Enhanced simulation and training have been game changers, says this nurse educator.
On this episode of HL Shorts, we hear from Dr. Jason Dunne, chief academic officer at the Arizona College of Nursing, about how new technologies like AI and robotics are impacting nursing education. Tune in to hear his insights.
Healthcare providers won't embrace telehealth unless they're reimbursed properly. But advocates say they should be looking at more than just the cost.
With all the talk focused on AI these days, telehealth would like to remind everyone that it’s still around. And it isn’t going away.
In fact, despite announcements to the contrary, health systems and hospitals across the country are embracing telehealth to address key pain points, including access issues and workforce shortages. In many instances virtual care has become the norm, rather than the cool new concept.
“Telehealth [and] telemedicine has just exponentially grown,” says Danielle Louder, director of the Northeast Telehealth Resource Center (NETRC), part of a network of federally funded telehealth resource centers scattered across the U.S., and director of U.S. Programs at MCD Global Health. “We’re seeing more strategic, in-depth and creative approaches across the landscape, including integration of artificial intelligence and augmented reality, and are eager to continue our work with partners to advance the use and impact of telehealth across the region and beyond.”
The NETRC, part of the National Consortium of Telehealth Resource Centers, which consists of 12 regional and two national centers, held its annual conference this week in Nashua, N.H. The three-day event, drawing close to 100 attendees, addressed some of the biggest issues in telehealth, including state and federal regulation, innovative use cases, the growth of AI and remote patient monitoring (RPM), and finding the right business case for scalability and sustainability.
And that’s where things get interesting.
Telehealth had its moment in the spotlight with the COVID-19 pandemic, when as much as 70% of healthcare encounters were done virtually to curtail the spread of the virus. Those numbers dropped after the pandemic as patients sought to return to their doctor’s office, but while some pundits claimed this would end the telehealth experiment for good, most health systems and hospitals still see the value of offering virtual care alongside in-person care.
The challenge lies in understanding the value of virtual care—and explaining it to both hesitant providers and skeptic payers.
Jason Goldwater, president and CEO of Laurel Health Advisors, which has conducted several federal and state studies focused on telehealth value (including an ongoing analysis for the state of Connecticut), says healthcare providers won’t fully embrace telehealth unless they’re paid for the virtual visit at the same rate as they’re paid for in-person care. And insurers, especially private payers, aren’t embracing payment parity.
But Goldwater argues that telehealth has a value that goes beyond reimbursement, and both providers and payers need to understand what he calls social ROI.
“Traditional ROI metrics undervalue what telehealth can really provide,” he said during a presentation at the NETRC meeting. “People should be looking at the full spectrum of benefits.”
For example, he said, telehealth visits improve access to care, enabling patients to meet with providers at the time and place or their choosing. This means fewer missed or canceled appointments, which in turn means better adherence to care management, which cuts down on emergency and adverse health events and improved long-term health and wellness. In addition, telehealth leads to a much higher patient satisfaction rate, which in turn can lead to improved medication adherence.
In addition, a telehealth platform might reduce stress on providers by enabling them to shift from in-person to virtual appointments, creating a daily workflow that doesn’t wear them down. This in turn will improve care outcomes and reduce the operational costs tied to a stressed workforce, including time off and departures.
Telehealth can also enable providers to connect more easily with specialists and other services, reducing the need for multiple appointments for patients and improving care management and outcomes.
And finally, telehealth reduces the environmental impacts caused by travel, giving patients the opportunity to receive care from home and even giving providers a chance to work from their homes on occasion.
Goldwater says these factors aren’t often included in the ROI of a telehealth program because healthcare executives and payers are too often focused on cost.
He recommends that healthcare leaders take the following steps:
Leverage stakeholders to support a good telehealth strategy.
Invest in a data infrastructure to give providers both the information they need to improve care and decision-makers the data they need to prove ROI.
Focus on the long-term benefits of telehealth rather than short-term ROI.
Align incentives to support providers, patients and payers.
Leverage technology to create an effective platform.
Beyond that, he says, healthcare leaders need to create a platform for evaluating telehealth programs that factors in social ROI, and that means creating standardized valuation frameworks and assigning monetary values for all SROI benefits.
For example, a program that improves medication adherence might show the cost to the health system when patients aren’t taking their medications, while a program that reduces provider stress and burnout will show the cost to the health system in increased time off and vacation requests and filling positions because of turnover.
Nurses are at high risk for death by suicide, according to these studies.
September is Suicide Prevention Month, and CNOs need to be aware of the risks and warning signs among their workforce and provide mental health resources and programs.
According to the American Association of Critical-Care Nurses (AACN), the suicide risks are higher for nurses because of several different reasons, including high levels of stress, hectic schedules, exposure to trauma, workplace violence, and a lack of healthy work environments. Other factors include feeling a lack of support and preparation for the job, leadership concerns, depression, and financial issues.
Hear more about how this health system is tackling staffing and nurse education challenges, according to their nurse leaders.
The nursing industry is always changing. With the introduction of new technologies, new generational needs and values, and innovative ideas about recruitment and retention, it seems like there are always new disruptors and challenges that CNOs have to face.
Dr. Kathy Boyle, chief nursing officer at Denver Health, and associate CNO, Dr. Natalie Nicholson, have been implementing new programs over the last several years that tackle these disruptors and improve the overall wellbeing and environment for their nurses.
To address staffing concerns, Denver Health has started offering a hybrid work model for nurse leaders, and nurse apprentice programs to focus on recruitment and retention.
"Our nurse leaders can work from home a day a month, or every two weeks," Boyle said. "We are now researching this intervention through first qualitative research to see the impact on our nurse leaders, and then now we're studying the impact on staff."
"[The nurse apprentice program] has been a really big support not only to the staff," Nicholson said, "but it has created a pipeline to getting student nurses within the Denver Health walls."
To boost nursing education, the health system has placed over 2000 clinical placements since the start of their longitudinal clinical placement program, Boyle explained, with the intent to continue key partnerships with nursing schools and to support students in their careers and entry to practice.
Nicholson added that Denver Health also has programs that encourage high school students to come into the medical field and help them continue their nursing education and careers.
"In the end, I think what we are encouraging here with our nursing profession is that continuous learning," Nicholson said, "we should never stop learning and we want to support and encourage and grow our nurses in the way that they would like."
Listen to this week's episode of the HealthLeaders Podcast to hear more on how Boyle and Nicholson plan to keep tackling disruptors and improving the experience of their nursing workforce.
The health system is launching a project with IBM Research to identify clinical signatures using audio-visual interviews and digital health data from patients 15-30 years old.
As healthcare organizations explore how to use AI to influence patient care, they’re training their sights on ambient and generative AI technology that can sift through data and point providers in the right direction.
The latest to embrace this strategy is Mount Sinai Health Care, whose care teams want to identify young people in need of mental health services and give providers the information to improve care.
The New York-based health system is partnering with IBM Research on what it’s calling the Phenotypes Reimagined to Define Clinical Treatment and Outcome Research (PREDiCTOR) study. The research will use AI tools to comb through not only audio and video interviews but a wide range of digital health data to identify predictive markers that would allow care providers to identify and arrange treatment more quickly and effectively.
“Every clinical visit provides a wealth of untapped behavioral data that includes spoken language, eye contact, and facial expressions from both the patient and clinician,” Cheryl Corcoran, MD, an associate professor of psychiatry at Mount Sinai’s Icahn School of Medicine and co-leader of the research project, said in a press release.
“With advancements in computational approaches, these behaviors can be operationalized and quantified through analysis of audiovisual data obtained from the recording of clinical interviews,” she said. “Coupled with valid behavioral data derived from smartphones that track physical activity metrics like step count and distance traveled, geolocation, social interactions like text messages and phone calls, sleep patterns, and audio data from diaries, we can develop clinical signatures that are indicative of key outcomes.”
The $20 million project, funded by a grant from the National Institute of Mental Health (NIMH), will include researchers from Harvard, Johns Hopkins, Columbia and Carnegie Mellon Universities and use ambient tools developed by Deliberate AI.
The project aims to focus AI on one of the more pressing healthcare issues in the U.S.: the soaring rate of mental and behavioral health concerns. Often the onus of diagnosing these concerns falls on providers who don’t have the background to detect subtle clues.
The research team is focusing on patients between the ages of 15 and 30 who are seeking treatment at one of six Mount Sinai Health outpatient mental health clinics. Researchers say that age range “represents a developmental window during which many disturbances of thought, emotion, and behavior emerge and when diagnoses and prognoses are often still unclear.”
The researchers will combine digital health data with audio and visual recordings of the patients’ visits over a year. They’ll then develop clinical signatures that characterize what those patients present when seeking help, which providers can then use to fine-tune care management.
“Our goal is to gain a better understanding of what predicts whether young people stay in mental health treatment or drop out, and what predicts whether their symptoms worsen such that they need acute care in an emergency crisis center or hospital,” Guillermo Cecchi, PhD, director of the computational psychiatry and neuroimaging groups at IBM Research, said in the press release. “We have shown in our research that artificial intelligence can be used to predict some outcomes in controlled experimental settings, but we believe that current advancements are powerful enough to be applied in the context of usual clinical practice.”
A new report predicts a surplus of some nurses, but a shortage of others.
For the past several years, the workforce shortage in healthcare has persisted, especially since the COVID-19 pandemic.
Nurses in particular have felt the impact of the shortage, and CNOs have been working around the clock to recruit and retain the best talent possible to bridge the gaps.
However, the numbers seem to be shifting, depending on the profession.
A new report by Mercer predicts that by 2028, there will be an estimated overall surplus of nearly 30,000 registered nurses (RNs) across the country. Some states will still likely experience shortages, including East Coast states such as New York, New Jersey, and Connecticut, which are predicted to fall short by 16,000 RNs.
Unfortunately, the prognosis is not as positive for other nursing positions.
Nurse practitioners
According to the Mercer report, there will be a nationwide shortage of nurse practitioners (NPs), despite this category having the fastest predicted growth rate at 3.5%.
The report emphasizes that NPs are a critical component of preventative care delivery in the country, and they will remain so in the future. A shortage of NPs could mean disruptions to primary and preventative care delivery, especially when combined with predicted physician shortages.
The report recommends that health systems in states with smaller shortages or surpluses continue to monitor their markets to recruit NPs.
Nurse assistants
For nursing assistants (NAs), the report predicts a shortage of more than 73,000 nationwide. According to the report, NAs make up 8% of the healthcare workforce in the United States, and they were 40% of healthcare support occupations in 2023.
Texas, California, and New York are the states that are likely to experience the greatest NA shortages, which will have a ripple effect on the rest of the nursing industry. The report explains that a lack of NAs will increase workloads for RNs, which can lead to more burnout and increased turnover rates.
Moving forward
So, what can CNOs do?
CNOs must continue to focus on recruitment and retention strategies that consider the needs of their nurses. Offering benefits such as flexible scheduling and career advancement opportunities will entice nurses to come and stay at health systems as well as reduce burnout.
Jennifer Croland, vice president and CNO at OSF HealthCare Saint Francis Medical Center, previously emphasized to HealthLeaders the importance of flexible scheduling and listening to frontline nurses.
"The first thing that I would say needs to be done is you have to listen to the front line and really understand what it is that they're telling us," Croland said. "I think just admitting to ourselves that what we're doing is not working is the first step."
The Mercer report recommends a four-pronged approach to tackling these potential shortages and surpluses.
Understand specific supply and demand needs by occupation and department
Strengthen your labor supply pipeline
Retain existing talent
Lower staffing demands
For more information, view the entire report here.
HealthLeaders is convening top clinical executives from across the country to address key issues facing CMOs today.
This week, two dozen CMOs, chief physician executives, and chief clinical officers are set to discuss top healthcare issues at the HealthLeaders CMO Exchange, including workforce challenges, the role of advanced practice providers, AI, and telehealth.
The HealthLeaders Exchange program is the organization's premier thought leadership and peer-to-peer learning opportunity for healthcare executives. In addition to the CMO Exchange, HealthLeaders holds Exchange events for a range of healthcare leaders, including CEOs, CFOs, CNOs, and revenue cycle executives.
CMO Exchange member Thomas Balcezak, MD, MPH, executive vice president and chief clinical officer at Yale New Haven Health, talked with HealthLeaders recently to highlight four critical concerns for CMOs at this week's event.
Recruitment and retention of healthcare workers
When it comes to the recruitment and retention of physicians, they have similar desires as other professionals, according to Balcezak.
"They want to know that they are getting a fair deal," Balcezak says. "They want to know that their work is rewarding and enriching to their personal lives. They want to feel like they are making a difference. They want to work for an organization that shares their values. And they want to work with other individuals who are similar to them and treat them fairly."
At Yale New Haven Health, there are several shared values between physicians and the organization, Balcezak explains.
"We put patients first," Balcezak says. "We treat patients and staff with respect. We make sure that we live the values of the organization, including integrity."
According to Balcezak, retaining healthcare workers is informed by an adage: People take a position for the job, but they leave a position because of their manager and the environment that the manager creates.
Balcezak recommends that healthcare leaders pay attention to both aspects of that adage to retain staff.
"We need to make sure that salary and benefits are competitive," Balcezak says. "We also need to make sure that how healthcare professionals are treated is positive and that their leadership is trying to make the working environment continuously better."
Thomas Balcezak, MD, MPH, is executive vice president and chief clinical officer at Yale New Haven Health.Photo courtesy of Yale New Haven Health.
Role of the advanced practice provider
The role of advanced practice providers (APPs) has not expanded clinically at Yale New Haven Health, but the health system is committed to maximizing their impact, according to Balcezak.
"We talk about working at top of license—not just for APPs but for all kinds of caregivers such as respiratory therapists, nurses, and physicians," Balcezak says. "We want to make sure that all of our practitioners are working at top of license."
At Yale New Haven Health, APPs work under the direction and supervision of physicians, and they take on tasks that free up physicians to work at the top of their licenses, according to Balcezak. The tasks assigned to APPs vary in the inpatient and outpatient settings.
In the inpatient setting, physicians admit patients, set care plans, and discharge patients. This leaves several tasks that APPs can perform, Balcezak explains.
"In between admission and discharge, there is follow-up care, daily progress notes, and other aspects of care that an APP can do extremely well under the direction of a physician," Balcezak says. "APPs can also perform functions such as screening, history, and physical exams preceding surgery and other procedures."
In the outpatient setting, APPs can perform functions such as routine office visits and checking on care progression under the supervision of a physician. These are the primary roles for APPs at Yale New Haven Health, Balcezak explains.
"While working at the top of their license, the efforts of APPs allow physicians to see more new patients, to create treatment plans, and to do surgeries and other procedures," Balcezak says. "The ideal role of APPs on care teams is to extend the expertise and time of physicians."
Adoption of artificial intelligence
Yale New Haven Health is in the early stage of adopting AI technology. Balcezak gave three examples of where AI is impacting care delivery at the health system.
Ambient listening: The health system uses ambient listening to capture encounters between clinicians and patients. The technology creates a template note for the clinician to review, edit, and authenticate.
"AI is going to allow us to streamline documentation and allow the clinician to spend more face-to-face time with the patient," Balcezak says. "This is going to free the clinician from endless typing."
Radiologic procedures: The health system has an AI tool that does preliminary reads for some radiologic procedures.
"That allows the physician to have preliminary ideas about the findings of radiologic exams, then independently confirm or deny them," Balcezak says. "This can save physicians time and improve their diagnostic acumen."
Patient monitoring: The health system is using an AI tool called eCART to monitor patients in the inpatient setting. eCART continuously evaluates the patient's electronic medical record, looking for evidence of clinical deterioration. It measures and monitors data, including nurse notes, clinician notes, laboratory results, radiology results, and vital signs.
"It can flag to a nurse or any other caregiver to make sure patients are evaluated clinically in person if it looks like the patients are deteriorating," Balcezak says.
Pictured: CMO Exchange members enjoy the reception cruise at the 2022 event.
Telehealth trends
The volume of telehealth visits at Yale New Haven Health has decreased significantly since the height of the coronavirus pandemic, but telehealth has become an established care delivery modality at the health system, according to Balcezak.
"The pandemic taught us that telehealth is highly effective, and it is a satisfier for both clinicians and patients," Balcezak says. "While we are not using telehealth as frequently as we did during the pandemic, we know that it has an important role to play. My prediction is that we will be using telehealth more for routine visits and follow-up visits, especially in primary care."
Balcezak expects specialty consultations via telehealth will increase across the country.
"We have a shortage of clinicians in certain specialties in the United States that disproportionally impacts rural areas," Balcezak says. "As we become more comfortable and facile in using telehealth, we can better serve rural communities and other communities that lack specialty clinicians."
The HealthLeaders Exchange is an exclusive, executive community for sharing ideas, solutions, and insights.
Please join the community at our LinkedIn page. To inquire about attending a HealthLeaders Exchange event and becoming a member, email us at exchange@healthleadersmedia.com.
Dr. Kathy Boyle, CNO at Denver Health, and Dr. Natalie Nicholson, associate CNO at Denver Health, chats with nursing editor G Hatfield about how Denver Health is tackling disruptors in the nursing industry.
Nurses are at a high risk for death by suicide, but there are ways nurse leaders can help.
Nursing is an incredibly difficult profession.
Nurses face new challenges, including high stress emergency situations, workplace violence incidents, and death, on a daily basis with patients and families. All of those events can take a major toll on a nurse's mental health, which can lead to more serious problems.
September is Suicide Prevention Month, and CNOs need to be aware of the risks and warning signs among their workforce and provide mental health resources and programs.
Nurses are at risk
According to a 2023 study from JAMA Network, from 2008 to 2019, the risk of suicide was higher for healthcare workers, specifically registered nurses, healthcare support workers, and health technicians, compared to non-healthcare workers.
Another 2021 article published in the Journal of Psychosocial Nursing reported that the available data from the CDC's National Violent Death Reporting System showed nurses were 18% more likely to die from suicide than the general population between 2007 and 2018. The risk of death by suicide for female nurses was twice as high than the general population, and 70% more than female physicians.
According to the American Association of Critical-Care Nurses (AACN), the suicide risks are higher for nurses because of several different reasons, including high levels of stress, hectic schedules, exposure to trauma, workplace violence, and a lack of healthy work environments. Other factors include feeling a lack of support and preparation for the job, leadership concerns, depression, and financial issues.
How CNOs can help
While the numbers are startling, nurse leaders can make an impact. It's critical that CNOs take steps to address the underlying issues that contribute to suicide risks to improve the work environment to keep their nurses safe and healthy.
According to Betty Jo Rocchio, senior vice president and chief nurse executive at Mercy, the CNOs at the health system support the whole person by offering flexible work hours so that nurses can choose how and when they work.
"Mental health and well-being are important for both an individual's personal life and work life," Rocchio said. "Flexible hours and environments support the needs of our nurses and ultimately provide the space for our nurses to deliver compassionate, quality patient care."
Additionally, Mercy has programs in place that support whole health, Rocchio explained, including a robust employee assistance program with an abundance of mental health resources.
"People flourish when we support them as a whole person," Rocchio said, "by tending to their physical, mental, emotional, and social well-being."
According to Deana Sievert, chief nursing officer at Ohio State Wexner University and Ross Heart Hospitals, and HealthLeaders Exchange member, there are two areas that CNOs should focus on: staff support structures and nursing workflows.
"By dividing into these two categories, the CNO can assure a broad focus on structures and supports," Sievert said, "but also a zoomed in view that looks at the day-to-day frustrations that can gather and increase stress and dissatisfaction which thereby impacts mental health and wellbeing."
Sievert also recommended implementing an employee assistance program and a strong-structured shared governance model, but Sievert also emphasized the need for a more proactive approach.
"There are some in the nursing community that I have heard are doing a simple screening of the nursing team, through very brief individual surveys," Sievert said, "to help identify those subtle red flags that could lead to reactions such as depression, anxiety, or even suicide.
Sievert is hopeful that this strategy will become more widely used throughout the nursing industry.
"I applaud those organizations and CNOs that have moved here," Sievert said, "and I am hopeful that this becomes a best practice that many of us adopt."
Advice for nurses and leaders
Rocchio also emphasized the important role that CNOs and other nurse leaders play in creating a sustainable work environment where nurses feel supported.
"It's of the utmost importance for our nursing leaders and teams to have a close professional relationship so they can help and support each other," Rocchio said. "Changing the care delivery model to meet workforce needs, designed and supported by nurse leaders, is the key to a healthy workforce, healthy work environment, and a workflow that supports the best patient care possible."
As a note to nurses who might be struggling with their mental health, Rocchio offered some words of wisdom.
"Mental health is critical. As nurses, we tend to set aside our own needs and take care of others first. We must remember that before we can take care of others, we must first take care of ourselves. It's imperative because our families, friends and patients need caregivers who are mentally, physically and emotionally healthy. Supporting our team and paying attention to their needs supports a healthy workforce and environment. Healthcare and nursing put patients and caregivers at the center of our care model because people matter!"
Sievert also had some words of encouragement for nurses.
"First and most importantly, ask for help. We are all here and hope that there is comfort in being able to reach out. Then I would encourage reaching out to your nursing leaders. I assure you we do care about you. We want to help, and we want to support you. Please do not let the stigma that often still exists stop you from asking for help. You are too important to us!"
The 988 Suicide and Crisis Lifeline is a hotline for individuals in crisis or for those looking to help someone else. To speak with a trained listener, call 988. Visit 988lifeline.org for crisis chat services or for more information.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
While many say the technology will help clinicians improve care, the workforce shortage and other pressures may prompt healthcare leaders to use AI when they can’t find or afford providers. And consumers may even prefer that.
One of the enduring concerns with AI in healthcare is that it may someday replace the doctor or nurse. And while many experts say the technology is designed to help clinicians improve patient care, there may come a time when that prediction is true.
“We can’t hire our way out of the problem right now,” says Brian Anderson, MD, co-founder and CEO for the Coalition for Health AI (CHAI), who warns that health systems won’t be able to find the doctors and nurses they need to keep pace with increased demand for services, especially from a growing senior population.
The reality is that the healthcare workforce shortage isn’t going to improve any time soon, and healthcare leaders will have to make some hard decisions over how and when care is provided, even as new technologies and strategies create opportunities for care outside the hospital, clinic, and doctor’s office. Healthcare sites are shutting down at an alarming pace because they can’t be staffed, while consumers are demanding access when and where they need it.
And if they can’t see a real doctor, maybe an AI program will do the job.
“We ultimately need to begin grappling with where is the appropriate place where providers aren't in the loop” and AI can be used in their place, he says. “I think that's going to be one of the real challenges.”
In some health systems, nurses are worried their jobs may be negatively affected by AI, and have lobbied for assurances from management.
At the recent HIMSS AI in Healthcare Forum in Boston, Lee Schwamm, MD, SVP and chief digital health officer at the Yale New Haven Health System and associate dean of digital strategy and transformation at the Yale School of Medicine, said healthcare leaders may soon have to include AI in contract negotiations, especially in rural regions where the workforce shortage is particularly acute.
He and others at the forum noted that health systems and hospitals struggling to stay open might see a benefit in using AI platforms to replace clinicians they can’t afford or even find.
At the same time, a growing number of patients are saying they’d prefer an AI doctor to a real one, especially if it improves access and convenience and is covered by insurance.
According to a recent survey of 2,000 consumers by Customertimes, almost 40% say doctors will eventually be replaced by AI.
"The truth is that quality care in the U.S. is often a luxury, available primarily to those who can afford it”, Max Votek, a former pharmacist who co-founded the digital consulting firm. He noted 83 million Americans lack access to primary care services, while new patients wait an average of 26 days just to get in front of a doctor.
“AI will enable quicker access to doctors when time is critical and help reduce costs in many cases,” added Gilbert Merariu, CIO for the pharma research company PSL Group, in the Customertimes press release on the survey. “Consider low-income individuals who may not afford a doctor's visit. With AI, they could chat with an AI that has all his historical medical info and already identify the possible next steps. Then a final review can be done by a DR (at a much lower cost and higher volume) to start his treatment. This would streamline the process and make healthcare more accessible.”
According to the survey, slightly less then half of those surveyed are optimistic about the adoption of AI in healthcare, while 17% fully trust and half somewhat trust AI-powered healthcare. Some 15% are willing to follow medical advice generated by AI, and another 25% would do so if that advice were free.
In addition, 58% said AI would ultimately benefit providers rather than patients, a nod to the belief that the technology can address many of the industry’s biggest pain points. Some 18% said AI will soon be better than humans in diagnosing and treating conditions, while 44% said that will take place “in a distant future.”
Most importantly, 57% of those surveyed said AI will lead to healthcare layoffs, while 13% said the technology will help save jobs. And 10% said AI should replace doctors in the foreseeable future—and another 28% said that will happen but shouldn’t.
Pictured: CMO Exchange members enjoy the reception cruise at the 2022 event.
