Dr Alfred Atanda Jr., Nemours Children's Health, shares a case study and explores how to leverage e-consults, both synchronous and asynchronous, in practice. Host Stacy Lloyd (AMA Director of Digital Health and Operations) also poses some follow-up questions about risk litigation, payment, and more.
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Lloyd: Welcome. My name is Stacy Lloyd. I'm the director of digital health and operations here at the AMA and will be your host. I'm excited about today's topic. We haven't previously covered it. In our program, e-consults are a form of telehealth that occurs between physicians and/or potentially other types of clinical providers via phone, video, and other virtual platforms, that allow for two-way communication and are often used to increase care coordination, increase access to high-quality specialty care, reduce unnecessary referrals, among other things. For the program today, you'll hear a case study from Dr Atanda, and then we'll have a brief discussion to dive into some key questions around e-consults.
So I am excited to introduce our presenter for today's session, Dr Alfred Atanda Jr. He is a pediatric orthopedic surgeon at Nemours Children's Health in Wilmington, Delaware, where he is chief of the Center for Sports Medicine, director of clinician wellbeing, and assistant professor of orthopedic surgery at the Sidney Kimmel Medical College at Thomas Jefferson University. As Director of Clinician Wellbeing, he works to promote professional satisfaction and practice sustainability for physicians, bringing awareness to the many ramifications of physician burnout, lack of well-being, and physician suicide. He's also responsible for vetting and implementing systems-level innovative solutions, to reduce burnout related to documentation burden, external regulatory constraints, and clinical workflow inefficiency.
His future goals and aspirations are to reimagine how health care is delivered, by leveraging digital health and telemedicine technology to appropriately triage, navigate, evaluate, and treat orthopedic patients. He's the chief editor of the world's first textbook solely dedicated to telemedicine and orthopedic surgery and sports medicine, and he has also launched a telemedicine concierge service for parents of youth athletes called Sports Link MD.
That's an impressive resume. Really excited to have you here today, Dr Atanda. Welcome. Again, thanks for joining us and I will hand it over to you to kick us off with the case study that shows us e-consults in action, and then we'll chat a little bit after that.
Dr Atanda: Thanks so much, Stacy, and to the AMA for having me. This is really exciting stuff. As an orthopedic surgeon, we kind of get locked into our world of broken bones and plates and screws and such, and we always are really cognizant of trying to improve health care outcomes for our patients, keeping our patients safe, of course. But one of the things that has really been lacking, at least in our world, is how we deliver that quality health care. And I think that's something that is kind of the new frontier of medicine, and I really appreciate how the AMA is bringing this forward. I did get my start in doing telemedicine back in 2015, way before COVID made it cool. And that's kind of where my role with e-consults kind of came from, because I realized that there had to be a better way of doing the work that we're doing.
Start off, as you said, with a quick case example. The kid, I think he's about 15 years old, football player, he has a medial epicondylar fracture. So he got hurt on a Friday night playing football, and he went to an urgent care. They got x-rays, they saw that it was broken, but they were really worried and concerned that he was a child and they put him in a splint and he went to another urgent care, believe it or not, that treated kids more frequently, and he was there and they saw him. They saw he was splinted, saw what he had, and they said, “Well, he has an unstable elbow fracture. He's going to need surgery. He's going to need surgery soon, and he's got to be in an emergency room.” So of course, he goes to the first emergency room, you can see where this story is going, and he's seen and evaluated.
All the while, he is still in that same splint. They all have his x-rays and they're like, “Oh, well, you need to go somewhere where they treat kids.” So of course, he comes to Nemours, and the second-year orthopedic resident wakes up at 2:00 AM and goes and sees him. And for us in our world, yes, it's a fracture. Yes, it's possible that it needs surgery, but it's definitely not an emergency. It's something that can be done electively. So we sent him home. So you can imagine the experience of the family. All the while, the child is in pain, he just broke his elbow. He's nervous, he has no idea what to expect, if he needs surgery, when he's going to have surgery. He's being told all of these things along the way by various providers and people, of what he may need to have done. The timing on this took about eight to 10 hours of their life, going through all of these different health care organizations and not to mention the resources, right?
Every place he was seen, somebody had to check his height and his weight, and put him in a room, and check his vitals, and talk to him and check his insurance. And a doctor or a provider had a document that they did all of those things. So there's so much being sucked up. But in actuality, in all those places, he didn't really get what he needed, which was specialty care and advice about how to treat his elbow, until he got to see us. And not to mention the money, I mean, you're paying copays, insurance is paying money. He was told that it was an urgent thing and it had to be transferred in an ambulance. That he could not go in his own car from that first ED to our ED, and that costs thousands of dollars.
So, when I actually talked to the mom of this patient because she was upset about this, as you can imagine, and my thought is, imagine a world if you could have taken my knowledge and my expertise at the point of contact, at any of those original places. I could have looked at his elbow films, I could have looked at his actual elbow via video, I could have talked to the outside provider, the mom. Really level set everything and managed the situation from an expectation level, but also logistically and just said, “Hey, listen, he's in a splint. Just send him home. Here's our number. Come back in your own car on a Monday morning when everybody's nice and fresh.”
So we kind of dove into this a bit more, and me being a nerd, I wanted to do a quality improvement project. So we looked at all of our transfers from outside hospitals for a year's worth of time, and we had about 350 of them. And what we found was that 30% of the time, they actually didn't even need to come to our emergency room. They were just kind of told they needed to come or people felt that they needed to come, but there was no way of me and my orthopedic colleagues consulting with the outside hospital. All these people just showed up and then we triaged and managed them.
On average, it took about nine hours of time between the outside hospital and our hospital. You can imagine when you come to our ED, you're not a VIP, right? You've been sitting in an outside hospital, you get transferred by an ambulance and then you're waiting in our ER for another three or four hours. But we collaborated with our value-based services organization, our ED folks, our transport folks, and telemedicine to really understand, how can we reimagine this process? And what I'm really interested in is if you look at this kind of bottleneck design, there's very few ways that people can get into a health care ecosystem. And that's usually just going to your PCP, going to an urgent care, going to an ER, and everybody's kind of going through the same channels. But if you look at the health care ecosystem, there is so many ways.
It's just that people don't really know how to get in, and they just kind of go by the path of least resistance. And I see myself in the future being more of an air traffic controller, seeing all the patients with fractures and injuries, all across the Delaware Valley where I happen to practice. And help guiding them and navigating into our system, at the right point of contact, to see the right provider at the right time, for the right issue. And a lot of that stems from me being able to talk to the outside providers.
Now, when you think of planes taking off, it's the same thing. There's like pre-flight stuff, in-flight stuff, and when they land, every patient's problem is very similar to a flight pattern. It has a longitudinal continuum and a journey, from the time they realize they have an issue to the time that their issue was resolved. And I think by really connecting myself to the outside providers, we can really function to navigate people along that continuum of the journey. It isn't just episodic, where I just see you in the ER and I give you some paperwork, discharge paperwork and say, “OK, go see orthopedics.” And then it's up to you, to figure out when and who, and how.
Imagine if someone like myself or another similar provider had that knowledge to guide you from step to step to step, and manage your expectations, answer your questions, teaching the other providers, so we can all do this together to appropriately navigate patients. And this is kind of in my mind, the goal of e-consults and provider-to-provider communication. And I think about it in two main flavors. So the previous example was synchronous care I was imagining. Imagine if I could be talking to an urgent care doctor in real time, when a patient is in front of them. And that's a little bit harder to do because I work and I have other responsibilities. But if you could do that, we've been piloting that at our organization.
We've been leveraging technology to interface with outside PCPs, emergency room docs, urgent care docs, a specialist on a screen, educating the patient, educating the family, guiding them. And you can even do it with physician extenders and physician assistants, and advanced practice nurses, and having somebody kind of on the ground floor. And then, the specialist will be helping to guide treatment and educate folks. What we do, even to a further extent, is even just with medical assistants and athletic trainers. We can do simple things like having them put on a sling for patients, having them remove stitches, take casts off, or change wet casts. And I think, that's kind of the new frontier, because a lot of times people would get up and come and see me, just to get a boot or just to get their stitches taken out. But imagine if they can stay in their medical home, in their primary communities, have somebody on the ground floor with them, but infuse my knowledge, and my advice and expertise, to where it needs to go.
Switching gears to asynchronous consults, was I think what most people think of when they think of e-consults. You think of store and forward, or typing emails. So this is asynchronous messaging. So someone like myself gets some sort of message, whether it be a paragraph, whether it be an x-ray, whether it be a clinical vignette, and it's usually routed from a primary care physician to a nurse triage station. And that individual then siphons those messages out to the appropriate specialist. I come up with opinion or guidance, or a treatment plan and then it goes back to that original PCP or provider at some point in the future, usually within a day or two. I've been doing this since about 2016 or so, with several different companies, and we're hoping to bring that to our larger organization at some point in the future.
And it can be really helpful because like I said, the PCPs in these situations are often very well versed with the problem, but they just need a little bit more reassurance, a little bit of guidance. They may not be totally comfortable with just sending someone to therapy or getting an MRI. So it's very, very convenient and streamlined to just get my knowledge to where it needs to go, as opposed to just sending the patient to see me for a non-operative problem, that could be really handled well and appropriately by the original physician.
Large health care systems, we make money by doing two things—seeing patients, doing procedures, or a third thing, like ordering tests. Those are the three primary ways. So it's kind of outside of the box thinking to have a specialist designed, to then be able to engage with the outside world. Because that's not typically when people view me as a surgeon, they see me as somebody producing in the operating room. And the idea that I would not do that so I can then engage with people on the outside, it's kind of foreign to people, but it definitely has its benefits. You're definitely going to need the appropriate buy-in. So C-suite level individuals are the ones, oftentimes, who make the decisions. And you're going to have to convince them that, not only is this just good for health care, it's good to streamline things, it's good to minimize waste, but it's also good for potential revenue generation.
With e-consults and provider-to-provider communication, I think the number one premise is how do we figure out how to leverage technology appropriately to move knowledge, move expertise, and move guidance, as opposed to move people? Because everything outside of our worlds are very convenient, whether it be e-commerce or video streaming, or ride-sharing. You can do everything, any way, quickly, at the palm of your hands. But in order to access specialty care, sometimes that could, like an act of God or an act of Congress, just to just be evaluated by somebody. So hopefully this little case vignettes will spark some questions and good discussions as how we can dive into that premise a little bit further.
Lloyd: So as I'm sitting here listening, how is this a little bit different, or what takes it a step beyond just care coordination? That when you start to get into the billing for it, and asking for payment for these types of services, how does that e-consults really go beyond care coordination, to make it warrant essentially, a billable service?
Dr Atanda: One of the main things in care coordination is it's a lot of logistics. I think a lot of times historically, people think of care coordination as scheduling appointments, setting up appointments, ensuring that patients have what they need before and after appointments. And the thing about e-consults, it involves that, but it also brings in the notion of a treatment plan, where care coordination doesn't really do that. Once you have your treatment plan, then we coordinate the care from there, but this is at ground zero. Somebody shows up somewhere to see a physician, and then that physician leverages technology in some which way, shape or form, to then engage with somebody who can help guide that patient but also educate that physician. And I think that's what that next level is, because that's historically what is missing.
When people call my institution, it's usually about, how do you get an appointment to come and see me? Whereas now if you're doing e-consults, it's not necessarily really about coming to see me. It's almost like phone a friend, like, “Hey, here I am. I'm managing this issue, but I would just like to just have a little bit more guidance or help with these questions.” And I think that's something that's not very common, and that's what kind of makes it a very robust, independent billable service.
Lloyd: I think that is right on point and a good distinction to put out there and talk about that. It really does go beyond that. You did talk a little bit about the impacts to patients, which the time and money alone is huge. What else have you seen, in terms of positive impact to both patients and also the clinician, or the physician experience using e-consults?
Dr Atanda: Yeah, I mean, I think there are multiple stakeholders in this kind of endeavor. I think primarily first and foremost, it's going to be the patients. Because not to sound paternalistic, but ultimately they don't know where they should be going to get the care that they need. They just go to, everybody knows their medical home and their PCPs, and the urgent cares in their environments. But being shuffled from a PCP to a specialist for an orthopedic problem, every single time there's an orthopedic issue, it takes a toll on the patient. It takes time, it takes energy. God forbid, they live in a rural place where they have to go 200 miles to see a specialist.
So I think the capacity and the ability to get, quote, unquote, “specialized care,” in an environment that you're comfortable with, that you're used to, that's near your house, I think is huge. And to be honest with you, even if you live one mile away from the specialist, if you don't have to go, but you can still trust that your primary physician is guiding you appropriately with that specialist input, I think that's a win-win for the patient, not just with time and energy, but also their overall comfort level, and the normal expectations they have from a PCP perspective or a physician perspective.
I mean, to be able to have specialist advice at your fingertips is huge, because most of the time if they want to engage with somebody like me, it's almost impossible. Most health systems have so many barriers in between the people that need my advice and me. There's so many levels, you can't just call this hospital and just talk to an orthopedic surgeon, typically. So having that chain of command at their fingertips is going to be helpful. And also, it'll give them the confidence and empower them to take on maybe some more complex patients in cases, because they have that knowledge and expertise readily available to them.
And then finally, from us, then I can guide and control the types of patients that I'm seeing. From a well-being perspective as a surgeon, I want to see surgical patients. If I can have my knowledge and expertise go to where it needs to go for some of the more simpler issues and non-operative issues, I'm still helping people. I'm still generating revenue, I'm still being of value to my community, but I'm also maintaining my practice and keeping it streamlined. So I'm doing the kind of things that bring me joy, the things that I want to do, and the things that my practice is set up to do. So I think multiple stakeholders can benefit from this in multiple different ways, just depending on the viewpoint.
Lloyd: Yeah, I think that's great. I think there's tons of benefits to this and positives. Have you seen any negatives? And I think, particularly before we dig into the details or the nitty-gritty of billing for these types of services, knowing that some of that may be passed down to the patient, maybe they're not used to receiving charges for something that feels very like it's always been a part of care or something, right? Have you experienced any kind of patient complaints or frustrations around getting billed for something, or not completely understanding, that is a type of billable service or something like that?
Dr Atanda: Yeah, I mean, I think you just have to be very careful about transparency. Just as if I went physically to the emergency room and I saw a patient with my resident or whatever and I billed them, I don't know how much the ER is actually telling them, that they're going to receive another bill and another consult. So being able to tell them that, really isn't any different than if I went there in person. So if it's not an emergency room or if it's a PCP's office, you have to have full transparency and even ask them like, “Hey, are you OK if I do this?”
Now, a lot of the systems that are out there, these e-consult services are actually funded by payers and different government systems, because they know that it's cheaper than just having each patient go on and around, and just seeing specialists. So a lot of times there isn't an extra cost to the patient. But if it's a system where there would be, where they're directly billing that individual's insurance, I think just letting them know ahead of time that, “Hey, you maybe billed an extra 50 or a hundred dollars for this visit,” but it may save you a trip 200 miles to go see a specialist. It may get you your knowledge and advice that you're seeking in a day or two, as opposed to waiting a month to go see a specialist.
I think, people mostly focus on the financial aspect and people getting excess bills, but what is the alternative? You think of the traditional way, OK, you see your PCP, you don't get an extra bill, but then you come and see me 45 days later for a problem that's not even surgical. And you took time off of work, you took your kid out of school, because I'm a children's hospital. All of those things are extremely costly and frustrating to people. It's just that it's not easily quantifiable.
So we tend to focus on, “Oh, somebody got an extra bill for 50 bucks, how are you going to mitigate that?” But having people seek specialist care in a completely inefficient fashion most of the time, is probably way more costly than an extra $50 e-consult bill. But again, it's all about transparency, being open and honest with the patients, and if they don't want to do it for any extra bill, obviously, then you don't have to do it. But I think it should at least still be an option for sure.
Lloyd: I think that's a great point. And thinking back to your example of how many different places that kid had to go right before they got an answer, and paying each copay for emergency room, and urgent care and all the things.
Dr Atanda: And imagine if you offer that mom, “Hey,” at that first urgent care, “For an extra $50, we'll have Dr Atanda take a quick look at your x-ray, help guide me to guide you to where you need to go, as opposed to three extra facility visits.” And it's interesting, because when we talk about e-consults and something that's a little outside the box, like I said, people focus on that.
But that clinical scenario that I showed you, that only came to light because the mom was upset and didn't want to pay our organization, that's not out of the ordinary. Maybe not for visits, but I guarantee you people go to a PCP, then to an urgent care, then to our emergency room all the time. A lot of those times, it's not really anything that warrants an emergency room visit. And for whatever reason, nobody says anything about that, because everybody's getting paid theoretically at all of those sites. There's enough chicken for everybody, so everybody's happy. But in the vein of future value-based payment models, that probably will go away, and then people are going to have to readily adopt these sorts of outside of the box treatment methods, for sure.
Lloyd: All right. Well, speaking of payment, can you share a little bit more around billing for these services and what codes to use, or when to use them, and what you do in your practice?
Dr Atanda: So my large experience with e-consults is mostly outside of my primary practice here at the hospital. Mostly what we do telehealth for is very typical of what most people do telehealth for, so just managing your own patients and that sort of thing. There are actual codes for asynchronous versus synchronous provider-to-provider communications, and there are codes for simple phone consultation. And these are legitimate codes that even existed prior to COVID, but obviously exploded a little bit once the pandemic hit. And most payers do recognize them, because they tend to follow CNS guidelines and policies. So it's going to be your synchronous codes, your asynchronous codes, and then telephone, phone consultation codes. Interprofessional codes is what they're called.
Lloyd: We have someone that is about to start volunteering to do some e-consults, and was interested in what to expect and what to do to prepare for this type of role. Anything from your experience on more of an individual level? What did you do to prepare yourself to start doing this a little bit more often?
Dr Atanda: Yeah, so I think the number one thing that's key is going to be workflow. So if you're just volunteering and you're doing this on the side like I do, I'm a full-time orthopedic surgeon, but I do these things in my own time. It has to be amenable to your current practice, in terms of just your normal workflow and how you get through your day. So a lot of the consults that I do, I usually have one to two days to respond, and that's very helpful for me. So I can do my regular job and the last half hour of the day or when I get home, I can bang through a couple emails or respond to a couple of folks. There's certain companies out there that suggest you respond within three hours or within six hours. I can't do that, right? I could be in surgery for six hours, and I can't respond or do anything.
So whatever it is that you try to do, you have to make it conducive to your particular workflow as a physician because oftentimes you're not going to just stop your day job and just start doing e-consults right off the bat. It's going to be fluid and dynamic. You can be doing both for a while, but if it takes off, maybe you do a lot of e-consults and a little bit less of your traditional practice. But it has to be something that works for you because if it doesn't, then you're just going to quit. That's the bottom line. You're going to do it. It's going to be too stressful, it's going to be too taxing, especially if you're volunteering and not getting paid for it. You don't want it to be a burden. You want it to be something that kind of melds well with your regular practice.
So if you have two or three days to respond to an email, I think that's a very good setup, and then you find time that it works well for you. I usually do it outside of work hours, so I don't interfere with my regular practice as a surgeon, but if it's something that's going to be through your own organization and your hospital, then you may be able to do it during your work hours or carve out, “Hey, from 8 to 10, two days a week, I'm going to respond to e-consults,” or something like that. But I would say, I mean, obviously, there's lots of things to consider, but first and foremost, it's just logistically and practically, how are you going to weave this into your current workflow?
Lloyd: Great tips. For those that are looking at this from an organizational perspective and maybe how to get buy-in, what do you think those measures of success are that can help gain buy-in? And/or show the success of an e-consult program?
Dr Atanda: I mean, I think the primary goal right now, if you've a bunch of, a large PCP network within your organization, theoretically, most of the time if they see something that requires a specialist, they're going to send them to a specialist. But over time, what you may find is you can look at the percentage of time that they're now sending people to specialists for similar problems. And the goal is to decrease that percentage, so they can keep some of those patients for themselves, and they're only sending people to specialists when they need to. One of the things that we look at with e-consults is that very thing. What's the outcome of the consult? Is it, the PCP can still manage this patient? I need more information to be able to decide who should manage the patient versus, “Hey, this patient needs to go see a specialist.”
Those are the three main pillars, and I think a lot of times the last thing, sending to see a specialist is what mostly happens in a lot of situations, but I think capturing that for a particular provider, a physician in a particular practice is going to be key. Because you want that percentage that gets kept with the PCP, that they're comfortable taking care of, you want that to be as high as possible just so that it's best for the patient. PCP can manage the patient, and then that's also not something that necessarily has to see the specialist.
Next thing you want to look at is, we do a lot of work with appointment timing, like how long it takes to get particular appointments. So what you may find is that by engaging the physicians talking to each other, it's going to help streamline and facilitate patients getting in. So if I talk to a particular doc and they say, “Hey, listen, this kid has this injury,” blah, blah, blah. “They need to be seen.” Now, I can then talk to my team and say, “Hey, listen, this doctor just called me about Johnny. He has cartilage injury in his knee. I really want to get at that quickly and get an MRI. Let's facilitate him getting in.”
As opposed to that PCP just having Johnny's mom call the general scheduling office, and he bounced around and people saying, “Oh, well, Dr Atanda's on vacation. He is doing this.” It just helps people get in quickly. And not that Johnny is a VIP. It's just that now I already know. I know what he needs. I know the best time for me to see him. I know what I can offer him. So being able to look at how appointment times are hopefully decreased, based on an e-consult program, I think is going to be huge.
And then last but not least, you definitely want to show that the quality of care isn't decreasing. So you want to find a way to look at patients who kind of are referred through the e-consult network to specialists, versus not referred to specialists, or if they just stay with their own PCP. You want to show that the care and the outcomes, however you normally monitor outcomes, is the same regardless of if the patient stay with the PCP, or if they were just referred over to me both for a non-operative problem. You'd want to show that the care is equal and that'll give you more confidence that, just with a little bit of specialist advice and expert expertise, it's OK to be treated by your PCPs.
So it's definitely going to be a lot of, and I wholeheartedly believe in having appropriate metrics. I don't think you should go on, take on an endeavor like this and just say, “OK, let's do it. It'll be good for patients. We'll save money.” And then that's that. You need to have the metrics outlined ahead of time. How are you going to measure success? How often are you going to look to measure success? And then, what's your contingency plan? If you don't get to that successful level that you've stated for yourself, what are you going to do about that? Are you going to scrap the program? Are you going to pivot? Are you going to augment? Are you going to kind of turn it off for two or three months and then retool and revamp things? So having some idea of how you're going to measure success and what to do about it, I think is almost as important as the program itself, for sure.
Stacy Lloyd: When you're doing these types of services, asynchronously or synchronously, do you usually do them through the electronic health record? Or are there other types of platforms or technologies that are out there, that you use to kind of provide these services?
Dr Atanda: Yeah, I mean there's both. Some health systems have their own e-consult service, like we do very impromptu, informal staff messaging through our electronic health records. So it's not a formal e-consult program. There's no billing, but docs can text me and email me through the EHR Epic that we use, and I can review the patient's chart. When you do that, kind of, with private companies, most of these companies have their own platform. So you would log in, you have your username and login, and then everything is in there. Sometimes it's web-based, sometimes it's app-based, sometimes it's both, but it all depends on just which company you're engaging with or which health system you're engaging with.
As long as it's secure and it's something that's easily accessible by the physician specialist, I think it is the most important thing. It has to be convenient for me to be able to log on, in whichever way that they have. So it can't be something that's really cumbersome, that requires two and three and four factor authentication. The best ones for me are the ones where I get a text message. I click the link, and it takes me straight into the platform with the question and the patient data. I actually don't have to log in directly, because it's been embedded through my cell phone number and it's unique to me. The more cumbersome ones are the things where I have to get on a computer and log in, kind of the old-fashioned way, but it's a crapshoot of what you're going to get. But there's lots of different variations out there. You just want to make sure it works the best for your specialists and your PCPs.
Lloyd: One final question. Are you responsible or reliable for your advice? And what agreements or things need to be in place, to kind of protect yourself when you're doing this?
Dr Atanda: So when I engage, the six or seven companies or so that I do this for on the outside, each and every one of them provides me with liability insurance, that's provided to me for free. Not to say that it's highly litigious what we're doing, but there's always just in case. My practice as a physician at Nemours, that I have liability insurance there. That does not cover me to do that. So if you are going to do this as an individual physician, you want to make sure that you are covered to do so. If you were going to make an offering as a system or an organization, you want to make sure that the folks that are doing this for you are covered, whether it be within the walls of your own organization or their outside docs.
Again, I don't think it's a very litigious area, but depending on your specialty, a lot of what I'm doing is just kind of broken bones and fractures in kids. If you're doing something a little bit more complex like oncology and different things like that, then you want to make sure that you're covered to the level that you find to be appropriate.
Stacy Lloyd: Thank you, Dr Atanda, for joining us and sharing your expertise.
Dr Atanda: Thanks so much for having me. Have a great day, everybody.
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If applicable, all relevant financial relationships have been mitigated.
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