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HIPAA Compliant E-mail - Myths and Facts

HIPAA Compliant E-mail - Myths and Facts | EHR and Health IT Consulting | Scoop.it
Every day I get questions about HIPAA compliant e-mail, and many days I see or hear something that leads healthcare organizations and their business associates in the wrong direction.

These Myths and Facts can help you make the right e-mail decisions. I have included links to give you more details and so you can see the official information yourself.

MYTH – All e-mail systems are HIPAA compliant.

FACT— FALSE. Free web mail services like Gmail, Yahoo! Mail, Hotmail, and those provided by an Internet Service Provider are not secure and no electronic Protected Health Information (ePHI) should be sent through these systems, either in messages or attachments. In 2012, an Arizona medical practice paid a $ 100,000 penalty for sending mail from an Internet-based e-mail account. They also used a publicly-accessible online calendar for patient scheduling.
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Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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What is the difference between an EMR and an EHR? - Practice Fusion Blog

What is the difference between an EMR and an EHR? - Practice Fusion Blog | EHR and Health IT Consulting | Scoop.it

An electronic medical record (EMR) is a digital version of a chart with patient information stored in a computer — not a filing cabinet. The electronic file contains everything you’d find in a paper chart, such as medical history, diagnoses, medications, immunization dates, allergies. While EMRs work well within a practice, they’re limited because they don’t easily travel outside the practice. In fact, the patient’s record might even have to be printed out and mailed for another provider to see it.

What is an EHR?

An electronic health record (EHR) does everything an EMR does, but with the added benefit of making health information instantly accessible to authorized providers across practices and health organizations. One EHR can bring together information from current and past doctors, emergency facilities, school and workplace clinics, pharmacies, laboratories, and medical imaging facilities. It can also contain insurance information, demographic information, and even data imported from personal wellness devices.

EHRs are the future of healthcare because they provide critical data that informs clinical decisions, and they help coordinate care between everyone in the healthcare ecosystem. EHRs also have the ability to:

  • Streamline the workflow of providers
  • Reduce duplicative testing
  • Reduce delays in treatment
  • Offer access to evidence-based tools to support clinical decisions



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Capitol Hill turns up heat in EHR interoperability — Could a digital health startup save the VA? — No sign of slowdown in health IT lobbying - POLITICO Morning eHealth

Capitol Hill turns up heat in EHR interoperability — Could a digital health startup save the VA? — No sign of slowdown in health IT lobbying - POLITICO Morning eHealth | EHR and Health IT Consulting | Scoop.it

CAPITOL HILL TURNS UP HEAT ON INTEROPERABILITY: Senate Democrats have joined Republicans in demanding an investigation into whether heavily subsidized electronic health records systems are blocking the free exchange of patient health information that was a major objective of the multibillion-dollar federal program. The comments, accompanying a spending bill, signal that dissatisfaction with the meaningful use program among doctors and health IT professionals is bubbling up in both houses of Congress, though it isn’t clear whether it will lead to short-term action. Federal health IT officials have been trying to prompt better health exchange among EHR systems and have made interoperability — the free flow of information among health systems — a central goal of their efforts over the next year. Without freer data exchange, say those who should know, the electronic health records won’t lead to the kind of health care improvements and cost controls sought under the Affordable Care Act and the 2009 HITECH Act

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EHRs key to medication reconciliation | Healthcare IT News

EHRs key to medication reconciliation | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

Electronic health records have a big role to play in improving hospitals' medication reconciliation, a new study finds, but challenges related to data quality, technology and workflow remain.

[See also: Barcoding still a key tool for safety]

Medication reconciliation is a systematic way to reduce medical errors by ensuring accurate patient medication lists at admission, during a hospitalization and at discharge. Unintended discrepancies are common, with some research finding they affect as many as 70 percent of hospital patients at admission or discharge – with almost one-third of those potentially causing harm.

Still, despite hospital accreditation and other requirements, use of med rec technology has lagged for many reasons – including insufficient physician engagement, which stems, in part, from lack of professional consensus about which physician is responsible for managing a patient's medication list, according to the new report from National Institute for Health Care Reform.

[See also: Medication tracking system helps Ohio hospital cut waste]

NIHCR is a nonpartisan, nonprofit organization launched by United Automobile Workers, Chrysler, Ford and General Motors. Between 2009 and 2013, it contracted with the Center for Studying Health System Change to conduct objective research and policy analyses of the organization, financing and delivery of healthcare in the U.S.

Conducted for NIHCR by researchers Joy M. Grossman, Rebecca Gourevitch and Dori A. Cross, this study examined how 19 hospitals nationwide were using EHRs to support medication reconciliation.

They found that key challenges to effective medication reconciliation include improving access to reliable medication histories, refining EHR usability, engaging physicians more fully and routinely sharing patient information with the next providers of care.


"Enhancing ways for key stakeholders – patient safety advocates, policy makers, researchers, EHR vendors, hospitals and clinicians – to share the best EHR designs and hospital implementation strategies will be key to realizing the potential safety and efficiency benefits of EHR-based medication reconciliation," they write.

The NIHCR Research Brief, "Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation," also finds:


  • While hospitals reported that EHR vendors have been adding and enhancing medication reconciliation functionality over time, more than a third of the hospitals in the study still used a partially paper-based process at admission, discharge or both.
  • Many hospitals had at least some access to external electronic sources of medication histories to generate more accurate pre-admission medication lists, for example, from affiliated physicians practices' EHRs. But use of this feature varied, reflecting mixed views on whether the added information was reliable enough to be worth the effort to incorporate it into the record.
  • The hospitals with fully electronic processes at admission or discharge had implemented EHR medication reconciliation modules, which like paper forms, allow comparison of medication lists at those transitions. Actions taken on each medication are then automatically converted into orders, substantially streamlining the workflow by eliminating the need to re-enter data.
  • Hospitals with fully electronic processes at discharge also were able to take advantage of the discharge medications in the EHR to electronically generate legible and more patient-friendly discharge instructions and electronic prescriptions. Less commonly used features included the capability to incorporate the same medication list into the discharge summary and electronically share discharge medication information with the next providers of care.



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Electronic health records don’t increase Medicare fraud, study finds

Electronic health records don’t increase Medicare fraud, study finds | EHR and Health IT Consulting | Scoop.it

Concerns that nationwide electronic health record adoption could lead to widespread fraudulent coding and billing practices that result in higher health care spending are unfounded, according to a study from the University of Michigan Schools of Information and Public Health and the Harvard School of Public Health.

Following the passage of the HITECH Act in 2009, more than 5,000 hospitals became eligible for financial incentives to adopt and engage in "meaningful use" of electronic health records. Early results show that more than half of all eligible hospitals have qualified for incentives. The Act was motivated by the expectation that electronic health record use would improve the quality of care and reduce costs by avoiding inefficiencies, inappropriate care and medical errors.

However, some experts have suggested that the increased documentation abilities of electronic health records could lead to practices like upcoding, in which care providers select billing codes that reflect more intensive care or sicker patient populations, or record cloning, which involves copying and pasting the same examination findings for multiple patients. Both these issues could drive up health care costs by documenting and billing for care that did not occur.

The study, by Julia Adler-Milstein, U-M assistant professor of information, and Ashish K. Jha, Harvard professor of public health, is published online in the July issue of Health Affairs.

"There have been a lot of anecdotes and individual cases of hospitals using electronic health records in fraudulent ways. Therefore there was an assumption that this was happening systematically, but we find that it isn't," said Adler-Milstein, who is also an assistant professor of health management and policy in the U-M School of Public Health.

To examine these claims, the researchers analyzed longitudinal data to determine whether U.S. hospitals that had recently adopted electronic health records had greater subsequent increases in the severity of patents' conditions and payments from Medicare, compared to similar hospitals that did not adopt. The research focused on hospitals that would be likely to change their coding practices: for-profit hospitals, hospitals in competitive markets, and hospitals with a substantial proportion of Medicare patients.

Despite widespread stories and concerns among policymakers about the potential for electronic health records to increase fraudulent billing, the authors found that adopters and non-adopters increased their billing to Medicare at essentially identical rates. They found the same results among the groups of hospitals most likely to use electronic health records to increase coding and revenue.

With no empirical evidence to suggest that hospitals are systemically using electronic health records to increase reimbursement, the study's findings should reduce concerns that EHR adoption by itself will increase the cost of hospital care.

The results also suggest that policy intervention to reduce fraud is not likely to be a good use of resources. Instead, the authors recommend that policymakers focus on ensuring that hospitals use EHRs in ways that are most likely to reduce health care spending and improve the quality of care.

The paper is titled, "No Evidence That Hospitals Are Using New Electronic Health Records to Increase Medicare Reimbursements." Health Affairs is a peer-reviewed journal focusing on health policy thought and research. The study will be published in an upcoming print edition of the monthly journal.



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The Lessons Thus Far From the Transition to Digital Patient Records

The Lessons Thus Far From the Transition to Digital Patient Records | EHR and Health IT Consulting | Scoop.it

Soon after the financial crisis hit, the Obama administration decided to toss into the economic stimulus package a carrot to accelerate the computerization of health care. Within the roughly $800 billion pump-priming project, the health technology initiative could be seen as a modest down payment on the future: about $20 billion in incentives spread over several years to encourage doctors and hospitals to move from paper records into the computer age. The Bush administration had championed the cause, and, seizing a crisis-created opportunity, the Obama administration put up the money.

But ever since, the government-promoted drive for electronic health records has been assailed as everything from a handout to greedy tech companies to the advance guard of socialist medicine. In an editorial in February 2009, The Wall Street Journal called the program a “stalking horse for government-run health care.” Forecasts and studies of the impact of the incentive program have been similarly varied. Some predicted big dollar savings and improved care, while others came to the opposite conclusion, seeing higher costs and medical errors induced by complex technology.

At first glance, a new research paper, published in this month’s issue of Health Affairs, only adds to the confusion. The research paper found no evidence that hospitals adopting electronic health records were systematically using them to drive up their billings. The research by Julia Adler-Milstein, an assistant professor at the University of Michigan School of Public Health, and Ashish K. Jha, a professor at the Harvard School of Public Health, would seem to contradict an analysis done in 2012 by The New York Times and a similar one by the Center for Public Integrity, a nonprofit investigative journalism group. Both those analyses found higher costs for Medicare patients at hospitals using electronic health records.

In an interview, Dr. Jha said his research with Ms. Adler-Milstein did not refute the findings of The Times and the Center for Public Integrity. Certainly, Dr. Jha said, there were cases of doctors, nurses and clinic assistants using the automated point-and-click and cut-and-paste features of computerized health records to change the billing codes for treatment to patients and to charge more. But the new research, Dr. Jha said, covered a broader slice of data, including inpatient hospital billing as well as the emergency room reimbursements that, along with visits to doctors’ offices, were the main focus of the Times analysis.

The research with Ms. Adler-Milstein, he noted, also included a control group to adjust for factors like digital-record users being more likely to be larger institutions and teaching hospitals, which are more effective at billing and may be sent more seriously ill patients.

The researchers did not find systematic higher Medicare billing in hospitals that was attributable to electronic health records. “The bottom line,” Dr. Jha said, “is we didn’t see it.”

The Health Affairs article refers to the Times analysis, which “pointed to an association between E.H.R.s and higher payments” as helping to fuel concern about the potential for fraud and abuse. Dr. Jha said the Times analysis also prompted his research with Ms. Adler-Milstein — to look for how widespread the problem might be, or not.

Dr. Jha said he was surprised they did not find systemic higher billing, but Ms. Adler-Milstein, a former graduate student of his at Harvard, said she was not. Her assumption, she said, was rooted in simple economics. Hospitals in general operate on slender profit margins, she observed, so “lots of resources are devoted to maximizing coding using all available information in the paper or electronic record.”

The concerns raised have also brought government scrutiny to the potential for using digital technology to overbill and inflate costs.

Dr. Jha has been studying the impact of digital health records for years. A research paper he published in late 2009, as the federal government was about to embark on the incentive program, cast doubt on how much hospitals that had already adopted electronic health records had achieved lower costs and improved care.

Today, Dr. Jha says he remains skeptical. Some things have changed markedly. In 2008, 9.4 percent of the nation’s hospitals were using basic electronic health records, according to the American Hospital Association. By 2013, the percentage had soared to 59.4 percent, propelled by the federal incentive program.

“So far,” Dr. Jha said, “we’ve mostly spent a lot of money to transition from paper to electronic records.”

No one thinks a modern health care system can cling to paper records. But the policy goal of the federal incentive program was to use digital technology to curb costs and improve care. The legislation was called the Health Information Technology for Economic and Clinical Health Act. And there are examples of health care providers that use digital patient records effectively — mostly large medical groups, like Kaiser Permanente, the Mayo Clinic, the Cleveland Clinic and the Marshfield Clinic, that have worked with the technology for years.

But Dr. Jha said there was “certainly not yet” evidence of a payoff nationally from the federal incentive program.

That is hardly surprising. The economic dividend from any technology, from steam power to the electric engine to the computer, takes time to appear, as people figure out how to make the best use of the new tool. In 1987, when the personal computer revolution was more than a decade along, Robert M. Solow, a winner of the Nobel in economic science, mordantly observed, “You can see the computer age everywhere but in the productivity statistics.” By the 1990s, the impact on productivity became evident.

The principle of the technology-payoff time lag is true in many industries. But in health care, there is a case for special vigilance as well as for patience. The more digital patient records and decision-support software become part of diagnosis and treatment, the higher the stakes: In health information technology, there are no clinical trials or tests with randomized controls, as there are for drugs, for example. True, digital data does not go into the body, but it can increasingly guide what does.

That is why the Food and Drug Administration, in cooperation with the National Coordinator for Health Information Technology and the Federal Communications Commission, is developing what the government calls a “risk-based regulatory framework” for digital health technology. It is also a reason Dr. Jha says he believes the federal incentive program, which got under way in earnest in 2011, will be stretched out to eight or 10 years rather than the five years of the original plan.



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EHR + Geography = Population Health Management

EHR + Geography  = Population Health Management | EHR and Health IT Consulting | Scoop.it

Duke Medicine is combining the data of EHRs with geography information to create a program which can predict patient diagnoses.

Duke University Medicine is using geographical information to turn electronic health records (EHRs) into population health predictors. By integrating its EHR data with its geographic information system, Duke can enable clinicians to predict patients' diagnoses.

According to Health Data Management, Sohayla Pruitt was hired by Duke to run this project; she has a master’s degree in geographic information systems, or GIS. “I thought, wow, if we could automate some of this, pre select some of the data, preprocess a lot and then sort of wait for an event to happen, we could pass it through our models, let them plow through thousands of geospatial variables and [let the system] tell us the actual statistical significance,” Pruitt says. “Then, once you know how geography is influencing events and what they have in common, you can project that to other places where you should be paying attention because they have similar probability.”

iHealth Beat explains that the system works by using an automated geocoding system to verify addresses with a U.S. Postal Service database. These addresses are then passed through a commercial mapping database to geocode them. Finally, the system imports all U.S. Census Bureau data with a block group ID. This results in an assessment of socioeconomic indicators for each group of patients.

“When we visually map a population and a health issue, we want to give an understanding about why something is happening in a neighborhood,” says Pruitt. “Are there certain socioeconomic factors that are contributing? Do they not have access to certain things? Do they have too much access to certain things like fast food restaurants?”

Duke is working to develop a proof of concept and algorithms that would map locations and patients. They are also working on a system to track food-borne illnesses.

“It’s easy to visualize or just say, ‘Oh, this person lives in a low income neighborhood with lots of fast food restaurants.’ You could probably do that very quickly,” Pruitt says. ”But the only way to really understand the statistical significance of what’s going on and where else it’s happening or going to happen is through infrastructure development, by pre-downloading that data, prepping and pre-relating that data to every address and every EHR.”



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Promoting Patient Safety Through Effective Health IT Risk Management

Promoting Patient Safety Through Effective Health IT Risk Management | EHR and Health IT Consulting | Scoop.it

Everyone agrees that health IT safety is important.  Promoting Patient Safety Through Effective Health Information Technology Risk Management is a research report that looks into the challenges faced by hospitals and ambulatory practices that implement health IT risk management interventions.  The research was conducted by RAND Corporation and the ECRI Institute under contract to ONC.

The research report finds that health IT safety often competes with other  pressing priorities  for limited resources within health care organizations.  It also tells us that users of electronic health records (EHRs) see EHRs as a solution to patient safety problems, and may not understand new risks that may be introduced by EHRs.

This study involved 11 organizations and six case studies.  Some of the main findings are:

Readiness

  • Organizations with the highest level of readiness to engage in detecting and mitigating health IT risks have in-house expertise and prior experience in conducting organizational quality improvement and risk management projects.   Organizations without such experience may find it challenging to detect and mitigate health IT risks.

Alignment with other Initiatives

  • “Previously known problems” with the EHR were more likely to be selected as targets of intervention than were problems identified through a diagnostic assessment.
  • Projects appeared more likely to progress if they were aligned with the organization’s other priorities and current initiatives, such as attesting to the requirements of the Medicare and Medicaid EHR Incentive Programs.

Organizational Leadership

  • Organizations whose project teams had close involvement of executive leadership were more likely to make progress in identifying and mitigating safety risks.

Challenges in Identifying Health IT Safety Risks

  • Organizations tended to view health IT as a solution to patient safety problems, while overlooking the potential of health IT to contribute to safety problems or to create new types of safety risks.
  • Ambulatory practices encountered greater challenges than hospitals in identifying and addressing health IT safety risks.

Challenge of Matching Project Scope and Resources to the Demands of the Health IT Safety Project

  • The most frequently cited challenge to successful implementation of projects was the timely and adequate allocation of staff effort and other resources to the project.
  • Mismatch between the selected scope of the project and the available staffing sometimes led to poor project design (even when substantial expertise was available within the organization).

Practical Tools to Identify and Address Health IT Safety Risk

  • Health care organizations, and in particular small ambulatory practices, need tools to help them identify and address safety risks attributable to health IT.
  • Current patient safety reporting tools would benefit from innovations to improve efficiency.

ONC has begun to address some of the challenges identified in the research report.  Most importantly, the SAFER Guides, posted by ONC earlier this year, help EHR implementers learn about risks associated with EHRs and offer “recommended practices” for avoiding those risks and optimizing the use of EHRs to make care safer.   ONC has also published a guide on How to Identify and Address Unsafe Conditions Associated with Health IT.

The Agency for Healthcare Research and Quality (AHRQ), patient safety organizations, and health IT software developers are working to make the reporting of adverse events easier, using the Common Formats.  In addition, ONC is working with The Joint Commission to help health care providers understand, avoid, and mitigate risk factors that may be created by health IT safety events.

We encourage you to review this research report and join a dialogue about how to promote the safety and safe use of EHRs.



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EHR payouts climb near $25 billion | Healthcare IT News

EHR payouts climb near $25 billion | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

Electronic health records incentive payments to eligible hospitals and providers have continued their upward trend, with the Centers for Medicare and Medicaid Services paying out a whopping $24.4 billion to date.    That rose steadily from June's $23.7 billion, and May's $22.9 billion.   Also on the rise are the numbers of participating Medicare eligible providers, which climbed 991 to 317,294, Medicaid EP's increased 1,249 to 157,890 and hospitals inched up by 10 to 4,737.   [See also: EHR incentive cash climbs to $24B.]   Most of the attention and subsequent questioning during the HIT Policy Committee meeting on Tuesday focused on the finding that just eight eligible hospitals and fewer than 1,000 have attested to Stage 2 of meaningful use.   Elisabeth Myers of CMS' office of e-health standards and services cautioned that it would be "dangerous" to draw conclusions from such a small data set, since the only EPs and EHs that were even in the running to attest to Stage 2 by now were those providers that had installed a 2014-certified EHR by Jan. 1 of this year, conducted a calendar-quarter reporting period by April 1, and attested by June 30.   Delving into the demographics shows that there aren't any major differences across various hospital and medical group size; however urban professionals are slightly overrepresented this time, said Jennifer King, chief of research at ONC's office of planning, evaluation and analysis.   In terms of organization size, King added, ONC sees a good proportion of smaller practices in the Stage 1 cohort that would be able to go to Stage 2.



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Physicians prefer VistA, so should decision makers | Healthcare IT News

Physicians prefer VistA, so should decision makers | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

Let’s start simply with the results. The questions will come later.

In their 2014 EHR Report—a survey of 18,575 physicians on their EHR preferences—Medscape concludes that doctors like using the VA’s Computerized Provider Record System (CPRS), the core electronic record in the broader VistA platform, more than any other solution.

Here’s what they said.

The highest-rated EHR, with a score of 3.9, is the Veterans Administration EHR: VA-CPRS. It’s regarded as one of the best overall by our physician respondents.

(Of course, Medscape said a great deal more than this about CPRS and EHRs in general. And their survey revealed much about how physicians view the use of EHRs and the vendors who provide them. I would encourage anyone who’s interested to look at the report in more detail.)

With regard to physician satisfaction, Epic finished in 8th place, Cerner was rated 15th best and Meditech 18th. Scattered among these enterprise solution providers are practice-based EHR vendors like Practice Fusion, Amazing Charts, Medent and eMD’s.

So, why is VistA CPRS the preferred choice? In a word, design. The VA built the system with two design goals: improved patient care and rapid adoptability. Physicians at the VA rotate through services and the system has to be adoptable with minimal (2 hours) training; they learn it as they take care of patients.

Other studies confirm that physicians find VistA CPRS “straightforward” to use.  Because it was designed to take better care of patients, doctors can see how the system directly and positively impacts clinical care, which is not the default product of EHR use.

A summary of categories in which VistA CPRS was rated number 1 among enterprise solutions illustrates how well the VA did in meeting physician needs.

  • #1 – Ease of data entry
  • #1 – Physician satisfaction
  • #1 – Staff satisfaction
  • #1 – Overall usefulness
  • #1 – Usefulness as a clinical tool
  • #1 – Connectivity
  • #1 – Reliability
  • #1 – Practice Situation: Hospital Network
  • #1 – Practice Situation: Independent

Maybe you’re wondering how a government-derived software system could be more highly rated than private sector alternatives. As mentioned above, the VA’s goals are to develop a system that improves care for veterans and is easy to learn. Contrast that with the natural overarching goals of proprietary EHR providers, which is to automate the enterprise and make money.

Complex systems require extensive and expensive training, and certification courses. They create dependency on an omniscient vendor for support and development.  And most enterprise systems started as administrative departmental applications and then morphed to incorporate the clinical side. Ease of use and patient outcomes were not primary concerns in their design.

Importantly, proprietary enterprise systems are also not easily interoperable, and even if they can be, proprietary vendors would often rather they not, thank you very much.

VistA CPRS was rated best for connectivity, “scoring 4.0 or better in all domains measured.”  The Medscape report also comments on the growing importance of connecting physicians to improve care coordination.

Connectivity becomes increasingly more important as concepts of “care coordination” take hold, and also as hospitals and private practices work to make their operations more efficient … According to the Office of the National Coordinator for Health Information Technology (ONC), only a minority of physicians with EHRs from different vendors are exchanging clinical summaries of patient visits with other physicians.

So, if VistA is the preferred choice, why is adoption of VistA-derived systems outside the VA so low? One explanation is lack of awareness.  How many hospitals and clinics know that VistA code is public domain and available without expensive license fees?  That private companies are succeeding by offering development and support  for VistA-based solutions?

Of course, the other explanation is that decision makers think the success of VA VistA is irrelevant—that it’s a nice story and good for veterans, but ultimately of little use in the non-federal healthcare sector.

This is simply untrue.

Well, for large academic medical centers and cash-rich nonprofit (cough, cough) healthcare systems, it may be true. I mean, who would ever stand in the way of a hospital’s right to overpay for Epic?

But most of American healthcare—independent and resource-challenged hospitals and clinics that dot the landscape and serve the most needy—does not live in that world. To increase efficiency and lower costs, America needs an affordable, customizable and robust solution that can interface with just about anything, including Epic.

As the Medscape report makes clear, there is really only one system that meets those requirements. Given the high level of dissatisfaction with EHRs, especially among physicians, and how difficult it is to realize health IT transformation in any organization, there is wisdom in adopting a system that minimizes opposition.



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What EHR/PM vendors should do as 63% of buyers look to replace existing PM solutions

What EHR/PM vendors should do as 63% of buyers look to replace existing PM solutions | EHR and Health IT Consulting | Scoop.it

Melissa McCormack, a medical researcher with EHR consultancy group Software Advice, recently published their medical practice management BuyerView research, which found that 63% of the buyers were replacing existing PM solutions, rather than making a first-time purchase.  This mirrors the trend we’ve seen across medical software purchasing, where the HITECH Act may have prompted hasty first purchases of EHR solutions, followed by replacements 1-2 years later. For PM vendors, this means there’s a huge opportunity to market your products to practices as an upgrade, even if they’re already using PM software. I reached out to Melissa to ask her to elaborate on the implications of the trends she found in her recent research. Here’s some advice for vendors and solutions providers.

1. As EHR meaningful use requirements grow more involved, standalone billing or scheduling systems are becoming less viable. In fact, nearly 70 percent of the buyers we spoke with wanted integration between practice management and EHR. The trend of PM buyers looking for robust EHR integration grows more pronounced each year, and shows no signs of tapering off since EHR meaningful use requirements increasingly require physicians to utilize charting, billing and scheduling in tandem. Vendors who can offer seamless integration between these applications will have a clear advantage over those who cannot.

2. Another regulatory pressure influencing PM software replacement is ICD-10. Compliance with the new code set is a major driver not only of practice management purchases in general, but specifically of replacements—25% of buyers replacing an existing solution cite a concern that their current solution wouldn’t support the code set switch. Despite the implementation deadline having been extended to October 2015, we’re seeing practices give a lot of thought to preparation, and they’re realizing the software they use will play a major role in their own readiness. Vendors who are confident in their ICD-10 readiness should take care to communicate that confidence to their existing users, as well as marketing it to prospective customers.

3. The medical practice management software buyers we talk to clearly prefer cloud-based systems. Among buyers with a preference, 88% want cloud deployment. We’re hearing from smaller practices that they value the low up-front costs, as well as not needing to maintain servers and dedicated IT staff. Additionally, buyers appreciate the remote access options afforded by cloud solutions. Some buyers even seem to conflate “cloud” with “remote access” and “mobile access” (even though those features aren’t unique to cloud-based products), suggesting these are the features of cloud-based software they are most concerned with. In fact, almost 20% of buyers identified mobile access as a top priority. Vendors who offer mobile support are at an advantage and should highlight their capabilities prominently.

4.  Practice management software buyers come from diverse roles within practices. We saw clinicians and administrative staff represented almost equally—46% and 40%, respectively—among our buyer sample. Vendors should consider their audiences when marketing their products and tailor communication accordingly, giving equal weight to the unique benefits for clinicians and administrators.



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Readers Write: Data Exchange with C-CDA: Are We There Yet? | HIStalk

Readers Write: Data Exchange with C-CDA: Are We There Yet? | HIStalk | EHR and Health IT Consulting | Scoop.it

Do you think you have all the interoperability criteria to meet current and future stages of the EHR Incentive Programs? A new study published in JAMIA found that most providers don’t.

The study concluded that providers likely are lacking critical capabilities. It found that some EHR systems still don’t exchange data correctly using Consolidated Clinical Document Architecture (C-CDA), which may prevent providers from receiving future Meaningful Use (MU) incentives.

After sampling several platforms used to produce Consolidated Clinical Document Architecture (C-CDA) files, the research team from the Substitutable Medical Applications and Reusable Technology (SMART) C-CDA Collaborative — funded by the ONC as part of the SHARP research program — found a number of technical problems and obstacles which prevented accurate data exchange between different EHR systems.

There is already wide-scale production and exchange of C-CDA documents among healthcare providers this year due to the EHR incentive program and for meeting Meaningful Use requirements. Indeed, live production of C-CDAs is already underway for anyone using 2014 Certified EHR Technology (CEHRT). C-CDA documents enable several aspects of Meaningful Use, including transitions of care and patient-facing download and transmission.

Stage 2 Meaningful Use requires that providers be capable of producing C-CDA files, which contain both machine-readable and human-readable templates used to exchange patient data between EHRs during transitions of care. While all 2014 CEHRT must have the ability to create these files, some vendors are unfortunately not using the basic XML and HL7 technology correctly.

To find out how these variations affect providers and their participation in Stage 2, the researchers sampled 107 healthcare organizations using 21 EHR systems. They examined seven important elements of the documents: demographics, problems, allergies, medications, results, vital signs, and smoking status, all of which are required to be included in the C-CDA for Stage 2. They found errors in the XML that conflicted with HL7 standard usages, rendering the document ineligible to meet the Stage 2 rules for interoperability.

One key takeaway from this research is that live exchange of C-CDA documents is likely to omit relevant clinical information and increase the burden of manual review for provider organizations receiving the C-CDA documents. Common challenges included omission or misuse of allergic reactions, omission of dose frequency, and omission of results in interpretation. Unfortunately, only some of these errors can be detected automatically.

The team found 615 errors and data expression variation across 11 key areas. The errors included “incorrect data within XML elements, terminology misuse or omission, inappropriate or variable XML organization or identifiers, inclusion versus omission of optional elements, problematic reference to narrative text from structured body, and inconsistent data representation.”

"Although progress has been made since Stage 1 of MU, any expectation that C-CDA documents could provide complete and consistently structured patient data is premature," the researchers warned. The authors also note that more robust CEHRT testing and certification standards could prevent many of these troubling errors and variations in the technology and that the industry may also benefit from the implementation of data quality metrics in the real-world environment.

The researchers recommended several steps to improve interoperability: providing richer, more standardized samples in an online format; requiring EHR certification testing to include validation of codes and vocabulary; reducing the number of data elements that are optional; and improving monitoring to track real-world document quality.

The researchers make the case for using a lightweight, automated reporting mechanism to assess the aggregate quality of clinical documents in real-world use. They recommend starting with an existing assessment tool such as Model-Driven Health Tools or the SMART C-CDA Scorecard. This tool would form the basis of an open-source data quality service that would:

  • Run within a provider firewall or at a trusted cloud provider
  • Automatically process documents posted by an EHR
  • Assess each document to identify errors and yield a summary score
  • Generate interval reports to summarize bulk data coverage and quality
  • Expose reports through an information dashboard
  • Facilitate MU attestation

"However, without timely policy to move these elements forward, semantically robust document exchange will not happen anytime soon," the authors stated. “Future policy, market adoption and availability of widespread terminology validation will determine if C-CDA documents can mature into efficient workhorses of interoperability,” the report concludes. It would seem that if policy changes are not put in place, there could be risk in the Meaningful Use program not actually being all that meaningful.

This month CMS released the proposed 2015 Physician Fee Schedule. Among other things,it includes proposals to revise the physician supervision requirements for Chronic Care Management (CCM) services and proposes to require CCM practitioners to use EHRs certified to meet at least the 2014 Edition Meaningful Use criteria, which require the ability "to capture data and ultimately produce summary records according to the HL7 Consolidated Clinical Document Architecture standard."

Since this new proposed rule includes expanding the use of the certification program beyond Meaningful Use and specifically mentions the C-CDA standard, I thought I would ask Joshua Mandel, one of the authors of the study, for his thoughts.

"It’s not too surprising that CMS’s efforts to improve chronic care management would build on Meaningful Use requirements," he said. "In the section you’ve quoted, CMS, is simply saying that Eligible Providers would need to use MU-certified systems (just as they must use MU-certified systems to attest for MU incentive payments). And so C-CDA capabilities come along for the ride in that decision. I can certainly say C-CDA is better than nothing; and C-CDA 1.1 is a specification that exists and has been implemented today, so it’s a natural choice here."

While there are challenges in implementing and making good use of C-CDA documents, there is little doubt that HHS is continuing to drive the use of these standards forward through various policy levers. The ability to exchange relevant clinical information for transitions of care is a key enabler in transforming our healthcare system to paying for quality instead of quantity.

Despite these challenges, we are beginning to see success in the marketplace. Building on this success and continuing to improve content standards is critical if true interoperability is to become a reality.


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New challenge for team that passed Turing test: health insurance

New challenge for team that passed Turing test: health insurance | EHR and Health IT Consulting | Scoop.it
Starting in January, group medical practices and integrated health care systems that serve counties in five states, including California, will encourage patients to enroll in Medicare through Wholesale Change, the company told The Chronicle. To some computer scientists, a machine that passes the test crosses a threshold distinguishing human intelligence from artificial intelligence. "How much can we rely on a low Turing test threshold for interaction with a simulated 13-year-old to lead us to an intelligent and complex health care decision?" said Noah Lang, CEO of Stride Health, a San Francisco website that also generates personalized insurance recommendations. According to a 2009 analysis by the Kaiser Family Foundation, just 10 percent of Medicare beneficiaries choose the cheapest prescription drug plans available. Another co-founder and the chief technology officer, Anwar Parvez, is a senior director at Software AG, an enterprise software company with 10,000 customers. On top of the standard hospital and medical insurance, there are options for managed health care, prescription drug plans and policies that provide supplemental coverage. In late 2012 and early 2013, Wholesale Change tested the service on more than 5,000 patients in California. Because the site wasn't up, most users talked to a person on the phone who asked the same questions that the site would. Prestige from Turing testSonny Patel, CEO of CadenceCare, which does billing and other services for physicians in Los Angeles, said his doctors will start advertising Wholesale Change's services to patients in August. Others say the test is irrelevant to the field, which is making huge strides in tools such as speech recognition and responsive apps and search engines.
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VA reduces admissions by 35% due to telemedicine services | EHRintelligence.com

VA reduces admissions by 35% due to telemedicine services | EHRintelligence.com | EHR and Health IT Consulting | Scoop.it

The VA might be struggling to find its way out of very hot water when it comes to its scheduling services, but there’s more to the healthcare system than the mushrooming scandal. The VA has long been a leader in the telemedicine arena, and a new study published by Adam Darkins, Chief Consultant for Telehealth Services, highlights some very positive results from the suite of programs and pilots. Eleven percent of veterans received some portion of their care remotely in 2013, with the number of patients accessing telehealth through the VA growing approximately 22% annually, Darkins says. Remote programs have contributed to a 35% reduction in hospital admissions among home telehealth patients and a 59% reduction in bed days of care throughout 2013.


In the past year, the VA’s telehealth services have provided nearly 1.8 million episodes of care to over 608,000 patients. Forty-five percent of those patients lived in rural areas with limited access to physical facilities, and may not have received adequate care without clinical video services, mHealth, and home health services to support self-management for depression, PTSD, and other chronic conditions. Of the 144,520 patients enrolled in home telehealth services, 41,430 are living independently in their own homes instead of relying on long-term institutional care.


The successful home telehealth program has saved approximately $2000 per patient per annum, Darkins reports, with a patient satisfaction score of 84 percent. Clinical video telehealth services, which cover 44 specialties including dermatology, cardiology, mental health, and amputation care, has produced a 94% patient satisfaction score and a savings of $34.45 per consultation.


Remote mental health care reduced bed days of care by 38 percent, the study adds, with more than 1.1 million patient encounters delivered since 2003. In 2013 alone, there were 278,000 patient encounters dealing with mental health at more than 150 VA medical centers and 729 community-based outpatient clinics. Almost 7500 patients with chronic mental health conditions are living independently thanks to telehealth support.


“Telehealth training is not offered in medical schools, or included in health professional curricula,” Darkins writes. “With over 8,146 sites of care many in rural and remote locations, technology support is a critical success factor in developing telehealth services, and a risk that must be mitigated in their subsequent sustainment. Telehealth crosses traditional boundaries between information technology and biomedical engineering services, requiring comprehensive and dedicated support.”


“Telehealth in VA is the forerunner of a wider vision, one in which the relationship between patients and the health care system will dramatically change with the full realization of the ‘connected patient,’” Darkins concludes. “The high levels of patient satisfaction with telehealth, and positive clinical outcomes, attest to this direction being the right one.”

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eClinicalWorks CEO Girish Navani Talks the EHR’s Role in Population Health Management

eClinicalWorks CEO Girish Navani Talks the EHR’s Role in Population Health Management | EHR and Health IT Consulting | Scoop.it

eClinicalWorks’ CEO Girish Navani discusses the success his company has had with EHR development, the role EHRs play in population health management, and how the latest data-based technologies are opening up new possibilities for providers.

You don’t have to look far to find fault with EHR products these days. In fact, conduct a quick news search online and you’ll find that most of it isn’t too good. The sophisticated possibilities of EHR integration have given way to complex problems for providers, leaving many asking, where did EHRs go wrong?

For that answer, we turned to a company with a thought leader who seems to be getting it right. “Our success has been two fold,” said Girish Navani, the co-founder and CEO of eClinicalWorks, a provider of ambulatory HIT solutions, including EHRs and practice management solutions. “We have built an EHR that is more intuitive, but the fact that our EHR does more than the standard EHR out there is what has helped us really go further.”

It’s that very act of attempting to go further that seems to be snagging many providers’ plans as the move from the lighter criteria of Stage 1 of meaningful use (MU) and onto the more stringent criteria of MU, Stage 2, which includes patient engagement and sharing EHR data as its cornerstones. Organizations looking to satisfy the accountable care models, which rely on population health management (PHM) practices, are hitting the similar snares of interoperability and lack of engagement features with their EHR/EMR products.

As a result, many providers are looking to swap or supplement their technology to gain access to more sophisticated tools. While this has sent some technology vendors scrambling, eClinicalWorks is busy building upon its successful foundation; it’s one of the top two EHR developers in the market serving more than 85,000 providers in all 50 U.S states. The company has moved swiftly from EHR development to offering a variety of products, including its eClinicalWorks CCMR, the most used population health solution across all function ACO categories, according to KLA



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EHR Replacement Roadmap to Success | EMR and HIPAA

EHR Replacement Roadmap to Success | EMR and HIPAA | EHR and Health IT Consulting | Scoop.it

We’re just now starting down the road of the EHR replacement cycle. Meaningful use has driven many to adopt an EHR too quickly and now the buyer’s remorse is setting in and we’re going to see a wave of EHR replacements. Some organizations are going to wait until meaningful use runs it course, but many won’t even be able to wait.

With this prediction in mind, I was interested by this Allscripts whitepaper: Key Hidden Reasons Your EHR Is Not Sustainable and What To Do About It. I always learn a lot about a company when I read whitepapers like this one. It says a lot about the way the company thinks and where they’re taking their company.

For example, in the whitepaper, Allscripts provides a list of questions to consider when looking to replace your EHR:

  • How do you DEPLOY the right core IT systems to succeed with value-based care?
  • How do you CONNECT to coordinate care with key stakeholders and manage your population?
  • How do you better ENGAGE patients in their own health?
  • How do you analyze mountains of raw data to ADVANCE patient and financial outcomes?
  • How do you get everyone within your own organization to FOLLOW THE ROADMAP to EHR success?

You can see that these questions share a certain view of where healthcare IT and EHR is headed. Imagine how this criteria would compare with the criteria for EHR selection even five years ago. Although, I wonder how many doctors really share this type of approach to EHR selection. Do doctors really want their EHR to handle the above list? Should they be worrying about the above items?

I don’t doubt that doctors are going to be more involved in population health and they’re going to need to engage patients more. However, this list does seem to lack some of the practical realities that doctors still need from their EHR. In fact, as I write this, I wonder if it’s still too early to know what a next generation EHR will need to include. Of course, that won’t stop frustrated EHR users from replacing their EHR just the same.



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There's more to eRx than you think | Healthcare IT News

There's more to eRx than you think | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

In followup to my guest post from Dr. Marvin Harper about e-prescribing gaps, John Klimek, senior VP of standards and information technology at NCPDP, wrote the following helpful guest post:   The National Council for Prescription Drug Programs leaders and members read with interest the guest post from Marvin Harper, CMIO at Boston Children's Hospital, entitled "Limitations of e-Prescribing Standards." Harper's thoughtful post brings a critical issue to light: the need for increased industry awareness and adoption of the full functionality that already exists in e-prescribing standards – going beyond the core requirements of meaningful use. Electronic prescribing is important in improving both the quality of patient care and patient safety. It provides a key point of communication between care providers and can help improve patient compliance with treatment regimens.   [See also: E-prescribing makes huge gains.]   E-prescribing standards: what's covered Three standards are used in e-prescribing: the NCPDP SCRIPT Standard and the NCPDP Formulary and Benefit Standard, and the ASC X12 Standards for Electronic Data Interchange Technical Report 3 – Health Care Eligibility Benefit Inquiry and Response – 270/271. The eligibility transaction is typically exchanged prior to the patient encounter and can supply the prescriber system with information about the patient's pharmacy benefit, including the payer, member ID, formulary and coverage pointers, and other details. The formulary and benefit standard provides a means for pharmacy benefit payers to communicate formulary and benefit information to prescribers via technology vendor systems at the point of prescribing. The file exchange includes information on formulary status, alternative drugs, co-pays and other information.  The healthcare industry is currently using SCRIPT Standard version 10.6 which contains thirteen different transactional exchanges for e-prescribing functions, including:  

  • Sending a new prescription;
  • changes to a prescription;
  • renewals and resupply exchanges;
  • cancellation of a prescription;
  • fill status notifications;
  • medication history; and
  • census exchanges.

Most of these transactions have been named in the regulations associated with the MedicareModernization Act. While the electronic exchange of new prescriptions, renewals and medication history have grown exponentially, implementation of other transactions has been very slow.   Other capabilities, including the specific issues raised by Harper, are also available in the existing standard, underscoring the urgent need to increase awareness and industry-wide adoption of the breadth of functionality afforded by the e-prescribing standards. Among them are:  

  • Structured and codified sig: promotes greater consistency in specifying directions and for clinical review/analysis. The current version used by the industry contains a 140 byte free text field, along with fields to describe the route, indication, vehicle, site, timing and duration. The structured and codified sig format present in SCRIPT version 10.6 was not intended to support 100 percent of sigs; however a pilot found that 95 percent of the fully parsed sig strings were accommodated by the format. Enhancements incorporated in SCRIPT version 2012+ include a more robust Structured Sig Segment which supports a text field size of 1000, as well as other enhancements, recommendations and clarifications from the pilot.
  • Support for patient observations: allows prescribers to supply patient height, weight, diastolic and systolic blood pressure. Patient weight is useful for validating proper pediatric dosing. Based on questions posed by a Council on Clinical Information Technology Executive Committee article, recommendations for pediatric prescriptions were included in the SCRIPT Implementation Recommendations document publicly available for implementers here under "NCPDP Resources." A challenge is for the prescribing systems to send this information. Enhancements for more observation measurements were included in a more recent version.
  • Support for scheduled medications: provides fields necessary to enable e-prescribing of controlled substances.
  • Compound prescription support: approved in SCRIPT version 10.8 when industry champions came forward to analyze the needs and work through the requirements.
  • Adverse events/reactions: the NCPDP SCRIPT Standard supports the exchange of drug use review fields. The industry is actively exploring adding the use of adverse events/reactions/etc., which is used in other transactions, for the use in the e-prescribing transactions via the NCPDP WG11 e-prescribing Best Practices Task Group.
  • Support for prior authorizations: provides the means to exchange information needed in prior authorization requirements, including access to information on covered medications at the point of care, information on PA approvals and denials. The ePA transactions were added in a more recent version that industry participants are actively implementing.

Moving the needle on adoption and implementation of e-prescribing standards E-prescribing standards have been enhanced based on requests by the industry which has opted to build functionality in layers. For example, the SCRIPT Standard version 10.6 was published in 2008, with enhancements that are approved and published at least twice a year. But publication is one action; implementation is another. So the question is: How do we move the needle to increase adoption and implementation of the e-prescribing standards?   1. Technology/system vendors can take the lead, or wait for a mandate – There are many demands on industry vendors for impact analysis, development, implementation, testing and distribution. Then there is coordination of both prescribing and pharmacy systems implementation, and all within regulatory requirements. In an effort to build a predictable, repeatable process, the industry will be examining if a cyclical implementation timeframe could be adopted to move versions in a more timely and expected manner. In the absence of a mandate, uptake on adoption and implementation depends on technology vendor priorities.   2. Share lessons learned to improve implementation guidance – Implementation can be slow when you are blazing new trails. The data itself is complex. It may be pulled from data that is not discrete or doesn't use the same nomenclature or requires the use of an unfamiliar vocabulary. The electronic exchange can be complicated. It forces analysis of manual workflows. Trading partners may be at different stages of implementation maturity. Benefits are seen from different perspectives. Industry experience in the use of the functionality available is needed, with lessons learned to improve future implementation. NCPDP has active task groups including e-prescribing Best Practices Task Group, Implementation of Structured and Codified Sig Task Group and many others that are open to materially interested parties to come together in consensus to develop industry guidance, implementation guidance and future enhancements to the standards.   The complex but vital enhancements to industry standards are developed by the dedicated volunteers across the healthcare industry who share questions, findings and recommendations. NCPDP, the standards development organization, provides the forum for this important work.



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EHR Incentive Market Share Charts Worth A Thousand Words | EMR and HIPAA

EHR Incentive Market Share Charts Worth A Thousand Words | EMR and HIPAA | EHR and Health IT Consulting | Scoop.it

One thing I really love about the government lately is their goal to be as transparent as possible. Certainly they still have a ways to go, but I think healthcare has done some significant things when it comes to transparency into the government health programs. A great example of this is the Health IT Dashboard which has all of the data for the various health IT programs.

I don’t want to steal Carl Bergman’s thunder, because he’s already posted some really interesting Hospital EHR market share data and his previous EHR market share data. Plus, he’s planning to dive into the meaningful use market share data next. I love the approach of multiple sources when it comes to evaluating EHR market share and so I look forward to his analysis of EHR incentive market share against the EHR adoption market share from Definitive Healthcare and SK&A.

Until then, I thought I’d give you a taste of the EHR vendor participation in the EHR incentive program. This data comes from the ONC dashboards listed above and are put into some really nice snapshots of the data by ONC.

First up is the data for EHR vendor attestations by eligible professionals (ie. ambulatory doctors):

And the EHR vendor attestations by hospitals:

It’s worth noting that the above data is just the EHR incentive money data. No doubt the actual EHR adoption data would have a few differences and include some companies in specialties that don’t qualify for EHR incentive money. Not to mention specialty specific EHR vendors who likely don’t make the chart even if they dominate their specialty. These charts do serve as an interesting proxy for EHR market share that’s worthy of discussion even if it doesn’t paint the full picture. Plus, even more important will be to watch the change in these numbers over time.

With that disclaimer, we could analyze this data a lot of ways. I’ll just offer a few interesting insights I noticed. First, 711 vendors have been used in the ambulatory EHR incentive program. That’s a lot of vendors. Only 78 of those 711 supply secondary EHRs as opposed to the primary EHR. 452 EHR vendors supply a primary EHR to less than 100 eligible professionals. 200 EHR vendors supply a primary EHR to fewer than 10 eligible professionals. These observations and a comparison of the ambulatory versus hospital EHR incentive charts’ “Other Vendors” shows how fragmented the ambulatory EHR market share is right now.

I was also intrigued that Mitochon Systems, Inc. was on the list even though they shut down their Free EHR software in May 2013. They had white labeled their EHR software to a number of other companies and so it will be interesting to see how that number evolves. I assume they sold the software to those companies, but I hadn’t heard an update.

On the hospital side of things, MEDITECH certainly doesn’t get the credit they deserve for the size of their install base. The same goes for CPSI, MEDHOST and Healthland. I think their problem is that people only want to read about the Mayo, Cleveland Clinic, and Kaiser’s of the world and so the articles about Billings Montana Hospital (I made that hospital up) rarely happen. I should find more ways to solve that since the small hospital market is huge.

I do wish that there was a way to divide the ambulatory chart into hospital owned ambulatory practices and independent ambulatory practices. That would paint an even clearer picture of that market.



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What If Your EHR Only Had 25 Doctors? | EMR and HIPAA

What If Your EHR Only Had 25 Doctors? | EMR and HIPAA | EHR and Health IT Consulting | Scoop.it

I recently had lunch with an EHR vendor that had an extremely small number of providers. I’ve known this EHR vendor for about 5 years, so this isn’t a new EHR vendor that’s trying to establish themselves in the industry. Instead they’ve focused on having a small, nimble team that’s focused on making the EHR work the right way for the doctors. It’s a novel approach I know, but pretty interesting that his business can survive with so few providers. Also worth noting is that the EHR is certified for meaningful use stage 2 as well.

Now think for a minute how the development process of an EHR vendor would be better if your EHR only had 25 doctors (For the record, the EHR vendor above has a few more than 25 doctors). Would it be much easier to satisfy just 25 physician users? Imagine the personalized service you could provide your users.

One of the real challenges I’ve seen with EHR vendors is that when they’re small, they are extremely responsive to their end users and the end users are very happy. As the EHR vendor grows, they lose that personal touch with the end users and many of those originally happy end users become dissatisfied with their EHR experience.

The problem with scaling an EHR user base is that you can’t make everyone happy. You have to make compromises that will be great in some people’s eyes and terrible in another person’s mind. What large EHR vendors do to try and solve this problem is they create configurable options that allow the end user to customize their system to meet their personal needs. Problem solved, right?

The problem with these configurations is two fold. First, you can’t make everything configurable. Once you go down the path of making everything configurable, it never ends. There’s always something else that could be made more configurable. So, the culture of configurability leads to unsatisfied users who can’t customize everything (even if what they want to customize shouldn’t matter).

Second, if everything is configurable, then it makes the implementation that much more complex. I’ve written before about the need for EHR vendors to have great “out of the box” user experience, but balancing that with allowing the user to configure everything that’s needed. This is a real challenge and most fail. Just look at the number of high priced EHR consulting companies out there. Many of them could better be defined as EHR configuration companies since the configuration needs are so large and complex.

Returning to where we started, when you’re an EHR vendor with 25 doctors you don’t have to build in all the flexibility and configurability. You’re small enough that as an EHR vendor you can do any needed customizations and configurations for the end user. Plus, with this kind of personalized service you can charge a little extra as well.

When you look at EHR development, there’s a spectrum of approaches starting with a fully in house, custom designed EHR through a fully outsourced EHR that can apply to any organization or specialty. In many ways a 25 doctor EHR has a lot of the same benefits of a fully custom EHR software, but spreads the costs of development across more doctors.

As a business, maybe a 25 doctor EHR company won’t dominate the world. Maybe they won’t have a huge exit to some other company or an IPO. However, that doesn’t mean it’s not a great small business if it’s doing something you love. Once you get World Domination out of your sites, it changes a lot of things about how you do business.



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EHRs And Disease Prediction

EHRs And Disease Prediction | EHR and Health IT Consulting | Scoop.it

Much of the chatter around electronic health records (EHRs) revolves around efficiency and cost cutting in clinical practice. There is even a bit of discussion about the use of EHRS to improve population health. But is there more benefit to be found in individual patient health?

Perhaps the greatest potential of the EHR, (and the concept applied to a broader application, the EMR) lies in the role it can play in predicting clinical outcomes around a range of diseases and conditions.

This application is still very much in its fledgling stage, but here are just a few examples of how data analytics, when applied to EHRs in mindful ways, can bring about positive changes in patient health.

Predicting Sepsis

One of the most recent examples we saw came out of UC Davis. Researchers there found that, by compiling and analyzing routine information — blood pressure, respiratory rate, temperature, and white blood cell count — as pulled from EHRs, they were able to predict early stages of sepsis, a condition that is a leading cause of hospitalization and death in the U.S. It took them only three measures — lactate level, blood pressure, and respiratory rate — to calculate the likelihood that a patient would die from the condition.

As of March of this year, the research team was working on a specific, sepsis-risk algorithm that would automatically be calculated in the EHR.

Progressing Kidney Disease

Data from EHRs has also played a key role in predicting the need for dialysis after a patient with chronic kidney disease progresses into kidney failure.

The Journal Of The American Medical Association in 2011 studied patients who were referred to nephrologists between April 1, 2001, and December 31, 2008, in an effort to develop and validate predictive models for the progression of chronic kidney disease.

According to the study, “Our models use laboratory data that are obtained routinely in patients with CKD and could be easily integrated into a laboratory information system or a clinic EHR.” It also notes that emerging literature suggests that the methods lead to “improved patient outcomes with individualized risk prediction and with advances in information technology that allow for easy implementation of risk prediction models as components of EHRs.”

All data for the study where pulled from nephrology clinic EHRs. Researchers found the use of routinely obtained laboratory tests can accurately predict progression to kidney failure in patients with chronic kidney disease between stages three and five.

Cardiovascular Risk

EHRs have also been used to improve cardiovascular risk prediction. A study (available from the National Institutes Of Health), analyzed whether internal EHR data (using flexible, adaptive statistical methods) could improve clinical risk prediction. The study used the fact that EHRs have been extensively implemented in the VA system as an opportunity for exploration.

It found that, “despite the EHR lacking some risk factors and its imperfect data quality, health care systems may be able to substantially improve risk prediction for their patients by using internally developed EHR-derived models and flexible statistical methodology.”

Controlling Hypertension

Another prevalent health issue in the U.S., hypertension, has seen researchers apply predictive analytics using EHR data to gain more insight into the disease. This study, from the Journal Of Informatics In Health And Biomedicine, sought to identify transition points at which hypertension is brought in, as well as pushed out of, control, through the use of EHR data.

The study of 1294 patients with hypertension (who were enrolled in a chronic disease management program at the Vanderbilt University Medical Center) found that accurate prediction of transition points from a control status could be achieved.

The most notable takeaway from all these examples is that in each one, EHRs were found to not only be a reliable and beneficial method in predicting patient outcomes, but that the analytics themselves were simple to perform and most likely easy to implement on a larger scale. These results spell opportunities for all solutions providers who work in using data analytics to bring improved results to their clients.



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Crafting a Next Generation IT strategy | Healthcare IT News

Crafting a Next Generation IT strategy | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

During my 16 years as CIO, I've witnessed the transition from client server to web, from desktops to mobile, and from locally hosted to cloud.   

As Beth Israel Deaconess merges and acquires more hospitals, more practices and more care management capabilities, what are its strategic IT choices?

I will not even mention "best of breed", because I think the industry has abandoned such a strategy as unworkable in an era when everyone needs access to everything for care coordination, population health, and patient/family engagement.

The choices are basically two

a.  Single monolithic vendor application for everyone everywhere
b.  Best of Suite - the smallest number of applications/modules that meet the need for business integration (defined in the graphic above)

It's extremely popular among academic medical centers, ACOs, and healthcare systems to choose "A", often at great cost.

BIDMC has a 30 year tradition of building and buying systems balancing costs, agility, and functionality.

As I plan for the next generation of IT systems, I favor "B" and believe I can achieve our business goals in shorter time, at lower cost, with less risk.

Here's the thinking.   

1.  At BIDMC, we need a web-based, mobile friendly, cloud hosted solution that has the agility to support rapidly evolving research, education, and clinical requirements.   The culture at BIDMC is not top down, command/control, willing to compromise but bottom up, collaborative, and impatient for innovation.    We will continue to build the core clinical systems at BIDMC until there is a vendor application that meets the cultural requirements and is affordable.

2.  At all other sites, we will use cloud hosted inpatient and ambulatory vendor-based systems that are aligned with the business requirements and culture of the institutions.

3.  Our budgets are very limited to serve 22,000 users and 3000 doctors.  Operating budgets for IT are 1.9% of the total spend.   Capital is about $10 million a year.   One time capital for major IT initiatives is unlikely to ever exceed $20 million.    When I hear about expenditures of hundreds of millions for IT systems, I really wonder how the economics are sustainable.

4.  Interoperability for care coordination across a small number of applications is possible via bidirectional viewing, pushing summaries, and pulling records via the state healthcare information highway.

5.  Business intelligence/analytics across the network is supported by financial and clinical registries, populated via well described interfaces.

Over the next 90 days stakeholders from throughout the organization will complete the next generation IT plan as follows:

July - strategy complete, draft budgets submitted
August - organizational structure for unified enterprise IT proposed, budgets finalized
September - staffing plan finalized and timelines aligned for execution beginning October 1

As with any plan, change management will be the most challenging aspect, balancing time, resources, and scope.

Over the coming months, I'll share the decisions we've made for a cloud of community hospital functionality and a cloud of ambulatory EHR functionality that unifies all our practices.



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E-prescribing makes huge gains | Healthcare IT News

E-prescribing makes huge gains | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

The prevalence of prescribing via electronic health records has skyrocketed over the past decade. Almost unheard of in 2006, nowadays more than 70 percent of physicians e-prescribe, according to new data from the Office of the National Coordinator for Health IT.

[See also: E-prescribing grows despite complaints]

Thanks in large part to two federal initiatives – first the Medicare Improvements for Patients and Providers Act of 2008, or MIPPA, and later meaningful usee-prescribing has made huge gains through the first quarter of 2014, the report from ONC's Meghan Hufstader Gabriel and Matthew Swain shows.

Using data from Surescripts, the nation's largest e-prescription network, the study shows a steep and steady climb for eRx – from 7 percent in 2008, when MIPPA was passed, to 24 percent in 2011, when meaningful kicked off, to 70 percent today.

[See also: eRx rate in NY state to see 'explosive growth']

The growth has occurred nationwide, Gabriel and Swain point out. At the end of 2008, only one state, Massachusetts, had physicians prescribing via EHR on the Surescripts network at a rate that exceeded 20 percent.

Just over two years later, in January 2011, 35 states could boast e-prescribing rates above 20 percent, with five states above 40 percent.

By this past spring, those numbers were even higher, with every state above 40 percent and 28 states exceeding 70 percent of their physicians using EHRs to prescribe. Minnesota, which stood at 100 percent; Iowa, at 95 percent; and Massachusetts, at 94 percent, had the highest rate of physicians e-prescribing as of April 2014.

Beyond the doctor's office, e-prescribing has made even bigger gains in pharmacies – in the same period, the percentage of community pharmacies nationwide wired to accept prescriptions via EHR has reached 96 percent. Maine and Delaware are the top two states, with 99 percent each.

Meanwhile the number of new and renewal prescriptions sent electronically has increased a whopping 14-fold, according to the ONC report. In 2008, just 4 percent of new and renewal prescriptions were sent electronically. By 2013, that number was 57 percent.

Interestingly, the four states with highest volume of prescriptions – California, Texas, New York and Florida – are all below the national average, Gabriel and Swain show, which "presents an opportunity to increase the proportion of new and renewals sent electronically among these states."



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Ending debate on EMR effectiveness? | Healthcare IT News

Ending debate on EMR effectiveness? | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

For at least the last decade, the health IT field has seen a scholarly back-and-forth on the effectiveness of electronic medical records. As soon as one study is published that finds technology has little impact on patient outcomes, another emerges that seems to show just the opposite.

These studies are frequently limited by the size of the data set or scope of the analysis. Take, for example, a June 2014 JAMA article that found meaningful users of electronic health records failed to deliver improved care for five chronic diseases. According to one news report, the new study cast “doubt on whether the tens of billions of dollars invested to encourage EHR adoption among healthcare providers is really enhancing patient outcomes.”

The analysis, it turns out, included just three months of data from 818 physicians (about .1 percent of the 834,769 active physicians practicing in the United States) across seven clinical quality measures. By the way, all those physicians were employed by a single hospital or its affiliated practices.

[See also: An EHR 'buying spree'? Maybe not quite.]

And the variable being studied? It distinguished physicians who qualified for MU1 against those who did not. Considering the low bar set by MU1, the distinction might not signify all that much.

So what if, instead, you had a data set that drew from ALL the hospitals in the United States. And what if that data ranked healthcare IT adoption not on MU1, but on a multi-tiered scale, from no technology use to completely paperless systems? And what if the outcomes studies included 19 patient cohorts in five service lines, from heart failure and pneumonia to sepsis and stroke, with findings adjusted for risk and other differences in patient health status?

That study might be a little more authoritative when it comes to evaluating "whether the tens of billions of dollars invested to encourage EHR adoption among healthcare providers is really enhancing patient outcomes."

[See also: Consider the power of incentives.]

And the good news is, that study now exists and it has found that EMRs do have a measurable, positive impact on care as measured by clinical outcomes of risk-adjusted mortality rates.  

The preliminary analysis is the first fruit of an effort to connect data from the HIMSS Analytics Database, and its comprehensive EMR adoption model (EMRAM), with Healthgrades' own hospital performance database, which measures hospitals on mortality and complication rates across multiple service lines.

Based on the joint study by HIMSS Analytics and Healthgrades, hospitals with high EMRAM scores showed improvement in the capture of data about the patient, measured by the predicted mortality rate in the Healthgrades model. And the actual performance (based on the actual number of mortalities) for hospitals with high EMRAM scores was significantly better than hospitals with low EMRAM scores in four specific conditions, indicating a relationship between the use of an EMR and the actual outcome.

One example is mortality from heart attacks. The mortality rate at high EMRAM facilities (9 percent) is half that of heart attack mortality at low EMRAM facilities (18 percent).

Of course, not all cohorts and service lines were equally affected by differences in health IT adoption. With neurosurgery, there is no mortality difference between high and low EMRAM facilities. But overall, all five service lines studied show statistically significant positive relationships to EMRAM scores for at least one group of diagnoses and procedures.

“For patients, they should know that the risk-adjusted outcomes – and the actual outcomes in some cases – are better at hospitals with higher EMRAM scores,” says Healthgrades Senior Data Scientist William R. Wyatt.

In total, 4,583 facility records were selected from HIMSS Analytics data, a segment that represents the total number of facilities with complete data from 2010 through 2012. That three-year time period was chosen because it aligns with the most recent Healthgrades reporting period.

"This effort is quite remarkable," notes Lorren Pettit, vice president of market research at HIMSS Analytics. "By working together, we’ve been able to provide one of the most comprehensive and detailed analyses of the association between EMR capabilities and quality outcomes."

Wyatt and Pettit say the collaboration is likely to continue and grow. Researchers from Johns Hopkins are now working with Healthgrades and HIMSS Analytics on a grant application to the Agency for Healthcare Research and Quality to move beyond these preliminary findings and assess the impact of EMRs on other outcome measures.



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Progress Slow for FDA Surveillance System

Progress Slow for FDA Surveillance System | EHR and Health IT Consulting | Scoop.it

The Food and Drug Administration’s active surveillance system designed to search health data to uncover adverse safety events for newly approved drugs is coming under fire from critics who say that progress is coming too slowly.


Aaron Kesselheim, M.D., a health policy researcher in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham & Women’s Hospital in Boston and an Assistant Professor of Medicine at Harvard Medical School, believes the FDA’s Sentinel system is promising, but says the jury is still out on whether the regulatory agency will in fact succeed in achieving its goal.


“The problem is that the essential work in the Sentinel system of distinguishing the signal of the safety event from the noise of everything else that’s going on with a drug in the post-approval observational setting is really very, very hard,” Kesselheim  told a July 9 congressional hearing. “In the last six or seven years, the Sentinel initiative has been focused on the methods used to try to do this and has made relatively slow, steady, little progress in trying to assess these kinds of methods.”     

As proof, he added that the FDA “itself still refers to the Sentinel initiative as the Mini-Sentinel pilot program now six or seven years out from its creation.” Mini-Sentinel is leveraging electronic healthcare data--principally claims data but also including data from EHRs--to monitor the safety of FDA-regulated medical products.

According to Janet Woodcock, M.D., director of the FDA’s Center for Drug Evaluation and Research, theMini-Sentinel system can survey more than 350 million person years of observation, 4 billion pharmaceutical dispensings, and 4.1 billion patient encounters.

Woodcock testified July 11 before a congressional hearing thatSentinel uses pre-existing electronic health care data from 18 data partners, capturing information on more than 150 million patient lives. Eighteen large healthcare organizations from across the United States, including Aetna, Humana and Kaiser Permanente, are serving as data partners for Mini-Sentinel.


However, Kesselheim warns that there is “still much, much more to be done before we can rely on the Sentinel initiative for any sort of real active surveillance and I think that that’s far in the future.”

“My understanding is that the funding of the Sentinel initiative going forward is still up in the air. So, I would encourage Congress to continue to fund it. But, I would also not get peoples’ hopes up that the Sentinel system is going to be some white knight from a post-market surveillance point of view,” he said.

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Electronic Health Records & the Data of Health Care [Infographic] - datascience@berkeley

Electronic Health Records & the Data of Health Care [Infographic] - datascience@berkeley | EHR and Health IT Consulting | Scoop.it

datascience@berkeley Blog RSS

Electronic Health Records & the Data of Health Care [Infographic]

June 17th, 2014 by  Jenna Dutcher  1
Filed Under: electronic health records, healthcare, Infographic
datascience@berkeley

“In the next 10 years, data science and software will do more for medicine than all of the biological sciences together,” said venture capitalist Vinod Khosla. Data science holds great promise for patient health, but patient data is only actionable in so far as it is digital. This is where Electronic Health Records (EHRs) come in. By 2019, the majority of physicians will have adopted a basic EHR system, and with good reason, too. EHRs may reduce outpatient care costs by 3 percent.

Going in for dialysis? It’s a good bet that your information will be collected and stored digitally, as 80.6 percent of dialysis practices have adopted EHRs. If you have a wellness check-up scheduled, be prepared to fill out some paperwork — only 35.9 percent of general preventative medicine practices have adopted EHRs.

This “Electronic Health Records & the Data of Health Care” infographic from datascience@berkeley explores the health data revolution, the difference between Electronic Medical Records and EHRs, which states and practices adopted electronic systems, and what the future of the digital health industry looks like. Get ready for the next wave of medical innovation.


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For portals, speak patients' language | Healthcare IT News

For portals, speak patients' language | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

Serving a multi-ethnic patient population that speaks six different languages – with five different alphabets! – is just one of the Stage 2 meaningful use challenges for New York Hospital Queens.


It's a tall order for many providers to meet MU's 5 percent threshold for patient access, even when they're located in English-speaking communities with a relatively high level of tech-savviness.

But for an urban community with many immigrants -- who also speak Spanish, Chinese, Korean, Russian and Greek -- the hurdles can be just that much higher, especially when most patient portals are accessible in English only.


Add to this the fact that most personal health record apps require an email address to create an account, and the prospective pool of people who could compose that 5 percent of patients gets winnowed down even further.


Still, the hospital is moving forward this summer with a "full court press" on patient engagement and fully expects to attain that oft-elusive access goal: ensuring that 5 percent of patients discharged between July 1 and September 30 access their medical records online.


"That 5 percent figure doesn't sound like a large number," says Camela Morrissey, vice president, public affairs and marketing, and chief marketing officer at New York Hospital Queens. "But for us, when you do the math, with our discharges in that period of time, it's probably between 450 and 500 patients."


The challenges of getting that many different people to log on to a patient portal are numerous.


Kenneth Ong, MD"It starts with patients having to give us their email so we can send a validation email and they can verify they are who they say they are," said Kenneth Ong, MD, chief medical informatics officer, New York Hospital Queens.


Given that not everyone has an email address, "We've had to engage help desk resources devoted entirely to the patient portal, in order support patients – which of course is an extra effort and extra cost on our part," says Ong.


That's not the only thing that's necessitated changes to the way the hospital does its daily work.


"The portal is in English, and our patient population speaks a number of different languages," says Morrissey. "We have to be able to deliver patient information in six languages. Being able to bridge that is a big challenge in the workflow, because we actually have to bring in some translation services."


It also, not insignificantly, "narrows the pool of patients who are most likely to find this relevant and accessible in its current form," she adds.

All that means New York Hospital Queens has had to have an all-hands-on-deck strategy to getting as many patients on board with the engagement initiative as possible.


"It's really requiring a very full-circle approach on our part," says Morrissey. "We've got everybody from Ken's group in informatics, to IT, to marketing and public affairs handling the communication, to our registration and admissions people, to our health information management people, to our volunteers and our patient advocates."

The hospital is "putting on a full court press," she says, "increasing the encouragement to provide a valid email address at registration. That's had the effect of increasing the number of email addresses that we collect."


After all, she says, "our patient population, like probably most, has concerns: 'If I give you my email address, are you going to spam me? Are you going to chase me for a bill?' Our folks who have been collecting that information up front have been educated and have a chance address those concerns."


Beyond the registration desk, another key strategy has been to take the outreach and education directly to the patients' bedsides.

"We have (staff) who are actively helping patients register and log into the patient portal using iPads," says Ong.


That's been a boon so far, says Morrissey, helping to "encourage any patients who have not provided their email at registration ... to register for a portal account and begin using it, to a) help them understand how to access and b) get them familiar with it and see the benefits of it."


To encourage patients to log on to its patient portal, New York Hospital Queens employees wear buttons like this one.Those selling points are made clear at the bedside, she says: "This is a convenient way for you to access your medical record. And you'll only be able to do that if your email address matches."


So far, the response has been gratifying.

"I would say it took a couple weeks for that to pick up some traction and streamline the way people were registered," says Morrissey. "But we've seen an increase in both the upfront collection and the frequency of the accurate match, once we're getting someone to register for a portal account."


As those numbers have gone up, the hospital is starting to think more creatively about new ways to reach out and new patient populations to target.


"As we get more facile internally with (these new workflows), we're focusing on some of our units where we have folks we think will be more eager to do it," says Morrissey. "Maybe that's our mother/baby population. We're looking at adding some features to the medical record that will make the parent want to look at it -- maybe a footprint and a photo of the baby. So we're getting a secure photo service to do that, enabling the uploading of that photo."


Still there are technical challenges inherent in the patient-facing software (a tethered portal from Allscripts), says Ong.


"It's still a relatively new technology, and even though we've had it for a while, you always find new problems when patients try to access it," he says. "Things like resetting passwords: In order for the patient to verify who they are in the registration, they have to remember what they identified as their primary email address as well as their preferred phone number that they gave the registrars.


"Speaking for myself, I can't always tell you what my preferred number is – and I have three email addresses," he adds. "If it's a challenge for me, and I work in IT, you can see what a challenge it is for many patients as well."


"We've created some very detailed but simplistic instructions for people that they get at their point of entry into the organization and we allow them to write down the email address that they use at that time," says Morrissey. "We suggest they write down their username and give them instructions on how to create a secure password.


"We made a decision here that rather than giving people 57 pieces of information or not giving them anything, we would give them one very simple thing to allow them to do this," she adds. "All of our staff, including volunteers and medical students who are part of the volunteer force going to the bedside to encourage patients to use this, everybody is using the same instructions and the same piece of paper."


Morrissey says the hospital is "absolutely" confident that a "very consistent effort," from the "moment people walk in the door," will see online patient access top 5 percent "for the full 90 days – and then after."

Even with such a challenging population to engage, she's sure that the hospital's enterprise-wide efforts will pay off: "We won't miss the mark on this, no way."


Beyond merely meeting meaningful use, after all, projects like these ultimately make for better outcomes.


"I really think that's going to make a difference and I would encourage anyone to do it," says Morrissey. "If it's a stretch for an organization to try, it's worth the stretch, because it's going to be better for patient care."

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inquiry@technicaldr.com or 877-910-0004
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