Duke Personalized Health Blog

Welcome NC CEO Forum Participants

On Friday, February 3rd, Dr. Ralph Snyderman spoke about “Taking Health Personally” at the NC CEO Forum. He introduced the concept of Personalized Health Care, the inflection curve of disease development, personalized health planning, and outlined the role of the individual in proactively managing their health and healthcare.

We are excited about your interest in Personalized Health Care. If you would like to learn more about the concepts behind Personalized Health Care, all of our published works can be found here. Two important pieces to read are: 1) To Adopt Precision Medicine, Redesign Clinical Care and 2) Personalized Health Care: From Theory to Practice

The image below is Dr. Snyderman’s “Prescription for a Personalized Health Plan”, which was featured in his presentation.

screen-shot-2017-02-03-at-9-02-23-amPlease continue to check back with this website. In the future, we hope to provide you with information to help you get started in your own personalized health planning and information for you to bring to your primary healthcare provider to enable the creation of your annual personalized health plan. If you’d like more information in the meantime, please email us at personalized-health@duke.edu.

Best,

The Duke Center for Research on Personalized Health Care

New Article in NEJM Catalyst

On December 28th, Ralph Snyderman, Caroline Meade, and Connor Drake of the Duke Center for Research on Personalized Health Care published an article in NEJM Catalyst’s “Care Redesign” section. The piece, titled “To Adopt Precision Medicine, Redesign Clinical Care” highlights the importance of care redesign for more effective use of personalized and precision medicine (PPM) technologies. It outlines our vision for a 5-step clinical workflow, personalized health planning, that can deliver individualized care grounded in proactivity and patient engagement.

We are excited to share this work with you through NEJM Catalyst-if you’re interested in reading the piece, click HERE

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Image from http://catalyst.nejm.org/adopt-precision-medicine-personalized-health/

 

A Chancellor’s Tale: Transforming Academic Medicine

During his fifteen years as chancellor, Dr. Ralph Snyderman helped create new paradigms for academic medicine while guiding the Duke University Medical Center through periods of great challenge and transformation. Now, he has written a book chronicling his experience.

Dr. Ralph Snyderman's book is 336 pages and is available for purchase

Ralph Snyderman’s book is 336 pages and is available for purchase

 

Under his leadership, the medical center became internationally known for its innovations in medicine, including the creation of the Duke University Health System—which became a model for integrated health care delivery—and the development of personalized health care based on a rational and compassionate model of care. In A Chancellor’s Tale Snyderman reflects on his role in developing and instituting these changes.

Beginning his faculty career at Duke in 1972, Snyderman made major contributions to inflammation research while leading the Division of Rheumatology and Immunology. When he became chancellor in 1989, he learned that Duke’s medical center required bold new capabilities to survive the advent of managed care and HMOs. The need to change spurred creativity, but it also generated strong resistance.

Among his many achievements, Snyderman led ambitious institutional growth in research and clinical care, broadened clinical research and collaborations between academics and industry, and spurred the fields of integrative and personalized medicine. Snyderman describes how he immersed himself in all aspects of Duke’s medical enterprise as evidenced by his exercise in “following the sheet” from the patient’s room to the laundry facilities and back, which allowed him to meet staff throughout the hospital. Upon discovering that temperatures in the laundry facilities were over 110 degrees he had air conditioning installed. He also implemented programs to help employees gain needed skills to advance. Snyderman discusses the necessity for strategic planning, fund-raising, and media relations and the relationship between the medical center and Duke University. He concludes with advice for current and future academic medical center administrators.

The fascinating story of Snyderman’s career shines a bright light on the importance of leadership, organization, planning, and innovation in a medical and academic environment while highlighting the systemic changes in academic medicine and American health care over the last half century. A Chancellor’s Tale will be required reading for those interested in academic medicine, health care, administrative and leadership positions, and the history of Duke University.

Endorsements

“Dr. Snyderman has presented readers with a critical, reflective, personal, and at times painful account of his thirty-five-year tenure at Duke. He presents a perspective of Duke, and of a growing academic medical center, as honestly and frankly as possible, without being harsh. His candid reflections are refreshing, given most leaders’ tendencies to either sugarcoat the past or vilify those who have stood in their way. A Chancellor’s Tale provides invaluable insights into the workings of a large and respected U.S. academic medical center and into the mindset of one of its top leaders who steered the ship through rough seas and calm waters, raising Duke to its current national and international prestige.”E. Albert Reece, MD, Vice President for Medical Affairs, University of Maryland

“Compassionate physician, award-winning biomedical scientist, successful pharmaceutical executive, medical educator, and administrator, Ralph Snyderman’s remarkable and multifaceted career spans the full range of biomedicine. Here he describes in vivid detail how, as Chancellor, he transformed Duke University Medical Center into a powerhouse integrated health system while pioneering the innovative and widely emulated approach now known as prospective or personalized medicine.”Robert J. Lefkowitz, MD, Investigator, Howard Hughes Medical Institute, James B. Duke Professor of Medicine, Duke University

“Providing a unique perspective on the internal politics at Duke, Dr. Snyderman exposes many of the complexities and problems inherent in the governance of any academic medical center. A Chancellor’s Tale is also a story of what Dr. Snyderman witnessed through his eyes and ears and of his creative leadership. I admire him greatly for what he accomplished at Duke.”Michael M. E. Johns, MD, Interim Executive Vice President for Medical Affairs, University of Michigan

“Dr. Ralph Snyderman is a doctor’s doctor, the best of the best in American medicine. In A Chancellor’s Tale, he effectively synthesizes his extraordinary breadth of experiences into something more than the sum of its parts-a visionary, transformative view of what true health care can be at a time when it is most needed. If you only read one book on transforming health care this year, this is it. Highly recommended!” Dean Ornish, MD, Founder & President, Preventive Medicine Research Institute, Clinical Professor of Medicine, University of California, San Francisco

About The Author

Ralph Snyderman, MD, is Chancellor Emeritus, Duke University, James B. Duke Professor of Medicine, and Director of the Center for Research on Personalized Health Care at the Duke University School of Medicine. He previously served as Chancellor for Health Affairs at Duke University and as the founding President and CEO of the Duke University Health System; Dean of the School of Medicine at Duke University; Chair of the Association of American Medical Colleges; Senior Vice President, Medical Research and Development, Genentech, Inc.; Director, Laboratory of Immune Effector Function, Howard Hughes Medical Institute; Chief, Division of Rheumatology and Immunology at Duke; and Senior Investigator, National Institutes of Health. Dr. Snyderman has received numerous honors, including the Personalized Medicine World Conference Pioneer Award (2016), the North Carolina Life Sciences Leadership Award (2014), the Association of American Medical Colleges David E. Rogers Award (2012), the Industrial Research Institute Medalist Award (2008), the Ellis Island Medal of Honor (2003), and the CIBA-GEIGY Award for Lifetime Achievement in Inflammation Research (1992). He has authored almost 400 manuscripts and is the editor or coeditor of several books. Dr. Snyderman lives in Durham, North Carolina.

Watch Dr. Snyderman discuss his book below. For more information about the book, please visit Duke University Press’s website.

Following the Money: How and What We Reimburse Doctors for Matters

There is growing recognition that a re-orientation of our nation’s health care system towards prevention and quality is underway. The Affordable Care Act (ACA) seeks to forge a path to a new era of health care reimbursement based on the “triple aim”: 1) improving the patient experience, 2) facilitating better health outcomes, and 3) reducing the per capita cost of health care. It turns out that it matters how and what we pay for to improve the delivery of care.

What is the fee for service reimbursement model? What’s wrong with it?

The fee for service (FFS) reimbursement model is the way most health care services are financed and is the system most familiar to Americans when visiting their provider. In short, it is a way of billing the payer for each health care service delivered (like an office visit, test, or procedure). The health system or health care provider sends you or your insurance company an invoice with the services that were delivered.

Why is this a problem? Economists worry it incentivizes physicians to bill for more treatments, labs, or visits because the payment they receive is dependent on the quantity of health care services they deliver. By doing this, it creates a potential conflict of interest with patients since health care systems are rewarded for performing duplicate tests, over-prescribing medications, providing more health care services than is required, and other strategies to maximize the amount of billable care.

One of the most concerning and perverse problems with the FFS reimbursement model is that it is not aligned with efforts to prevent disease and promote health. As health deteriorates, it results in more opportunities for billable health care services (e.g. more lab tests, visits to the doctor or emergency room, and prescriptions). Since efforts to engage patients in prevention and health promotion have low reimbursement rates, or are not reimbursed at all, health systems are effectively penalized financially for developing innovative care models that keep people from getting sick. In other words, it makes more financial sense from the health system’s perspective to bill for an expensive surgery than it does to have a health coach or nurse work with patients to make lifestyle changes to prevent or alter the trajectory of their disease, perhaps eliminating the need for expensive and invasive surgery.

Where has this approach led us?

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In the US we pay far more than any other country in the world for health care, but all of that money doesn’t translate into the best health. Despite our highest per capita spending on health care, we have a lower life expectancy compared to other developed nations. It demonstrates the need for a system that encourages greater efficiency and a focus on prevention.

What’s the alternative?

It will take a nuanced approach to balance the competing goals of reducing costs and improving the health of patients. Whatever the funding mechanism, there’s a moral and financial imperative to create a system that incentivizes a more rational approach to reimbursing for health care services.

An often-underappreciated aim of the ACA is the focus on moving away from FFS towards a model of health care financing that takes into account quality and efficiency. Included in the ACA, the Accountable Care Organization (ACO) is a new type of healthcare organization that aims to improve quality and reduce the total cost of care for a population of patients. This can be achieved via different types of payment plans. The alternative being tested by emerging ACOs and larger health systems is known as a value based reimbursement model. The goal is to incentivize and reimburse based on what everyone agrees is the ultimate measure of a successful health care experience, better health. Collecting data to understand which health care services improve health outcomes and penalizing health systems that bill for unnecessary testing or are constantly readmitting patients due to complications are critical first steps.

The health care delivery model of the future will be one that embraces the ethos of personalized, patient centered and proactive care. It will be designed to predict disease, personalize prevention and treatment, and collaborate with patients to help them reach the highest levels of wellness. Providers and health care systems are capable of developing these types of innovative delivery models, so long as we accelerate movements towards reimbursement reforms that support and incentivize this more rational and compassionate approach to medicine. By incentivizing quality over quantity, we’re moving in the right direction.

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Big Data: What It Is and How It Can Affect Your Health

Big Data in Healthcare
Many industries have been quick to invest in and adopt infrastructure to support “big data” in recent years, but what exactly is “big data”? And how can it be applied to the healthcare industry? “Big data” differs from regular data in that it is less structured and exponentially larger, and requires much more effort and expertise to manage and maintain. Analyzing the information contained in big data sets has the potential to inform strategies for care delivery to improve overall health outcomes.

Big data in healthcare comes from a multitude of sources: medical records, biographical information, clinical results, medical surveys, and even fitness, sleeping, and eating data tracked by new wearable technology. This infographic by IBM summarizes where big data in health is coming from and in what forms.

The Institute for Health Technology Transformation claims that healthcare organizations have produced over 150 exabytes of health-related data to date. For reference:

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How can big data make care more personalized?
Though analyzing large, non-uniform data sets is a complex process, the findings can be used to tailor care to individuals. This allows more efficient and cost-friendly medical care. Big data enables a more complete analysis of a patient’s overall health and behavior, which allows medicine to be more personalized to each individual experience through personalized risk assessment alongside management and treatment choice. Siemens, a health care engineering firm, summarizes the emergence and practical applications of big data in healthcare in this video.

Big Data in Risk Assessment
Big data has the capability to improve assessment of a patient’s risk for certain health problems through both lifestyle tracking and genetic testing. Because we now know that an individual’s health is based on both their genetic risk and their environment, the more data we have about an individual, the more comprehensive the picture we have of their health. Risk-assessment tools are capable of utilizing big data inputs about a patient, including their family medical history, lifestyle choices like exercise and diet, biographical data, and clinical records. Once this is collected, comparisons can be made between the patient and hundreds of thousands of others who share similar backgrounds or diagnoses, allowing an assessment across multiple dimensions. When combined with a full genetic profile, an individual’s risk for a variety of health-related issues can be pinpointed with more precision than ever. For example, through data analysis we could determine that males who have a certain gene are more at risk for a certain health problem if they live in certain geographical regions. By recognizing this factor, the patient can take greater measures to lower his risk and prevent the problem.

Big Data in Maximizing Treatment Effectiveness
Even for one particular disease, every case is unique and not every patient will have equal success with the same treatment. This is because diseases interrupt biological pathways in different ways and require different treatments to target their effects. Big data leads to a greater understanding of this disease complexity that contributes to variance in treatment success. Even the effects of non-biological treatments, like behavior-change interventions, can be analyzed, which can help identify certain barriers to healthy living that are common across similar groups of patients. This can allow us to personalize interventions to certain individuals, making them more effective.

Big Data Infographic

There are a number of nationwide initiatives attempting to aggregate big data. President Obama’s Precision Medicine Initiative (PMI) is one of them. This cohort program has a goal of collecting data from at least 1 million volunteers in the nation, in addition to other projects like the Million Veteran Program (MVP). Hopefully, the PMI will be able to overcome the challenges of big data and provide a base model for future big data initiatives in healthcare.

Further Reading:
IBM Analytics in Healthcare
Big Data in Healthcare Made Simple
Institute for Health Technology Transformation Big Data Summary

Where’s the Plan? Health and Retirement

Just last week, I attended a workshop titled “Staying Out of Debt and Planning for Your Retirement”. Sounds like a bore, right? Not so much. Though the only incentive offered was free lunch, this workshop was highly attended, and attendees actively took notes and asked questions throughout the entire presentation.

During the workshop, we were asked to create a plan outlining what we want savings for in the future, both in the short term (1-5 years) and the long term (10+ years). Though each attendee had different priorities, everyone’s lists had similarities; luxuries that most people want to have and work their lives towards obtaining. Buying a house, having children, paying for college, traveling, purchasing a new car, and many others were on the list. As I sat in this workshop learning about how to plan for my retirement, it struck me that my retirement savings will mean nearly nothing if I am not healthy. If I were to develop a chronic illness, not only could it potentially be very costly to pay for medications and medical bills, but also without my health, how will I be physically able to enjoy any of the luxuries I worked so hard for?

This led me to the question: why do we plan for our savings and retirement, but not for our health? Imagine if we planned for our health and well-being just like we do for our retirement. What would that look like?

There are many similarities between the planning for retirement and planning for health.

1) It all starts with some kind of risk score.

2) We all want to plan for different, very personal reasons. Each of our plans should be influenced by why we want to save or be healthy.

3) Meeting with an expert is key to creating a successful plan. The expert’s job is to combine your desires with their expertise to create a workable, realistic plan.

4) We all know what everyday choices and actions are going to keep us “healthy”, either financially or physically. Building the right habits is the key to success. Easier said than done, right?

5) Starting early and taking baby steps can make all of the difference. Small steps are the key to success.

6) Overall, these plans should be a road map for how we are going to save or be healthy over time. This requires creating achievable goals and tracking progress using resources available to us.

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While retirement planning has become a relatively successful industry, the concept of health planning is still foreign to most of us. With all of the resources and infrastructure available to support retirement, there’s no wonder so many people are taking their planning for retirement so seriously. Bringing the same attitude towards investing in health and well being is something we could all benefit from. We work hard to enjoy retirement in the future, but bettering our health is something we can do now and reap the benefits of right away. The question is, where’s the plan?

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A Collaborative Effort: Preventing and Treating Childhood Obesity

Though the childhood obesity rate has been declining over the past several years, more than 1 in 6 children in the United States are still considered obese. Obesity takes both a physical and psychological toll on children. Obese children are more likely to be bullied, suffer from low self-esteem, and become depressed. They also face serious health risks such as a greater likelihood of obesity in adulthood, heart disease, type 2 diabetes, and cancer. Obesity risk is influenced by a multitude of factors including genetics, environment, access to healthcare, and behavior. However, often times the only factor that can be modified and controlled by the patient is behavioral decisions, which account for 30% of an individual’s health. Personalization of care starting in early childhood could be a strategy for properly targeting behavioral factors such as diet and exercise to continue the decrease in childhood obesity rates.

Childhood obesity is difficult to treat since children do not have full control over their health behavior. In fact, it has been found that parental health behavior heavily influences their children’s eating habits and preferences being formed in the first five years of life. Not only this, but with one obese parent, a child has a 50% chance of becoming obese. With two obese parents, this chance increases to 80%. Change cannot solely come from personal adjustments, but needs family support as well. Thus, treating childhood obesity means improving health behavior for the entire family. Personalized health planning between individual patients and providers has already been developed and is being adopted by many health providers. However, in order to effectively combat childhood obesity, personalized health planning for entire families needs to be further explored.

A study conducted by New York University’s Langone Medical Center found that over 90% of parents believed their overweight children were “about the right weight.” When parents are unwilling or unable to recognize their children’s true health status, it is up to primary care providers to refer children and their families for treatment. One program specifically targeting childhood obesity through family-centered solutions is the Duke Healthy Lifestyles Program. The Healthy Lifestyles Program relies on lifestyle modification with the help of dietary, medical, physical therapy, and behavioral providers. Each family receives personalized treatment options. Unlike with adult obesity, the treatment goal of childhood obesity is usually to stabilize rather than lose weight since children are actively growing. The Healthy Lifestyles Program not only involves medical professionals at Duke Pediatric Primary Care, but also partners with the Durham City Parks and Recreation Department. This unique model connects health care with community resources, which is needed to overcome some of the economic and environmental barriers to beneficial health behaviors. When standard interventions such as the Healthy Lifestyles Program are not effective in combatting obesity, pharmacological options need to be turned to. While there are many medications available for treating adult obesity, Orlistat is currently the only medication approved for treating childhood obesity by the Food and Drug Administration. Even with the personalization of medicine among youth and adults in treating obesity, doctors should examine further personalization among individuals, as Orlistat is less effective in children with type 2 diabetes.

Personalizing care in childhood obesity presents unique barriers because coordination between the child, the family, and the healthcare team is challenging to achieve. Moving towards a personalized, proactive, and participatory care model for children by involving a child’s family support system should be seriously considered in order to effectively combat not just childhood obesity, but also a multitude of chronic illnesses that often begin in childhood.


Wendy Ji is an intern for the Duke Center for Research on Personalized Health Care and a junior attending the University of North Carolina at Chapel Hill.

Health for Now and the Future: Personalized Health Planning in Prenatal Care

The United States has room for improvement in maternal and child health. Compared to other members of the Organization for Economic Co-operation and Development (OECD), the U.S. has high rates of infant mortality (7 per 1000 live births) and ranks second to last in overall child well-being. While indicators of health such as infant mortality, infant deaths, and preterm births all declined from 2000-2012, the US Department of Health and Human Services’ Office of Disease Promotion and Health Prevention recognized that a continued decline in all these indicators is necessary to meet 2020 goals. In addition to addressing larger social determinants of health within the U.S., taking a more proactive, preventative and participatory approach to prenatal care has potential to improve prenatal health.

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As infant health is inextricably connected to maternal health, one of the key components of prenatal care is engagement of the mother in the management of her own health. In the U.S., diabetes, hypertension and obesity are common factors that contribute to pregnancy and birth complications, increased use of medical services and longer hospital stays after delivery. The personalized health planning model could better address these common chronic conditions by engaging mothers in health care decision making through a health self-assessment and shared goal setting process. It is an approach that equips providers to provide recommendations for the next steps in a patient’s care. The patient and provider set goals for the patient’s health that are SMART: specific, measurable, action oriented, realistic and timed to facilitate gradual steps towards improved health outcomes through lifestyle modification. Ideally, a mother’s pregnancy specific goals would be integrated with the primary care provider’s (PCP) health plan. Coordination and continuity of care between a prenatal provider and PCP is key for successful goal achievement and taking full advantage of a personalized health plan.

There is exciting work happening that utilizes this type of participatory and proactive approach to ameliorate birth-related health outcomes and enhance the prenatal health care experience for mothers. One well-documented example is CenteringPregnancy, a model of group pregnancy care from second trimester to birth based on “the belief that health care should be centered or focused on the individuals participating in the care experience at any given time.” In a Centering appointment, expecting mothers first have individual assessments with the provider and use self-assessment tools to practice self-care and prepare for the day’s group activity. During the group activity the provider facilitates discussion around a health topic using hands on activities and drawing from individual experiences and concerns. Several studies indicate that Centering programs may reduce emergency room visits and preterm births while increasing prenatal knowledge as compared to traditional care. Centering programs cover topics included in traditional prenatal care (such as breastfeeding, labor, delivery and infant care) and provide opportunities for the provider to address issues such as gestational diabetes and obesity through organic group discussion and workshops.

CenteringPregnancy is a great example because it incorporates elements like health self-assessments into a clinical model while actively engaging and empowering the patient to manage their health and the health of their child. However, the length of Centering appointments (90 to 120 minutes) and number of patients in each shared appointment may be unsuitable for expectant mothers short on time for appointments or who anticipate pregnancy complications. It is here that tailored health planning during pregnancy, coordinated with primary care and postnatal care, has the most potential for improving health outcomes.  Through personalized health planning’s systematic approach to patient-centered care, chronic conditions threatening a healthy pregnancy can be addressed early on by bringing meaningful, focused goal setting and enhanced patient-provider collaboration to prenatal care.


Sierra Reid is an intern for the Duke Center for Research on Personalized Health Care and a senior attending the University of North Carolina at Chapel Hill.

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Combating Drug Addiction with Personalized Care

The addiction epidemic is a largely neglected public health crisis in the United States. A study conducted by The National Center for Addiction and Substance Abuse at Columbia University found that 40 million Americans over the age of 12 suffer from addiction to alcohol, nicotine, and illicit substances. This figure greatly overshadows the 27 million Americans with heart disease, the 26 million with diabetes, and the 19 million with cancer. So why is such a prevalent problem receiving such little attention?

The way the current U.S. health system treats addiction is partly to blame. Current treatment methods, when and if a patient receives treatment, are either inconclusively effective or generalized. A scientific consensus on the effectiveness of popular 12-step therapy programs such as Alcoholics Anonymous or Narcotics Anonymous has yet to be reached, with different studies finding the programs beneficial, neutral, or even detrimental to recovery. In addition to therapy, medical professionals recommend medication be used to help facilitate recovery. However over 90% of medications properly function in only 30% to 50% of patients. For example, though methadone is useful in managing adult addiction, it is not suitable for teens. In addition, it is even harder to find the right medication for each patient in addiction treatment due to patient relapse and adherence. Yet most doctors are still treating addiction with a one-size-fits all approach and prescribing popular medications without really considering the individual characteristics of the patient at hand.

Personalization of care could be the answer to getting America’s drug addiction under control. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a new approach developed by the government’s Substance Abuse and Mental Health Services Administration that serves as a resource for health care centers looking to deliver early intervention. This could have enormous effects in preventing the onset of addiction with the 80 million risky drug users currently in the United States. Personalized medicine, which is providing “the right drug for the right patient at the right time,” is currently being applied to more effectively treat addiction after it has already appeared in a patient. By matching specific medication to certain genes, addiction can be effectively combated on the first try. The question of whether an alcoholic would respond better to naltrexone, acamprosate, or disulfiram or whether an opiate addict would respond better to naltrexone, methadone, or buprenorphine could soon be answered with a low cost blood test. Finally, due to the chronic nature of drug addiction, “a short-term, one-time treatment is usually not sufficient.” Personalized health planning is a potential strategy to ensure treatment regimens are being followed, to engage patients in combatting drug addiction to improve their health, and to alert providers if a different treatment approach is needed.

Risky drug use and drug addiction costs the U.S. government over $468 billion annually. However, only 10% of individuals with drug addiction receive treatment and few health care providers know how to treat addiction. What is needed now is a logical new approach to managing addiction that is both patient-centered and cost effective. An emphasis on early prevention and tailored treatment options could not only save billions of dollars, but also millions of lives. As personalized approaches to care are refined, it is of the utmost importance to ensure addiction treatment does not get left behind.


Wendy Ji is an intern for the Duke Center for Research on Personalized Health Care and a junior attending the University of North Carolina at Chapel Hill.

Ralph Snyderman on the Progress of Personalized Medicine

Dr. Ralph Snyderman presents his thoughts on personalized medicine and its progress in the last 15 years in his guest blog post “Personalized Medicine: Then, Now and Coming Soon” on the Personalized Medicine Coalition’s blog, Education & Advocacy.

To read more, and learn the background behind Dr. Snyderman’s report card for personalized medicine progress (pictured below), click here.

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