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Posts Tagged ‘Clinical Documentation’

The ICD-10 Needs YOU

leading-the-pack-480908-sIt’s going to happen, right?  As soon as we finally cross the finish line to the ICD-10 transition, surely there will be plenty of skilled specialists on-hand to navigate the thousands of new codes to master.

Well, not exactly.

According to a piece in the ICD10 Monitor, “Limited coding resources long have been an industry reality. According to a June 2011 survey by the American Health Information Management Association (AHIMA), 40 percent of respondents said shortages were the result of a lack of qualified coders. This mirrors similar findings from a 2009 AHIMA survey on coding practices. In a discipline rife with change, the coder shortage problem only will exacerbate problems as organizations migrate to ICD-10.”

Ouch.

Truth is, despite continued unemployment, medical coders remain in high demand.  Their work ensures critical payments and reimbursements travel through the billing cycle, and preserves the integrity and accuracy of the patient narrative with regard to procedures, diagnosis and billing.   Theirs is a critical role done without fanfare, quietly underwriting the healthcare marketplace’s profitability and patient satisfaction.

So why do we care?

It is in our interest for skilled medical coders to be in plentiful supply, as coding and transcription reside hand in hand.  The reports we painstakingly transcribe, or the data we enter into the EMR are turned over to coders.  Our work feeds theirs, and in turn, their efforts ensure the text we transcribe is accurately input into the system.

So what does it take to become an expert medical coder, able to leap tall buildings and wield 141,000 codes in a single minute? According to AHIMA, the following:

  • The ability to work independently
  • Strong knowledge of the medical terminology
  • Adept critical thinking and communication skills

Ideally, candidates for these careers are detail ninjas.  They naturally demonstrate a precision, and never accept the status quo.  They dig deeper, ask questions, check their sources, and dot their i’s and cross their t’s.

While there is no specific formal education required, many employers seek candidates with a Certified Medical Reimbursement Specialist (CMRS) certification. The process takes roughly a year to finish, and includes information about basic physiology, anatomy and the sciences. Other important components of the certification include:

  • Medical terminology
  • Computer database management
  • Billing and coding procedures
  • Insurance procedures

Think you’ve got what it takes?  The opportunities for medical coders and specialists are only going to increase. As health care providers and hospitals scramble to determine whether to outsource, or train new talent internally, the savvy job seeker wins the race to October 1, 2014.

Want to join in the conversation?  Leave a comment here, or on our Facebook page.

Doctor, Heal Thy ICD-10 Worries – The game’s not just for Coders Anymore

965897_data_01Is your practice counting down to October 1, 2014 with fear, or anticipation?

The transition to the ICD-10’s keeping just about everyone up at night – and not just coders either.  Everyone in the health care revenue cycle – physicians, payers and vendors – has got a stake in the game.  One company even coined an affliction for HIMs, coders and physicians alike – “ICD-10 Stress Syndrome. “ (Is there a code for that??)

Like it or not; there are just 200 some days until the deadline.  (Cue the creepy organ music…)   And while HIMs everywhere are scrambling to prepare, doctors are most at risk for lack of readiness.  “If claims are not submitted accurately, physicians simply won’t be paid.  According to Beth Hertz’ piece in Medical Economics, “With less than a year until the one-day ICD-10 conversion … a physician’s ultimate life preserver is going to be planning and training,” says Shari Erickson, MPH, vice president of government and regulatory affairs for the American College of Physicians.

The piece goes on to argue the leap from the ICD-9 to the ICD-10 is historically ambitious, requiring a much more precise detailing in reporting diagnosis.  Outpatient diagnostic codes will increase from about 13,000 to 68,000.  Go time to learn all those?  (How about time to just get to the bathroom between patient intakes?)

The system requires training for everyone on the team – including coders, billers and providers. This is a ONE-DAY transition, so readiness has to happen immediately with plenty of preparation ahead of time.  Distress call!

5 Tips for Moving From Panicked to Prepared

Keep calm and prepare on for a smooth transition on October 1st

  1. Small practices may want to secure a line of credit to mitigate cash flow issues temporarily if payers aren’t ready.  “It would be prudent to take out a credit line equal to about 5% of the total reimbursement for the year for the practice. “  -Michael F. Arigo, CPHIT, CPEMR managing partner of No World Borders
  2. Identify a Project Coordinator or Point Person.  Identify someone on staff who can assume responsibility for training, implementation, communication and accountability to keep the process on track for the big date.  Ideally this person is familiar with coding but if not, choose someone who will embrace the challenge and find the help they need.
  3. Fight the urge to get overwhelmed.  Keep it in perspective; learning every single new code isn’t necessary.  Become familiar with the ones used most often in your practice – identify the top 20 codes for medical and diagnoses procedures and start there.
  4. Connect with your EMR vendor.   If your practice uses an EMR, your vendor should be a great resource.  Be certain to connect with them to ensure delivery of software upgrades and ask if they offer training. 
  5.  CALL iDATA!  While clinical documentation has long been regarded by doctors as a necessary evil, physicians must become more involved in the process of ensuring documentation meets the high standards of the ICD-10 compliance.  Partnering with an expert company (like iData!) aligns physicians with expertise to ensure documentation – for which the ICD-10 environment requires considerably more detail – is captured accurately and efficiently.

 So don’t panic.  Just get prepared.  We can help!

 

Chime in here or on our Facebook page – or connect with me personally at ktant@idata-llc.com.

Warmly, Kendall Tant, CEO, iData 

 

 

 

 

 

 

 

 

 

 

 

Habits: Breaking the Cycle, One Cookie at a Time

cccookiesWhat is it that you do over and again, without thinking?  Brushing your teeth is one.  It’s ingrained, automatic, a good habit.  Driving is another – it’s become routine, something you can do singing to your favorite tunes or chatting with your teenager. Consistent exercise is a positive habit, as is expressing love to our family or going to worship each week. Some habits are affirming, even powerful.

Then there are those habits that aren’t so great for us, like smoking, or in business, staying with the same vendor because it’s just, well, habit.  Why can’t we just nix those habits, already?

Because it turns out, habits are really tough to break without intentional effort.  What is a habit, exactly?   Oxford explains it this way:  “a settled or regular tendency or practice, especially one that is hard to give up.”  What’s the one thing you do you do over and again you wish you could just stop doing, never to look back?

Charles Duhigg, New York Times reporter and author, asked himself the same question.  His answer?  Cookies.  Each day around 3:30, he’d head to the cafeteria for a chocolate chip cookie. He thought it was because he liked cookies, and his waistline revealed the story he worked on faithfully each day.  It was a habit he just couldn’t seem to kick.  Inspired by a revelation about the prevalence of habits in the military, he did a little investigative journalism himself, which he shared in his book, The Power of Habit:  Why we do what we do in Life and Business.   (Turns out he made his former habit work for him!) 

During his self-study, Duhigg discovered that what he was after wasn’t really the cookie. By shaking up his routine, he discovered it was social connection he was really after.  The cookie led to a reward – in his case, time to chat with colleagues during a break.  It’s never about the cookie!

Habits form, he argues, via a 3-part process.  First, there’s  a cue, or trigger, that tells your brain to go into automatic mode.  A cue could be a person, a place, a time of day, an image, an emotional state, and others.   The cue signals the launching of a behavior, then engaging in a routine, or the behavior itself, such as eating the cookie.  Finally, the reward reinforces the brain to remember the process going forward.  Are we really all the different from mice in this regard?

Duhigg replaced his cookie habit with a new behavior attached to the reward of social interaction, tossed the cookies aside, and lost 12 pounds in the process.  Getting inspired?

According to an NPR interview with Duhigg, “neuroscientists have traced our habit-making behaviors to a part of the brain called the basal ganglia, which also plays a key role in the development of emotions, memories and pattern recognition. Decisions, meanwhile, are made in a different part of the brain called the prefrontal cortex. But as soon as a behavior becomes automatic, the decision-making part of your brain goes into a sleep mode of sorts.”    

So, like driving that becomes automatic – pun intended – breaking your own habits at home or work requires awareness, time and effort.  But habits can be transformed into adopting something powerful and positive.  Like golf.

What about you?  Is a lingering habit holding you back from experiencing excellence?  Such as, for example, exploring other clinical documentation companies?

At iData, we’d like to become your next hard habit to break.

Read an excerpt from Charles Duhigg’s book here.  Then, chime in.  Share your experiences with us across social media, or make a comment on our blog post.

 

The Annual Report: Alive, Kicking and Grateful

KT HSYou may have heard the doom and gloom.  But Don’t buy into it.

Seems plenty have eagerly authored eulogies for the field of medical transcription.  The emergence of the EHR (Electronic Health Record) with its promise to deliver reduced costs, interoperability and shared patient data across platforms can’t be labeled, “Mission Complete” just yet.   It sounds like Utopia, but both the technology, and its usage is still maturing.

In the years since the passage of 2009’s HITECH Act, while much has been achieved in the name of Meaningful Use, we’re still very much navigating a time of transition.  And clinical documentation is front and center.  Can you remember any other time in history during which the patient record garnered so much press?

The EHR still has some work to do in making doctors happy.  Over and again, word is doctors are frustrated with entering patient data while trying to focus on patients.  The clinician’s narrative doesn’t always fit neatly into drop-down templates embedded into EHR systems, and voice recognition software still requires editors to proof and affirm the integrity and accuracy of the data.

In other words, the medical knowledge and human touch skilled transcriptionists bring to the table is still very much necessary, often even preferred.

While some say the future for medical transcription is bleak, we’re here to tell you that at iData, we’re thriving, and even growing as we head into 2014.   (We’ve noticed plenty of our competitors are still in business, too.)  As Mark Twain quipped, “The reports of my death have been greatly exaggerated.”  Our roles are changing, but they’re hardly extinct.   We’re grateful for our loyal customers – hospitals, doctors and group practices – who are finding innovative ways to integrate our expertise into emerging technologies.  At the end of the day, we are the “faces” behind the integrity and safety of the patient record.

One of our largest customers, in fact, renewed a multiyear contract.  During negotiations no one issued even one complaint.  This is a facility to which we return hundreds of reports a week – in fewer than 90 minutes each!  So during this season of gratitude, we’re thankful for our talented staff of MT’s, editors and operations group who work tirelessly each day for our customers, and ultimately, for patients.

It’s true – our industry is adapting, and even facilitating the healthcare marketplace’s assimilation to the digital age.  Our work hasn’t been replaced, but instead complements the mandate for seamless EHR interfaces.  Our ability to capture discreet (or selected) data from dictated reports empower doctors toward efficiency, and our highly trained and skilled MT’s use templates to make report completion more efficient.  Further, when the clinician prefers, we use speech recognition. Agility, flexibility and diverse, robust solutions that address varied needs enable us to create customized solutions.  Oh yeah – and on time. Or it’s free.  Where else can you get that kind of guarantee?

So for us, the future’s a bright one.  Our plan is to stay ahead of trends, embrace change and innovate new solutions – just like our customers.

Wishing you a Merry Christmas and Joyful Holiday Season!  For the record, you’re the reason we exist!

Planning for the Hospital of the Future

Red cross 1During the season of gratitude, we’re thankful for hospitals – and not just because they heal the sick.  They’re customers – and our interoperable clinical documentation services empower their mission.  Never before in history has the patient record received so much attention.  And our own industry is adapting to change along with the rest of the healthcare marketplace.  So we have a vested interest in learning what they’re innovating under pressure, and expanding patient base.

We wonder, wouldn’t they like to just close the doors for a day and think, plan and strategize?

Well, a few of them left their hospitals long enough to brainstorm with others in the name of progress.  In November 2013, U.S. News and World Report gathered hospital executives and experts to the first annual “Hospital of Tomorrow” forum.  One thing’s for certain – the times, they are a-changing.  The strongest will thrive, and they inspire us to do the same.

The Inaugural Launch

Cleveland Clinic CEO Toby Cosgrove launched the inaugural forum coordinated by US News & World Report with a keynote speech, discussing the issues with which hospitals are coping right now.   (Watch it here.)

A panel discussion about the changing face of hospitals and health care ensued, as did break out sessions that included topics such as staffing solutions, designing hospitals for the 21st century care,  absorbing the newly insured, and new strategies for preventing re-admissions. Big stuff.

As you can imagine, the Twitterverse lit up with discussion, collaboration and debate under @USNHOT13.  Round up the industry’s best and the brightest, and you’re bound to conjure varied opinions and passions!  Check out the tweets, pictures, quotes and musings posted during the conference.

For HIM’s and IT and records managers who didn’t get to go, check out a recap of two technology related issues discussed at the forum:

Uncovering the Power of Big Data

While navigating massive amounts of information is nothing new to hospitals, “Big Data” is the latest buzzword that’s got everyone talking.  In the context of medicine, innovative thinkers will figure out how to sift and utilize key data to predict and solve clinical issues, and also, to facilitate better hospital management.

According to the US News & World Report, Brad Ryan, a general manager at IMS Health stated, “Effective interpretation of Big Data can help identify which new technologies are working and which aren’t.” (Shameless plug:  iData’s customers enjoy the delivery of critical data that can be parsed, extracted and exploited for purposes other than the EMR.  In the future, what if treatment could begin before the patient experienced real symptoms, just indicators, for example?)

Is your hospital harnessing the value of the enormous amounts of data to collect genetic information, spot business trends and more?  It’s an enormous task and we’re curious how others are mining through to find the “diamonds” contained within.

Applying Technology to Hospital Business Needs

We often think of technology related to medicine in terms of patient care, such as robotic, or computer assisted surgery.  But one breakout session during the forum apparently discussed the need for technology to empower the business side of healthcare.

Troy Kirchenbauer, general manager of Aptitude LLC, an online direct contract market for healthcare, talked about the critical need for effective supply chain management.   Their platform serves as a transparent and open space in which hospitals negotiate and manage contracts.  Their service builds thriving partnerships between hospitals and suppliers, driving down costs, promoting compliance and improving efficiency in supply chain management. (Visit aptitude.com for more.)

We applaud the great work done by US News & World Report to knit together invested providers, legislators and vendors to sharpen the sword together for the good of everyone’s ultimate customer – the patient.  We look forward to hearing about the next forum.

For a full recap of the topics discussed at the forum, click here.  Want more tips, information and news related to healthcare documentation, IT and administration?  Sign up for our newsletter in the upper right hand corner!

 

Image courtesy of Dreamstine.

For Forward Thinking Hospitals, the Future is NOW

hospitalWe spend a lot of time serving hospitals, and the times are changing.  Hospitals today are doing critical work in the most real-time setting there is – the doors never close; patients never stop arriving.  Many of them are embracing ground breaking, forward thinking work under tremendous pressure to adapt to a rapidly changing landscape.  No rest for the weary!

The clarion call to deliver a more personalized, flexible and empowered health care experience to a highly invested customer base (remember, patients are customers after all) is one heard across the country.  While the topic of health care is landing square in the eye of the storm these days, we thought it would be interesting to showcase a few herculean efforts hospitals are making to forge the new frontier.

In a two-part post, we’ll introduce a few heroic hospitals doing some heavy lifting, breaking ground from which other hospitals can draw inspiration:

Personalized Medicine

The Mayo Clinic’s Center for Individualized Medicine is working toward leveraging the power of gene sequencing, which looks to patients’ genomic blueprints to determine aspects of their health.   In a piece for US News and World Report, the center’s director, Gianrico Farrugia, said the primary value should be the needs of the patients, and, “We can’t live up to it unless we turn to genomics.” Perhaps in the not too distant future, patients will be able to tote their genome mapping on their iPads.

Telemedicine

This sizzling hot new delivery mode enables clinicians to interface with patients via video conferencing to assess, diagnose and monitor health issues remotely.  Telemedicine most often benefits patients and families in rural communities by broadening access to distant specialists; plus, hospitals can  bring in readily accessible staff to meet unexpected demands, such as in the ER.   Mercy Health was an early pioneer in telehealth, beginning in 2006, equipping its ICU with telemedicine capabilities.   Since then, Mercy has reduced mortality rates to 20 percent below the expected level, and reduced hospitals stays’ durations by 30 percent, according to the US News & World Report.

Physicians in Executive Leadership

The entrenched hierarchies that divided a hospital’s clinical and administrative staff are dissipating.  After all, who has a deeper understanding the real needs of patients than doctors on the front lines?  Today an increase in physician hospital executives who work in tandem with hospital administration to develop policy and make critical decisions regarding patient care is a model garnering more interest.   According to Becker’s Hospital Review, now there are more than 60 joint MD-MBA degree programs, compared to only a smattering in the 1990s, for example.

Becker’s cited San Diego-based Scripps Health as one example of a system that broadened physicians’ role in decision-making.  When the Physician Leadership Cabinet was created, the group included chiefs of staff and CEOs from each hospital campus, along with the VP of nursing. The cabinet strengthens collaboration between Scripps administrators and physicians as they develop strategies to improve quality and efficiency while reducing costs and clinical variation.  Win win!

We applaud the continuous efforts of progressive minded hospitals to innovate toward improved patient care, reduced waste and costs, and a more flexible,  empowered patient experience.  As always, we stand ready to empower physicians with an integrated approach to capturing the physician’s narrative with accuracy and speed.  After all, it all begins with a patient’s story. More on that in part 2!

Want to connect with Kendall Tant?  Find him on Linkedin.

 

Get Schooled: UC San Diego’s Leading the Charge in Reducing ED Wait Times

KT HSWe always remember that the people we serve are patients, who are served by doctors, who often work in bustling hospitals and relentless emergency rooms.  What was your last experience in the ER like?  Efficient, or agonizing?  We’re betting you remember exactly how long it was before you were seen, particularly if your emergency didn’t include spurting blood or broken bones.  It’s never fun.

According to the CDC, between 2003 and 2009, wait times in hospital emergency departments increased by 25%, or from 46.5 minutes to 58.1 minutes on average.    No one likes to wait, and languishing in the ER, holding onto a throbbing arm or a wailing toddler tops of the list.  A possible solution?  Telemedicine.  Yes, George Jetson, the future is here.  One medical school on the cutting edge is forging the new frontier.

Citing an epidemic of overcrowding for more than 2 decades, The UC San Diego School of Medicine recently launched a pilot program to explore the merits of connecting doctors to patients from remote locations when the ER gets overwhelmed.  How?  You guessed it – by empowering technology to become more humanizing.  The doctor will see you NOW – albeit via computer monitor.

According to UC San Diego, “The study is the first of its kind in California to use cameras to bring on-call doctors who are outside of the hospital to the patient in need.”  Aside from decreasing patient wait times and improving patient care, the project may help alleviate the staffing issues associated with matching adequate resources to erratic ER cycles.

Dubbed the Emergency Department Initiative to Rapidly Accommodate in Times of Emergency (EDTITRATE), consenting patients are prioritized accordingly and linked to an offsite (but immediately available) physician via high fidelity sound and video, or telemedicine station.  An ER nurse facilitates the process.  High fidelity sound and video enables the telemedicine physician to examine a patient’s eyes, nose, throat and skin, listening to the heart and lung sounds through the module.  Lab and imaging tests may be ordered, reviewed and documented as well.  Finally, the attending physician onsite reassesses the patient to confirm findings and actions, and can take time to address patient concerns and questions.

Funded by a $50K grant by the University of California Health Quality Improvement grant, the goal is to expand the project’s reach to the ED in La Jolla.  If successful, hospitals across the nation may adopt a similar model.

What are your thoughts?  Is this one more step toward improving patient care and satisfaction, particularly with the market opening to so many more people?  Or, does telemedicine create one more barrier to the connection between doctor and patient?  Time will tell.  Till then, we’re keeping the pulse on the response.

 

Measuring Turn-around-time (TAT): Is your MT provider’s STAT – or DOA?

1398762_clock

In our industry, turn-around-time, or TAT, is everything – well, part and parcel with accuracy and quality.  Each one is critical component – we have to deliver it all.  Every medical transcription company claims their service is the speediest.  But how do they prove it?

And if they’re not measuring up – do they put their money where their mouth is? They should.  We do.

24:  More than just a T.V. Show

First – yes; you should expect a medical transcription provider to deliver – but also, to prove they’re doing it. It’s critical, because patient records provide necessary information from which the clinician’s work flows – for analyzing history, making diagnosis, making references to specialists and protecting against litigation.  Never underestimate the power of the patient record!

So of course, the speed with which data is extracted, recorded and returned is paramount, and turn-around-time to our industry is akin to arrival and departure times in the airline industry.  It’s the basis by which our success is measured.  The “gold standard?”  Ideally, most reports should be returned in 12 – 18 hours, others, from the emergency room for example, should arrive back within 1 – 6 hours.

At iData, we guarantee our turn-around-time, or our clients don’t pay.  We think it doesn’t get any more committed than that!

Drilling down:  Questions to ask your Clinical Documentation Provider

There are plenty of choices in finding a clinical documentation provider – no argument there.  Of course we think you should choose our locally owned small business because we invest so intimately in our customers.  Regardless of your choice, it should be an informed one, so we recommend asking the following questions when searching for a new provider:

  1. What is your average turn-around-time in delivering reports?  A provider should have no trouble giving you a solid answer on this and should provide exacting data to show a history.
  1. What quality controls are in place?  Speed is critical, but it cannot be sacrificed at the expense of quality.  A slip of the key, a misinterpreted medication dosage can cause serious damage.  (Around here our systems ensure each report passes through no less than 3 quality controls.  But that’s just us!)
  1. What kind of technology platform supports their infrastructure? It’s essential that a medical transcription provider use the most cutting edge technology that allows for mobile usage, cloud-based storage and EHR interface.  We have to adapt even before our clients do so we can move at the speed of light when the time arrives.
  1. How do they measure turn-around-time? Each provider should offer their customers reports measuring their turn-around-time.  It should be easy to analyze their performance based on delivery after initial data is provided and customers run their own real-time reports.

Like we said – our guarantee at iData is to deliver reports on time, every time – or our customers don’t pay.  We’re pretty incentivized to get them turned around on time, every time.  Just what the doctor ordered.

 

Code Green: Reduce your “e-waste” quotient

Earth Day has come and gone, but we think it’s sort of like Christmas.  Shouldn’t we have a “green” spirit all year long?

1246798_electronicsPracticing ecologically sound and sustainable policies are garnering continued interest across the healthcare marketplace.  Have you been introduced to the Healthier Hospitals Initiative (HHI)?  This collaborative effort between hundreds of hospitals, the Center for Health Design, and Practice Greenhealth seeks to improve environmental health and sustainability in the health care sector in 6 key areas: engaged leadership, healthier food, leaner energy, less waste, safer chemicals, and smarter purchasing.

Going green is far from today’s flavor of the month – it’s propelling to “new normal” status faster than a Silicon Valley coding competition.

IT departments can lead the charge, too.  How do your efforts to reduce “e-waste” – or electronic equipment that is nearing, or at the end of its useful lifecycle - stack up?  According to a recent blog post in Earth911, “In 2009, about 2.37 million tons of discarded TVs, computers, peripherals (including printers, scanners, fax machines), keyboards, mice and cell phones ended up in the waste stream in the U.S, according to EPA facts and figures.”

How does your medical center or business recycle, re-use or upcycle electronics that are no longer in play?  Currently, there is no Federal mandate to recycle e-waste. There have been numerous attempts to develop a Federal law, but to date – no surprise – consensus hasn’t been reached.  There are however, guidelines to follow within each state that rival the stringency of any Federal mandate.

Electronic products are made from valuable resources and materials – metals, plastics, and glass – all of which require energy to mine and manufacture. Donating or recycling consumer electronics conserves natural resources and avoids air and water pollution and greenhouse gas emissions caused by manufacturing brand new materials.

The problem is, some electronics, such as color CRTs computer monitors, color CRT TV tubes, and smaller items such as cell phones and other “hand-helds” may test “hazardous” under Federal law.  If so, they are subject to special handling requirements under Federal law, subject to certain exemptions.  Still, the EPA does encourage the reuse and recycling of used electronics, including those that test “hazardous.”   For those regulatory requirements, visit EPA’s website.

Responsible Stewardship of e-waste is a Health Matter

It’s in our local and global interest to dispose of e-waste carefully to prevent the exploitation of those in impoverished countries where much of the e-waste from the U.S. has historically been disposed.  Media coverage of companies that transferred e-waste overseas where unsuspecting workers scavenged through potentially hazardous material to forage recyclable metals exposed the problem our e-waste caused.  This spurred many states to pass e-waste recycling laws that help to ensure responsible recycling and disposal of hazardous materials – check out your state’ s policy here.

Of course, a great deal of electronic components relegated to “e-waste” status isn’t waste at all, but rather could serve as readily marketable for reuse. It’s why companies such as Bitlist.com have emerged to turn one man’s e-waste into another man’s aftermarket treasure.   At iData, we recycle all of our electronics locally, and we’re always searching for new ideas and resources.  What’s your organization’s policy?  Check out EPA’s site for ideas on recycling electronics.  And share your resources with us; let’s all work together to make every day, Earth Day.

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