical use.
The video demonstrates how the Google EHR tool offers all patient information needed in one place. For example, a doctor can see data about a patient’s primary complaint, plus the results of lab work, without switching between tools. Users can simply switch between tabs, much like on an internet browser, to see different information.
A search box at the top allows people to use natural-language queries and find what they need. The system also handles potentially misspelled words, similar to searching for something on Google.
Context to Patient Information
The Google EHR tool gives authorized users access to data via tables and charts, allowing them to see how a patient’s condition changes over time. When users import data from another location, it’s highlighted grey to differentiate it. Simply hover the cursor to see the original source.
5G is on its way, promising high-speed internet access to everyone, everywhere. But how will increased connectivity impact overall security? Cybersecurity companies in the healthcare industry are working to effectively secure hospital networks and medical devices against hacks and vulnerabilities, but as technology like 5G becomes ubiquitous, more and more devices will have additional — and often unnecessary — connectivity features, thus creating more potential for vulnerabilities and breaches. Taking a proactive approach to cybersecurity is the solution we need to see more of in 2020.
In 2020, I expect there to be a significant push on price transparency to help patients (and providers) align more on the actual cost of services. This will help patients know what they are getting into before services are rendered and help providers secure payment prior to any procedures being performed. There has been an upward trend on this in the urgent care space, but I expect there to be an major expansion in 2020 with many other types of healthcare providers.
The tools available in the market, which will gain great adoption in 2020, will help to not only estimate costs, but will also help provide financing options for patients. These financing options often come with high interest rates, but give patients the ability to get the services they need today. With high deductible health plans continue to gain market share, patient out of pocket costs will continue to rise in 2020. Healthcare providers can no longer afford to wait for these funds after the fact, as patients take longer than the average insurance company to pay their bill.
Therefore, providers will be eager to secure payment before services are rendered in an effort to combat this new challenge they haven’t dealt with until recent years. With higher patient responsibility these healthcare providers have seen higher bad debt write-offs than ever before. The struggle providers are facing as more and more patients can’t afford to pay their bills is battling the thought of sending patients to collections and/or firing patients from their practice.
In 2020, providers are going to have to set stricter guidelines, collect more money at the point of service, offer financing options, and give greater financial transparency to patients (and themselves) before providing services. This opportunity is ripe for more healthcare technology companies to come in with price transparency and financing technology, coupled with patient engagement tools. These tools will help providers both engage patients and secure a form of payment to limit write-offs and increase collections.
Without this, we will continue to see more patients turned over to debt collections and even more patients filing for bankruptcy, due to their healthcare care costs getting out of hand. Healthcare technology companies in this space can help alleviate this issue and reduce the burden to both healthcare providers and patients.
Artificial Intelligence (AI) and Big Data Solutions – platforms that aggregate large amounts of patient data, like EHRs/EMRs, will continue to partner with leading AI companies to combine the massive amounts of patient data with other analytics and capabilities to help monitor and treat populations. Digital health management will expand beyond chronic disease management to become a mainstay in the general population.
People will continue to adopt the right technology for their health goals and use digital health management to navigate their healthcare journey. Femtech will continue to expand aggressively as the female population looks to help manage every aspect of their health with both in-person and digital resources.