Life Sciences Role in Delivering Value-based Care

Demonstrate Value

"Demonstrate value" is a familiar request for anyone working in the life sciences industry. Historically new treatments have been evaluated in terms of how safe and efficacious they are compared to the standard of care. With the many changes in the healthcare industry, and expedited through healthcare reform efforts, there is a focus on enhancing patient outcomes and decreasing healthcare costs. The industry is struggling to provide adequate solutions.

A recent study by the management consulting firm Oliver Wyman surveyed 200 physicians in value-based delivery models such as accountable care organizations (ACOs). The goal of the study is to understand physician attitudes toward the role life sciences companies have in helping value-based healthcare providers deliver better care at a lower cost. The results found that…

• 61% of respondents said they agreed or strongly agreed that there is a role for branded drug therapies in reducing the overall cost of patient care when used appropriately
• Only 37% agreed or strongly agreed with the statement, “Pharmaceutical companies have the capabilities to reduce the total cost of care and improve patient outcomes.”

Life sciences companies are struggling to understand their role and how to enhance patient outcomes and reduce costs.

Telehealth solutions are customized based on the patient’s health condition to gather patient vital signs and health symptom interview data. This information can be used to demonstrate the value a treatment has on patient outcomes and in reducing healthcare costs. We recently published a white paper on telehealth solutions, and the benefits life science companies can expect from telehealth solutions.

Download the white paper

As a part of the Oliver Wyman study senior executives from ACOs were interviewed. There was a quote from a former CEO of a Medicare Advantage ACO and he said, “Drugs can cost more, but they have to prove real value to the patient in order for payers to agree to pay more.”

Now is the time to act—bold thinking and brave leadership is needed. The need to demonstrate value is not going to fade away, rather it will intensify. Additionally, there are many tools and solutions available to provide payers and healthcare providers with evidence that a treatment positively impacts patient outcomes and decreases healthcare costs.

Insights into Slowdown in Healthcare Spending

I have an insatiable personal and professional interest in the transformation of healthcare delivery and its impact on our economy and citizens. At the heart of the Affordable Care Act (ACA) are payment reforms that will drive a transformation in how healthcare is delivered. Additionally, rising healthcare costs have immediate effects on the economy as they take a larger proportion of workers’ wages. Recently, economists estimated that growth in healthcare costs would slow due to the recession and the slow recovery. However, healthcare costs have slowed more than estimated raising questions as to the reasons why.

The Kaiser Family Foundation conducted a study to understand how the recession contributed to the slowdown in healthcare spending, and what other factors contributed to the slowdown as well. The study found…

• 77% of the cost slowdown is due to the recession 
• The remaining nearly 23% is due to…
• Continuing changes in the way healthcare is delivered
• Rising levels of patient cost-sharing in private insurance plans that discourage patients from using healthcare services

To further understand the changes in the way healthcare is delivered, Annie Lowrey, of The New York Times published an interview with Drew Altman, president of the Kaiser Family Foundation. Mr. Altman described the nearly 25% reduction in healthcare spending as “the whole ballgame” in holding down costs in the future. He went on to say, “It’s more than just ACA reforms, it’s just the beginning. But in the long run, those are the most important ones, because they have the force of Medicare and national policy behind them.” That’s a powerful and insightful statement, and one I think most early innovators in transforming healthcare delivery share.

As the Kaiser Family Foundation study point out, changes in healthcare delivery are contributing to the decrease in healthcare spending. Accountable care organizations (ACOs) have been forming rapidly and I’m very interested in insights into how they are performing. On Tuesday, April 23, The New York Times published an article on how Advocate Health Care, based in Oak Brook, Illinois, has established an ACO with Blue Cross and Blue Shield of Illinois. The article provides an overview of how they are taking steps to control costs and improve quality.

Under the agreement, Advocate Health Care has seen…

• Hospital admissions drop by 6%
• Days spent in the hospital are down 9%
• The average length of stay has declined, and many other measures show they are providing less care

I hope you find these resources helpful and insightful. I’d love to hear your thoughts on the Kaiser Family Foundation study and articles on Advocate Health Care’s ACO. Please share other resources you’ve run across on transforming healthcare delivery.

Why Now?

Carolyn Buck Luce Shares Thoughts on the Future of Telehealthcare

Carolyn Buck Luce

Carolyn Buck Luce, Managing Director at Imaginal Labs, shared her thoughts on the future of telehealthcare in a recent blog post. Carolyn presented at the Telehealthcare Leaders Forum, held April 17 and 18, 2013, in Newport, Rhode Island, and shared insights on how innovation can address dramatic changes in the healthcare system.

Carolyn’s blog post is insightful and reminds us that disruptive innovations are driven by unmet needs. Several key themes resonated for me as I read Carolyn’s blog post…

• Now is the time to act
•  Healthcare reform efforts by Medicare and Medicaid are fueling changes in how healthcare is delivered and emphasizing the need to improve patient outcomes and decrease costs
• Patients want a more active role in managing their health
• Healthcare providers and payers are incentivized to deliver better care and decrease costs
• Now is the time to innovate
• New technologies and tools are available to deliver health care more efficiently and less expensively
• New business models and strategies are being considered—players across the healthcare industry from providers, health systems, payers, home care agencies, and life sciences companies recognize the need to do business differently and put patients and their outcomes at the center of their business

I’d love to hear your thoughts on Carolyn’s post. Specifically, how are you and your organization using disruptive innovations and technology to enhance patient outcomes and decrease costs?

New Products: Tunstall Vi, Cellular PERS, Tunstall iVi Fall Detection Pendant

New Telehealthcare Products

Tunstall Americas released three new products that improve patient care and enhance outcomes. "These exciting products underscore the value of our telehealthcare specialization and our commitment to innovation," said Brad Waugh, President and CEO, Tunstall Americas. "Capabilities like the Tunstall Vi's second button that support non-emergency services and enhance patient care is a great example of the power of our Integrated Engagement Platform."

These solutions expand on Tunstall's proven telecare/PERS systems, and will be on display at the American Telemedicine Association meeting in Austin, Texas, May 5-7, 2013.

• Tunstall Vi telecare/PERS unit is sleek in design with an attractive non-clinical look and features a 2^nd button that can be customized for non-emergency needs such as nurse triage, medication refills, or appointments. The base console supports push-button and intelligent fall detection pendants. It is compatible with land line, cable, and VoIP phone services and is FDA listed and UL approved. 
  
• Tunstall CEL450, home based cellular PERS, brings safety into homes without traditional telephone or internet phone service. This FDA listed, UL approved system provides families with more choices in home health monitoring solutions.
  
• Tunstall iVi Fall Detection Pendant automatically detects falls. The monitoring center is alerted when a fall is detected. Receiving assistance quickly after a fall ensures better outcomes for patients. The iVi Fall Detection Pendant is compatible with the Tunstall Vi and CEL450 units.

These exciting additions to Tunstall's Integrated Engagement Platform improve care management, decrease costs, and help provide better outcomes. "Tunstall is unique in our depth of experience and dedication to remote patient monitoring, particularly Personal Emergency Response," said Kevin Doyle, Telecare/PERS Solutions Manager. "Since we design and manufacture our own equipment and have over 30 years' experience in emergency contact center services, healthcare entities increasingly view Tunstall as the best long-term partner."

Harnessing the Power of Patients

Transformative changes are happening in the life sciences industry, and companies cannot afford to continue to function as developers, marketers, and manufacturers of treatments. Rather, life sciences companies must become a critical partner in the delivery of healthcare.

Becoming a partner in the delivery of healthcare is a significant change, and in order to succeed new business models are needed. Life sciences companies must shift their focus to putting patients, and not healthcare providers, at the center of their strategy. Intuitively we know we must engage patients as they take a more active role in managing their health, but this is new territory for most life sciences companies. In a highly regulated industry we like to learn from the experiences of others, and early adopters of this approach are at a point where they can share outcomes and insights.

Recently Quintiles published a white paper titled “Harnessing the Power of the Digital Patient”. The report shares their approach focused on digital channels to engage and recruit patients for clinical trials. The report shares results from the Quintiles digital patient experiences beginning with the creation of Mediguard.org in 2007, ClinicalResearch.com in 2009, and more than 350 patient programs developed on behalf of their clients.

What resonated with me was that the core of the Quintiles digital methodology is building trusted relationships with patients and providing opportunities for patients to engage in managing their own health. Aren’t these the keys to success with any life sciences program whether it contains digital channels, print materials, telephone interactions, or face-to-face meetings?

The Quintiles digital programs resulted in streamlined product development, proven product value, and accelerating product adoption and adherence, specifically…

• Informing study protocol design by connecting with patients on-line to understand positives and limitations of individual protocols
• Supplementing investigator recruitment by leveraging the reach (ie, it’s global) and specificity (ie, the ability to tightly target the desired patient population) of the internet
• Driving study retention by cultivating long-term patient relationships
• Accelerating product adoption once the product receives regulatory approval by converting study participants into early adopters and leveraging them as product advocates
• Supporting market access by leveraging patient reported outcomes from clinical trials
• Helping patients maintain therapy by understanding patient motivation, providing value-based services, and enabling communication and learning

While these are specific results seen with digital programs, I think similar results can be expected with programs focused on building relationships with patients and empowering them to manage their own health. Many new technologies are available to achieve these goals. Patients need options so they can select tools that meet their needs and preferences from on-line communities and educational websites, to telehealth solutions that monitor patient vital signs and symptoms in their own homes, and nurse educator programs that provide 24/7 assistance to answer patient questions.

Ultimately, the most successful programs are designed around patient needs and use multiple channels for convenient and efficient opportunities to engage patient’s based on their preferences.

I’d like to hear your thoughts on how you are engaging patients and empowering them to manage their health. Have you, or your company, used innovative technologies? If so, please share your insights and experiences.

David Lee Scher, MD, Shares Thoughts on Remote Patient Monitoring and Value-Based Healthcare

Remote patient monitoring is on the rise

David Lee Scher, MD, is a pioneer adopter of remote patient monitoring (RPM) technology more than 13 years ago, and has become an astute observer and expert on barriers to the adoption of RPM and other digital technologies. He recently posted on his blog, The Digital Health Corner, an interesting blog on how remote patient monitoring will lead to value-based healthcare.

The post provides insights into how newer payment models, such as Medicare payment penalties and bundled payments that are a part of the Affordable Care Act are “…creating an economic environment which is conducive to the widespread use of remote patient monitoring for recently discharged hospital patients and those with chronic diseases, says Dr. Scher.” In the post, Dr. Scher talks about why RPM is a practical solution, why it needs to be utilized now, and where it fits into existing strategies.

I’d love to hear your thoughts on Dr. Scher’s post. Specifically, what challenges do you see in adopting remote patient monitoring.

Dr. Scher participated in a panel discussion at the recent Telehealthcare Leaders Forum. As a part of the panel, he and his colleagues shared insights on overcoming clinical, financial, and marketplace barriers to speed the adoption of telehealthcare solutions and technologies, which include remote patient monitoring technologies.

Telehealthcare Leaders Forum: Rapid Fire Panel

The inaugural Telehealthcare Leaders Forum includes a panel of healthcare innovation experts representing the broad span of the healthcare industry including a healthcare provider, an expert in bringing novel technology and products to market, and an expert in new business models for the life sciences and pharmaceutical segment of the industry. In this Interactive and quick-paced Q&A session, these experts will share their insights and answer audience questions about implementing novel technologies and business models in their organizations.

On Thursday, April 18, Andy Principe, President Starling Advisors, will moderate a panel comprised of...

Lyle Berkowitz, MD, the Associate Chief Medical Officer of Innovation at Northwestern Memorial Hospital in Chicago, Illinois. In this role, Dr. Berkowitz is responsible for finding, creating, piloting, and spreading innovative technologies, processes, and business models that increase value for the organization. Dr. Berkowitz is an active speaker and author on topics such as EHRs, HIT usability, physician adoption strategies, and primary care innovation.

Suneel Ratan is the Principal of Care Architecture and a senior advisor to the Center for Technology and Aging, where he has been focusing on the application of internet-based technologies to improve the lives, health, and wellbeing of older adults and the disabled.

Ceci Zak was most recently the Vice President of Commercial Capabilities at sanofi. In this role, Ceci oversaw a think tank and learning lab for novel business solutions, the digital center of excellence, and commercial training. Prior to this role, Ceci held numerous roles in marketing and sales within the industry.

Andy Principe is President of Starling Advisors, a firm focused on partnering nationally with safety net organizations that envision a broader and more impactful role as health reform is implemented.

White Paper Available! Telehealth Solutions Enhance Health Outcomes and Reduce Healthcare Costs

White paper: Can we enhance health outcomes with telehealth?

There is intense pressure for the life sciences industry to demonstrate that treatments enhance health outcomes and decrease healthcare costs. Life science companies need tools to track patient outcomes, and gather data that demonstrates the impact a treatment has on health outcomes.

Telehealth solutions can be customized to gather patient vital signs and interview data based on the patient’s health condition. This information can be used in many ways to enhance health outcomes and reduce costs.

This white paper provides an overview of what telehealth is, factors driving the healthcare industry to focus on increasing outcomes and reducing costs, how telehealth solutions can enhance health outcomes and reduce costs, benefits life science companies can expect from telehealth solutions, as well as share results from two key studies of telehealth solutions.

If you’d like a copy of the white paper titled “Telehealth Solutions Enhance Health Outcomes and Reduce Healthcare Costs”, please click to request it. I’d love to hear what you think of this latest white paper—is it helpful or not? Also, please share with me areas you’d like to see more information and recommendations on.

Telehealthcare Leaders Forum: Telehealthcare Business Models Panel

The inaugural Telehealthcare Leaders Forum includes a panel of experts that have successfully launched telehealthcare programs. Panelists will share insights on overcoming clinical, financial, and marketplace barriers to speed the adoption of telehealthcare solutions and technologies. Best practices for successfully implementing telehealthcare solutions will be shared.

On Wednesday, April 17, Andy Principe, President Starling Advisors, will moderate a panel comprised of...

Steve Guttormson directs marketing, public relations and business development activities for PioneerCare, a non-profit organization providing a diverse spectrum of services including 24-hour skilled nursing care, assisted living, memory care, adult day services, and independent apartment living for older adults.

Michele Lowe is the Executive Director of Northwood in the Community, a division of the Northwood Group of Companies, the largest continuing care organization (ie, community support, homecare, and long term care) in Atlantic Canada.

Suneel Ratan is the Principal of Care Architecture and a senior advisor to the Center for Technology and Aging, where he has been focusing on the application of internet-based technologies to improve the lives, health, and wellbeing of older adults and the disabled.

David Lee Scher, MD, is the Director of DLS Healthcare Consulting, LLC, which advises digital health technology companies, their strategic partners, investors and their clients. As a pioneer adopter of remote patient monitoring (RPM) technology more than 13 years ago, Scher became an astute observer and expert on clinical, financial, and marketplace barriers to the adoption of RPM and other digital technologies.

Linda Wick, RN, CNP, is a Nurse Practitioner who manages the Essentia Health Heart Failure program. The Essentia Heart Failure program is a nationally recognized program for their long standing outcomes that meet the triple aim of low cost, high patient satisfaction, and quality outcomes.

Andy Principe is President of Starling Advisors, a firm focused on partnering nationally with safety net organizations that envision a broader and more impactful role as health reform is implemented.

Tunstall Americas Grand Opening Event for New Data and Operations Center in Pawtucket, Rhode Island

Pawtucket, RI - Data and Operations Center location

Tunstall Americas, a leader in independent living technologies and 24/7 healthcare communication services, will host a grand opening on Tuesday, April 16 at 4:30pm at their new data and operations center at 100 Freight Street in Pawtucket, Rhode Island.

The opening marks an important milestone in the growth of Rhode Island's healthcare technology business sector, and the result of close cooperation between Tunstall Americas, the City of Pawtucket, and the State of Rhode Island. Multiple state and city agencies and departments have collaborated to make this relocation a reality.

Full Article

David Lee Scher, MD, to Speak About Speeding Adoption of Telehealth Solutions

David Lee Scher, MD, will participate in the TelehealthcareLeaders Forum on April 17, 2013. Dr. Scher will take part in a panel discussion with experts that have successfully implemented telehealthcare programs. The panel will share insights on overcoming clinical, financial, and marketplace barriers to speed the adoption of telehealthcare solutions and technologies. Best practices for successfully implementing telehealthcare solutions will be shared.

For more information, including a complete agenda, for the Telehealthcare Leaders Forum visit www.tunstallamac.com/TLF. 

Full story

Keynote Speaker for Telehealthcare Leaders Forum - Carolyn Buck Luce

Carolyn Buck Luce will be presenting a keynote address at the Telehealthcare Leaders Forum on Wednesday, April 17th at 10am ET.

Reframing Innovation: Addressing Changes Reshaping the Healthcare System

Carolyn Buck Luce was the Ernst & Young Global Life Sciences Market Leader responsible for serving global life sciences companies with assurance, advisory, tax, and transaction solutions. In that capacity, Carolyn was responsible for E&Y’s strategy, thought leadership, resourcing, learning, and solution development to best serve clients in the Life Sciences Industry. She has served in various capacities on internal management committees at E&Y and is a frequent speaker at industry events. Carolyn is currently an Adjunct Professor at Columbia School of International and Public Affairs, teaching Management and Gender. Carolyn also has authored Harvard Business Review publications and frequently speaks at events on the topic of women’s leadership and empowerment.

For more information, including a complete agenda, for the Telehealthcare Leaders Forum visit http://www.tunstallamac.com/TLF.

Keynote Speaker for Telehealthcare Leaders Forum - Jason Hwang, MD, MBA

Jason Hwang, MD, MBA, will be presenting a keynote address at the Telehealthcare Leaders Forum on Wednesday, April 17th at 11:30am ET.

Promise of Healthcare Innovations and Disruptive Solutions for Healthcare
 
Jason Hwang, MD, MBA, is an internal medicine physician who, together with Professor Clayton M. Christensen of Harvard Business School, and the late Jerome H. Grossman of Harvard Kennedy School of Government, co-authored “The Innovator’s Prescription: A Disruptive Solution for Health Care”. Dr. Hwang previously co-founded and was the Executive Director of Healthcare at Innosight Institute, a non-profit social innovation think tank. He taught as Chief Resident and Clinical Instructor at the University of California, Irvine. He also served as clinician with the Southern California Kaiser Permanente Medical Group and the Department of Veterans Affairs Medical Center in Long Beach, California.

For more information, including a complete agenda, for the Telehealthcare Leaders Forum visit http://www.tunstallamac.com/TLF.

Powerhouse Pharma Panel to Address How Innovation May Enhance Patient Outcomes at the Telehealthcare Leaders Forum

Telehealthcare Innovation Panel Announced

The inaugural Telehealthcare Leaders Forum includes a panel of life science industry leaders that will share their views on new technologies such as telehealth, telecare/PERS, and mhealth, and how these technologies help the industry enhance patient outcomes, manage chronic conditions, improve patient adherence, demonstrate treatment value, and enable data sharing.

Comprehensive Event Info

Register Online or by phone (877) 354-6111

On Wednesday, April 17, Carolyn Buck Luce, retired Market Leader from Ernst & Young, will moderate a panel comprised of...

Lisa Callender oversees strategy and operations for contact centers at Bristol-Myers Squibb. Lisa has extensive expertise in consumer and business marketing operations and strategies including consumer insight and satisfaction.

Lynn O'Connor Vos is Chief Executive Officer and President of Grey Healthcare Group. Lynn is leading efforts to use digital capabilities to transform healthcare marketing to impact outcomes and achieve improvement. She developed text4baby, the country's number one mobile health program.

Vera Rulon is Director, External Medical Communications at Pfizer Medical. Vera managed the Clinical Informatics team at Oxford Health Plans, where she supported building a Special Management Company that created an episode of care reimbursement strategy.

Ceci Zak is the Vice President of Commercial Capabilities at Sanofi. In this role, Ceci oversees a think tank and learning lab for novel business solutions, the digital center of excellence, and commercial training. Prior to this role, Ceci held numerous roles in marketing and sales within the industry.

Assoc. Chief Medical Officer of Innovation at Northwestern Memorial to Speak About Healthcare Innovation

Dr. Lyle Berkowitz

Lyle Berkowitz, MD, will speak at the Telehealthcare Leaders Forum, Thursday, April 18, 2013. Dr. Berkowitz will share his learnings on how more than 15 organizations across the nation have been innovative in their use of healthcare information technologies, from new ways to use EMRs and telemedicine, to the use of analytics, mobile, and gaming techniques in healthcare. Dr. Berkowitz will share real world stories of how these organizations started, how they succeeded, and the lessons they learned along the way.

Full Story

The Telehealthcare Leaders Forum is scheduled for April 16^th to 18^th in Newport, Rhode Island, and includes healthcare industry stakeholders and experts, and government officials. For more information on the event, e-mail TLF@TunstallAMAC.com, call 1-877-354-6111, or visit www.tunstallamac.com/TLF.

Tunstall Announces Telelehealthcare Leaders Forum

Tunstall Americas announces the inaugural Telehealthcare Leaders Forum, an educational and informational event for healthcare organizations, payers, pharmaceutical companies and key leaders throughout the healthcare industry.

Full Story & Agenda

The Telehealthcare Leaders Forum is scheduled for April 16^th to 18^th in Newport, Rhode Island, and includes healthcare industry stakeholders and experts, and government officials. For more information on the event, e-mail TLF@TunstallAMAC.com, call 1-877-354-6111, or visit www.tunstallamac.com/TLF.

Preparing for the Future: Trends that are Re-Shaping the Industry

The Future of Pharma

PwC report: From Vision to Decision: Pharma 2020

PwC recently published its latest report on the future of the pharmaceutical industry, titled “From Vision to Decision: Pharma 2020”. Since 2007 PwC has been studying the challenges and major trends the pharmaceutical industry faces. The report provides an in-depth look at the future for the industry, and below I’ve highlighted five major trends from the PwC report that are reshaping the marketplace.

1. Instances of chronic disease are increasing, placing even greater pressure on already stretched healthcare budgets.

75% of healthcare expenditures are related to chronic disease, according to the Centers for Disease Control and Prevention. In 2010, healthcare expenditures in the US neared $2.6 trillion, and accounted for 17.9% of the US gross domestic product (according to the Centers for Medicare and Medicaid Services). New ideas and tools are needed to help us decrease healthcare costs, while increasing the effectiveness of our healthcare system.

Life sciences companies can contribute solutions in the form of disease management and patient adherence programs. Industry experts agree that one way to decrease future healthcare costs is to boost patient engagement in managing their conditions and increase patient adherence rates.

2. Healthcare policy-makers and payers are increasingly mandating what doctors can prescribe.

One part of the puzzle for decreasing our healthcare costs is to standardize treatment approaches. There are many ways that treatment approaches can be standardized, and they most likely will include following recommended treatment guidelines, product-specific outcomes data, and pricing negotiations with manufacturers.

Life science companies need to be prepared for this shift. Know how your product compares to its competitors. Offer programs that enhance patient outcomes. This demonstrates partnership and that the company stands behind the products they offer.

3. A growing number of healthcare payers are measuring the pharmacoeconomic performance of different medicines.

Widespread use of electronic medical records will give them the data they need to insist on outcomes-based pricing. This is a game-changer for manufacturers, as they will have less power to set prices for their products. New digital tools will provide new options for managing disease and wellness; as well as provide the ability to capture outcomes data at the practice, institution, and health system level.

4. Boundaries between different forms of healthcare are blurring as clinical advances render previously fatal diseases chronic and the self-medication sector expands.

The entire healthcare industry is being transformed. Various factors are converging to change how healthcare is delivered. The center of this transformation is the patient, which when engaged and empowered to manage their health is a critical success factor. Digital health tools and new scientific understanding, which translates into novel and innovative treatments, enable these transformations.

Think about patients at the heart of your program. Understand patient challenges in managing their health and condition. Additionally, expand your view to encompass the entire healthcare system. Understanding shifts in healthcare delivery models, new digital tools and applications, and how patients are using these to manage their condition will help you to develop programs that provide value.

5. Governments are beginning to focus on prevention rather than treatment.

No longer is the focus on treating a condition. Significant advances have been made in screening and diagnostic testing for various cancers. Additionally, there is evidence to support that many chronic conditions are exacerbated, and in some cases caused by, poor lifestyle choices and decisions. Payers are looking to prevention and wellness initiatives as mechanisms for decreasing future healthcare costs.

Life sciences companies can contribute solutions in the form of disease management and wellness programs. These programs boost patient engagement in managing their conditions, and ultimately lead to decreased healthcare spending in the future.

These trends compound the challenges the industry already faces. There are many opportunities if the industry can look beyond their traditional role of providing new medicines. Life science companies that shift their focus to patients and providing innovative healthcare solutions will be successful in the year 2020.

I want to hear your thoughts. Do you agree that the trends highlighted are re-shaping the healthcare industry? What are you and your company doing to prepare for these shifts? Are there trends that you’d include on this list? This is an important discussion, so please share your thoughts.