G.T. LaBorde, Chief Executive Officer at IllumiCare

Make Your EMR Work For You with G.T. LaBorde, Chief Executive Officer at IllumiCare

: [00:00:01] Welcome to the outcomes rocket podcast where we inspire collaborative thinking, improved outcomes, and business success with today’s most successful and inspiring healthcare leaders and influencers. And now your host, Saul Marquez

Saul Marquez: [00:00:18] Outcomes rocket listeners welcome back once again to the outcomes racket where we chat with today’s most inspiring and successful health care leaders. Today I have an outstanding guest. His name is G.T. Laborde. He’s the chief executive officer at Illumicare. At Illumicare, They focus on influencing physician orders by illuminating and really what they focus on is electronic medical record workflow. The financial and patient safety implications of access utilization. This helps physicians be better stewards of their patient safety as well as the hospital’s resources. Deity’s had a really long history in healthcare and what I’d like to do is just open up the mike to him to introduce himself on anything that I may have missed. G.T. welcome to the show. Thank you so much.

G.T. LaBorde: [00:01:06] A pleasure to be here. Yeah I’m actually a retired attorney so there were health care there and some have told me those retired attorneys are the second best kind of attorneys who can figure out everybody’s favorite kind. But anyway.

Saul Marquez: [00:01:22] Nice. I love that. We’ll catch you into the medical sector, G.T.?

G.T. LaBorde: [00:01:26] Not a friend of mine from high school actually. Who brilliant guy. And he invented a data mining techniques in the late 90s to track infections in hospitals. I was always an economics major and I always had kind of a business and entrepreneurial and sort of finance mind and knew one day that he might invent something and we would we would make a company out of it and that’s what happened so we built a company called Mad mind that tract infections in hospitals and did quite well with that and that’s where we really kind of built the team and cut our teeth on understanding healthcare and finances and the nitty gritty of healthcare data and all that good stuff.

Saul Marquez: [00:02:05] Wow that is fascinating.

Saul Marquez: [00:02:06] And you know one of the things that I find so interesting is that as a chat with the healthcare leaders in our industry the power of thinking and you sort of planted the seed back when you knew you were going to create something with your friend. And fast forward here you guys are creating different businesses together and the message there for the listeners is your thoughts are the field which you sow your future. And as we work to create better outcomes and reduce inefficiencies in health care what is it that you’re thinking and how is it that it’s playing out in your life. So appreciate you sharing that G.T.

G.T. LaBorde: [00:02:44] That you’ve had today.

G.T. LaBorde: [00:02:45] Illumicare is based on the idea of another friend of mine actually he was also a practicing physician.

G.T. LaBorde: [00:02:51] So now I find I’m the business guy that comes along and takes these great ideas but these docs who have their their hands in the middle of it and see opportunities to improve the process and try and make them reality.

Saul Marquez: [00:03:04] Really that’s a talent you know to be able to turn ideas into businesses is not easy what is it that you believe helps you do that.

G.T. LaBorde: [00:03:14] No you just need a well firstly I put all the really. They’re the ones who have come up with that with the genius idea and how we really need to change things.

G.T. LaBorde: [00:03:23] You know there are just so many little blocking and tackling kinds of skills that you need to kind of turn that into reality you have to understand how to protect that intellectual property to understand really what’s going to be possible and how you could make it easy on health systems or providers to adopt the solution that you have in mind. Just think of things from their perspective. And you know obviously the easier you can make it on them to adopt what you’re thinking about the more likely it is you’re going to be successful in selling them. You know that thing I’m in interest interest a lot of a lot of other skills accounting and recruiting and being able to find the other technologist and salespeople and all those other you know the army of other people that you need to make it successful and then the ability to raise money to fund all of that effort or just a lot of little things that you’ve got to do just right. And even if you do them all just right you might still fail. That’s the course of entrepreneurship.

Saul Marquez: [00:04:17] That’s right. That’s right. And say you’ve been around the block several times obviously successfully and so success becomes a habit in your time in this field.

Saul Marquez: [00:04:28] What would you say you know now were here and now you’re with a Illumicare what’s a big area of focus that should be on the agenda of healthcare leaders today.

G.T. LaBorde: [00:04:38] I really believe in the Illumicare is really all about making the cost of things transparent to providers. It really was amazing and we as we got into really investigating prior studies and so forth.

G.T. LaBorde: [00:04:51] The one piece of data that providers who are being asked by the way to provide quote value based care but that no one ever tells them at the time they’re making these decisions what things cost.

G.T. LaBorde: [00:05:03] If someone told us to go into a restaurant and get good value for our money and we opened up the menu and there are no prices on the menu and there are no prices on the wine list oh how exactly what are you supposed to do that.

Saul Marquez: [00:05:14] You could get out of control quickly.

G.T. LaBorde: [00:05:16] Yeah. So I mean who knows tonight by this Keano from Oregon or this you know this otherwise you know there’s not a price on any bottle item.

G.T. LaBorde: [00:05:25] I’m not sure how you’re supposed to make a value based decision. There were efforts in health care to kind of make prices transparent to consumers. But we really you know I mean and those have had mixed results and the problem is that consumers don’t really choose they don’t know enough to know really what an appropriate alternative is or what really is in their best judgment. So the experts who have that knowledge are the physicians or the providers. And so really it’s about informing them and making cost transparent to them so that they can really exercise their clinical judgment understand really what’s appropriate and what is the most efficient way of doing what needs to be done.

Saul Marquez: [00:06:04] Yeah. That’s a really great point. And to your knowledge G.T. what percentage of physicians out there are given this transparency in pricing.

G.T. LaBorde: [00:06:14] It’s a very difficult thing I think. I think that percentage is tiny. The problem with doing this. Many physicians get told sort of after the fact they have these quarterly or or periodic meetings with administrators who may tell them look you’re you tend to be a high cost provider relative to your peers on this specific argi or something like that. But that’s not very actionable. I mean you know sitting in those meetings it’s very hard for a provider to know what decision do you want me to make differently because really that’s what happens at the end of a quarter is really accumulation of a thousand little decisions right. And so the key is is to giving this cost data to people in real time as and when they’re making the decision or when making the next decision of what to do. And the challenge with that is that the clinical data that you get in real time is often dirty. It’s often unstructured. Absolutely doesn’t have unique identifiers that in any way match supply chain data. So for example you may see a clinical order for an I.V.

G.T. LaBorde: [00:07:16] medication and it’s in nearly equivalent will even the identifier of that medication in the clinical data very frequently doesn’t match the identifier of that drug in supply chain data. So you go to pharmacy and you ask how much this cost. There isn’t like one number one unique identifier that ties the two together. And by the way they don’t buy anything and a milk equivalent. It’s a unit of measure that’s an expression of a combination of a certain amount of drug and when a certain amount of failing given over a certain drip rate over a certain timeframe so you have a problem with units of measure a different you can’t even tie the two identifiers together it’s a lot of work to do this in real time. And that’s why really so few people do it or very few if any do it. It’s because it’s just it has all these inherent difficulties in doing it. So those are all the difficulties technically that you have to overcome if you want to actually achieve this kind of transparency.

Saul Marquez: [00:08:11] And how is it that Lumad care helps get around that.

G.T. LaBorde: [00:08:14] It just because even in our prior business we’ve just had about 15 or 20 years of working with real time HO7 feeds from hospitals and building systems that can both auto map things as well as systems that are very sophisticated and efficient in handling outliers and even having humans deal with the really extreme cases. All in real time so it’s a huge infrastructure that enables you to kind of keep up with this constant flow 24/7 flow of healthcare data messy. You know health care data and turn it into something that is structured and really amenable to financial and risk analysis so that you can give providers something in real time that helps them make better decisions.

Saul Marquez: [00:09:01] That’s really fascinating. It sounds like you guys embed yourselves in the infrastructure and make it possible that way. Can you give the listeners an example of how Illumicare has created results through the system.

G.T. LaBorde: [00:09:13] Absolutely. So it’s been studied in both academic settings as well as community hospitals in several of these places what we’ve done is essentially run kind of a controlled trial where you take hospitalist an internal medicine physicians and you may take two thirds of them and provide and give them this tool that by the way just appears either embedded within or hovers on top momentarily of the electronic medical record. And then if they don’t interact with it it automatically minimizes and gets out of their way.

G.T. LaBorde: [00:09:43] So a lot of the design of this party is like it’s going to be kind of workflow friendly let’s say.

Saul Marquez: [00:09:48] I was looking at some of the screen shots on your website and it looks pretty slick.

G.T. LaBorde: [00:09:52] Yeah we worked with about 145 physicians in building it. And one of them you know one of the recurring themes was we have alert fatigue. You don’t slow down the workflow. I want you to be there if I want to learn something or I want to access something I want it to be available but I don’t want to have to click something degree or something don’t slow me down. Yeah. You know don’t obstruct my workflow and so we really built that a physician’s view because of course my business partner is a practicing doc and he hates being slowed down. So that’s part of it. But yeah in both academic and community centers we run these tests where because of the nature of how it’s engineered you don’t have to give it to every physician in the hospital initially you can really pick and choose which physicians have access to it and so will give it to all two thirds of the hospitalist and two thirds of the internal medicine docs and then not give it use as controls. The other third in the same hospital and then we’ll track their spending habits so we know every order for a medication lab or radiology tests of every provider we know who the ordering provider is and we know the cost of those tests so we can kind of track historically the spending of each provider on a DRDO adjusted basis on a risk adjusted basis.

G.T. LaBorde: [00:11:02] And then there’s that spending change after they get access to this tool and then does that change in spending differ from the controls you didn’t ever have access to it.

G.T. LaBorde: [00:11:12] So it’s both the historical comparison as well as a comparison to a control group of the same type of Doc in the same hospital and in every case we’ve done that we’re finding that the providers who have access to it lower the cost of care by something like 200 to 300 dollars per admission. So when they see cost data it really causes them to be.

G.T. LaBorde: [00:11:32] Those two things that causes them to be more diligent more thoughtful and in ordering so that really kind of translates to fewer orders per patient or per patient day. And then when they see in their mind two drugs that are clinically equivalent in the situation and one is five times more expensive than the other.

G.T. LaBorde: [00:11:49] They tend to choose between the one they’re not wasteful. I mean it providers do the right thing if they have the right information.

G.T. LaBorde: [00:11:55] So the combination of those two things ultimately means that it both lowers the cost of care lowers the amount of resources being consumed on an inpatient stay which is really good for hospitals because for most of their patients they get paid some fixed fee whether it’s some 60 arrangement like an ACA or whether it’s ideology payment or whatever. I mean the vast majority they get a penny saved is a penny earned for them.

G.T. LaBorde: [00:12:20] Right it’s also good for patients because really everything that we do for every drug you know when we we give a patient 12 and 14 medications and you know we stick them 60 70 times to run a bunch of labs that may or may not be absolutely necessary. It’s not good for patients that everything that we do to them involve some risk. And so it isn’t just about making the cost transparent. But we also make those clinical risk transparent so we show providers hey here’s how much radiation exposure this patient has received and what the cancer risk of just that medical radiation exposure means to them in their lifetime. Here’s how much blood you’ve taken from the patient and phlebotomy and the risk of anemia from all those years. They’re on three antibiotics. Here’s the increased risk of them getting Sieda because of what you’re doing because of the current prescriptions they’re on now we never say therefore you should change or whatever we never tell a doctor what to do.

G.T. LaBorde: [00:13:17] But we bring to light these kind of human and economic costs and give them and allow them to make decisions without Amaan.

Saul Marquez: [00:13:24] And I think that’s super interesting. Sounds like you found a home and these three levers of medication costs lab costs and radiation.

G.T. LaBorde: [00:13:33] We settled on those because those are three items of marginal spin. So when you know many people say well we like to save hospitals money because we can reduce length of stay or something like that.

G.T. LaBorde: [00:13:44] And what you find when you’re of CFO of a hospital is it’s really hard to then look to a department budget and say OK you know we’ve reduced length essay by point two days. I can see that savings here sort of a large amorphous thing.

G.T. LaBorde: [00:13:57] And so whereas when providers are switching from the five times as expensive drug to the ones you know do the cheaper drug right. You could look at the pharmacy line item and say wow we’re spending a lot less on the very expensive drug or wow we’re you know we’re running a lot of these tests and therefore whether ordering fewer reagents or whether it’s spending less on send out to reference labs whatever it is is that cost becomes I mean you can actually point to a line item and say wow yes I can see the results of that. And these are three things that our provider controlled. You know we thought about does it make any sense to tell a provider what a you know what a gauze cost or something like. Now they can’t do anything about that but they are exercising judgments about what medications a patient gets or what labs will be ordered. I mean is the providers that control about and therefore if you’re going to put something in their workflow put something that they have control over you can help them make a better decision.

Saul Marquez: [00:14:51] I think that’s really great. And you know G.T., I’ve been in conversations with a lot of health care leaders and you’re right.

Saul Marquez: [00:14:57] I mean it’s to speak to a CFO about savings through cost avoidance like reducing length of stay or something like that. It’s not as hard cold as a line item as these. And I think it’s pretty cool. Have you’ve aligned these three physician controlled costs. And it’s an easy way to not necessarily easy but easier way to truly understand the savings that you’re giving a system. I’m floored by how affordable this looks. I mean I’m looking at the site here and per patient. It’s like 12 dollars and 50 cents.

G.T. LaBorde: [00:15:30] Right. So why is it so easy.

G.T. LaBorde: [00:15:34] Well what’s really interesting about this platform is this it can display other information. So really the displaying of cost and risk is like the first thing that we can do for health systems and what becomes fun for our customers as they adopt this and they see the huge savings and they’re paying not that much for the platform and so it’s something that they like and they were positive about. But then they start to think about well if you have this platform that can put information in front of physicians in a non-intrusive way by the way we can actually show different things to different users and different things in different environment.

G.T. LaBorde: [00:16:10] So the way that we’ve engineered this little ribbon is that it can show one thing to a case manager something different to her oncologist something different to a hospitalist something different a patient is the ECB or ambulatory versus on a particular inpatient unit.

G.T. LaBorde: [00:16:26] So hospitals have the flexibility after they’ve sort of adopted this platform to begin to leverage it in other ways. And so hospitals can then spend more to do more with it. It becomes fun for them to see you know a way of sort of using it to do lots of different things and so we’ve seen them bring in pharmaco genomic data you know at the point where we’ve seen them use it to bring in population health type things on an outpatient basis to bring in predictive analytics at the point of care. There are all these you know there’s lots of data that can help providers that isn’t in the EMR.

G.T. LaBorde: [00:16:56] So it really becomes kind of this malleable tool to do other things with as well.

Saul Marquez: [00:17:00] That’s fascinating. And I think it’s cool that he just kind of hey here’s here’s some capabilities that we’ve seen or proven now that you’ve seen how it work. It’s up to you how you want to morph this tool and Illumicare will help you get there.

G.T. LaBorde: [00:17:13] Let me just pause and give give physicians a lot of credit here.

G.T. LaBorde: [00:17:17] The biggest issue the two things that when we really started the company that seemed to be administrators biggest worry a physicians would would find it you know would they even want to know what things cost it specially because they don’t really directly make any more money if they’re making these decisions appropriately. Would they even care. And I have to say that there’s you know in every for every provider we talked to said man give me the information and I will I will do the right thing. It’s like trust me to do the right thing. And now more and more people I mean I had to you know I met with two large health systems over the last just four or five days. And both of them without prompting said this is something that our our physicians are asking for they want to know what things cost. They’re conscious about it and they would like us to provide that to them. I just want to give a shout out to you know the physicians to say they really will do the right thing if we if we give them the information that empowers them.

Saul Marquez: [00:18:11] Oh absolutely. I think that’s a great shout out G.T. and this thing is really really awesome. It wasn’t always so. Maybe maybe you can share it with the listeners setback or a mistake that you made in the process of building it and sort of what you took from that moment.

G.T. LaBorde: [00:18:28] The hardest thing about building something like this is taking the responsibility to make it work in every different environment. So here’s what I mean by that. The easiest way to build a solution is to get all this data from a hospital where the Rachel 7 or some other way and then build a Web site that people log into because you can control that environment you can control how it’s displayed what it looks like.

G.T. LaBorde: [00:18:51] You don’t have to worry about integrating with anything else. And we really kind of set out to say how can we build this in a way that is so flexible that you don’t have to integrate it with the EMR. It will work on its own and display as you change patients in the EMR.

G.T. LaBorde: [00:19:06] It will also kind of change patients it will sort of match you it will maintain contact. That’s called that to do that involves so much complexity. And there was a lot of you know it was really going to be possible can we really do this. And that took a good probably a year year and a half to figure out you know lots of ups and downs and failures of Hoddy without controlling the inputs in the environment necessarily because you want to be able to do it on top of that that can help us learn are on top of McKesson on top of all these different that it’s like all these different EMRs without having to directly integrate with them.

Saul Marquez: [00:19:36] Can you build something that flexible and boy there were a lot of there were a lot of bumps along that engineering road. You know where you’re just hoping that it flashes on the screen right. Does it until like you got to go back and fix something.

G.T. LaBorde: [00:19:46] And so that’s the hardest part is if you’re willing to take the heavy lifting so the hospital doesn’t have to do it to implement your solution then it means you have to engineer all kinds of flexibility into your solution to be able to adapt to all these crazy environments you find when you know doing business with many hospitals.

Saul Marquez: [00:20:02] So are you guys able to interface with all the different EMR systems at this point.

G.T. LaBorde: [00:20:07] When we started building this you know like the word interface is a four letter word for most hospitals because there are just so many projects that you know that kind of deep integration or you know back and forth with the EMR causes all kinds of headaches and then upgrade problems and all kinds of other stuff. And so we set out to try and build something that was EMR agnostic and required no integration. It’s like boy how do you do that and why would you do that. And the why is because we can implement faster you know like once somebody decides they want which you have. I want to validate that decision as fast as I can. So the way that you know by implementing it and beginning to show value in the people who trusted us along the way to give us the honor to work for the health system I want to be able to demonstrate results them as fast as possible. And so to do that means that you’ve got to engineer it in a way that you can really implement it without a lot of heavy lifting on the part of the hospital and that means you can use whatever age of 17 they have they don’t have to build one to your back.

G.T. LaBorde: [00:21:05] It means I don’t require integration with the EMR. I’ve already figured out how to display this on and on the screen without having to integrate anything with it. It’s all of these little things that you engineer into your solution to make it was really an eye to implementation because easier you make it on them the faster it will go for everybody and a more though they’ll appreciate you as a vendor.

Saul Marquez: [00:21:27] Yeah that’s pretty cool. It sounds like you guys sat back and you asked the question early on you know what are the main obstacles to adoption. And certainly you know one of the things that happens is the integration piece with all these EMR is the fees that are associated with it. And you guys tackle that head on. And it wasn’t the easy thing to do but it sounds like it’s really worked out as an access point for you all. So nice work on that. That’s really interesting how you guys did that.

G.T. LaBorde: [00:21:51] Appreciate we just have a soft heart. I mean I certainly do for hospital CEOs. They have a super hard job. I mean a hospital is a difficult place to run. You know there are a lot of different moving parts. A lot of complexity lost to different I.T. solutions that may or may not talk to one another that you’ve got to make play nice with everything and it’s a tough job. So you know our view is going to make us as painless as possible to the hospital IDs so that they can worry about a well for sure.

Saul Marquez: [00:22:19] So what would you say what are your most proudest medical leadership experiences that you’ve experienced to date.

G.T. LaBorde: [00:22:24] It’s just really love sitting down with the administrators customers who have trusted you the CEOs and the CIOs and the CMOs and the CMI those people who get involved in acquiring Illumicare and being able to come back to them within a month or two months or three months and go live and show them the results that their providers are having with this tool. It’s just so heartening that you validate the decision that they’ve made. You really can help them. I mean one CEO recently told the group that they’re having their best year financially and they attribute some of that just a bit of that to the solution and even said you know physicians aren’t generally positive about most IT things that we do for them. But this is one of kind of randomly overheard providers speaking positively about so.

Saul Marquez: [00:23:12] Very cool.

Saul Marquez: [00:23:13] You know it’s just the validation that you get that you know when you’re doing the right thing and you really are both providers and administrators value what you do and your solution it’s it’s awesome.

Saul Marquez: [00:23:21] Yeah that’s really great. Appreciate you sharing that. And yeah definitely sounds like the differentiated piece on this is the ease of use.

Saul Marquez: [00:23:28] So let’s go to the part of the podcast here where we build a medical leadership course together on what it takes to be successful it’s the 101 or the ABC’s of G.T. and so we are going to write out the syllabus together and it’s a lightning round there’s four questions. And after we finished that with your brief answers you’ll recommend the book to the listeners you ready.

G.T. LaBorde: [00:23:50] OK.

Saul Marquez: [00:23:50] All right. So what is the best way to improve healthcare outcomes.

G.T. LaBorde: [00:23:54] I mean obviously given my life’s work I believe that cost transparency.

Saul Marquez: [00:23:57] What is the biggest mistake or pitfall to avoid in running a business or running healthcare or healthcare.

Saul Marquez: [00:24:04] You know I would say whatever comes to your mind right now.

G.T. LaBorde: [00:24:07] May not organizing your personal life in a way that allows you to be successful at work. You know it family first obviously and it sort of God and family and get here getting that done right with you more on that one really kind of really kind of invest yourself in your life’s work because you’ve got that stuff right.

Saul Marquez: [00:24:26] I love that man. How do you stay relevant as an organization. Despite constant change.

G.T. LaBorde: [00:24:30] You have to constantly change too.

G.T. LaBorde: [00:24:36] I mean I wake up every day trying to do today better than I did yesterday and try to improve what we do over what we did yesterday.

Saul Marquez: [00:24:42] Love it. What is one area of focus that should drive all else in your organization.

G.T. LaBorde: [00:24:48] Just the customer experience. If you are bringing value to the provider making decisions and empowering them to make better decisions for patients and for resource allocation everything else will take care of itself.

Saul Marquez: [00:25:01] Awesome. And what would you say that book that you recommend for our listeners.

G.T. LaBorde: [00:25:05] It’s an oldie but still a goodie. I think it’s crossing the chasm recently re read it and I think you have to understand that and maybe the Gartner hype cycle you sort of have to understand the technology adaption life cycle.

G.T. LaBorde: [00:25:18] And if you’re building a solution or have some new innovation understand where you are in the adoption of that and that will in many cases drive the way you communicate about it how you have to influence its adoption price and I mean there’s just so many implications about introducing new innovation that it’s important to understand the technology adoption life cycle.

Saul Marquez: [00:25:42] That’s pretty cool. I’ve never read that and that’s Jeffrey Moore right. I think that’s right. Yeah. I just pulled it up. Looks pretty cool. Outcomes rocket listeners make marketing and selling high tech products to mainstream consumers. This is one that I’ll definitely add to my list. Appreciate you sharing.

Saul Marquez: [00:25:57] And to the listeners all of the things that we’ve discussed here with G.T. you’ll be able to find it on our Web site. If you go to www.outcomesrocket.com/GT. You’ll be able to find the show notes and also links to any of the things that we’ve discussed including this book and also Illumicare and all the services that they provide. And so before we conclude, G.T., another time just flies I really just enjoyed our time together. I’d like to just open up the mic to you one more time seek and share a closing thought.

Saul Marquez: [00:26:29] And then the best place where the listeners can get a hold of you.

G.T. LaBorde: [00:26:32] Closing thought I guess would be that you know health care is complicated it’s dynamic it’s super tough to run a health care organization. I get that I mean you know your reimbursement changes every year it’s in and then it’s you know every 10 years it’s radically different in the make up of insurance and government reimbursement and so forth. It’s incredibly difficult. And then there’s all kinds of innovation that happens in actual care and medicines and procedures and things like that.

G.T. LaBorde: [00:27:00] So it’s it’s an amazingly dynamic field but I don’t think that should discourage us from from trying to you know make it more efficient from trying to put our own stamp and our own influence on it and so I’m just excited to play just a little part in that effort and enjoy really working with some of the best healthcare systems in the country to figure out how we can help them become more efficient.

Saul Marquez: [00:27:22] And what would you say the best place for the listeners to reach you.

G.T. LaBorde: [00:27:24] Yeah our website has contact us information and that’s the best way to get through to me.

Saul Marquez: [00:27:29] Hey we’ll really appreciate you spending the time here. I know you’re pouring your heart and soul into this work that you’re up to.

Saul Marquez: [00:27:36] And for the listeners if something that that G.T. said struck a chord with you. Take a look at the website. Check out what they’re up to. It really looks like a fantastic platform to help reduce inefficiencies and really do a better job for our patients and also our providers. And so just want to thank you again G.T., for spending some of those up to connect with you soon.

G.T. LaBorde: [00:27:57] Thank you.

: [00:28:01] Thanks for listening to the Outcomes Rocket podcast.

: [00:28:05] Be sure to visit us on the web at www.outcomesrocket.health for the show notes, resources, inspiration and so much more.