The readers of EMR and HIPAA have been incredible lately in sending in great commentary on the EMR industry. The following is one such commentary about the issues associated with the now widely seen trend of Hospitals acquiring practices. The person asked to remain anonymous and for the names of the specific EHR vendors to be removed. I agreed since I think the trend is more important than the specific companies.

One trend that I find extremely (and personally) troublesome is the migration from homegrown EMR’s to less functional Hospital based EMR’s – a migration that is occurring frequently now that most small practices are being purchased by Hospitals.

In our case, our small hospital administration decided unilaterally (without MD input) to implement a poorly designed EMR from it’s IT vendor. This has been a colossal failure, as none of the doctors were able to use the EMR. Hospitals are easily seduced by their IT vendors, and think that they can have only one software vendor. They think that all EMR’s are basically the same, either a Ford or a Chevy mentality. They don’t want the docs interfering with the decision process. They don’t have any idea of information and work flow in a doctor’s office. And now they are getting ARRA stimulus funds, and sometimes grant money from local endowments.

We doctors have asked that administration find us one practice that is successfully using the EMR they selected. I think they found 1 doctor 1,300 miles away who was able to make it tolerable. The hospital EMR is CHIT certified, so that doesn’t mean much. Hospital Software vendors have quickly tacked together some sloppy EMR’s in order to save their customer base, and have easily deceived administrators into buying these inferior products.

Our administration has pulled back from implementation, just having us use the scheduler, nursing putting in vitals/meds, and we just enter the ICD-9′s and charges. But another push to MU is coming soon. I have told admin that they must cut my daily schedule from 20 to 10 patients per day. I think that the ARRA stimulus funds and this whole Medicare push for EMR is having a negative effect so far, as least for me. I was using [EMR Vendor] (and still am unilaterally) to organize my data, and generate notes. It’s light years ahead of the EMR the software vendor selected.

I have heard my story repeated many times. The trend of Hospital owned practices may be inevitable, but it has severe negative consequences for EMR, in my opinion.

John’s Comments: While I don’t necessarily agree with the broad ranging comments about administrators not caring or listening to doctors, I’ve heard it far too many times to disagree completely. There’s little doubt from my experience that many hospitals don’t do a great job listening to doctors in selecting an EMR software. However, I’ve also seen many doctors who are terrible to work with when it comes to any discussion of an EMR. So, let’s not kid ourselves into thinking that the doctors are completely blameless either.

One important point that is made is that doctors like using EMR software that they select. As more and more hospitals acquire practices, this issue is going to come to a head. I won’t be surprised if it’s actually a major part of the reason that the cycle of independent doctors starts again.

I’ve been really intrigued lately by the changing media landscape. Things like Blogs and Twitter are providing opportunities for basically anyone to be able to share a message with the world. Certainly, many of the blogs don’t get read and a tweet on Twitter falls off people’s radar very quickly. However, some of the better or more interesting ones rise to the top and provide an interesting and sometimes dissenting voice to the conversation. Personally, I think this type of open discussion around topics is valuable and beneficial as long as people maintain a certain level of respect and decency.

My question to you then, is what would you say to a Healthcare IT audience?

As I considered on this difficult question myself, I decided the message that I would want to deliver: You can resist all you want, but the future of healthcare will require IT.

Pretty much every day, someone comes on this site to talk about the benefits and challenges associated with EMR and EHR in their office. As I’ve listened to the various challenges that people have posted, I’m sympathetic to them. However, almost all of those I’ve heard boil down to poor EMR selection or poor EMR implementation.

To me, the EMR selection is the absolute most important part of the EMR implementation process. Far too many doctors and clinics don’t take the time and effort that’s required to really go through a proper EMR selection process. I’m very sympathetic to them for a lot of reasons (ie. It’s not their job or interest, there are 300 EHR vendors, there aren’t great resources for differentiating EHR, there are a lot of perverse incentives, etc). However, it’s worth the cost to do it right. Otherwise, you should wait until you can do it right.

However, I believe that EMR is still only one small part of how healthcare IT is going to impact healthcare. Just last night I was at a local event and someone who use to work in the casino industry has been working for the past year or so on an app that helps improve doctor to doctor communication. Fascinating stuff.

Personally, I see us just at the very begging of a revolution in healthcare IT. IT is going to start invading every part of healthcare and will pretty much be impossible to avoid.

Certainly there will be some (possibly many) who continue to resist the adoption of technology in their clinic. However, I’m seeing more of a shift by patients and doctors that are interested in finding more ways to integrate technology into their healthcare. Most of the doctors aren’t sure what to do next, but they’re looking.

I can certainly understand and appreciate those that say that the current EMR and healthcare IT offerings aren’t up to snuff. The fact is that many of them aren’t. However, that doesn’t change my belief that IT is still going to change how healthcare is provided. It just may mean that healthcare will be changed by an IT offering that most of us don’t know about today.

My greatest wish would be that we could close the case on whether healthcare IT is important and/or it can change healthcare. Instead, let’s put our energy into finding the ways that it can change healthcare IT for good. All of us focused on using healthcare IT and EMR for good in healthcare would produce some amazing results.

Time for the latest entry in my series of Common EHR Implementation Issues. See also my previous posts on Unexpected EHR Expenses, EHR Performance Issues and a little follow up to avoiding the EHR performance issues altogether.

This weeks common EHR implementation issue is: Inadequate EHR Templates.

Before I begin with the major issues of inadequate EHR templates, it’s worth noting that there are a few EHR software out there that use a different EHR documentation paradigm than templates. For example, some use voice recognition to power their documentation. Others have a system that learns your documentation over time and based on that learning remembers how you want to document certain procedures. Others, use lots of independent documentation methods (one EHR vendor calls them controls – check box, radio button, freetext field, etc.) which can be grouped and used in interesting ways.

However, even with all of the above alternative documentation methods, there’s often an element of templating that’s occurring. They’re PR and marketing people will shudder at the term template, but concepts related to templates seem to pretty much always apply. For example, in voice recognition there’s something called a Macro. That’s basically a template. The EHR system that learns your documentation method is just using your initial documentation in the EHR to create personalized templates of how you like to document. The independent documentation methods often group those various “controls” into groups of common visits. That sounds like a template to me.

I’d be interested to hear of an EHR system that doesn’t use the principles of templates. It is worth noting that all EHR templates aren’t created equal. Some are much more flexible than others. Now to some details.

The inadequate EHR templates shows itself in a number of different ways.

No Specialty Specific EHR Templates – This has to be the complaint I hear the most. It usually goes something like this, “The EHR salesperson said they had templates, but they don’t have any templates I can use.” Did someone say EMR salesperson mis-communication? Yep, happens all the time. Let’s be honest for a second. How could the EHR salesperson know how good their cardiology or neurology templates really are? They just go by what they hear and what they’re told by the EHR company.

Incomplete or Unusable EHR Templates – You may have noticed a subtlety in the quote I put above. At the end the doctor says “templates I can use.” Maybe the EHR salesperson isn’t lying to you about them having those cardiology or neurology templates. Maybe they do have a bunch of templates for those specialties (or whatever specialty that interests you). However, just because they have templates for those specialties doesn’t mean that you’re going to want to use any of the templates that they’ve created.

My favorite complaint is when they say that the specialty templates seem to have been created be a general medicine doctor and not an actual specialist from that field. I’ve heard it far too much not to mention it.

The other major problem with this point is the unique documentation preferences of each doctor. Has there ever been any two doctors that document the same way? We could debate the good and bad merits of such documentation, but the point is that each doctor is very different. Some feel the need to over document the encounter. Other doctors want to just document the bare minimum. Plus, some (purposefully or not) do a terrible job documenting the visit. The templates in an EHR could reflect any of these various documentation patterns and depending on your perspective could mean that EHR has inadequate templates for your needs.

Hard to Modify, Add to, or Adjust – While not specifically an inadequate template, this is an important part of templates. Turns out that if a user can easily modify, add to or adjust a template that is inadequate, you’re going to be a lot better off. Some template systems are like pulling teeth to modify. Others are amazing at how you can on the fly modify the template.

One promise I can make you, You WILL want to modify their templates. I can’t say I’ve ever heard of someone using the templates perfectly out of the box. Well, maybe I’ve heard of one or two using them, but that was when they were complaining that they had no way to modify the things they wanted to change.

Avoiding EHR Template Inadequacies

The best way to avoid this issue is to test drive the EHR software and the specialty specific templates you hope to use. Run through the templates like you’re charting on some common patients. You’ll learn a lot about what templates are available doing this than anything else. You’ll see if the templates are overkill or below standard for your needs.

Another great test is to try using multiple templates for a complex patient. How easily is that done and how well does the documentation display?

Then, during your EHR demo with the EHR salesperson, ask them to modify part of the EHR template they’re using to document. Tell them you don’t like to ask one of those questions, so you’d like to see them remove it from the template. Many are likely to respond, “It can be done, but I’d have to switch systems to do it or I’d have to call in to tech support to make the change.” I think we all know the real message they’re sending.

For those not interested in EHR templates, you might take a second to read Dr. West’s Experience implementing EHR templates in his office.

In my post about the common EHR implementation problem of EHR slowness, I mentioned that I’d follow up with a post on how you can avoid the EMR slowness issue altogether. It’s better to avoid than fix problems.

The best way to approach EHR performance issues is to make them part of your EHR selection process. EHR performance issues could and should be a deal breaker for you when you’re evaluating EHR companies. How then can you identify EHR software that might have these performance issues?

Red Flag #1 – EHR Demo Slowness – Bring a red pen to your demo and every time they say something like, “It’s not usually this slow?” or “It must be slow because it’s running on my laptop.” make a BIG RED mark on your paper (or tablet if you’re advanced like that). Even one red mark should be cause for concern and investigation.

Certainly there are situations where environmental issues can cause slowness to an EHR. So, you can’t completely rule them out completely for this, but this is their demo. This is there one time to shine. If they can’t get their EHR demo running at full speed, what makes you think an EHR production environment will be much better?

You can make an extra red mark if it’s a SaaS EHR that’s providing the demo. They might say it’s just “the internet connection.” Well, guess what? Soon, that’s going to be you using that EHR and often on similar internet connections.

Of course, the message to EHR vendors is to make sure your demo runs as fast as your production system.

Red Flag #2 – Site Visit Slowness – While the demo can tell you a lot about an EHR software, it can’t necessarily tell you the speed of the EHR software. Just because the EHR is fast during the EHR demo, doesn’t mean that same EHR software will be fast in a production environment. Add this to the multitude of reasons why a site visit to a current user of that EHR is so important.

Make sure to do that site visit at one comparable in size and users to your clinic. You don’t want to look at the EHR responsiveness of a solo practice if you’re going to be a 6 provider multi clinic setup. Size matters when it comes to EHR speed.

Once on site, you can get an idea of the speed and responsiveness of the EHR software in two ways. First, observe the users of the EHR in the clinic. See if they exhibit any of the systems listed in the first section of this post. Another observation is to see how quickly they’re clicking around the EHR. If you see a lot of clicks in a row with little waiting in between clicks, that’s a great thing. If you see them click, wait, click, wait, click, click , wait. Be afraid.

The second way is to ask the EHR users. The problem with doing this is that only one response has value. If they say the EHR is slow, then you’ve gleaned some important information that’s worth checking on. If they say the EHR is fast, then you don’t necessarily know. The problem is that you don’t know what the user considers fast. What’s their frame of reference for saying it’s fast? Do they know what fast is? Have they just been using the EHR software so long that they’ve hit a rhythm that makes it feel faster than it really is? It’s a good sign if they say that it’s fast, but take it with a grain of salt.

Red Flag #3 – Use A Demo EHR System Yourself – Most EHR vendors will provide you a way to demo the product yourself. This isn’t a fool proof method to test EHR slowness, but it’s another decent test of the EHR’s responsiveness. Try it out using your internet connection and your computer hardware. Nothing like first hand experience documenting some patient visits to learn about the speed of an EHR.

EHR Speed Suggestion – Don’t Skimp on Hardware
Far too often I see a clinic skimp on the hardware requirements and regret it later. In fact, they often end up spending the money twice since they have to buy new hardware since they skimped in the beginning.

Of course, this suggestion can be taken too far as well. The computer and laptop manufacturers will try to sell you the whole kitchen and you might only need the stove and refrigerator. To put it in more practical terms, you’re going to want plenty of RAM, but do you really need the webcam, Blu-ray player, and special 100 in 1 media device?

Just because an EHR vendor says their EHR software can work on a certain hardware configuration doesn’t mean it should be used on that hardware configuration. In the middle there’s a spot between can and overkill that’s called optimal. Find that hardware configuration and you’ll be a much happier EHR user.

Conclusion
Don’t accept an EHR that’s slow. Make sure that the EHR performs at a satisfactory level. I know of nothing that frustrates a clinic more than a slow EHR.

This was a great piece of advice that was given at my Health Tech Next Generation EMR 101 panel.
@2healthguru – Gregg Masters
We run from EMR vendors w/products that offer lots of free hours of training. Means EMR UI not Intuitive @brandrew0 #HTng11

I’d only clarify that unlimited free support is good, but it’s when they suggest you use a week of that free support that you run.

I can’t remember exactly where I saw someone talk about the “WIIFM” (What’s in it for Me) principle, but it really is an important principle that when understood can have an amazing impact for good. This post isn’t about whether you should live a life asking WIIFM. I’ll leave that question to people much smarter than me. Instead, I want to look at how applying the WIIFM principle to others can help those working on a successful EHR implementation.

In most cases I’m talking about, the WIIFM should be changed to “What’s in it for Them?” Understanding the answer to this question can help you as an EMR consultant, an EMR vendor or even a practice manager or doctor that’s trying to work through an EMR implementation.

One of the first things I cover in my e-Book on EMR selection (It’s free, check it out) is the idea of getting buy in from those that will be affected by the EHR implementation (that’s usually everyone). One of the best ways to get EHR buy in from people is to understand the WIIFM. It’s not fool proof, but it’s one good strategy for getting people on the same bus, going the same direction.

Let me tell you that there’s always a way to find a WIIFM in an EHR implementation. This list of EMR and EHR benefits is a great place to start. However, many of those benefits can be extrapolated in ways that will show what’s in it for every person in the clinic.

Let’s say for example, that your goal for implementing an EHR is to increase clinic revenue by freeing up chart storage space so you have an extra exam room for another provider. You can then talk about what that new revenue can be used for to improve the clinic. Maybe it could include bonus checks or other incentives. These become tangible things that staff can use to better understand WIIFM in an EHR implementation.

I’m sure many of the nay sayers out there are thinking, but an EHR doesn’t provide those benefits. That’s why it’s so important that you define which benefits your clinic is striving to achieve before you select or implement an EHR. The list of benefits you use to show WIIFM ends up being your goals for your EHR implementation. They can be used to define your EHR selection process. They can be included in the EHR contract so you have some assurance or protection if the EHR vendor can’t deliver on their sales promises. Not to mention, after the EHR implementation you have a way to measure if it was a success or not based upon those goals.

Test the WIIFM principle. Not from an arrogant Me Me Me approach. Instead, step into the other people’s shoes and ask WIIFM. This approach can really help improve any EHR Implementation if applied correctly.

When I learned that HITECH included funds setting up the regional extension center system to support small medical practices in implementing EHRs, I thought, well, that sounds OK.

I wasn’t thrilled, mind you, as I wasn’t optimistic that a government-sponsored organization would produce the quick EHR adoption process HITECH demands, but it wasn’t a bad thing.

Since then, I’ve gone from mildly interested to downright irritated.  While I wasn’t expecting the RECs to blaze a path to glory, I thought it would be nice if they produced great educational materials and sessions, made themselves highly accessible to physicians and offered clear guidance on vendor selection. As far as I can tell, we’re largely zero for three.

Yes, as a recent a recent study notes, the RECs are doing better at some of these things of late. According to a recent study by the eHealth Initiative, they’ve now reached most of the 100,000 PCPs they’d hoped to enroll, and they’ve developed better vendor specifications.

That being said, they really don’t seem to be that focused. Hey, if a privately-funded organization took this long just to begin to get started with their work, they’d already be out of business.

Not only that, when I made one completely unscientific mystery-shopper call to a REC, the staff member I spoke to didn’t seem to have much on the ball. He didn’t have anywhere to direct me for further information, didn’t have any informational meetings pending, couldn’t define clearly what his group could do for me and didn’t even bother to get my contact information.

Of course, that may have been a freak instance, but I’m beginning to doubt it. The buzz I hear is that the RECs have barely a clue as to how to reach their target population, and don’t really speak their language. Some of my EMR-savvy buddies think they’re just about useless.

I do truly hope that the RECs get their act together — maybe all they need is better marketers — but I’m not holding my breath.  My advice to doctors: Keep pushing on your local medical society, your IPA, your hospital partners and your practice management consultants to shed some light on the EMR adoption process. You’ll get further, faster.

I know I’ve written about ERP and EMR before, but the more I think about the EMR selection and implementation process, the more I see the same issues that are experienced with an ERP implementation.

The one issue that is a bit different about EMR versus ERP is that there are only a small handful of ERP vendors to choose from. However, we have 300-600 to choose from in the EMR world. That’s an important and challenging difference.

However, the similarities to ERP are many. One of the most striking is how the EMR like the ERP is something that’s going to be used and have an effect on the entire organization. As such, the need to manage the participation of multiple stakeholders is so key.

The key to a successful ERP implementation is to have a great project leader.  Someone who is great at working with various departments. They are great listeners who hear and understand each departments needs. Then, they have to be great at making the case for each depaartment’s needs.

The same is true for EMR. You need an EMR implementation champion who is great at listening to all areas of the clinic: nurses, doctors, front desk, billing, medical records, etc. Sometimes this can be done well by a physician lead, but is more likely to be a practice manager, IT support (if they have project management skills), or an outside consultant. 

It’s easy to underestimate the challenge of “herding sheep.” Done right, it can work very well. Done wrong and your clinic is likely going to have the opportunity to try again after the failed EMR implementation.

There are other comparisons worth considering, but this one was striking me today. I’ll be interested to hear stories and experiences from those who have implemented an EMR. Did you have a strong leader to help pacify the different stakeholders in your clinic? 

I’ve had some interesting reactions to my post about the various characteristics of a Jabba the Hutt EHR Vendor. One of the more interesting conversations happened by email with a reader named Richard. Yes, I have lots of interesting back channel discussions.

After a lengthy email exchange, I asked Richard if I could post our discussion on the blog so you could participate as well. He agreed and even commented, “I look forward to an expansion of our discussion.” So, here you go (or at least scroll to the bottom for a short summary of my feelings).

The conversation started with this email that Richard sent me:

I understand your reluctance to name names in your article, BUT… this is exactly what is needed.

I’ve taken a few days to ruminate over what I was going to suggest and I’d like to hear your thoughts on this if you have time.

With your readership, I suspect there are plenty of users and observers of current packages and lots of opinions. Why not set up something like a Wiki-EMR site to provide a resource that will allow everyone to provide input into the details making “Jabba” and “Han Solo” EMR systems and see where it goes? Maybe it could eliminate some of the BS surrounding some of these systems and help others who are trying to sort out there own future needs. I’m sure there are plenty of people out there who want, need and are willing to provide information on the state and future of EMR and what is BS and what isn’t. I certainly would. Let me know your (or your readers) thoughts.

Richard

Here was my response:

Hi Richard,
Yes, this is something I’ve thought a lot about. The key question for me is how to publish some sort of “authenticated” information. Most systems are so easily gamed and/or abused that they basically have no worth. I haven’t figured out a scalable way to be able to provide information that is actual data and not provided with undue influence.

As I read your email, I wondered if some sort of combination of LinkedIn might be the key. At least then any review that’s done would be tied to an individual. Although, by doing so, you’d then discourage many of the most interesting reviews and feedback because their name would be explicitly tied to the review.

Along these same lines I’ve wondered how I could provide a “Meaningful EHR Certification” that wasn’t based on a pass/fail system that has no value. Instead it was a mixture of qualitative and quantitative data that would actually be of value to the reader. Scaling that up is the challenge I have with that idea. Not to mention figuring out the right financial model for it.

So, as you can see I’m with you on wanting more specific information out there, but not sure how to overcome the abuse and the scale that you need for it to be valuable.

As a side note, I do have a wiki page: http://emrandhipaa.com/wiki/Main_Page and it even has an EMR and EHR Matrix of companies. Although I closed registrations since spammers were getting into it.

Richard then provided this response:

It seems to me that user editing must be do-able if Wikipedia has found a way. Additionally, I think that unvarnished truth through comments creditable or not (but differentiateable ) would be a place for insiders or knowledgeable users and IT pros to vent. I realize that it is open to abuse, but a user moderated (or whatever Wikipedia uses) forum will turn upon such miscreants and their abuse might well backfire. I realize it is quite a project, but I’ll bet there are a handful of your readers, if not many more, that would gladly help put something this critical in place. If this can be pulled off, it might create “the world’s foremost authority” * in EMR.

I don’t know much at all about this, but I have a feeling that so much is riding on all of this and that there is a vacuum of useful, meaningful and understandable information that is needed to make this whole thing work. I know there must be something prescient sounding I could offer here, but it might be just indigestion that’s giving me this feeling. John, there must be some other smart guys around; try to round up some and see what they think.

Then I offered this response which shows I’ve been on Wikipedia far too much:

I’ve been rolling around something like this since I first started blogging about EMR. Wikipedia’s a bad comparison because it tries to formulate 1 truth instead of a series of opinions about something. Plus, Wikipedia relies on the masses of people (we don’t have enough mass) and even they get to a point where they regularly lock pages after abuse happens. Wikipedia’s a crazy community once you get into it. There are flame wars and battles on Wikipedia that rage in the background that most people don’t realize are happening.

Travel and hotel sites are a better comparison actually. Since reviews of hotels are more similar to a review of an EMR. The hotel owner wants to put the best reviews on there and can plant good reviews amongst many other ways to game the ratings and review systems. I read an interesting story about how Trip Advisor tried to deal with this. Unfortunately, it put on the image of successfully battling it, but didn’t do that well. Matters much less when you’re talking about a hotel versus an EMR.

I agree that it could become the authority on EMR software if it’s done right. Although, for me to do it, I have to find a model that’s authentic, honest, reliable, scalable and that makes sense economically. At least until I sell off a company for a few million. Then, maybe I can cut out the economical requirement.

Then Richard commented:

I didn’t realize that abuse was that rampant and that a fix was so difficult. I think I see some of the problems. You almost need a cadre of “fair witnesses” to explore the opinions and observations of users and provide incorruptible analysis. Not a promising outlook.

I’d be happy to assist this enterprise in any way I can, but don’t think I would bring anything very useful to the table. I feel you may be the right person to bring something like this to fruition, but the resources needed may be out of reach. It’s too bad there isn’t a Consumer Reports -like group out there for something like this. Maybe some group has enough vested in the outcome of shake-out to fund independent assessment and provide a forum for users.

I know very little about the technology involved in EMR, I am more aware of the medical business and needs for improvement in record and information management. Additionally, if cost containment can’t be managed and a “best practices” can’t be incorporated into every patient’s care then our society may be doomed economically (even morally). You’re doing something valuable, so keep it up, there must be a way to sort out the players and the technology so we can get on with the real need which is getting something useful and beneficial installed for quality patient care. Even getting this discussion broadened is worthwhile.

Well, there you go. If you made it through that, then you must really care about EHR and healthcare IT like I do.

In summary, I think it’s quite clear that it’s an incredible challenge for those searching for EHR software to find reliable information. The need for good EHR vendor information is extraordinary and no one has cornered that market…yet? There is no “consumer reports” for EHR software.

I haven’t yet identified a model that’s authentic, honest, reliable, scalable and that makes sense economically to deliver said “consumer reports for EHR software.” (or maybe I’m just too lazy, scared, busy, etc to try)

I do think that this site and the other members of the Healthcare Scene blog network provide a valuable independent resource for those selecting and implementing an EMR. My free EHR selection e-book was one effort to help providers in the EHR selection process in a very targeted way.

Are there other things that I (we) could do to help even more? I’m sure. If you have ideas, I’m interested to hear. You see my off the top of my head criteria above.

If nothing else, we can reach Richard’s goal of “broadening the discussion”

Casey Quinlan wrote a really fantastic article about why “What’s the ROI?” is only half the question in healthcare IT. She quickly identifies the real challenge with putting an ROI on an EMR implementation by acknowledging that an ROI discussion quickly leads to a financial discussion. Indeed! The financial side is only have of the EMR ROI question.

I’ve written about the EMR ROI up down backwards and forwards. You have the camp that wants EMR software saying that it provides a great ROI and you have the camp that doesn’t want EMR saying that it doesn’t. The correct answer is that they’re both right. Your EMR ROI is often what you make of it. Not to mention that what you make of it starts with your EMR selection.

In any ROI discussion, I quickly point people to this list of EMR benefits. In EMR presentations, I like to divide that list of benefits into “Guaranteed Benefits,” “Possible Benefits,” and “Debatable Benefits.” In fact, I should probably do the same on that page when I have some free time.

However, Casey, in the article linked above asks a very important additional question, “What will it cost to do nothing?” Then she suggests, “The answer to that question shows the way forward.”