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Inside the May 2006 print edition of Canadian Healthcare Technology:

Feature Report: Developments in surgical systems

Toronto hospitals collaborate on
e-Learning system

Three Toronto organizations – Mount Sinai Hospital, the University Health Network, and Sunnybrook Health Sciences Centre – have joined forces to develop an e-Learning system that allows for collaborative creation and sharing of courseware and training materials.


Survey ranks top IT projects in hospitals across Canada

Canadian Healthcare Technology magazine’s most recent survey of IT trends in hospitals found that technology spending is on the upswing. The average hospital IT budget increased to 2.5 percent of the operating budget in 2005, a hefty increase from 1.4 percent two years earlier, in 2003.


Voice-enabled radiology

Lakeridge Health, a hospital group based in Oshawa, Ont., has successfully combined voice technology with radiology reporting. It has also integrated its PACS with the hospital information system.


New X-ray technology

Physicians and researchers in Montreal, working in conjunction with teams in Paris, France, have devised a new X-ray system that takes high-res, 3D images with dramatically far less radiation for patients. The system is designed for orthopedic applications.


Effective nurse-call systems

New technologies for alerting nurses, and for intra-hospital communication, have recently appeared. They’re driving the use of wireless solutions in hospitals.

Canadian Forces PACS

The Canadian Forces have implemented a Picture Archiving and Communication System that will soon allow for remote diagnoses to be completed in 60 minutes, as opposed to six weeks. The system has been implemented at bases in Canada, ships at sea and foreign locations.

PLUS news stories, analysis, and features and more.


Toronto hospitals collaborate on ambitious e-learning initiative

By Andy Shaw

TORONTO – Reading, ‘Riting, and ‘Rithmatic sure ain’t what they used to be in the healthcare setting – judging by the ‘e-learning’ initiative undertaken jointly by Mount Sinai, the University Health Network (UHN), and Sunnybrook Health Sciences Centre.

The three Toronto hospitals have been collaborating since 2004 with the aim of doing nothing less than transforming how, both individually and collectively, they certify, educate, train, retain, and recruit their staff.

In doing so, they plan to eliminate the inefficiencies of traditional instructor-based classroom teaching (while not doing away with it entirely), and to capitalize on the convenience and cost savings of self-conducted, internet-based e-learning.

So far, they have: surmounted their technical differences; jointly purchased a common yet highly adaptable learning management system (LMS) that initially can track the progress of 10,000 trainees; individually deployed a number of LMS-driven courses internally; and are readying to roll out a first training course that is common to all three.

The LMS, now a product of Mountain View, California-based SumTotal Systems, provides a common database that all three hospitals can draw on. The SumTotal platform is the foundation for creating and sharing courses not only among themselves, but eventually among a wider circle of hospitals.

“This all started as an internal UHN nursing initiative,” says Brenda Laurie-Shaw, UHN’s director of nursing informatics. “Our vice president and chief nursing executive, Mary Ferguson-Paré, had asked us to see how we could use technology to improve the education of our clinical nurses. And that need sprang out of a number of things, including SARS, where we learned how difficult it is to communicate new information quickly.

“Also, we do a lot of repetitive training for both annual certification requirements and for new hires. We’re a multi-site facility, so we recognized that even within our own hospital, we had duplication of effort by educators developing similar training courses, which were not standard across the organization.”

The appeal to UHN of applying educational technology, specifically a learning management system, is that the hospital can escape most of the costs and constraints of the physical classroom and make standardized courses available to nurses on their own time, 24 hours a day, seven days a week, from the hospital or from home.

An LMS can therefore free up clinical educators to spend more time helping their charges apply their knowledge. What’s more, it enables users to institute life-long learning practices that increase job satisfaction, thereby helping to retain hospital employees and attract new ones.

Those possibilities, of course, were not unique to UHN. When Ferguson-Paré presented UHN’s project to her chief nurse peers at other Toronto teaching hospitals, she found a lot of interest among them.

“Our joint project really began in 2004, when all the teaching hospitals in the Toronto area were invited (by the UHN) to come and discuss what we might do together, since we all have to deal with so many of the same training and courses,” says Marilyn Sanli, who is the manager of information systems at Mount Sinai. “A number of those hospitals remain interested, but in the end it was Mount Sinai, UHN, and Sunnybrook, who made the commitment after we asked ourselves: Can we share content? Can we share skills? And can we share costs?”

Saying “Yes” to all three by all three was made easier, adds Sanli, by the sheer economics of collaboration.

“Together, we were able to purchase (with some Ontario Ministry of Health help) a large volume of seats (10,000) at a far cheaper rate than we could have individually. And with every system you buy, there are implementation charges and project management charges and other one-time expenses. So we were able to split all those three ways as well.”

Most importantly, given the idiosyncrasies of each hospital, the tri-partite group also purchased authoring tools. The TrainerSoft tools enable each hospital to create e-learning courses specific to their unique needs.

“We each have a section in the database where we can store our individual content,” explains Sanli. “And we set up security such that we can each have our own say in placing restrictions on the database and defining who gets access to what.”

But it is the common ground that’s most compelling.

“Every hospital has to do the same infection control, the same occupational health, the same safety and other training courses that are basically all the same,” says Sanli. “So no one hospital has to take on the task any longer of developing something completely on their own.”

What the three hospitals have been doing on their own is not only developing internal online courses, but also adding applications that complement the shared LMS.

Sunnybrook, for example, is building Canada’s first clinical multimedia library. With the help of Sonic Foundry’s Mediasite technology, the hospital is automating the capture, retrieval, and sharing worldwide of rich-media content – ranging from videos, audio tapes, webcasts, and press conferences, to professional development tutorials – that can all be used in a wide variety of ways, including as subject matter for formal training courses.

“That was made possible from a Bell Canada research grant, and we’ve used that in partnership with Sonic Foundry to develop the library,” says Sam Marafioti, vice president of eHealth and chief technology officer at Sunnybrook. “But it does fit with what we are doing jointly with UHN and Mount Sinai in e-learning. The richer the content of our library, the better off everyone’s training and education can be. It adds value both to anywhere, anytime learning for individuals, and also it helps foster the needed communication and teamwork that sustains that learning. And here we have the library and our e-learning up and running. All we are doing now is adding content to both.”

Mount Sinai, an old hand at e-learning, knows both its advantages and its limitations. As a result, the hospital’s strategic approach to education and training is a mix of new e-learning and traditional classroom techniques.

“In fact that’s what we call our approach, ‘Blended Learning’, says Sanli. “And what that means is that we take the best of technology-based training and we take the best of classroom training and we blend them. It’s a bit like belonging to a book club. You read the book first on your own, and then you get together to discuss it, and compare with other people what you learned from it.

“So the e-learning the nurses do from an online course on wound and skin care, for example, that’s the knowledge acquiring part. But the second part, when they actually take that knowledge and start applying the know-how they’ve picked up about cleaning wounds, that’s when we get them together in a clinic or a classroom, with other nurses and with an expert instructor. Similarly, we have 500 of our physicians using the LMS to learn about clinical applications, including our computerized order entry system.”

All three hospitals are taking this blended learning approach, says Sanli, and are working on common standards along with other interested hospitals on how precisely they will share that learning.

“We have several collaborative e-learning committees that also involve the hospitals who weren’t operationally or financially ready at the time to help purchase the LMS system,” explains Sanli. “For instance, we have one committee looking at technical standards, so that physicians who work in more than one hospital can see just about the same screen, except for the different hospital logos, no matter where they go. We have another hospital that is looking at common content we can develop.” Eventually, she predicts course content and types of trainees will expand beyond its current focus on nursing interests at three hospitals. Sanli sees as many as 100 or more courses on every aspect of acute healthcare being available for healthcare workers of any stripe and in more hospitals – as the hospitals see the benefits and buy their share of seats in the SumTotal LMS.



Survey ranks top IT projects in hospitals across Canada

By Jerry Zeidenberg

TORONTO – Canadian Healthcare Technology magazine’s most recent survey of IT trends in hospitals found that technology spending is on the upswing. The average hospital IT budget increased to 2.5 percent of the operating budget in 2005, a hefty increase from 1.4 percent two years earlier, in 2003.

The survey, titled the 2005-2006 Report on IT in Canadian Hospitals: Current Capabilities and Upcoming Acquisitions, was conducted in 2005 under the leadership of research director Richard Irving, PhD, a professor of management science at the Schulich School of Business, York University, in Toronto. The results were published in 2006.

The study obtained extensive responses from 51 hospital and health-region CIOs about their plans for 26 different clinical applications and 15 administrative or ‘infrastructure’ applications.

When respondents were asked to rank the ‘Top Clinical IT Project’ currently under way in their organizations, the breakout was as follows:

2. e-Charting for Nursing Staff
3. Computerized Physician Order Entry

Similarly, we asked the CIOs and IT directors to rank their top projects on the infrastructure side. The breakdown was as follows:

1. Single Sign-on
2. Enterprise-wide Disaster Recovery Plan
3. Integration Engine

PACS: PACS was far and away the leading clinical IT project currently under development, most likely because the systems provide a rapid return on investment (ROI), both from a financial and clinical point of view.

As one radiology department chief told Canadian Healthcare Technology magazine, “PACS lead to a 15 to 25 percent increase in the efficiency of radiologists, and a 10 to 15 percent increase for technologists and administrative staff.”

Recently, several sub-themes have emerged in the PACS marketplace. First and foremost, hospitals are attempting to integrate cardiology department images in their PACS. For historical reasons, and often as a result of differing corporate cultures, cardiology and radiology departments have in the past tended to establish standalone imaging systems. It only makes sense, however, for radiologists and cardiologists to have fast access to studies from both departments.

According to the survey, the typical PACS project costs $2 million or more, takes 13 to 24 months to complete, and requires 400 to 500 person days for implementation.

Electronic charting for nurses: Since it is nurses, not doctors, who are checking on patients most often and monitoring vital signs, it’s not surprising that hospitals are making electronic charting for nurses a high priority. Once information is entered electronically in this way, it’s much easier for physicians to read and analyze as they make their rounds.

It should be noted that some vendors, such as medical device specialist Welch Allyn and communications giant Cisco Systems, are now releasing solutions that collect vital signs and automatically feed the results into electronic medical records. The systems not only ease the workload of nurses and improve the accuracy of record-keeping, but they also provide alerts for abnormal results and indicators – an advance on the patient-safety front.

CPOE: Computerized Physician Order Entry systems are designed to eliminate many sources of medical error. As such, they offer huge potential benefits. In recent years, a good deal of troubling information has emerged about the level of medical error in the healthcare system. For example:

• In 1999, the landmark U.S. study by the Institutes of Medicine, To Err is Human, estimated that 44,000 to 98,000 Americans annually die of preventable medical errors;

• In 2004, Canadian researchers Ross Baker and Peter Norton released Patient Safety and Healthcare Error in the Canadian Healthcare Sector, finding that one out of every 13 hospital patients experiences an adverse event, and that 37 percent of these are ‘preventable’. Moreover, an estimated 16,000 hospital patients die each year in Canada as a result of these mistakes. Adverse events add five to six days to the hospital of stay of patients.

Until recently, few hospitals attempted to employ a CPOE system. Early solutions tended to slow down the work of doctors – in order to process an order that formerly took a few seconds on paper, some initial systems forced physicians to complete a dozen or more screens, inputting data and waiting for responses. This took between several minutes to a half-hour – an unacceptable period of time for a busy physician. A CPOE of this sort at Cedars-Sinai Medical Center, in Los Angeles, infamously caused physicians there to revolt, resulting in the system to be scrapped in January 2003.

While the Cedars-Sinai Medical Center CPOE is often pointed to as a high-profile failure, the implementation deserves to be put into context. The system was developed in-house, and management admits the CPOE was ‘clunky and slow’. They also note that physicians were not part of the development process. Nevertheless, during its short lifespan of three months, the Cedars-Sinai CPOE generated 39,000 medication alerts, 35 percent of which led physicians to change their orders.

The median CPOE project costs $2 million plus, takes 13-24 months to complete, and requires 500+ person-days.

Single Sign-On: Single sign-on systems enable users to automatically enter various applications without logging out of one and into another. Single sign-on can be a huge boost to productivity, by dramatically reducing the time for a clinician to move from one computerized application to another. Indeed, in the past, the time and trouble to switch between computerized systems have created disincentives for doctors and nurses to use them.

The size and scope of the problem is illustrated by the number of systems that many hospitals currently have implemented. Ontario hospitals, for example, typically run different systems for ADT, lab, pharmacy, RIS, PACS, medication alerts and finance. They often tap into adjunct systems, like the Electronic Child Health Network (eCHN), the NORTH telehealth network, Cancer Care Ontario, and the Ministry of Health and Long-term Care. Said Jamie Bowie, CIO at the Credit Valley Hospital, in Mississauga, Ont.: “It is becoming more and more complex. Currently, we have about 60 interfaces to support.” For its part, Credit Valley Hospital has recently implemented a leading-edge single sign-on system that’s designed to resolve this issue.

The median single sign-on project costs between $200,000 and $400,000, and requires seven to 12 months to implement.

Enterprise-wide disaster recovery: When we asked CIOs about this problem in previous years, some said they simply didn’t have the budgets for both the applications they needed and off-site storage for back-up purposes. As a result, they went ahead with application development, and kept their fingers crossed when it came to disaster recovery.

Much more planning appears to be going on now – perhaps health regions have been chastened by the experiences of medical centres that have experienced actual disasters – such as Hurricane Katrina in the United States.

According to our survey, the median DRP project costs $50,000 to $100,000 and takes seven to 12 months to implement.

Integration engines: We’ve pointed to the multiplicity of discrete applications and computer systems operated by most hospitals – typically dozens of different systems are used.

Not only is obtaining quick access a challenge; so is interchanging data. For example, a clinician or administrator might want to update fields in a patient record from an ambulatory clinic into those of the hospital’s ADT or pharmacy system.

To do so, hospitals have been implementing integration engines – systems that copy the right data into the appropriate fields of corresponding applications.

Our survey found that the median Integration Engine project costs $600,000 to $1 million and requires 7 to 12 months to implement.

While many of the hospitals and health regions already possess a good number of clinical IT applications, many solutions are just starting to appear in the healthcare system.

As a major part of the study, we identified the information technologies that hospitals and health regions planned to acquire in the next 24 months. The top ranked systems were as follows:

• Data mining
• e-Learning
• Computerized ER
• e-Medical charting for nurses
• CardioPACS
• Computerized discharge planning
• Computerized OR charting
• Scanned charts in EPR
• Barcode tracking systems
• Computerized charting for allied health professionals
• e-Medical charting for physicians
• Computerized ICU charting
• Computerized voice recognition
• Radio-frequency Identification (RFID)

Similarly, when it comes to the adoption of infrastructure applications, the following will be acquired by many or most organizations in the next 24 months:

• Web portals
• Wireless access to patient records
• Enterprise-wide continuity plan
• Enterprise-wide disaster recovery plan
• Single sign-on
• Biometric sign-on
• Patient self-scheduling
• RFID equipment tracking

In an earlier study, CIOs told Canadian Healthcare Technology that 4 percent of the operating budget would be the amount needed to successfully implement their plans. Despite the recent surge in spending, that’s significantly more than what’s currently being invested.

According to Dr. Irving, “Canadian hospitals have been under-spending on IT for years and must now play catch-up.

“Moreover, substantial under-funding increases the risk of failure for major IT projects,” added Dr. Irving. “One way the risk of failure is increased is by extending the duration of the project to the point where the technology becomes obsolete or at best, relatively ineffective and costly.

“Another factor that increases the risk of project failure is the temptation to take shortcuts that may cut costs, but which also reduce the operational value of the project to the point where it is only marginally useful.”

Dr. Irving emphasized that it’s important to have enough funding to ensure that projects can be completed quickly, without cutting corners.

The 2005-2006 Report on IT in Canadian Hospitals: Current Capabilities and Upcoming Acquisitions, is available from Canadian Healthcare Technology. The full 74-page report, including 59 tables, costs $495.



Voice-enabled PACS makes images and reports available more quickly

By Andy Shaw

OSHAWA, ONT. – A picture archiving and communication system (PACS) at Lakeridge Health has made diagnostic imaging essentially paperless – but not voiceless.

The Lakeridge Health PACS is among the first in the country to successfully integrate a voice recognition system with what Lakeridge now calls its Enterprise Imaging Management System (EIMS).

The voice recognition component of the EIMS automatically transcribes the dictated reports of Lakeridge Health radiologists and appends them to diagnostic images that are in turn made part of the electronic health record (EHR) of the patient.

The voice-enabled EIMS links the four hospitals of Lakeridge Health, all in Durham Region, just east of Toronto. Tied together are three acute care facilities – a base hospital in Oshawa and two others in outlying Port Perry and Bowmanville – as well as a specialty care hospital in Whitby.

“It’s one of the few systems in the country that has integrated speech recognition with PACS Radiology Information System (RIS) and an EHR,” says Leon Chew, market development manager at GE Healthcare (Canada). “Others have tried, but there’s only been limited success. And it’s a particularly impressive accomplishment when you consider that the Lakeridge Health PACS is running over lines between some sites that are not high-speed.”

According to Lakeridge Health officials, not only has their voice-capable PACS been a technical triumph, it’s been a business-case winner as well. Their studies show that report turnaround times have dropped dramatically. In the case of reports connected with Emergency and In-Patient imaging, for example, the time it takes on average for them to be available has dropped from 50 hours (pre-EIMS) to 15.9 hours nowadays.

That speed improvement has translated into enhanced patient care.

“The fracture clinic is a great place to go for patient reaction,” says EIMS system administrator, William Field. “You can tell that the patient feels more involved, and is getting better care, because the orthopaedic physician can call up the image of a broken foot or ankle, show it to the patient and discuss it with them, all within five minutes of the image being taken.”

Field adds that not having to store tens of thousands of film sheets is a great cost and space saver within the hospital. Not to mention the impact on the environment outside of it.

“We no longer have to get rid of the chemicals used to produce the film,” adds Maria Hilts, EIMS manager. No more film, of course, means no more chemicals. Equally impressive are the workflow efficiencies that have been gained by radiologists. As they examine patient images on the screens of their workstations, they dictate their findings. The words they are speaking are instantly turned into text by the embedded PowerScribe voice dictation application from Dictaphone.

Once recorded and signed off by the radiologists, any authorized caregiver can view that text whenever a patient image is retrieved. “Our PACS is a terrific system,” says Dr. Jay Dahman, a Lakeridge Health pediatrician. “We can call up the radiologist reports along with the images. The images are so crystal clear and so easy to manipulate and measure. There is just no comparison with the old film and paper report system.”

It’s important to note that the system spans the entire hospital and its physicians. “We gave it that ‘Enterprise Imaging Management System ’ name because we wanted to make it clear that it meant more to the hospital than just another diagnostic imaging project,” says Lydia Antalfy, Lakeridge Health’s director of diagnostic imaging.

“We had interviewed our users and they told us they wanted to be able to go into their Meditech patient care inquiry application and not only find lab results and pharmacy results, but also to be able to click on that record and bring up the patients’ images and attached reports, too,” says Antalfy. “They didn’t want to have to enter a whole new system, nor have to remember a different password.”

A simple enough concept, but back in 2004, when the EIMS got under way at Lakeridge Health, there was no great confidence that the marketplace could deliver it. “In response to our RFP (request for proposal), most vendors told us they thought that kind of integration was possible, but they admitted they hadn’t actually done it before,” says Antalfy. “However, GE demonstrated to us, and to senior management at the hospital, that they could bring it all together; that physicians could enter the Meditech system and get all their images and reports.”

Consequently, GE Healthcare became prime contractor for the EIMS project, supplying not just the PACS system itself but pulling in Dictaphone and other suppliers. And the partners didn’t waste much time setting up the system.

“We took a modality by modality approach and moved quickly,” recalls EIMS manager Maria Hilts. “At the main Oshawa site we first went live with two imaging modalities, CT and MR. And right from the outset with those we were paperless and had speech recognition built in. Then, within the next six months, we had the rest of our modalities, save for nuclear medicine and mammography, similarly operational at each site.”

And now, the image-toting EIMS also extends off-site to Lakeridge Health physicians’ individual offices and homes.

“Most of our physicians have VPN (virtual private network) access to our EIMS via the internet,” explains Ehab Fanous, information technology (IT) systems consultant at Lakeridge Health. “After they log on to the VPN, they can securely go to the Meditech Hospital Information System. It has a link to a GE Centricity web server from which they can call up the images and the reports.”

Similarly, physicians on rounds at the hospitals can view the same data from Lakeridge health’s unique ‘COWs’ (computers on wheels) at the patient bedside.

The EIMS stores its diagnostic images and reports for immediate retrieval on an HP Storage Area Network (SAN). For long-term storage, GE gave the EIMS two-tier archiving that files one copy of each image and report to a DVD jukebox from Plasmon and another copy to a tape storage unit from StorageTek.

Antalfy says Lakeridge Health is now working on expanding EIMS’s functionality and reach: “It’s an image management system, so we can add almost any other kind of digital images to it. We’re looking in future at adding images produced by mammography, cardiology, opthalmology, or endoscopy – really any image that can be taken of a patient and added to the patient’s electronic health record.”


Innovative X-ray takes fast, whole-body images, at low dosages

By Jerry Zeidenberg

Two Montreal hospitals have installed prototypes of a new X-ray scanning machine that can produce whole-body images, with patients standing upright, in just 15 seconds.

Called EOS, and co-developed by teams in Montreal and Paris, France, the device takes high-resolution, 2D or 3D images using 8 to 10 times less radiation than standard X-ray machines and 300 to 1,000 times less than a CT scanner.

“The EOS radiograph of the whole body is very fast,” commented Dr. Jacques de Guise, professor at Montreal’s Ecole de technologie superieure and director of the Imagery and Orthopaedic Research Laboratory at the CHUM. In comparison, “if you use standard X-ray equipment and films, it could take 45 minutes to image the entire skeleton.”

Dr. de Guise, a leader of the teams that have devised the new technology, commented that today’s multi-slice CT scanners can also take very fast images, but they emit high doses of radiation. “To make 3D reconstructions from the transverse slices will require 500 to 600 images,” he said. “That’s a lot of images to store and process, and a lot of radiation is produced.”

By contrast, the EOS scanner requires just two images – one from the front, one from the side. From that information, special software is used to create the 3D images that are needed.

That being said, Dr. de Guise stressed that EOS is not meant to replace CT scanning, but is a complementary technology, especially in the orthopedic sector.

The EOS devices were installed in March at the Centre hospitalier de l’Universite de Montreal (CHUM) and the Centre hospitalier universitaire Sainte-Justine.

They will be used primarily for research purposes, but patients will benefit dramatically on the clinical front.

For example, Dr. de Guise noted that every patient requiring attention for scoliosis at the Hopital Ste. Justine, a pediatric hospital, will be enrolled in the research program using the EOS scanner.

That means children who require multiple X-rays to check their condition, plan surgery and treatment, and to conduct follow-ups, will obtain imaging with dramatically reduced levels of radiation.

“There will be 50 to 60 subjects a week,” commented Dr. de Guise. “The lower dosage is a superb benefit for them.”

Similarly, many patients at the CHUM will attain the same kind of advantage when enrolled in the various research projects surrounding the EOS scanner.

At the same time, the images produced by the scanner are expected to enable surgeons and other physicians to provide better diagnoses and treatments, due to the more detailed 3D images they will obtain.

The dual-ray EOS scanner, it should be noted, has a unique upright design, allowing patients to be scanned while standing.

This is extremely important to orthopedic specialists, as it allows them to see the effects of weight and pressure on bones and joints. As a result, they can better prepare for treatments – such as braces – and surgeries.

The EOS scanners at the two Montreal hospitals were acquired at a cost of $1.2 million. Of that, 40 percent was provided by the Canada Foundation for Innovation; 40 percent was from the government of Quebec; and the remaining 20 percent came from the partner institutions.

The systems will be commercialized by the lead French partner, Biospace, based in Paris. Dr. de Guise was unsure of how many could be sold in the years to come, but he said orthopedic surgeons and other musculoskeletal specialists who have seen the system have been impressed.

“They like it very much,” he said. In particular, they like the standing-up orientation of the images, the fast head-to-toe scanning, and the simultaneously available front and side images.

While it’s a specialized system that’s aimed at orthopedics, Dr. de Guise noted that with the aging of the general population, orthopedic issues are becoming increasingly important.

Dr. de Guise explained that two major innovations are responsible for the dramatically lowered X-ray dosage in the EOS.

First, a unique X-ray detector is used, based on cutting-edge research by French professor Georges Charpak, the 1992 Nobel Prize winner in physics and founder of Biospace.

In addition, very thin beams are used by the X-ray generators, which were designed and built in Quebec.

Dr. de Guise estimated that the software used in the device was developed equally by teams in Quebec and France – a 50-50 effort.