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October 19, 2010 News 19 Comments

From Buck Dharma: “Re: CIO salaries. Are you still keeping a list? Long time reader — appreciate the effort you take to keep this thing fresh.” I stopped running CIO salaries a few years ago when it became kind of a pain to dig them up from tax records, but I’ll try to do some every now and then when I have time (remind me or tell me the ones you want to know). Here are a few new ones for you: Partners Healthcare, $803K. Sentara, $692K. Memorial Hermann, $834K. Detroit Medical Center, $391K. Adventist Health System, $774K. Centura Health, $468K. Children’s Dallas, $635K. University of Maryland Medical System, $569K. Suddenly I’m feeling poor.

From A-Rod: “Re: Audax Health Solutions. One of few healthcare firms to be selected by Google to beta test a unique machine learning algorithm. Audax plans to use it to tag and sort healthcare content to predictively suggest it to the Careverge user.” I’ve read the buzzword-oozing About Us page for Audax and I still have no idea what exactly they do — something to do with social networking and benefit management (you would think they could be succinct being that they apparently worship Twitter and Facebook). Google or not, I ran out of interest before I ran out of prose.

10-19-2010 7-59-05 PM

From Elsie: “Re: UPMC. These are the folks whose $5 million CEO earlier this year closed the only hospital in Braddock, one of the nation’s most underserved cities, and are now rushing to demolish the building. UPMC rationalizes saying they want to turn the site over to Allegheny County for ‘future development’. Anybody who’s seen Braddock, the embodiment of poverty and urban decay in America, knows it’s just block after block of boarded-up storefronts and empty lots. Taking away that community’s only healthcare facility is the antithesis of humanitarian.”

From K-Rod: “Re: anesthesiologists. I agree that they are on the edge for patient safety. Wonder when (or if) surgeons will get there? What you may not know is that these talented nurse anesthetists can sing!” I’ve mentioned these amazing guys before — The Laryngospasms. They’d make great entertainment for an HIStalk event, right?

From WillOurSoftwareEverWork: “Re: McKesson Horizon Enterprise Revenue Management. Implementations have been suspended and Release 2.0 is delayed until next year.” Unverified. I e-mailed a CIO who should know and I think Inga tried an informal company contact, but we haven’t heard anything so far. Consider this false until someone confirms.

From Careener: “Re: DHIN. I don’t know if you saw this Delaware dust-up (no, not former witches as US Senate candidates). The Republican candidate for US Representative took a shot at his opponent over the Delaware Health Information Network, saying it is ‘mismanaged … with no tangible benefit.” I was involved with DHIN as a provider and it was, and is, an unqualified success, with Delaware being the first state to have statewide results delivery, HIE to EMR integration, and public health integration for pandemic and reportable results reporting. It is the model other stares are following. Love reading your updates, please keep up the good work.”

From Lady Pharmacist: “Re: National Hospital and Health-System Pharmacy Week, October 17-23. It’s that time of year again. Can you kindly give a shout-out to pharmacists and pharmacy technicians? If you’re thinking that hospital pharmacists and pharmacy techs are like the drugstore ones that Jerry Seinfeld makes fun of above, you couldn’t be any more wrong. Imagine a small group of professionals who handle with virtually 100% accuracy the thousands of medication-related orders generated in a hospital each day, except unlike lab and diagnostic radiology orders, any one of those orders could kill a patient because of an incorrectly prescribed dose, method of administration, allergy, or conflicting therapy. Pharmacists and techs prevent untold errors every day as unchallenged medication experts whose only interest is patient safety. The hospital pharmacy is a complex, demanding environment involving drug procurement and distribution, clinical monitoring, professional consultation, heavy duty informatics, significant clinical and research work, and careful monitoring of the use of high-risk meds that cure when used correctly and kill when not. I’ve worked in hospitals for quite a few years and watched the transition of hospital pharmacists and techs from the lick-and-stick pill pushers that Jerry skewers to professionals adding indisputable value to patient care with their brains and not just their hands, quietly and unassumingly preventing innumerable bad outcomes without much glory. If you look at the most tragic medication errors (see: Quaid babies), you will nearly always find a situation where doctors and nurses mishandled drugs without pharmacy involvement. My hospital is featuring Pharmacy Week in the lobby display case, so maybe yours is, too.

Listening: Bad Religion, prototypical SoCal punk for over 30 years. Strong harmonies, angry but literate lyrics (the lead singer is a Cornell PhD and UCLA college professor), and a hard rock edge make them better than the Ramones if you ask me. I played a few seconds of two songs from Stranger than Fiction and instantly bought it for my gym iPod. Love it.

10-19-2010 10-09-02 PM

Encore Health Resources is named to Modern Healthcare’s 2010 Best Places to Work in Healthcare, which I’m sharing since they sponsored last year’s HIStalk reception at HIMSS. They just hired their 100th employee. That’s Dana and Ivo above, of course. HIStalk sponsors making the list: maxIT Healthcare and MEDecision.

ThinIdentity changes its name to Aventura. They need to learn to write more disciplined press releases — this one prattles on without giving even a hint at what they sell until the final “About” paragraph (answer: some kind of logon/logoff tool). Their Web site is much better at using the few precious seconds of the average Web attention span to get to the damned point.

Grady Memorial Hospital (GA) chooses Apollo Health Street to convert its legacy patient accounts to a new PA system. 

How do you tell when a CEO is lying? (no, smart aleck, not when his or her lips are moving). According to a researcher’s algorithm, lying CEOs tend to overuse words like we and our team to refer to the company in presentations, also showing fake exuberance with words like fabulous, fantastic, and extraordinary. Honest ones say I, me, or mine to indicate that they take ownership of their claims. That’s until this article came out, of course, which will tip off CEO media handlers to coach their lying executives better.

Cerner will become a reseller of address checking and patient classification software from SearchAmerica, which is part of mammoth credit scoring vendor Experian.

Former Cerner LifeSciences CMO Robert Dubois MD, PhD is named chief science officer of the National Pharmaceutical Council. Their mission statement sounds noble, but based on their sponsors (drug companies) and their emphasis on innovation and value (the “we have enough scientists to sort of prove that our unbelievably expensive drugs are actually a good value” approach), I’m guessing the scientific aspect mostly involves marketing.

Illinois Bone & Joint Institute chooses the SRS Hybrid EMR for its 242 Chicago-area providers.

Weird News Andy awakens from apparent dormancy with this offering, which he titles “Smurfitis?” Police in the Baltimore area are called to check on an 89-year-old woman, who they find blue, motionless, and smelling of decomposition on her bathroom floor. Instead of checking for a pulse, they call up her son and tell him she’s dead. Three hours later, a guy sent over from the State Anatomy Board to transport her body for use as a medical cadaver notices that she’s breathing. She is rushed to the hospital and discharged to hospice a couple of weeks later, where she died for real shortly afterward. The police chief says the case is “deeply disturbing.”

10-19-2010 8-21-19 PM

A Claremont Graduate University research team introduces the HealthATM, designed to give low-income health clinic patients access to their health information anywhere. It can be used to schedule appointments, request prescriptions, look up lab results, and review medical content. Community clinics enrolled up to 100% of their patients, 75% of whom wanted to use it regularly. What a fantastic idea – not everybody has Internet access and PC knowledge.

Lake Health (OH) introduces digital way-finding to its all-digital TriPoint Medical Center. It offers visitors a kiosk-based virtual guide that helps them locate their destinations, including the ability to have directions sent by text message. That makes me reflect on the odd design of hospitals compared to other public buildings, where visitors (many of them first-timers) are expected to traipse around back hallways and through multiple buildings to find lab, radiology, registration, and all kinds of other departments, often within a single visit and involving visitor-unfriendly jarring architectural change along the way since hospitals are often expanded patchwork over decades without any obvious continuity (“take the Red Zone elevator to seventh floor and then follow the blue stripe, then make the first left through the closed double doors marked ICU Waiting …” Clearly the unspoken paradigm is: you may be our customer, but it’s your job to come to us, no matter how hard we make that task. I confess that I can and do easily get lost in my own sprawling hospital campus, hoping that nobody notices my backtracking and frequent “where the heck am I” cognitive dissonance pauses until I finally give up and ask whoever’s at the nearest nursing station.

In Canada, Queen Elizabeth Hospital (PEI) warns of ED delays due to the implementation of Cerner’s FirstNet and PowerNote, which the assistant medical director says have a steep learning curve.

10-19-2010 9-19-31 PM

Bartron Medical Imaging wins FDA approval for its medical imaging software, which uses image segmentation algorithms developed by NASA for analyzing satellite images to find abnormalities in diagnostic images, such as those for mammography. I snagged the knee slice above from the company’s sample image database (you can log in as user guest and password guest).

The FDA issues urgent Class I warnings for the recalled CareFusion Alaris PC 8015 smart IV pump, saying its intermittent wireless network lockups prevent nurses from making programming changes, with the resulting runaway pump potentially causing serious patient injury or death in some circumstances.

A 21-year-old computer technician hired to fix a Georgia doctor’s computer uses the doctor’s password to sign on to a hospital’s computer system. He’s arrested and charged with computer theft, computer forgery, password disclosure, and “theft by taking.” The hospital’s HR VP says he thinks the man was trying to show off his computer knowledge to get a hospital job offer. Doh!

Doctors in Taiwan say their counterparts in China want to work with them on telemedicine and preventive medicine programs via cloud computing, given Taiwan’s superior capabilities in IT and medicine.

An investigative article by ProPublica finds that hundreds of doctors shilling drug company products have been accused of professional misconduct, have been disciplined, or don’t have adequate credentials. They created an online database that lets you look up any doctor to see if they’ve been paid promotional fees for any of seven big drugmakers.

In the UK, the Cambridge University Hospitals trust will take a pass on the defunct NPfIT’s Cerner Millennium or iSoft Lorenzo offerings, choosing instead to do their own system selection.

10-19-2010 9-53-32 PM

East Tennessee Children’s Hospital releases its iPhone app, which offers hospital information, maps, directions, parking information, health articles, and a place to store medical information.

E-mail me.
 

HERtalk by Inga

10-19-2010 6-05-49 PM

David Blumenthal calls on HIT vendors to “include providers who serve minority communities in their sales and marketing efforts,” expressing his concern that EHR adoption rates are lower among providers serving Hispanic or Latino patients who are uninsured or rely upon Medicaid. Having once made my living making sales, I can assure Dr. Blumenthal that salespeople (and their bosses) are happy to sell their EHRs to just about anyone who will buy them. If this segment of providers isn’t buying EHRs, I doubt it is because vendors aren’t knocking on their door, but because these doctors don’t have the money. These are the physicians who have forgone the bigger incomes to treat the uninsured/underinsured and who rely on reimbursements from Medicaid, not the higher-paying commercial carriers.

Philips Healthcare posts a 14% increase in revenues to $2.67 billion for the third quarter. North American sales grew 11%.

Emdeon wins a subcontract from CSC to perform IT services for the Department of Defense Pharmacy Operations Directorate. As part of the 51-month contract, Emdeon will develop interfaces for immunization tracking and lab systems.

Nebraska Medical Center subscribes to the CapSite database to improve its capital expenditure process.

marion general

Marion General Hospital (OH) pays a $1.2 million fine for self-reported Stark law violations that occurred between 2003 and 2009. The hospital’s president says it failed to do the proper paperwork for several physician-related matters, including payments to to independent physicians who saw indigent patients and provided emergency room call. The hospital also did not properly document providing office space and services at below-market rates. If I didn’t know better, I would think the US attorney handling the case is running for re-election. In a statement that seems to ignore the fact that the case was self-reported, he remarks, “This is a significant victory for taxpayers and another step in our efforts to protect the Medicare Trust Fund.”

Texas Health Resources and Alliance HealthCare Services (CA) contract with Sy.Med to provide credentialing software.

union hospital

Union Hospital of Cecil County (MD) selects Wolters Kluwer Health’s ProVation Order Sets as its electronic order set solution.

The Scarborough Hospital in Toronto picks Access Intelligent Forms Suite to integrate with MEDITECH Magic. The Access product will improve forms management by pre-filling forms with patient information and auto-index barcode forms into the EHR.

Audax Health Solutions appoints Henry DePhillips MD as president of healthcare operations. He was previously with McKinsey and was chief medical officer of MEDecision.

timothy mills

RCM software provider Avisena hires Timothy Mills as VP of sales and marketing. He’s worked at NaviNet, Spheris, and CareScience.

Healthcare and financial transaction provider TransEngen appoints Mike Pileggi as EVP of sales. He was previously in sales roles with mPay Gateway and Misys Healthcare Systems.

Shareable Ink launches Shareable Ink Analytics for Anesthesia, a business intelligence module of its anesthesia record.

The American Hospital Association extends its exclusive endorsement of AT&T’s HIE services. AT&T Healthcare Community Online enables the secure exchange and sharing of patient data across multiple health systems. AHA also endorses AT&T’s voice and data networking services and wireless services.

management health

Management Health Solutions, a provider of supply chain software for healthcare, acquires Hospital Inventory Specialists, which offers inventory management solutions and analytical services.

Eight of Minnesota’s largest healthcare organizations connect their Epic systems to electronically share patient data. All are members of the Minnesota Epic User Group using Epic’s Care Everywhere software. The network includes access to estimated 3.6 million patients, or 75% of Minnesotans.

The CDC awards CACI International a 10-year contract to support the CDC’s IT infrastructure. The contract has a ceiling value of $1 billion.

perkins county

The board of directors of the Perkins County Hospital District (NE) approves a $1.5 million allocation to implement an EHR at the 20-bed Perkins County Community Hospital.

Xerox expands its healthcare footprint with the acquisition of pharma tele-services company TM Health.

KLAS reports that vendors offering integrated workforce management solutions are winning more deals than companies offering standalone staff scheduling products, even though providers prefer the functionality of stand-alone products. The top rated vendor was McKesson, followed by Clairvia, Concerro, API, and Kronos.

Evangelical Community Hospital (PA) commissions Keane Optimum as its financial, clinical, and EHR solution.

A reader sent me a note last week, noting that my avatar depicted “a very sweet young lady worthy of my attention strictly in a fatherly way.” A lovely and I am sure well-intentioned comment. A question to my fellow female HIT-types: why do you suppose that that statement leaves me disappointed and reminiscent of my early teens, when only the Ted The Geek-type boys noticed my existence? 

inga

E-mail Inga.

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Currently there are "19 comments" on this Article:

  1. I don’t know if the rumor re McKesson Horizon implementations being suspended is true or not (my guess: true), but, if it is, the folks at Siemens are saying “Join the club!” Soarian Financials is live, somewhere, supposedly. But its delays have been extraordinary and customers have lost count of the number of times they’ve heard, “with Version X.X, it will be ready for use at your hospital.” Now some sites are saying they want to wait for ICD-10 before migrating! Most sites signed for Soarian years and years ago and are still waiting. Development of Soarian Financials (originally codenamed TNT) started in 1997.

    We went from a crude satellite to landing a man on the moon in less time then it takes to build a new registration/billing system these days.

  2. #”21-year-old computer technician … uses the doctor’s password”

    I would be very curious to know how he obtained the doctor’s password. Yes, what the 21-year-old did, if proven, was wrong and should face the consequences.
    Should the doctor face criminal charges if he gave the password to this 21-year-old? “Hey, here is my password… fix this for me”. The law doesn’t take ignorance as excuse. Do you always lock the computer when you walk away? or do you leave it unlocked and, for bonus, logged in your EHR?

  3. Re: Braddock

    You always her that Pittsburgh has made a transition away from the steel industry to one that is oriented around healthcare, education, and finance. That’s true to a degree but tell that to the people in Braddock or other towns like McKeesport which have basically died since the steel industry collapsed in the late 70/early 80s.

  4. Calling DHIN an “unqualified success” just goes to show you how broad the REC experience can be. I am not going to name names or share much detail – I am very afraid of being blackballed or being served needlessly – but my multiple experiences wih DHIN were awful. I know of one practice who complained to the Feds. I suffered through ridiculous conflicts of interest that support all the negative commentary against the RECs (see your own Coker Group interview).

    One client shared with me the communication which indicated that DHIN couldn’t even get the state imms registry to work with them! Maybe that’s the registry being stupid and maybe it’s resolved, but the provider himself was underwhelmed.

    I’ve probably said too much for my own good as it is…but I wonder about the relationship of your original contact with DHIN. Every time I talk to them, they tell me how they “are a model for the rest of the country” and how they were the first to make connections…that comment sounds just lime the DHIN folks. Meanwhile, while speaking to the OK REC/HIE last week, they had no clue about the DHIN effort.

  5. To Inga: I suggest you change your Avatar image to be a full-body shot… I have a feeling that your reported “fabulous shoes” may change that “Sweet young Lady” impression!! George Clooney, beware!

  6. Re: Braddock

    What Elsie says is true, UPMC’s underperforming Braddock Hospital was closed in the name of ‘redevelopment’ including tax credits compliments of the City. Bright spot is Mayor John Fetterman whose major emphasis is improving the quality of life for the young people in Braddock. New York born and Harvard educated, this guy’s the real deal. As a native I appreciate the contribution and difference this man is making. http://15104.cc/braddock/

  7. Joe bouchard wrote:

    Calling DHIN an “unqualified success” just goes to show you how broad the REC experience can be… my multiple experiences wih DHIN were awful.

    I authored the foundational DHIN Plan of Study, accepted and executed by the DHIN Board in January 1999, but left the DHIN project in 2000 when I entered the pharmaceutical industry and moved away from DE.

    If what you write is true, this is a pity.

  8. Re: HIT adoption in poor regions: “David Blumenthal calls on HIT vendors to “include providers who serve minority communities in their sales and marketing efforts,” expressing his concern that EHR adoption rates are lower among providers serving Hispanic or Latino patients who are uninsured or rely upon Medicaid.”

    Has anyone tried to sell EHRs in Braddock, Pa? Even those with money who can afford it are abandoning the indigent, while robbing from the rich and taking for themselves.

  9. I wonder if Minnesotans realize so much of their health record is dependent upon a Wisconsin-made product. If they knew, there would be riots in the streets!

    In all seriousness, though, this site can always be counted upon to post the last Epic press releases. A bit of analysis would be nice, such as pointing out the fact that all Epic has done in Minnesota is gain a large market share in the state. I don’t know where the figure “3.6 million patients” comes from. This is 68% of the total population of Minnesota, but this Epic press release implies that these (by and large) hospitals are capturing that market share entirely, both inpatient and outpatient, which is only possible if all those hospitals and all their affiliated physician clinics are on Epic. Anyone know if every affiliated physician at every hospital in that health system is on ambulatory Epic? I know Dr. Larsen is, at his county medical center, but what about everyone else? Two conspicuous absences on the list are the VA and Mayo Clinic. I suspect in the end, much less than 3.6 million Minnesotans, and definitely less than 75%, will be able to one-stop shop for their medical records on Care Everywhere.

    What Epic has done is create an HIE for Minnesota. So what? There’s dozens of HIEs in the marketplace right now. What the article doesn’t mention, and what I’d like to hear feedback on, is what degree of sharing is there through this HIE? Even with all these facilities on the same HIE, are they able to import and export data elements into their systems? Are they just reading PDF documents stored in the HIE repository? Does anyone know of any health systems where inpatient or ambulatory Epic systems communicate between multiple facilities on Epic, or between Epic and a 2nd vendor software (like outpatient Allscripts or NextGen) in a way where there is an actual flow of data? If there’s not a real flow of data, there’s no advantage to being in Epic’s HIE over being in any other HIE.

  10. @Anonymous: Epic does not usually issue press releases. The link is to a press release from Health Partners, and the number of patients is presumably provided by the various organizations participating in Care Everywhere. You can use the contact information for these organizations and probably find out the answers to most of your questions, but that would involve some actual effort…

  11. @anonymous – it isn’t an epic press release, they don’t really do those often/at all. it’s a user group press release – note the focus on MNEUG. -10 points for reading comprehension.

  12. @Anonymous: Before you begin to cast aspersions on what was accomplished in Minnesota, you should probably spend some time learning about the functionality of EPIC. I can assure you, it’s a far cry from simple trading of PDF files. Another -10 points for commenting about something you obviously don’t know about.

  13. OMG, a runaway infusion pump, never saw one: ” with the resulting runaway pump potentially causing serious patient injury or death in some circumstances.”

    Runaway infusion pumps with nurses tethered to the CPOE terminal and barcoding scanner makes for a deadly combination. It takes too long to learn that an entire 500cc of heparin drip has been delivered in one hour, and with the nurses focus on the CPOE, they neglect the real time surroundings.

  14. @Suzy – what does CPOE stand for? Concentrate heavily on the second letter in that acronym…and a CPOE terminal? You mean computer terminal I suppose? CPOE is software that resides on a computer…just like Internet Explorer in which you use to access HISTalk to bash anything and everything regarding a Hospital Information System (HIS). Irony?

    Also, a barcoding scanner is a verification tool used in the medication dispensing process…patient safety. It follows the 5 rights of nursing and only ensures you don’t accidentally kill a patient. Are you really going to challenge checking you have the right patient, right med, right dose, right route, and right time? If anything it even helps create another “right” in checking that the right person is administering the meds.

  15. Looks like the Epic brigade is out in force tonight. I like how people assigned themselves points and declared themselves winners without answering the questions. Not only can I read, I can also do math, and can tell when someone has fudged some numbers to make it look like they are more dominant than they are. Clearly I don’t fully understand the functionality of Care Everywhere, which is why I wrote those questions. If anyone knows the answers, please feel free to post them:
    What sort of data flow does Care Everywhere provide from non-Epic EMRs?
    How does it deposit that information into the Epic record?
    This press release, which clearly touts Epic more than it touts the link between the hospitals, doesn’t actually indicate what level of data is flowing between systenms. Anyone in Minnesota have a sense of how this users group differs from a traditional HIE? Is this just another DHIN in the making?

  16. @All Anonymous: Please select a name so we can follow you and your contributions. The tradition started with Caddyshack characters, but you can get creative. Thanks!

  17. Suzy, my spouse was in ICU and rehab for almost a month last spring. After a career in HIS, it was interesting to take a look at the ‘inside’. The hospital had OE, entered by unit clerks, no documentation on-line. For 3 days, i bugged every nurse about when they were giving spouse a followup x-ray for a break, as I had been told be another nurse would happen before discharge. Finally, one nurse was diligent enough to search every single piece of paper in that medical chart, and found a nearly illegible scribbled MD note (on the back of another note) that said no x-ray, get one a week after discharge.

    I could be considered a cheap yankee luddite lol, but I will never believe paper and scribbles are in any way a better tool than a computer system. Implementation is key to success, but your negativity is counterproductive and somewhat hilarious.

  18. “which is only possible if all those hospitals and all their affiliated physician clinics are on Epic” I’ve had Epic’s coverage numbers (which they love to tout) explained as “number of people who, if hospitalized, might end up in one of our customers’ hospitals.” So all of those locations and affiliated physicians contribute to the number, even if their patients have never been documented in an Epic system. An odd metric to be sure; I think that’s where Epic gets their “30% of Americans” stat as well. Who knows if they adjust for overlap, but with such a fast-and-loose number I doubt it.

    “What Epic has done is create an HIE for Minnesota. So what?” I think (can’t confirm) Epic customers don’t pay an additional license fee for Care Everywhere. So Epic is expensive, but a built-in Epic-Epic HIE is a lot of bang for the buck if your neighbors use Epic. Not useful if your neighbor uses Allscripts – you pay extra for that.

    “Are they just reading PDF documents stored in the HIE repository?” As I understand it there isn’t a central repository. The hospital’s databases query each other (or maybe query Epic?) looking for the patient, and the data passed from one hospital to another. It sounds neat, but has big disadvantages: Every hospital’s connectivity issues impact the other hospitals access to external data, and if any hospital backs out or leaves Epic for another vendor all of that potentially lifesaving data is now unaccessible. The only advantage is no setup or maintenance costs for an extra repository. Still, I’m not sure we can trust the HIE solutions to provide “real flow of data” either, so maybe this is a good short-term solution.

    I can’t speak to the flow of data. I’ve heard it’s integrated into the chart and appears with local data, but to what degree is unclear. I’d love to hear whether they’re pulling labs w/ reference ranges, PACS images, etc.







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Reader Comments

  • Allscripts watcher: I agree with Goose Island. I have no dog in the hunt (and am uncomfortable with the Epic/Cerner duopoly - we need as mu...
  • Boy Wonder: More CareOtter (Allscripts side EHR) observations...CareOtter's webpage is suddenly down and the YouTube video reference...
  • Peg Leg Pete: The Allscripts Sunrise implementation at Baptist Pensacola is officially off the rails. The project is now two years out...
  • Redwood: Sounds like Care Otter’s secret sauce is running on top of Microsoft Azure. Not sure that warrants a special project t...
  • Andrew (Hedgeye): Hi Goose Island - Thank you for the comment. You are right about Jefferson Health and Epic. We believe Allscripts is a...

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