Tuesday, November 12, 2019

In the World of Clinical Dentistry - Knowledge Is Power

 


I'm not sure who came up with the expression "Knowledge is Power" but whoever thought of it was a genius. Those three simple words are true in many different ways. By bringing knowledge into the equation, we become much more powerful in ways we never considered.
Research and development in a myriad of subjects is rapidly increasing the “bottom line” of our knowledge base. Now that we have computers and machine learning, the curve continues to accelerate.

According to Industry Tap Into News, Buckminster Fuller created the Knowledge Doubling Curve. He noticed that until 1900, human knowledge doubled approximately every century. By the end of World War II, knowledge was doubling every 25 years. Today things are not as simple, as different types of knowledge have different rates of growth.

For example, nanotechnology knowledge is doubling every two years and clinical knowledge every 18 months. But on average, human knowledge is doubling every 13 months. According to IBM, the build out of the “internet of things” will lead to the doubling of knowledge every 12 hours. Now, this may seem daunting at first, but if you think about it, having access to all of that knowledge can open doors and let us do things we would never have dreamed of.

In the beginning

It used to be that the general practice was sort of a “clearing house” of sorts for procedures. The GP performed basic restorative procedures and simple procedures such as basic extractions and easy one-canal endodontics. Anything more complicated ended up in the hands of one of the local specialists.
Back then, fluoride was not yet in all the places and substances it is now. Restorative needs of the patients was the “bread and butter” of most general practices. Doctors were so busy restoring large carious lesions they didn’t have the time to learn and implement other procedures into their practices. If the patient’s teeth were misaligned, a referral to the local orthodontist. Impacted third molars? A referral to a local oral surgeon.

As time passed, fluoride began to work its magic and the scope of the general practice began to change. Restorative procedures changed from amalgam and “bombed out teeth” to slot preps and conservative composite procedures, and doctors began to look at ways to expand their services.
The rapid proliferation of internet connections in the late 1990s allowed doctors to connect with other doctors as well as digital databases of research that previously were only available to university or government-based researchers.

This allowed “in the trenches” practitioners to gain access to tremendous amounts of data and leading-edge techniques which allowed them to operate more efficiently and with more predictability. Now a doctor could learn a new technique while eating breakfast and perform the procedure twice before lunch that same day.

This created a feedback loop that greatly changed the way we practice. Whether an online database, an email chain from friends, or one of many other sources of information, the knowledge base of clinical dentistry expanded rapidly.

Sharing
As all of this knowledge expanded, the ability of the general practitioner to treat complicated cases also expanded. Because this expansion of knowledge was stored in a digital format, the ability to share and access that data became a simple matter of “point, click, learn.”

In truth, the doctor had the ability to not only learn, but to then provide immediate feedback to others. This allowed other doctors and educators to quickly evaluate and change procedures so everyone who was “in the loop” could quickly change protocols for the better.

As the operatory computer became the hub of the clinical technology wheel, doctors used their digital integrations to rapidly and reliably share clinical information. Procedures with complications could be tracked and solutions could be advised and attempted in practically real time. Sharing photographs, radiographs and clinical notes with others allowed for the rapid dissemination of clinical information.

For the full article, head on over to the Dental Products Report website.

Monday, November 11, 2019

Sleep and Pregnancy in the United States

 


I find it fascinating how citizens in the United States take for granted the amazing aspects of the statistics in our healthcare system.  We simply don’t even think about things like survival rates for procedures  or how predictable amazingly difficult procedures have become.  Recently a friend of mine had a hip replacement procedure performed.  Ten to fifteen years ago, this surgery would have required a hospital stay of a week or longer.  My friend also would have been flat on their back for several days before the staff even considered getting the patient mobile.  

Now by friend was gently gotten to his feet hours after the surgery.  Add onto that the fact that the surgery was done at 06:00 and my friend was released to go home that afternoon.  You read that right.  A weight bearing joint relationship surgery is now considered outpatient surgery!!!

So what does joint replacement surgery have to do with sleep and pregnancy?  Well just like outpatient hip replacement, we tend to take for granted how simple pregnancy and delivery can be.  

As I have become more and more interested in sleep and the affects it has on myriad aspects of our health, I’ve come across some pretty incredible statistics dealing with sleep and fertility.

Here are just a few of the things that have been noted regarding the differences in sleep between females and males:

Examples of sex and gender differences in sleep
A. Epidemiology of normal sleep in general population
 1. Sleep latency is longer in women than men;2
 2. Women <55 years report more sleepiness than men;2
 3. Older women report 20 minutes less sleep than men;2
 4. Women have more (106%) SWS and less NREM stage 1 sleep than men;3
 5. Men have more NREM stage 1 and stage 2 sleep than women;3
 6. Normalized delta activity in older women is lower than in older men.4
B. Normal sleep in animal models
 1. Female mice spend more time awake and less time in NREM than male mice;5
 2. Female rats show ∼50% decrease in REM sleep compared with male rats;6
 3. Slow wave activity during recovery dissipates more quickly in gonadectomized male rats compared female rats;5
 4. Restraint stress produces increase in REM sleep which is greater in male mice than females;7
 5. Sex-steroid modulation is greater in females than in male rats;6
 6. Young male fruit flies have bimodal (middle of the day and night) sleep and young female flies sleep mostly at night.8
C. Epidemiology of sleep disorders
 1. Women are at 40% increased risk for developing insomnia compared with men;9
 2. Women are at twice the risk for RLS compared with men;10
 3. Women with RLS are at higher risk for comorbid problems compared with men;11
 4. Antidepressant use is more strongly associated with RLS in men than in women;12
 5. Men are at twice the risk for OSA than women;13
 6. REM sleep disordered breathing is more prevalent in women and men (<55 years);14
 7. Depression is more strongly associated with apnea in women (OR 5.2) than in men (OR 3.4).15
D. OSA symptoms and presentation
 1. Women report different OSA symptoms than men;16,17
 2. Men consistently have higher apnea-hypopnea index compared to women across all ages;18
 3. Waist-to-hip ratio is more predictive of severity of OSA in men than in women;19
 4. Women have more partial obstructions compared with men;20
 5. Women have lower scores than men on Epworth Sleepiness Scale, which maybe be more sensitive to subjective sleepiness in men than in women;17
 6. Central nervous system white matter changes are more likely to occur in women with OSA than men.21
E. Treatment
 1. Women may require less CPAP pressure for OSA treatment of similar severity in men;22
 2. Women metabolize zolpidem 50% slower than men.23

Sex and gender differences exist in normal sleep and sleep disorders. Some examples discussed during the roundtable are listed.

CPAP, continuous positive airway pressure; NREM, non-rapid eye movement; OR, odds ratio; OSA, obstructive sleep apnea; REM, rapid eye movement; RLS, restless legs syndrome; SWS, slow wave sleep.

There is now very little doubt that the rest our bodies receive during sleep is incredibly important to how our bodies function.  Now we are seeing that even things such as fertility can be seriously affected.

Thursday, November 7, 2019

The Goetze Dental Family Celebrates 135 Yearswith New Fifth Generation Leadership!

 


Our world has changed a lot in the pst 20-30 years.  And it hasn’t just been the continuing extension and penetration of technology into every nook and cranny of our existence.  Unfortunately it has also been about the changes in business.  It seems that the small business environment has also suffered as “mom and pop” operations are forced out by large corporations that undercut on wholesale costs & put smaller competitors out of the landscape.

This has been apparent, not only in “normal” consumer brick and mortar businesses, but also in dentistry as well.  From a clinical standpoint the industry has seen a huge influx of corporate dentistry devouring or crippling the solo practice.  However, it’s also become commonplace on the supply side of the equation as well.  At one point in time small local solo practices in medicine and dentistry were supported by small local suppliers that were family owned and worked synergistically with each other for the good of the customer (the patient).

Yet, just as we’ve witnessed WalMart move into a town and quickly put local merchants out of business or buying them up, there has also been a tidal wave of small independent dental supply companies being purchased and absorbed by large supply companies.  These same large supply companies are also selling to corporate dental offices, but the prices they offer these corporate clinics are at a much lower price than those offered to the small traditional practice.

How does a smaller company like Goetze Dental manage to stay viable in today’s climate?  It’s a simple process really.  Goetze Dental realized that they are a 5th generation family owned company and that they owe this longevity to small family owned dental practices.  Because of that, they have chosen not to sell to corporate clinics and instead to support the customers that have supported them for 135 years.  Loyalty and treating customers like friends has been the secret to their continued success.

The good folks at Goetze Dental have a tremendous record of success that has come by treating their customers the way their customers deserve to be treated.  They also have an incredible team of dedicated employees that have incredible numbers of years of service and those numbers are just one more indicator of how their corporate culture extends from the customer to every employee.

Although I doubt I will be practicing when they celebrate their 270th anniversary, I hope they are still around to do so!  Congratulations Goetze, you deserve to celebrate a bit!

Goetze Dental turned 135 years old on September 24, 2019! We are so grateful to you and our entire Goetze Dental community for your trust and support over the years.

Marking the occasion, the fifth generation of leadership stepped into executive management with Ben Brunker named president and David Brunker named chief operating officer.  Owners and fourth generation family members, Don and Janet Brunker, will remain active in the business, with Don continuing on as chief executive officer and Janet as senior vice president, finance.

Ben Brunker joined the company in 2004 as a business analyst and in 2008 moved into the role of vice president of marketing.  He became vice president of sales and marketing in 2013.  Ben holds a bachelor's degree in finance from Missouri State University and an MBA in finance from The University of Missouri - Kansas City.

David Brunker began his career as a business analyst with Goetze Dental in 2014 and in 2015 he was named vice president of service.  David holds bachelor's degree in management and leadership from The University of Kansas.

Other leadership changes include role changes for longtime Goetze Dental employees Larry Dalrymple and Keith Lister. Dalrymple becomes vice president of merchandise and Lister becomes vice president of information technology and warehouse logistics.

It's been an exciting 135 years so far, and now the Goetze Dental family is sure the next are the best to come!

Wednesday, November 6, 2019

Healthcare Data Breaches Will Cost $4 Billion by End of 2019

 


Here’s some more interesting news on the entire IT problem that is faced by the healthcare sector these days.  I happen to love Black Book Market Research.  The company does a great job of staying on the leading edge of healthcare IT.  They recently released the following information which I think anyone involved with healthcare should read.  It doesn’t matter if you are a provider or an IT person, what Black Book has to say is pretty incredible… 

Read on:

Black Book Market Research LLC surveyed over 2,876 security professionals from 733 provider organizations to identify gaps, vulnerabilities and deficiencies that persist in keeping hospitals and physicians proverbial sitting ducks for data breaches and cyberattacks. 96% of IT professionals agreed with the sentiments that data attackers are outpacing their medical enterprises, holding providers at a disadvantage in responding to vulnerabilities.

A fragmented mix of 415 vendors offering data security services, core products and solutions, software, consulting and outsourcing received user feedback including large IT companies, mid and small security vendors and start-ups in the polling period Q4 2018 to Q3 2019.

Thus far in 2019, healthcare providers continued to be the most targeted organizations for industry cybersecurity breaches with nearly 4 out of 5 breaches, whereas successful attacks on health insurers and plans maintained with more sophisticated information security solutions with little change year to year. Over half (53%) of all provider breaches were caused by external hacking according to respondents.

Over 93% of healthcare organizations have experienced a data breach since Q3 2016 and 57% have had more than five data breaches during the same timeframe. Not only has the number of attacks increased; more than 300 million records have been stolen since 2015, affecting about one in every 10 healthcare consumers.

The dramatic rise in successful attacks by both criminal and nation-state-backed hackers illustrates how attractive and vulnerable these healthcare enterprises are to exploitation. Despite these wake-up calls, the provider sector remains exceedingly susceptible to ongoing breaches.

Budget constraints have encumbered the practice of replacing legacy software and devices, leaving enterprises more susceptible to attacks. “It is becoming increasingly difficult for hospitals to find the dollars to invest in an area that does not produce revenue,” said Doug Brown, founder of Black Book. According to 90% of hospital representatives surveyed, IT security budgets have remained level since 2016. As a percentage of IT health systems and hospital organizational budgets, cybersecurity has increased to about 6% of the total annual IT spend for CY 2020, however, physician organizations and groups report a decrease in actual cybersecurity expense allocated, with less than 1% of their IT budgets earmarked for cybersecurity in 2020.

A third of hospital executives that purchased cybersecurity solutions between 2016 and 2018 report they did so blindly without much vision or discernment. 92% of the data security product or service decisions since 2016 were made at the C level and failed to include any users or affected department managers in the cybersecurity purchasing decision. Only 4% of organizations had a steering committee to evaluate the impact of the cybersecurity investment.

“The situation did not improve in 2019 and dilemma with cybersecurity budgeting and forecasting is the lack of reliable historical data,” said Brown. “Cybersecurity is a newer line item for hospitals and physician enterprises and budgets have not evolved to cover the true scope of human capital and technology requirements yet, including AI.”

Last year’s Black Book cybersecurity survey revealed 84% of hospitals were operating without a dedicated security executive. As a solution to unsuccessfully recruiting a qualified healthcare chief information security officer, 21% of organizations opted for security outsourcing to partners and consultants or selected security-as-a-service options as a stop-gap measure.

In 2019, 21% of hospitals surveyed report having a dedicated security executive, although only 6% identified that individual as a Chief Information Security Officer or CISO. Only 1.5% of physician groups with over ten clinicians in the practice report having a dedicated CISO.

The estimated cost of a data breach by the respondent hospital organizations with actual breaches in 2019 averaged $423 per record.

In a separate Q3 2019 survey of 58 health system marketing leaders with organizational breaches in the past 18 months report expending between 51k and 100k dollars of unbudgeted marketing expense to fight any negative impressions on the hospital brand cast from data breaches and theft. Still, no marketing executive surveyed reported allocating 2020 budget funds to combat the consequences of patient privacy or record breaches.

That shortage of healthcare cybersecurity professionals is forcing a rush to acquire services and outsourcing at a pace six times more than cybersecurity products and software solutions, increased 40% from last year. Cybersecurity companies are responding to the labor crunch by offering healthcare providers and hospitals with a growing portfolio of managed services.

“The key place to start when choosing a cybersecurity vendor is to understand your threat landscape, understanding the type of services vendors offer and comparing that to your organization’s risk framework to select your best-suited vendor,” said Brown. “Healthcare organizations are also more prone to attacks than other industries because they persist at managing through breaches reactively and not proactively.”

The ability of non-CISO executives in healthcare organizations is not improving either. 70% of IT management respondents report their operations are not aware of the full variety of cybersecurity solution sets that exist, particularly mobile security environments, intrusion detection, attack prevention, forensics and testing. Last year 57% reported not having a good understanding of the cybersecurity product and service landscape.

58% of hospitals did not select their current security vendor in advance of a cybersecurity incident. 94% have not augmented their cybersecurity protections since their last breach. 35% of healthcare organizations did not scan for vulnerabilities before an attack.

“Providers are at a severe disadvantage when they are forced to hastily retain a cybersecurity firm in the midst of an ongoing incident as the ability to conduct the necessary due diligence is especially limited,” said Brown.

20% of healthcare organizations reported they felt intimidated by a vendor to retain services when the vendor identified a vulnerability or security flaw. “While the intrinsic nature of cybersecurity radiates pressures and urgency, hospitals shouldn’t let this dictate the vendor selection process,” said Brown.

On a positive note, 41% of healthcare enterprises have not formally identified specific security objectives and requirements in a strategic and tactical plan, improving from 60% in 2018. “Without a clear set of security goals, providers are operating in the dark and it's impossible to measure results,” said Brown.

87% of healthcare organizations have not had a cybersecurity drill with an incident response process, despite the skyrocketing cases of data breaches in the healthcare industry, and as of Q3 2019, 84% of hospitals and 65% of payer organizations did not have full-time cybersecurity employees.

27% of hospitals (up from 12% in 2018) believe that a Q3 2020 assessment of their cybersecurity will show improvement. 29% of hospital leaders believe their cybersecurity position will worsen and 79% of physician groups foresee increased cyber-attacks, as compared to 4% in other industries.

In 2019, 40% of providers surveyed still do not carry out measurable assessments of their cybersecurity status. Of those that did, 19% used an objective third-party service to benchmark their cybersecurity status, 7% used an objective software solution to benchmark their cybersecurity status and 73% self-assessed with their own criteria.

26% of hospital respondents and 93% of physician organizations currently report they do not have an adequate solution to instantly detect and respond to an organizational attack.

60% of surveyed CIOs did not evaluate the total cost of ownership (TCO) before making a commitment to sign their current cybersecurity solution or service contract. 91% reported they bought their cybersecurity solution to be compliant, not necessarily to reduce risk when the IT decision was made.

Healthcare organizations are hyper-focused on patient care and reimbursement. “Cybersecurity risks are not at the forefront of executives’ minds,” said Brown. “Medical and financial leaders also wield more influence over organizational budgets making it difficult for IT management to implement needed cybersecurity practices despite the existing environment.”

Tuesday, November 5, 2019

Medical Device Software VxWorks is Open to Hackers

 


One of the security problems we have in healthcare is the danger of proprietary or legacy software running devices that have a direct impact on patient care.  One of those systems that has come into the spotlight in 2019 is VxWorks which is developed by Wind River.  The software is something that runs in the background of many of the devices in our lives, however unlike major operating systems like iOS, Windows, or Android, many of us have never heard of it.  However, just because it manages things we don’t really pay much attention to doesn’t mean it is any less serious if it is engaged by hackers.

In this case VxWorks is currently running on 200 million (you read that right) devices and many of them are in the healthcare sector.  The company has stated it "can be found in surgical robots, infusion pumps, dialysis machines, pace maker programmers, assisted ventilators, etc. When critical Class III devices are being developed, and lives are at stake, medical device manufacturers have turned to Wind River. "

However, recently VxWorks has been in the news because of network vulnerabilities that could allow nefarious hacker types to break into it.  Because the code is used in so many specific devices, fixing it isn’t a simple matter.  Basically each device that uses it must be patched and it isn’t just a matter of a company setting up a patch which is then automatically downloaded and installed by every user.  In cases such as this, each unique end user would have to tell their devices to download and install the patch.  You can imagine the struggles of a company that manufactures surgical robots suddenly needing to update their operating system.  It could very well cause operational problems and/or affect patient care; and that is just one example.  Add to that the potential for FDA involvement and it is easy to see how big a problem something like this could turn out to be.

That sad part of this is that we have already seen that criminals don’t really care if patients and their lives are affected.  The Ransomware blitzkrieg we’ve seen in 2019 has shown in no uncertain terms that in the quest for money lives are not important to cyber criminals.

This isn’t meant to be an indictment of VxWorks, but it’s an example of how sideways things could potentially go with our dependency on life centric hardware.  I’m not currently aware of any dental devices affected, but that doesn’t mean there aren’t any.

If you would like to read more about the concerns the U.S. Government has on this situation, take a look at this page from the U.S. Department of Homeland Security.  

Monday, November 4, 2019

Coupled Electrophysiological, Hemodynamic, and Cerebrospinal Fluid Oscillations in Human Sleep

 


As someone who was diagnosed as a sufferer of Obstructive Sleep Apnea (OSA), I’ve become passionate about the importance of sleep and what a good night’s sleep can do for our bodies.

I’ve always been a Type A person and have pushed myself harder than necessary when it comes to sleep.  When I was younger, it was not uncommon for me to run on 4 to 6 hours of sleep on a regular basis.  My motto was a the ever popular “I’ll sleep when I’m dead”.  Unfortunately my ignorance of proper sleep eventually caught up with me.  This was especially true when I discovered that I had a genetically narrow airway.  Combining lack of proper sleep with the fact that even when I WAS sleeping I wasn’t getting restful sleep became a recipe for health problems later on.

Since I was diagnosed, I’ve taken a great interest in sleep and the importance of it for our overall health.

I recently came across a pretty interesting study about the movement of cerebrospinal fluid (CSF) during sleep.  It seems that while we sleep, our brain allows CSF to circulate more readily around the brain  and this allows different types of chemicals to be removed.  Many of these chemicals are one associated with memory problems.  The point being that even more information about sleep and its relation to health is being discovered.

The study is pretty fascinating reading.  It can be found at this link.  

Thursday, October 31, 2019

ADA Makes Their Position Known on Dental Care for Seniors

 


As our medical and healthcare system gets better and better, life expectancy AND quality of life continues to extend and improve.  However, with folks living longer, there is also the resultant problem of continuing with being able to function as we are accustomed to.

The problem for many is that they are now surviving longer than healthcare benefits were designed to last.  Actuarial tables are best guess estimates, but they are guesses none the less.  Because of that and the fact that many folks are going to need dental care throughout their extended lifespan, the American Dental Association made the current announcement today.  I feel it bears repeating here.  We *need* to take care of those who came before us.  We need to help those who are less fortunate and in need of our help.  I’m proud of the ADA for making their position known.

The American Dental Association has long recognized the importance of oral health care as a crucial part of overall health. For our senior population, those 65 and older, this statement is particularly relevant. Today's ADA strives to build upon previous leaders' efforts to educate and elevate this issue’s importance. Within the elderly cohort, who continues to expand numerically, it is imperative that the American Dental Association become the solution-based resource for this critical and time-sensitive issue.
The current discussions in Washington, DC, may have caught your attention. There are numerous House Bills attempting to add healthcare services to Medicare Parts A and B, and many include a dental benefit. The American Dental Association sees the pros and cons of individual aspects within these legislative bills, and we strive to yield positive results for both our members and the public.
Allow me to introduce the ADA Elder Care Workgroup.
The Current Landscape of Access to Dental Care for Seniors
Prior to introducing ADA efforts pertaining to elder oral care, it is useful to review the current landscape of dental care access for the elderly cohort. The ADA Health Policy Institute maintains the most robust data on the U.S. dental care system, drawing on publicly available as well as proprietary data sources.In 2018, the number of US citizens age 65 and over was 57 million, and that figure is anticipated to balloon to 84 million by 2050.


37% of seniors have some source of dental benefits coverage. Approximately 26% have private dental coverage, and 11% have public dental coverage (for example, Medicaid, Tricare, or the small number who receive dental benefits through Veterans Affairs).


63% of seniors do not have any form of dental benefits coverage.


What does coverage translate to in terms of oral health care use?43% of seniors had a general dental visit in 2016, up from 38% in 2000.

69% of seniors with private dental coverage had a dental visit in the past year.

16% of seniors with public dental coverage visited the dentist.

37% of seniors who are uninsured had a dental visit last year.

Dental care use also varies by household income.61% of seniors with household income above 400% of the federal poverty level visited the dentist.

24% of seniors with household income below 100% of the federal poverty level visited the dentist.

The disparities in dental care use and dental benefit coverage have clear implications for oral health. When it comes to various measures of seniors’ oral health, such as prevalence of untreated cavities or tooth loss, disparities by income, race, and dental insurance status are widening over time. That is, high-income seniors, in general, are seeing improvements in their oral health while for low-income seniors, improvements are either not as large or, in some cases, are non-existent.
The Time to Act is Now
As your president, I felt it was important that the ADA, as America's leading advocate for oral health, share this data with policymakerson the House Ways and Means Committee as they consider policy options to improve access to dental care among seniors, specifically through Medicare reform. Sharing data with policymakers in no way signals that the ADA supports any particular bill.

Data in and of itself is also not ADA policy. As a science-based organization, data is an extremely important input, but it is ultimately up to our esteemed House of Delegates to consider and vote upon resolutions to create ADA policy.

Looking back, the oral health success of Medicaid and CHIP for our youth has benefitted millions of young Americans. However, our elderly's oral health has not received the same discerning attention as our nation's children. This has been a widely discussed topic over the years within the ADA, and this topic's interest has escalated within the ADA House of Delegates over the past three years. In October, 2018, your ADA House of Delegates authorized Past President Dr. Jeffrey Cole to form the Elder Care Workgroup (ECW). Dr. Cole selected eleven dentists and one physician from varied backgrounds, and I reappointed the Elder Care Workgroup in September, 2019.

The Elder Care Workgroup felt strongly that in order for any dental program to be effective in improving the oral health of seniors and providing for their care, a robust network of providers is essential. If dentists are to be incentivized to enroll and provide care under a program, reimbursement must be at a level that accounts for the unique cost of dental care delivery.

After numerous meetings involving spirited, academic, informed and respectful debate, and secluded in their deliberations, The Elder Care Workgroup will present to the 2020 ADA House of Delegates a list of options. These options include a select portion of Center for Medicare and Medicaid Services (CMS) programs suitable for dentistry’s delivery model.

Thus, the Elder Care Workgroup has developed a multi-faceted approach, recognizing that the elder oral care issue's enormity requires innovative thinking. The ECW pursued solutions resulting in coverage for every elderly socio-economic level. The ECW's recommendations are not yet policy as the ADA House of Delegates has yet to vote. However, the ECW's work is progressing towards a presentable House of Delegates product next October.

I am proud to say that your ADA is on the leading edge of a solution, one involving private, non-profit and government programs.

The question is not, "should we do something." The question is, "how do we do it." The time to act is now.