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Readers Write: Never Had a Breach?

Never Had a Breach?
By Kev Larson

Never had a breach? I find it remarkable that so many on the HIStalk Advisory Panel can answer so swiftly, so confidently, and so authoritatively, “No, we have never had a breach.” 

I want to know how they know that. I want to know what they are doing — day in and day out — to monitor, audit, and confirm their operational performance that allows them to make that bold statement – the one that they report to HIStalk and its readers, their boards, and their patients.

I am sure you know the old saying, “The absence of evidence is not the evidence of absence.” For those that are reporting no breaches, just how hard are they looking? Would their staff even know what to report or how to report a potential breach? 

I am not saying that a perfect record is not in the realm of possibility. It is just so incredibly improbable that it defies common sense. I would really love to know the secret formula that has gotten those CIOs that report no breaches to the place where they have that level of confidence and certainty. I am sure others would, too.

Along these lines, I finally got a chance to read ISMG’s Healthcare Information Security Today Annual Survey in which 35 percent of the 200 respondents reported that their organizations had not suffered a breach of any size in the past 12 months. I realize that this is a dangerously low sample size, but let’s just take it at face value for the sake of illustration. The trend is not too terribly off from the responses from the HIStalk Advisory Panel. 

The question and response that really got me chuckling was this one, though. “What type of breach (of any size) has a BA with access to your organization’s patient information had in the past 12 months?” Can you believe that 59 percent of the respondents answered that their BAs had no breach of any size in the past 12 months? That is downright laughable and borderline reckless.   

CEs are doing precious little to evaluate, interrogate, or assess BA risk or compliance performance. Again, the absence of evidence is not the evidence of absence. If a CE responded to this question based on the BA’s self-report to them alone, that should not be enough information to give that BA a clean bill of health. We have to hold them to more rigorous criteria than that. 

The certain truth is the universe of BAs is exponentially larger than that of CEs, and BAs have only recently received the formal mandate to fully comply with HIPAA.  We have a long way to go in the BA community and CEs should be guarded, probative, and assertive in the management of their BAs. We cannot wait 10 years for our BAs to catch up.

What really matters in this discussion is what has changed under Omnibus. One of the most significant changes is that the Omnibus Rule replaces the “risk of harm” test that was so contentious in the interim final rule with a default presumption that any acquisition, access, use, or disclosure of PHI in a manner not permitted by the HIPAA Privacy Rule is a breach unless the CE or BA “demonstrates that there is a low probability that the [PHI] has been compromised based on a risk assessment.” [78 Fed. Reg. at 5,695] 

Kudos to the organizations that have employed a breach risk assessment process and have implemented it consistently. Interestingly, they seem to be the ones reporting their breaches in real time, even the small ones that they could have reported later. They have a real process and are actively demonstrating a posture of continuous compliance, which is the desired state according to OCR. 

However, there are a whole bunch of organizations that are just winging it. They have no process, no criteria, no tools, and no commitment. We see it all too often and it is just not enough.

Take the five-month window before you must comply with Omnibus to shore up this part of your program –  all things related to breach risk. Consider working with an expert consulting firm to help you. This is probably an area where a little investment can go a long way. 

Readers Write: Are Hospital EHR Vendors Primarily Software or Services Companies?

Are Hospital EHR Vendors Primarily Software or Services Companies?
By Kyle Samani

Hospital EHR vendors are not primarily software companies with professional services divisions. They are primarily professional service companies with software divisions.

Although the core value of hospital EHR companies is the software they develop, the bulk of the value they provide is in training, data conversion, setup, logistics, and support. These services are built on top of the software that they support, but are collectively more valuable than the software itself.

I’ve seen the challenge of deploying an EHR in a hospital first hand. Most of the challenges are with the people, not the software. Hospital EHR vendors derive most of their value for their professional services.

Hospital EHR vendors employ more services staff than software staff. At least 60 percent of the employees at the major hospital EHR vendors are in deployment and support services, not software design, development, testing, or administrative functions. Employees, especially road warriors, are expensive. The more employees involved in a given division, the more expensive and valuable that division is.

But perhaps even more important than sheer costs, healthcare IT staff need to receive sophisticated training in hospital workflows and software systems. Before the HITECH Act, there weren’t enough people with healthcare IT skills to deploy the entire country in five or six years. Many argue that there still aren’t enough people. The EHR vendors had to develop large-scale internal training programs to teach all of these people how to set up, train, deploy, and support hospitals. This is one of the greatest sources of value that the big EHR vendors have generated: an educated healthcare IT workforce. The scale and scope at which they’ve done that has been remarkable.

Epic employs 6,400 people and Cerner 11,900. I would estimate that at least 60 percent of those – or 11,000 people in just these two companies – work in training, deployment, and support roles. These companies and many others have developed phenomenally large internal training programs for their employees, who are usually fresh college graduates.

To provide a sense of scale, the University of Texas at Austin — one of the largest universities in the country by enrollment (60,000+ students) and located in a major US technology center — boasts that it has graduated a grand total of 333 people in its 9-10-week-long healthcare IT program since its inception a few years ago. Vendors are educating the workforce, not the educational system.

Training and conversion costs usually prevent hospitals from switching EHRs. These costs are multi-dimensional, spanning financial cost, employee personal costs, and opportunity cost of working through other initiatives such as Meaningful Use 2 and ICD-10.

As an employee at a smaller hospital EHR vendor, I’ve experienced this phenomenon. We are trying to spearhead the replacement market for hospitals that are dissatisfied with their legacy EHRs. Most of them love our product and are even willing to pay, but aren’t willing to change systems because the non-financial costs of change are too great for the organization.

Because the costs of switching are high, the cost of choosing the wrong EHR the first time is even higher. Most large software projects that fail do so because of the people, processes, and cultures, not because the software isn’t capable. In that sense, the services surrounding the software implementation are even more important than the software itself. The majority of the value that the vendors provide is in services, not software.

Looking at hospital EHR vendors as service companies can help understand management decisions that may not have made sense when looking at them as software companies. Decisions are made based on training and deployment realities, not software limitations. This analytical framework can also help explain vendor practices and methodologies (especially hiring), release cycles, growth rates, stability, and many other operating metrics.

Kyle Samani is inpatient deployment manager at VersaSuite of Austin, TX.

Readers Write: Achieving Value, A Different Kind of Medical Miracle

April 29, 2013 Readers Write 1 Comment

Achieving Value, A Different Kind of Medical Miracle
By David Bond

4-29-2013 8-37-19 PM

Practice management system (PMS) vendors have long sought to provide their physician customers with more capabilities than just traditional practice management and EHR capabilities. Specifically, providing outsourced patient statements and RCM services are some of the most important opportunities that have been identified to bring greater value to their customers and increased revenue to their firm.

However what I’ve seen is quite frankly an assortment of “half-measure” solutions that don’t efficiently utilize today’s interconnected world: portals that aren’t truly integrated, systems that don’t enhance a practices workflow or focus on usability for both the practice and patient alike. More importantly, that seek to find a solution that yields untapped profit opportunities for those PMS vendors that are able to satisfy these requirements.

In fact, many PMS vendors are mired in paper-based billing methods or a clunky billing portal instead of looking to implement an integrated solution that truly drives value for both the practice and the patient. I also find it interesting that most of these current billing mechanisms do little to significantly boost the profit margins of the PMS vendors offering these services in addition to their core offerings.

My aim is not to criticize these companies, as many have been very successful and offer fantastic products that are of use to their customers, but instead offer insight into new opportunities they can adopt to increase their efficiency and profitability. While the PMS providers might feel their current outsourced paper billing solutions put them in a more favorable light with their physicians, they do little to put more profits in their own pockets, streamline the billing process, help practices with their workflow, create clarity for patients, speed time to payment, or reduce errors on the back end.

Instead of going with a traditional solution that only marginally helps PMS vendors, how about something that can be easily integrated with most solutions and be welcomed with open arms by medical practices and patients alike?

Online billing, patient balance management, and reconciliation services that can be easily integrated with most PMS vendor offerings is in fact a reality today. It drastically reduces the need for paper bills and the cost and delays they create and makes obsolete billing portals that are not truly integrated. Presenting patient statements that are easily understood and allocate the remittance precisely to the services that were received creates clarity for everyone and is highly profitable for any PMS vendor looking to bolster their bottom line through a recurring revenue stream.

Want proof? A major PMS vendor ran the numbers and realized an additional $3 million in pure profit by integrating this capability with its core practice management offering used by 3,500 medical practices. I don’t care who you are, this is real money.

If you’re a PMS vendor and want to achieve real value, both in profitability and long-term customer retention, providing a simple and integrated online bill pay solution will get you there.

David Bond is EVP of PatientPay of Durham, NC.

Readers Write: The Shady Side of Value-Based Purchasing

April 27, 2013 Readers Write 1 Comment

The Shady Side of Value-Based Purchasing
By Data Nerd

Beginning October 1, 2013, CMS is implementing what it is calling “Value-Based Purchasing.” As a lifelong policy student, I cannot help but admire the mathematical and administrative intellect behind the program.

Even politically speaking, it has a stroke of genius to it. The funds come from a pre-determined source (starting at 1 percent of reimbursement payments) and the payouts cannot exceed a set amount (said 1 percent of payments). This is achieved by several stages of normalization, where scores are weighted and examined as part of a ratio rather than on their own merit. Hospitals can earn in excess of their 1 percent withheld payments either by improving their own scores over time or scoring better than the other hospitals participating in the program. This differential is then weighted and reweighted to ensure that payouts never exceed the 1 percent amount withheld from all participating hospitals. Awards are all dependent on industry performance as a whole, since the same sum of money will be awarded overall even if every hospital had perfect scores.

CMS is to be commended on the clear and concise way they made the details of the program readily available, providing everything from a slide deck to a recorded provider call to walk through examples. But that is where the understanding (and compliments) end for this data nerd.

By sharing all of the plans for the program, it was easy to get the impression that numbers could easily be crunched from data that is already open. However, open data sources cover quality metrics that were taken over measurement periods that differ greatly from the measurement periods being used by CMS to calculate awards and penalties. Even though we’re talking about the same metrics, we have different reporting periods, so the data is not going to be the same.

One could argue it is another stroke of administrative genius to craft a program then ensure that no one has the data needed to either predict or verify financial outcomes. Based on the latest release of quality data, none of the open datasets are compatible with what CMS will be using to perform VBP calculations (in green and yellow). Some data have yet to be released, while other archived datasets use different timetables, making it impossible to determine hospital eligibility for the program. MedPAR data could theoretically be used to calculate reimbursement withholdings, but without knowing which hospitals are eligible, it makes it impossible to predict which will participate, much less any other aggregate observations (will more hospitals lose than gain, will losses or gains be great or small, etc.).

With all of the talk about transparency, this whole program looks shadier to me with each passing fiscal year.


Readers Write: Misconceptions About the Health IT Workforce

April 22, 2013 Readers Write 9 Comments

Misconceptions About the Health IT Workforce
By Helen Figge, R.Ph, Pharm.D.

4-22-2013 7-02-48 PM

There are many misconceptions out there about workforce development in healthcare IT today. As technologies become introduced into the various healthcare settings to support quality healthcare, it is always assumed that one needs an advanced certification, advanced degree, and advanced resources to implement and support these technologies.

Well, yes and no. For viability if nothing else, these added career efforts are valuable, but truly viable workforce development plans in healthcare IT need to evolve and grow from the bottom up. You don’t make a cake by starting to put the sprinkles together before baking a solid foundation – the cake. The same holds true in the workforce of healthcare IT today.

Many now understand that the backbone to the evolution of the demand for “skilled “workforce today is due in most part to the electronic health record (EHR). Thanks to visionaries like Glen Tullman who positioned the EHR front and center in healthcare discussions, the healthcare market now realizes that the real need in the workforce today involves an understanding of the implementing, programming, interconnecting, and relationship of the EHR to clinician workflow.

One of the backbones to any workforce development plan is continuing education in helping to shape and evolve the IT workforce. Continuing education programs commonly exist for physicians, nurses, and pharmacists. However, there is very little formal infrastructure in place to provide continuing education to the IT workforce. A true educational program for any workforce entity that is sustainable and viable long-term needs to understand the “how” and “why” of the tasks at hand and then educate from that vantage point. 

How would you measure true workforce healthcare IT success? That is yet to be determined, but for all practical purposes, if you don’t understand clinician and healthcare workflow from its various angles and nuances, then you won’t be able to create a viable and competent overall workforce to support the needs out there today. The future of the health IT workforce rests in the hands of those clinicians that adopt the technologies, and in turn, the measurement of success will depend on having critical knowledge about the exact needs of these end users. There is no substitute for knowledge past to bring in the future direction.

The most realistic approach for a viable workforce development program is for organizations to recruit to their organizations and then create loyalty factors for the employees. This in turn provides a base of employees that an organization can draw from for an expanded workforce need. No one really knows the future skills needed in the healthcare workforce, but if an employee can use an iPad or their Android, then they have the potential to learn healthcare IT.

The wave of the healthcare future is mobile applications. You would be surprised how many individuals out there use technologies for various purposes that are non health-related. To get a trained workforce in healthcare IT, maybe we train these individuals through “gaming” learning from such gaming wizards like John Gomez, former CTO for Eclipsys.

Organizations should consider grooming from within and cultivate the talents of motivated employees to fill the voids being felt in today’s healthcare IT marketplace to fill the immediate voids, but also helping to create loyalty programs and career transition pathways for employees. Also, you would be surprised how many prior work experiences are much underestimated in the workplace today. Consider engaging individuals who might have soft and transferable skill sets from other previous positions, encourage them to create new ideas for the healthcare workforce and develop opportunities for long term employment.

There is no nirvana in the formula for developing a healthcare workforce, because if there were one, we would not be hearing endless complaints about not finding “qualified staff” for vacant positions. Groom from within, because healthcare is a forever changing process. It has to be because medicine is an evolving entity, so the skills we are seeking out now may be obsolete in a few years, but if you invest in the person from the ground up, the cake is well baked, so when it’s time for the sprinkles, the final product will look just right.

Helen Figge, BS, PharmD, MBA, CPHIMS, FHIMSS is a principal with Figge Workforce Development.

Readers Write: Five Ways to Improve the Healthcare User Experience

April 15, 2013 Readers Write 1 Comment

Five Ways to Improve the Healthcare User Experience
By Dan West

4-15-2013 5-53-12 PM

Unstructured information — the content that resides outside your organization’s core systems and processes — plagues practically every healthcare organization. For patient care, it’s the 25 percent of patient information – paper or electronic – that exists outside your EMR. In patient finance, it’s the data outside your billing and financial systems. And in accounting, it lives beyond the reach of your ERP system.

But why is unstructured information an issue and how can effectively managing it improve the user experience? Here are five steps to improve user experience at healthcare facilities.

Step 1: Identify it

Before you think of ways to better manage your unstructured content, you first need to understand what it is. For each organization, this content can be a different assortment of documents and information collected from all departments.

For example, in care delivery, unstructured content can be everything from faxed orders and diagnostic images to the actual paper chart. In accounting departments, invoices and the information surrounding specific financial transactions often exist as unstructured content.

The list goes on, but the key here is to understand the nature of the unstructured content each department faces.

Step 2: Get it out of the way

Odds are, paper and other physical content like faxes, EKGs, photocopies, and patient charts are in someone’s way. Sifting through a stack of faxes for that one piece of paper a nurse needs leads to frustration, reduces time spent caring for patients, and increases the likelihood that another piece of information may be lost or misfiled.

Even if your organization’s paper content is safely stored in a central filing location, that storage costs money and space that might be better allocated to patient care. An enterprise content management solution can help by allowing you to capture the diverse range of information and content within your organization – paper, faxes, diagnostic and digital images, insurance cards, patient IDs, and more. Capturing this content eliminates physical storage and management reducing frustrations about finding information and saving on storage and filing costs.

Step 3: Put it somewhere safe

Capturing that unstructured content is only the beginning. Now the question becomes — where you will put that information? An ideal solution will provides you with a single, secure repository for electronic storage of this unstructured content, reducing complexity in your IT environment by eliminating disparate, disconnected content silos.

Unstructured information also poses a security risk. Storing content in a secure location reduces the risk of a HIPAA violation while at the same time providing audit trails that make compliance with Joint Commissions, Sarbanes Oxley, and other initiatives much simpler.

Step 4: Make it easy to find

For this content to be useful, the people who need it should be able to find it easily and quickly. When integrated with an organization’s core applications, ECM solutions provide instant access to content within those systems, often with a simple click of the mouse.

For clinicians, that means finding information once in paper charts quickly within the EMR. For those in patient financial services, it means finding transactional billing data within the billing system instead of on an EOB or isolated EDI transaction. And for those in finance and accounting, it means finding an invoice within the ERP system.

Step 5: Send it where it needs to go

The last and final step helps people work more efficiently. Using electronic workflows will direct content to the appropriate staff based on rules you define is. For example, in HIM, coders and analysts receive electronic charts on the basis of encounter type, complexity, facility, or any other criteria suited to that department. In accounting and finance, invoices route to the appropriate approval channels based on amount or invoice type. Users work more efficiently within predictable parameters, ensuring processes run more smoothly and efficiently.


Unstructured content, regardless of its form, leads to user frustration. Following the steps outlined above will help your organization turn a source of annoyance into a point of efficiency. That, in turn, leads to happy users – users who understand the value of the systems and services your IT department delivers and supports.

Dan West is healthcare solutions manager at Hyland Software of Westlake, OH.

Readers Write: Buy or Build: SaaS Can Make Sense for Meaningful Use Reporting

April 12, 2013 Readers Write No Comments

Buy or Build: SaaS Can Make Sense for Meaningful Use Reporting
By John Hotchkiss

4-12-2013 5-41-22 PM

The trials and tribulations of Meaningful Use (MU) have given new meaning to the lives of many of us in IT, and often not in a good way. An average 250-bed community hospital submitting its 90-day attestation report must process roughly 3,000 records covering approximately 13,250 patient days, using nearly 300 data elements per record for core and menu measures with up to 600 data elements in each record in support of the clinical quality measures. That’s a tall order.

With a demand for codified and structured data, clearly MU attestation is a different animal than your typical federal report. As a result, most hospitals inevitably face the question of whether to build or buy an MU reporting system, with the possibility of a vendor SaaS-based system taking many of the headaches out of the process.

As a technology professional, I have had exposure to both solutions, and thought I would shed some light on the issues for those still searching for an answer.

Whether for a homegrown or vendor supplied solution, the first steps in report set up are choosing the measures to report and deciding between the various reporting options. To make informed decisions, every data element for Core, Menu, and Clinical Quality Measures has to be reviewed by staff to determine how the hospital wants information to be captured and presented.

Consider, for example, the base population for core and menu measures. Which method will the hospital use for selecting the Emergency Department (ED) patients to include with inpatients in the population? The choices include the Observation Services method, which uses only patients admitted for observation with the appropriate HCPCS code, or the All ED Visits method, using all patients admitting to the ED in the reporting period. The EHR capabilities available in each location inform this decision and drive many others that follow. For example, if the hospital chooses the All ED Visits method, is the ED actually documenting the required BMI and other data elements for all the measures? Must hospital staff be re-trained to do so?

Here’s the fork in the road: to create an in-house solution, IT folks must create a data map to see what fields the MU report needs, determine if those fields currently exist within the modules of the EMR, and then confirm that they are in the required MU format. Very often, IT needs to create new fields or modify existing ones.

Also, multiple modules must be examined because fields often span multiple system components. Without exaggeration, managing that initial data mapping to support the attestation report could take months, not to mention enduring the headaches of ensuring care management staff comply with appropriate data input.

Now finally, your reports are generated. Unfortunately, the first time around, data often fails to meet thresholds. So it must be determined whether this is a problem with the data or whether caregivers are simply not entering the required information in the correct format. This forces IT staff into detective mode to identify and fix the problems.

Applause, applause – the final report is created and filed. Not so fast. This leads to the nightmare of storing hundreds of thousands of auditable data elements and estimating MU storage requirements going forward. Estimates are that a 365-day attestation requires 3.6M to 7.2M data elements. Where will IT store all that data? And, how will the security issues surrounding sensitive patient information be managed? These are the types of issues that keep IT staff up at night.

A SaaS-based MU solution may be a good choice for many hospitals, particularly smaller community facilities without the bandwidth to support all of the above. With multiple challenges, offloading some of that burden makes sense.

Many hospitals will have already determined on their own the measures and reporting options they will use and the information format that required. With that behind them, some SaaS vendors have sophisticated data mapping guides to help hospitals analyze data right from the system itself to identify reporting gaps, to ferret out the problems and to determine information to be added or modified.

Some SaaS vendors can also extract the hospital’s data directly from all system modules to leverage data that the care providers are already entering, thereby eliminating duplicate data entry – a benefit that cannot be overemphasized. Also, some vendors cannot only identify whether measures are in compliance, but can also determine why measures may be failing and help the hospital take steps to correct the issue. As a result, patient care and hospital processes see immediate improvement while the patient is still in the bed.

Of course, with the SaaS solution, users enjoy all the model’s inherent benefits including elimination of software and hardware management, simplification of interface and upgrade management, and unlimited scalability for storage and computational capacity. Obviously some hospitals are just more comfortable with building MU reports themselves and retaining complete control over their data and the process. But for others, SaaS may be just the answer they seek for MU reporting and attestation.

John Hotchkiss is chief technology officer of IHM Services Company.

Readers Write: The Cost Savings Realized by Single-Platform Solutions

April 12, 2013 Readers Write 1 Comment

The Cost Savings Realized by Single-Platform Solutions
By Deborah Kohn

4-12-2013 5-31-54 PM

Medicare cutbacks, increased mergers and acquisitions, and declining revenues and margins are daily realities for healthcare provider organizations. Yet so are costly and often mandatory IT initiatives, such as replacing or implementing electronic health and financial record (EH&FR) systems, integrating and securing the next mobile form factor of computing devices, converting to ICD-10 for reimbursement purposes, and meeting the Affordable Care Act requirements.

How does a CIO not compromise on health information technology (HIT) delivery and still maintain cost containment priorities?

A well-developed, single HIT platform strategy for most applications can realize cost savings by optimizing the IT infrastructure, regardless of whether the platform resides on premise or in the cloud. For purposes of this article, a single computing platform is defined as one that provides a database and set of technologies across a set of heterogeneous applications.

However, still many provider organizations acquire and deploy heterogeneous applications that could be built on a single, common platform. Consequently, this approach continues to generate silos of systems that cannot interoperate and to burn holes in IT operating expense budgets.

Thankfully, no longer is the HIT industry faced with an abundance of best of breed EH&FR applications, typically with each sitting on top of its own proprietary computing platform. Top-selling EH&FR solution vendors finally are offering one or — at most, two — unified platforms for the myriad, structured data-based EH&FR applications.

On the other hand, today, many solutions that complement EH&FR systems remain siloed. Such solutions worth mentioning for this article include but are not limited to Picture Archiving and Communication Systems (PACS) solutions for the storage of image-generating “ology” applications and Natural Language Processing (NLP) solutions for applications such as speech recognition, computer-assisted coding (CAC), and business intelligence (BI). By deploying a single storage platform for PACS solutions or a single NLP platform for speech, CAC and BI applications, chances are that the platform will be around longer than any application an organization has today.

For example, when developing a strategy for managing all the image-generating “ology” applications in the enterprise, it behooves the provider organization to consider a vendor-neutral archive (VNA). This poor choice of name for a storage platform (a more appropriate name might be a PACS-neutral or image file-neutral archive) stores all the heterogeneous, enterprise modality images (DICOM and non-DICOM) in a single, replicated archive. This eliminates the need for each costly, siloed PACS archive and, more appropriately, changes the “A” In PACS from “Archiving” to “Accessing.”

Typically, the platform includes tools to help manage all the different lifecycles of the image data (e.g., retention scheduling and purging mechanisms). And, perhaps the biggest benefit to clinicians is that this platform allows for the creation of an aggregated, patient-centric record of all the enterprise images.

A VNA platform is expensive, requiring a large, complex, capital-intensive project. But well thought out strategies for deploying this platform over time have proven that significant cost savings are realized. Eliminating the organization’s most costly departmental PACS operating expense — recurring migrations with storage media migrations typically occurring every three to four years and PACS replacements requiring massive proprietary data migrations, typically occurring every five to seven years — alone cost justifies this single platform solution.

When developing a strategy for deploying diverse yet complementary EH&FR applications such as speech recognition, CAC software, and BI, it behooves the provider organization to leverage a single NLP platform product that manages each of these technologies well. All NLP engines perform some type of pattern matching, and  to varying degrees, incorporate both rules-based and statistics-based techniques. That means that a plethora of applications can be developed using a single NLP platform.

These applications include but are not limited to speech to text (dictation systems), text to code (medical coding), data analytics (data warehouse systems), foreign language translation (Google Translate), question and answer (IBM’s Watson playing Jeopardy), document classification (Outlook’s spam filtering), candidate identification for clinical trials (determining eligible candidates), adverse events (patients with gunshot wounds), core measures (patients who already had been treated), geographic disease epidemiology, and on and on.

At HIMSS13, several complementary EH&FR application vendors were demonstrating more than one heterogeneous application using a single NLP platform. Currently the challenge is that not one vendor offers most of the above applications or even the same applications. Where one vendor might offer medical coding and data analytics using a single NLP platform, another vendor might offer data analytics and candidate identification using a single NLP platform.

For cost justification and interoperability purposes, it behooves provider organizations to strategically look under the hood and determine where a single NLP platform can be deployed.

Deborah Kohn, MPH, RHIA, FACHE, CPHIMS, CIP is a principal with Dak Systems Consulting.

Readers Write: Optimization and ROI on HIT Investments

April 8, 2013 Readers Write 1 Comment

Optimization and ROI on HIT Investments
By Dave Vreeland

4-8-2013 8-13-34 PM

During HIMSS 13, our company had the privilege of bringing together a select group of HIT executives from some of the nation’s leading health systems for a breakfast discussion. The food was impeccable thanks to Chef Donald Link. The topic was measuring and maximizing ROI on HIT investments.

While incentive dollars offer a simple measure of ROI on the revenue side of the ledger, this represents only one aspect of the substantial benefits clinical systems can yield. The takeaway: a proper optimization program with broader consideration for the projects comprising it can bring a truly positive return to healthcare organizations over a 10-15 year period if properly considered and executed.

Since the passage of HITECH four years ago, we’ve seen vast deployment of clinical information systems across the country, many of which were highly accelerated in the rush to meet Meaningful Use and other regulatory deadlines. We’ve also seen these accelerated implementation projects, both successful and troubled, spawn subsequent optimization efforts, some focused on resolving original implementation issues and some focused on achieving benefits that could not have been anticipated earlier and became evident only after a wide audience of end users was actively working within the system.

We have learned whether an organization approached its baseline implementation strategically, with a focus on workflow and clinical quality goals, or took a more tactical approach targeted toward achieving minimal Meaningful Use and maximizing HITECH incentive payments, is unimportant in the broader scheme of things. The key lesson is that an overall program of work that includes a well-executed, relatively rapid initial clinical system implementation followed by a program of closely monitored optimization projects will maximize the financial return and other benefits.

Over breakfast, we shared a number of lessons learned when it comes to measuring the return on HIT investments:

  • Implementing clinical information systems is a significant investment that brings significant value.
  • Models to accurately reflect both the costs and the return on these technologies are developing, but this work is complex.
  • In order truly maximize the return on these investments, healthcare organizations must view the implementation effort more broadly and make optimization an organizational-wide operation.
  • Optimization is critical in achieving a return on HIT investments.

Dave Vreeland is a partner with Cumberland Consulting Group of Franklin, TN.

Readers Write: Epic’s MyChart Signup

April 8, 2013 Readers Write 31 Comments

Epic’s MyChart Signup
By Anonymous

To borrow from a physician’s comment, “When technology understands what people want from healthcare, our system has a chance. “

Last week while at my physician’s office, I signed up for MyChart. Since my healthcare provider organization went live on Epic about four years ago, my experience from a patient perspective has deteriorated significantly, becoming worse each year. I suspect this is also a result of cost-cutting actions and trying to do more with fewer people. 

My primary physician is terrific, but even she seems to now be distracted by data entry during our annual visit. I took my question list in and we talked about them.  She entered data and then I got home, realizing a couple of the issues were not ultimately addressed with a proposed solution, both of us sidetracked by data entry.

I have to say that I was totally underwhelmed by MyChart.

All I could really see in the record was a list of my meds, the ability to request a refill, and my most recent vaccines. The Health Summary stated that I have no "Health Issues," yet I was referred to a specialist for more tests and treatments.

Test results: I could not view any of my labs  or history of lab results. The message said, "On occasion, there are minor abnormalities reported with patient lab tests which are not significant. Any significant abnormalities will be addressed by your physician, who will give you the appropriate instructions.”

Medical history:  under Diagnosis, there was "anesthesia." I wonder if that diagnosis is for appearing "anesthetized" while navigating my healthcare?

There was more history on my parents than on me in MyChart.

Appointments: they did score here. My past and future appointments did appear. But to schedule the appointments, I had to go through nightmare IVR. One appointment scheduling system left me on hold for 11 minutes before reaching a person to schedule.

I received my first electronic message from one of the specialist’s assistants I am seeing. It was annoying to open the e-mail to find I have to go into the portal (yep,now what is my user name and what is my password…I have forgotten) to merely see an e-mail they sent with a link to an online education for a procedure, easily available to me if I Googled the topic. I was annoyed by the required time to retrieve message and the fact I thought it might be important and require my immediate attention. And later, to go back in to send a response.  

So I didn’t send an electronic response — I called them back. This "assistant" seems to know very little about the procedure. Every time we speak, there is a new tidbit of info which impacts my planning and what happens pre- and post-procedure. When I asked her why I wasn’t told this before, she responded, "I am just reading it now.”  

I still have no clear answers to questions I am posing as an informed healthcare consumer and advocating on my own behalf. I cannot imagine how my parents would navigate through this. In fact, they would not be able to do what I am having to do and would have been no-shows. 

Although I have now signed up for this revolutionary change in healthcare, I see minimal benefit to electronic messaging. I would put money on my actual physician not likely choosing to communicate with me through this portal in the near future.

Readers Write: The Economics of Google Glass in Healthcare

April 3, 2013 Readers Write 6 Comments

The Economics of Google Glass in Healthcare
By Kyle Samani

Google Glass is a fully-featured modern computer running a derivative of Android that fits into a glasses-like form factor that rests comfortably on your face. That includes CPU, RAM, storage, battery, a heads-up-display, a microphone, camera, speaker, WiFi, GPS, Bluetooth, and bone conduction technology.

Although Google has been shy to admit it, Glass will have some form of bone conduction technology so that you – and only you – can hear. Of course, you’ll be able to take a picture of or record anything at any time and transmit that data to the entire Internet wirelessly in real time. It’s quite an extraordinary technological breakthrough.

A lot of people think Google Glass can be used as a development platform to create amazing healthcare apps. So do I.

Many of these ideas are obvious, and many of them could be relatively simple to develop. But we won’t see most of them commercialized in the first year Glass is on the market, maybe even two years.

The most obvious analogy to Glass is the iPhone. It’s a revolutionary new technology platform with an incredible new user interface. Glass practically begs the iPhone analogy. Technologically, the analogy has the potential to hold true. But economically, it does not. Because of the economics of Glass, many of these great ideas won’t see the light of day any time soon.

First, there’s the cost. Glass will run a cool $1,500 when it lands in the US this holiday season. There’s no opportunity for a subsidy because Glass doesn’t have native cellular capabilities.

Second, and even more importantly, Glass needs to prove compelling given that you already have a pretty incredible smartphone in your pocket. When the iPhone launched, it competed with the non-consumption of 2007: dumb phones. Glass has to compete with a whole new class of non-consumption: iPhones and Androids. That means Glass has to be so incredible that you’re willing to spend $1,500 given that you already have an amazing smartphone in your pocket. Glass only provides marginal value. It’s a tough sell.

Take another look at the Google link from earlier in this post. Would you pay $1,500+ for any of those individual applications? Probably not. As a hospital CIO, would you pay $1,500+ per employee for hundreds of employees for any of those applications? Probably not.

Although these are all good ideas, the vast majority of Glass ideas aren’t compelling enough to justify the cost of Glass itself. This is inherently true in all Google Glass application markets, both consumer and enterprise. It’s especially true in healthcare given the additional costs of integrating into existing systems and processes.

Doctors in outpatient clinics face a similar challenge. Though some physicians, and perhaps some surgeons, will shell out $1,500 early on, most doctors won’t be willing to commit that kind of capital. I’m sure many physicians would feel concerned about making their patients feel socially uncomfortable, even if a given application proves clinical and financial ROI. But at some point down the line, doctors will probably adopt a Glass-like technology platform, especially with something like the MYO Armband. The human computer interaction (HCI) opportunities with a Glass+MYO armband are endless.

Over time, an increasing number of Glass healthcare apps will become available and the price of Glass and its competition (I’m looking at you, Apple. Also, learn why there will be no iWatch) will fall. Eventually, healthcare app developers writing on Glass will find success, but very few will in the first year Glass is on the market.

That does not mean that the Glass ecosystem is destined for failure. Glass has the potential to solve big problems. Capitalism dictates that app developers will figure out how to use it to solve big problems.

My favorite VC proverb is, "Provide pain pills, not vitamins." For every painkiller Glass app, there will be dozens of vitamins. The painkillers will drive the success of this platform. No one needs to buy Glass. But Glass can help people and create new efficiencies in enterprise markets such as healthcare, education, manufacturing, transportation, construction, gaming, tourism, and many others.

I’m incredibly excited about Glass. It will change the world. Maybe not in its first year on the market, but it will. No one thought much of the iPhone in its first year on the market, but it delivered a revolutionary new user interface and provided a new technology platform that app developers will extend to solve an enormous number of previously unsolvable problems. Glass will, too.

Glass developers, off to the races!

Kyle Samani is inpatient deployment manager at VersaSuite of Austin, TX.

Readers Write: Get Ahead with Mobile Job Hunting

March 29, 2013 Readers Write 1 Comment

Get Ahead with Mobile Job Hunting
By John Yurkschatt

3-29-2013 11-08-09 PM

According to a recent report from The World Bank, three quarters of the world now has access to a mobile phone. In addition, ownership of multiple mobile devices is becoming increasingly common, suggesting that their number will soon exceed that of the human population. Unbelievable, right?

Recently, at HIMSS, I encountered numerous people who were there to network about jobs in the industry. While speaking with many, I couldn’t help but notice that they were checking their smartphones often during our conversation. It became apparent that they were engaged in mobile networking at HIMSS as well. In fact, today’s job seekers are avidly using the following job related functions on their smartphones:

1. Search for jobs

2. Receive e-mail job alerts

3. Read about recruitment process and tips for interviewing

4. Apply for jobs

5. Share content on social networks such as Twitter

In the age of mobile technology, the job hunt is only a click away. The rise of mobile technology is changing the face of how job seekers conduct their search and how employers and recruiters are reaching out to top talent.

Savvy job seekers are using a number of mobile apps. I found three apps to be extraordinarily powerful for the job hunt and for meeting those people who have the jobs:

Hidden Jobs

3-29-2013 11-01-09 PM

This app provides you with job opportunities that are not posted on the company website. It tracks close to 2 million unadvertised jobs from companies that are growing and making headlines. In addition, if you are ever seeking a job at a particular organization, or within a geographic area, you must try Hidden Jobs.


3-29-2013 11-04-22 PM

According to its site, LunchMeet is a great tool for talent hunters; job seekers; career development professionals; entrepreneurs; people who seek or offer free consultation over lunch or drinks; business school students; business development, sales, and marketing people; and anyone who is interested in strengthening and expanding their professional network.


3-29-2013 11-05-55 PM

While this app is not necessarily a job search tool, it is the ultimate app to have while attending a conference. In fact, some job networkers at HIMSS found this app handy. Having Sonar enables like-minded individuals to easily connect while attending a conference, or within a certain geographic location. If I were in a networking frenzy, I would turn on my Sonar app and look for folks with similar interests. It is a great way to meet people you may have not known prior to arriving at the conference.

Let’s face it, mobile technology is changing the way people search for jobs and the way companies search for talent. It will only grow in popularity. Get a step ahead, or maybe, don’t get left behind. Take your job search mobile.

John Yurkschatt is project coordinator with Direct Consulting Associates.

Readers Write: The Chasm Between the Vision and Reality of Big Data

March 20, 2013 Readers Write 2 Comments

The Chasm Between the Vision and Reality of Big Data
By Ed Park

3-20-2013 4-35-43 PM

I attended the Bloomberg “Big Data” Conference in DC on Thursday, March 14. It was awesome. Folks from big business, big government, and beyond attended. Everyone was talking about the perils and opportunities of data – big data. As one executive creatively stated, “Data is the new oil, and what we want is the gold.”

I was lucky enough to take part in the healthcare panel. In short, my point of view is that healthcare desperately needs to attack and improve its many inefficiencies — much like how Walmart and FedEx have done — before it can successfully leverage big data to drive clinical enhancements. If we can’t get the simple stuff right— ensuring we follow up on lab orders, getting through Meaningful Use, etc. – we have no hope of getting to all of the great things we know are possible.

Athenahealth has brought insight and analysis to the way insurance claims are processed to ensure that the creation of claims and billing in general is streamlined. While this concept might seem simple, it has a powerful trickle effect. If physician practices can get claims and billing in order, they gain valuable time and resources to focus on care.

I tried to talk about the power of data in a tangible way by approaching the conversation from a “first things first” perspective. I tried my best to detail how data can be used to support primary care physicians’ workflow by selectively involving mid-level practitioners and administrators to take on tasks that doctors shouldn’t be doing. This in turn allows doctors to be fully present with patients.

To the dream-filled audience who perhaps thought the time for robot-driven care delivery was near, my goal was to keep it real by saying there is “no greater distance than the chasm between the promise of big data and where we are today.” The applications that healthcare needs to focus on first when it comes to big data are practical things: being more efficient, making administrative process fail-proof, identifying patient populations that are the most sick and most expensive, understanding what’s working and what’s not in the provider workflow, understanding the way patients act (or don’t act) based on a doctor’s order.

With this focus (to be more efficient), in time we’ll be better able to open the doors for healthcare to tackle data-driven clinical intelligence and improvement.

The future of big data in healthcare is bright. There are grand opportunities for patients and the industry at large as vendors, government, and health systems begin to embrace the idea of and build an infrastructure to support broad-based data liquidity. It is from this data openness that patients and providers will be empowered to take control of information to direct the health-related decisions they make.

It was mentioned at the conference that big data is not new, but what is new is “big, fat, messy, distributed data.” The challenge and opportunity is to bring together data to drive change based on evidence, with confidence.

Ed Park is chief operating officer of athenahealth of Watertown, MA.

Readers Write: Improving Patient Outcomes with Real-Time Decision Support and Analytics in the “Connected Home”

March 20, 2013 Readers Write No Comments

Improving Patient Outcomes with Real-Time Decision Support and Analytics in the “Connected Home”
By Fauzia Khan, MD, FCAP

Over the past decade, technology innovations have continually pushed the boundaries in the healthcare industry. Patient information in the hospital and ambulatory settings is now easily accessible through EHR/PHR systems and sophisticated Health Information Exchanges (HIE). With the addition of clinical decision support (CDS) and real-time analytics, clinicians are empowered to develop the best treatment plans for each patient, using intelligent and actionable information to improve care quality while reducing costs.

The mandate to embrace these technology innovations has been driven by federal government regulations, as well as disruption of the fee-for-service model. Although we have just barely embraced this model in the clinical world, what if these technology platforms could also be effectively used in the home setting?

With clinical decision support, patients could take a more active role in their own care. If the last decade was focused on inpatient, outpatient, and ambulatory data integration and interoperability, the next several years should focus on creating the “Connected Home.”

Data at the point of care in the home should be actionable, comprehensive, and increasingly accessible to patients, physicians, and payers. Whether that data is delivered through an HIE, EHR, or a smart device, patient data needs to be accurately captured and widely available, which will allow for the best healthcare decisions to be made. In time, once we move treatment closer to the individual, this will close crucial gaps, provide greater visibility, and accelerate decisions that lead to better outcomes.

All over the world, people want to be involved in their own care while remaining in their homes. Patients can receive attentive care in a comfortable environment, which ultimately improves their quality of life. If successful, home management will result in fewer urgent medical interactions and a reduction in hospital visits. In a recent Wall Street Journal story, the article demonstrated how the hospital-at-home concept is helping to take care of sick patients in the comfort of their homes.

With mobile technologies, ubiquitous Internet, and smart devices, the boundaries between home, hospital, and ambulatory and long-term care facilities will blur. Today, once data is captured through EHR, HIE, PHR etc., the next step is to make that information actionable.

With patient-specific and real-time information accessible at the point of care (the definition of which will also change), physicians could better manage common chronic conditions and patient populations. In addition to clinical decision support (CDS), another necessary layer to develop would be around analytics. CDS would empower clinicians to make more informed, evidence-based decisions, while real-time analytics would allow clinicians to view and analyze at-risk populations from both a preventative and interventional perspective. Analyzing patient populations and outcomes provides vital information for physicians that can significantly impact patients by triggering earlier interventions, reducing avoidable errors, and improving overall health outcomes.

A fully realized “Connected Home” is still in development, but it is certainly within reach. As we strive for more integrated technologies across hospitals and lab systems, we need to also spend our resources on developing a home network that can provide evidence-based data and real-time alerts to providers, patients, physicians, and even network managers. Once this integration takes place, the healthcare industry can focus its attention where it belongs—on better managing patients and populations.

Fauzia Khan, MD, FCAP is chief medical officer and co-founder of Alere Analytics.

Readers Write: Vendors – Welcome to the World of HIPAA

March 20, 2013 Readers Write 4 Comments

Vendors – Welcome to the World of HIPAA
By Frank Poggio

For the last decade or so, vendors were on the fringes of the HIPAA regulations. Just sign a somewhat innocuous BA agreement and let the provider worry about the details of compliance.

As of January of this year, the Office for Civil Rights (OCR) formally “invited” vendors into the HIPAA labyrinth of rules and regulations. In the new 500-page HIPAA Omnibus Final Rule, Covered Entities (providers) are required to send out new Business Associate agreements to their suppliers and vendors. You should get yours soon, and as an IT supplier, you will see several new requirements.

The biggest one is that system vendors that touch Protected Health Information (PHI) in any way must agree to commit to achieving full compliance with HIPAA rules by September 23, 2013. Touching means  coming in contact with — whether you create, capture, edit, change, store, pass on, reformat, convert, etc. a single piece of PHI even for even one patient. The HIPAA rules do not differentiate between full EHR systems, EHR modules, application type, middleware, report tools, conversion, or archive tools, etc. Basically, if your system touches it, you own it.

As an extreme example, say your software does only parking lot management for a hospital. If you somehow capture any personal ID data, your firm will have to meet HIPAA compliance.

A more realistic example is the typical analytics tool that takes detailed information, aggregates it, and generates only summary, management, or trend reports. Your analytical system (such as grabbing a UB bill file and calculating averages) may never report out or allow access to any specific patient PHI, but since you received the data on a case-by-case basis even though you may have stripped out the PHI before you stored the records, your firm and software must meet HIPAA compliance.

The Final Rule is clear that if you touch PHI, even if you don’t look at it, you must comply. There are no exemptions for encrypted data, servers in locked cabinets, or remote cloud systems.

As a vendor, what must you do to be HIPAA compliant? Your firm must supply documentation of:

  1. Policies addressing HIPAA privacy and security issues
  2. Privacy and security procedures
  3. Workforce HIPAA training
  4. HIPAA-compliant workflows
  5. Compliance for an audit or data breach investigation
  6. HIPAA compliance of any subcontractors you use

Your clients may require an independent audit of the above at your expense as a requirement for you to continue as their vendor. If you do not provide it, their legal counsel may advise them to replace your system with that of a competitor. Remember, the above must be in place before September 23, 2013. Lastly, if you or your provider client has a data breach and OCR finds you lacking in compliance, you could be fined $1.5million per breach.

As I noted in a past HIStalk Readers Write piece, ONC in Stage 2 “exempted” EHR Module vendors from testing on the privacy and security criteria (if the vendor so chose), but they did state that the vendor must still be HIPAA compliant. Which means, implement the ONC privacy and security criteria.

Welcome to the wonderful world of HIPAA.

Frank Poggio is president of The Kelzon Group.

Readers Write: Not Safer!

March 15, 2013 Readers Write 7 Comments

Not Safer!
By Ruth Bowen, MBA, CPHQ, CPHIMS

I’m an HIT professional in Philadelphia who lives in an area that supports multiple competing health networks. I am old enough to have a robust problem history and to have records that span multiple networks.

Having worked in this industry for 30 years, I am definitely a believer in the potential of EMR systems. But frankly, I am less safe.

All of my outpatient providers went from paper to a digital record. There wasn’t an opportunity for a conversion. Each of these practice systems took a different approach in terms of what data would initially populate the EMR. There are no standards here, only guidelines. There can be significant expense in terms of abstracting data from a paper record. Much of the data available in my paper records has just disappeared.

In one case, the paper record was simply scanned. I arrived for a visit with no problem list and no medication history and was treated as a new patient. The practice was dependent on my memory of events over 10+ years. In other cases, there was a subset of data, but in each case, most of the history was unavailable. The paper chart may have been scanned, but physicians do not page through images of paper record, so I consider the information unusable.

None of these EMR implementations has an interface from the laboratory system I use. In most cases, a subset of available laboratory results is transcribed into the electronic record. Although the physician also has a copy of the current paper lab results at the time of visit, the history of results in the EMR is incomplete and likely has transcription errors.

One of my physicians used to manually maintain a paper flowsheet for a subset of results significant to his specialty. That history is gone. His system doesn’t support the view he formerly had and there is no historical data that could populate a flowsheet or graph even if the capability was available.

The result is an increased personal safety risk related to multiple EMRs that are incomplete, each with a different subset of data. As it turns out, my responsibility in terms of patient engagement is record reconciliation at the time of visit, a reconciliation that is totally dependent on my memory. Not, I think, what ONC intended.

Ruth Bowen, MBA, CPHQ, CPHIMS is an independent HIT professional in Chesterbrook, PA.

Readers Write: A Balanced EHR Copy Forward Solution

March 13, 2013 Readers Write 8 Comments

A Balanced EHR Copy Forward Solution
By Kyle Samani

3-13-2013 5-53-18 PM

There’s been a recent wave of media coverage surrounding the topic of EHR copy forward functionality. Many have suggested that this function should be outright banned. The reasons vary, but in general most of the problems cited are related to the fact that the copy forward function in EHRs creates garbage and bloat in the patient’s record.

As someone who has experience designing and programming EHRs, who has deployed an EHR in inpatient and outpatient (PCPs and specialists) environments, and who has talked to hundreds of doctors about the subject in various presentations, I have a unique perspective to offer.

Lyle Berkowitz, MD, CMIO of Northwestern Memorial Hospital in Chicago, recently posted on the subject. He’s right. EHR copy forward is a great tool if used correctly. The problem is that EHRs make it too easy to abuse. Most of the copy forward functions in EHRs look at the last note and quite literally copy every field forward into the current note. This is problematic because full-note copy forward allows the doctor to copy forward too much information before all of it can be digested and understood.

There are easily dozens if not hundreds of data points in a given note. Doctors shouldn’t be encouraged to copy hundreds of data points into the current note before having a chance to complete the current assessment. It’s too much, too early in the examination process. The EHR should make it easy to copy forward information in manageable pieces.

I lead the original design of a function in my company’s EHR called Copy to Present in the latter part of 2011. It’s similar to the copy forward feature in most modern EHRs. The primary difference is that it doesn’t copy the entire note forward, just the active area of focus. The function is available in conjunction with a date dropdown on all major sections of the chart.


For example, the physical exam page contains a date dropdown at the top of the page. When a doctor visits the physical exam page, the date dropdown defaults to the current date. Doctors can quickly review an old physical exam summary by selecting from a date in the dropdown, which is populated with dates of previous physical exams for the active patient. When looking at an old date, the Copy To Present button appears. Clicking it copies forward the selected physical exam to the current note. The Copy to Present button doesn’t affect any part of the chart other than physical exam; all other areas are left intentionally untouched. After clicking the Copy to Present button, the physical exam data is editable as if the doctor had entered the data by hand.

A video demonstration of Copy to Present is above and here.

Copy to Present and the date dropdown are useful for data points that need to be collected and updated during every examination. Examples include chief complaints, physical exams, review of systems, and assessments and plans. In these scenarios, the Copy to Present function allows the doctor to understand what they recorded last time before copying forward to the current note. It provides the quick copy-forward function doctors want and need, while still allowing fine-tuned control over what’s copied forward.

However, Copy to Present is irrelevant when dealing with other types of information. For example, allergy lists, medication lists, problem lists, lab results, medical history, and surgical history. The most up-to-date versions of these data points should always be shown regardless of who last updated the list across any care setting (inpatient, outpatient, ED). EHRs should understand (but most don’t) that these pieces of information aren’t part of a particular note as much as they are relatively static pieces of data about the patient. Once labs and allergies are recorded, they should be available to any clinician that needs access to them, and they should always be up to date independent of any clinical note.

EHRs need to understand the kind of information they’re handling. Different pieces of information should be handled differently depending on what the information is, who is accessing it, and what that person needs to do with it. EHR vendors have a responsibility to ensure they provide the tools to make sure clinicians can get what they need, when they need it, and understand it as quickly as possible.

Kyle Samani is inpatient deployment manager at VersaSuite of Austin, TX.

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