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Are We Just Creating a Bunch of Patient Cliffs?

Posted on March 31, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In a recent discussion someone pointed out to me one of the real challenges of HCAPHS and reducing hospital readmissions. After the 60 days (or 90 days in some cases), hospitals don’t care if the patient is readmitted. What does this do? It creates a cliff where the patient is no longer followed, tracked, or supported by the hospital. The hospital doesn’t financially care any more since if you get readmitted to the hospital after 60 days, then it doesn’t count against their readmission score and they get reimbursed for another hospital visit. In fact, you could argue that it’s in a hospital’s best interest to have you readmitted after the 60 days since that’s more revenue for the hospital. The reality for many hospitals is that they need their beds full to run their business.

We’re already seeing this cliff in hospital readmissions, but I wonder if we’re going to see similar cliffs across all of the value based reimbursement programs that are to come. I think we probably will, but we’ll see what the final programs look like.

In some ways it makes sense why you’d want to set an arbitrary number of days after which a hospital readmission (or whatever health event you’re tracking) should not count against that hospital. It’s not like we can expect a hospital to prevent a patient from being readmitted forever. Or can we…at least for a specific condition?

It all gets really complicated and messy with thousands of nuances and variations. This is why I’m scared about what’s happening with value based reimbursement. Does anyone trust the government to dive into enough detail to make sure that the program rewards the right efforts and doesn’t penalize the organizations that are trying to do the right thing for the patient? Sometimes it feels like we’re just trying to move around deck chairs on the Titanic.

What does excite me is that we’re going to have much more data available to quantify the work that’s being done. We’re going to have much better ways to communicate with the patient. Patients are going to likely demand more transparency from their doctor. These are all movements in the right direction. I just don’t think patients are going to be happy with what they find. I know most doctors I know aren’t happy with it either.

I know they won’t be happy if they’re the patient that falls off the 60 day “cliff.” Patients will aptly ask, “So, you only care about my health for 60 days?”

This Time, It’s Personal: Virus Hits My Local Hospital

Posted on March 30, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

In about two weeks, I am scheduled to have a cardiac ablation to address a long-standing arrhythmia. I was feeling pretty good about this — after all, the procedure is safe at my age and is known to have a very high success rate — until I scanned my Twitter feed yesterday.

It was then that I found out that what was probably a ransomware virus had forced a medical data shutdown at Washington, D.C.-based MedStar Health. And while the community hospital where my procedure will be done is not part of the MedStar network, the cardiac electrophysiologist who will perform the ablation is affiliated with the chain.

During my pre-procedure visit with the doctor, a very pleasant guy who made me feel very safe, we devolved to talking shop about EMR issues after the clinical discussion was over. At the time he shared that his practice ran on GE Centricity which, he understandably complained, was not interoperable with the Epic system at one community chain, MedStar’s enterprise system or even the imaging platforms he uses. Under those circumstances, it’s hard to imagine that my data was affected by this breach. But as you can imagine, I still wonder what’s up.

While there’s been no official public statement saying this virus was part of a ransomware attack, some form of virus has definitely wreaked havoc at MedStar, according to a report by the Washington Post. (As a side note, it’s worth pointing out that if this is a ransomware attack, health system officials have done an admirable job of keeping the amount demanded for data return out of the press. However, some users have commented about ransomware on their individual computers.)

As the news report notes, MedStar has soldiered on in the face of the attack, keeping all of its clinical facilities open. However, a hospital spokesperson told the newspaper that the chain has decided to take down all system interfaces to prevent the spread of the virus. And as has happened with other hospital ransomware incursions, staffers have had to revert to using paper-based records.

And here’s where it might affect me personally. Even though my procedure is being done at a non-MedStar hospital, it’s possible that the virus driven delay in appointments and surgeries will affect my doctor, which could of course affect me.

Meanwhile, imagine how the employees at MedStar facilities feel: “Even the lowest-level staff can’t communicate with anyone. You can’t schedule patients, you can’t access records, you can’t do anything,” an anonymous staffer told the Post. Even if such a breach had little impact on patients, it’s obviously bad for employee morale. And that can’t be good for me either.

Again, it’s possible I’m in the clear, but the fact that the FUD surrounding this episode affects even a trained observer like myself plays right into the virus makers’ hands. Now, so far I haven’t dignified the attack by calling the doctor’s office to ask how it will affect me, but if I keep reading about problems with MedStar systems I’ll have to follow up soon.

Worse, when I’m being anesthetized for the procedure next month, I know I’ll be wondering when the next virus will hit.

Check Out the New Healthcare Entrepreneurs Chat

Posted on March 29, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As most of you have probably seen, I’ve been spending a lot of time interviewing healthcare IT professionals and posting those interviews to the Healthcare Scene YouTube channel. Often I think that there’s no better way to tell a story than to hear it from the people behind the story. Plus, I love trying to suck pieces of insight and wisdom out of someone who knows a lot more about a subject than me.

While my Healthcare Scene videos have focused on various health IT topics, I’m excited to also be doing a number of video interviews in a new series we’re calling Healthcare Entrepreneurs. I’m lucky to have Melissa McCool co-hosting the Healthcare Entrepreneurs chat with me and we’ve already been lucky enough to have a group of amazing entrepreneurs share insights and perspectives on entrepreneurship and healthcare.

A great example of this was our interview with Carissa Reiniger on The Challenge of “Focus” for Healthcare Entrepreneurs. Turns out that these lessons applied well to entrepreneurs from every industry and even apply well to those working for a corporation. It seems that Focus is a universal challenge. Carissa offered some great insights into how to work on this challenge.

2016 March - Telemedicine and Healthcare Entrepreneurship-blog

If you want to watch our next episode of Healthcare Entrepreneurs, you can join us live on Wednesday, March 30, 2016 at 7 PM ET (4 PM PT). We’ll be talking with Jamey Edwards, CEO of CloudBreak Health, about Telemedicine and Healthcare entrepreneurship.

We know that entrepreneurship in general is hard and entrepreneurship in healthcare has added idiosyncrasies that can make it even more of a challenge. Hopefully Healthcare Entrepreneurs can shed some light on these challenges, talk about things that can help healthcare entrepreneurs, and create a community of healthcare entrepreneurs who can help each other.

Cyber Breach Insurance May Be Useless If You’re Negligent

Posted on March 28, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Ideally, your healthcare organization will never see a major data breach. But realistically, given how valuable healthcare data is these days — and the extent to which many healthcare firms neglect data security — it’s safer to assume that you will have to cope with a breach at some point.

In fact, it might be wise to assume that some form of costly breach is inevitable. After all, as one infographic points out, 55 healthcare organizations reported network attacks resulting in data breaches last year, which resulted in 111,809,322 individuals’ health record information being compromised. (If you haven’t done the math in your head, that’s a staggering 35% of the US population.)

The capper: if things don’t get better, the US healthcare industry stands to lose $305 billion in cumulative lifetime patient revenue due to cyberattacks likely to take place over the next five years.

So, by all means, protect yourself by any means available. However, as a recent legal battle suggests, simply buying cyber security insurance isn’t a one-step solution. In fact, your policy may not be worth much if you don’t do your due diligence when it comes to network and Internet security.

The lawsuit, Columbia Casualty Company v. Cottage Health System, shows what happens when a healthcare organization (allegedly) relies on its cyber insurance policy to protect it against breach costs rather than working hard to prevent such slips.

Back in December 2013, the three-hospital Cottage Health System notified 32,755 of its patients that their PHI had been compromised. The breach occurred when the health system and one of its vendors, InSync, stored unencrypted medical records on an Internet accessible system.

It later came out that the breach was probably caused by careless FTP settings on both systems servers which permitted anonymous user access, essentially opening up access to patient health records to anyone who could use Google. (Wow. If true that’s really embarrassing. I doubt a sharp 13-year-old script kiddie would make that mistake.)

Anyway, a group of presumably ticked off patients filed a class action suit against Cottage asking for $4.125 million. At first, cyber breach insurer Columbia Casualty paid out the $4.125 million and settled the case. Now, however, the insurer is suing Cottage, asking the health system to pay it back for the money it paid out to the class action members. It argues that Cottage was negligent due to:

  • a failure to continuously implement the procedures and risk controls identified in the application, including, but not limited to, its failure to replace factory default settings and its failure to ensure that its information security systems were securely configured; and
  • a failure to regularly check and maintain security patches on its systems, its failure to regularly re-assess its information security exposure and enhance risk controls, its failure to have a system in place to detect unauthorized access or attempts to access sensitive information stored on its servers and its failure to control and track all changes to its network to ensure it remains secure.

Not only that, Columbia Casualty asserts, Cottage lied about following a minimum set of security practices known as a “Risk Control Self Assessment” required as part of the cyber insurance application.

Now, if the cyber insurer’s allegations are true, Cottage’s behavior may have been particularly egregious. And no one has proven anything yet, as the case is still in the early stages, but this dispute should still stand as a warning to all healthcare organizations. If you neglect security, then try to get an insurance company to cover your behind when breaches occur, you might be out of luck.

The Double Edged Sword of Healthcare Culture

Posted on March 25, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Rasu Shrestha, MD shared the tweet above today which caused me to ponder on the impact of culture on healthcare. This tweet was particularly interesting coming from Rasu who has created a unique culture of innovation within healthcare at UPMC.

While at RSNA, Rasu recounted to me how his UPMC innovation offices shares a building with the Google office. When interviewing candidates, many of those prospects interview at both UPMC and Google. There’s no way that Rasu and his team can compete with Google as far as perks. However, there’s no way that Google (at least the offices in Pittsburgh) can compete with the impact UPMC can have on the lives of individuals.

If it weren’t for the culture and mission of Rasu and UPMC, then they wouldn’t stand a chance recruiting people away from Google. However, that mission makes all the difference for the right person. Plus, if that person doesn’t understand the mission, then UPMC doesn’t likely want them in the first place.

While I believe that Rasu has created a special culture of innovation, the same can’t be said for much of healthcare. In fact, if you read the tweet at the top another way, healthcare culture is holding innovation behind in so many ways.

Said another way, Culture trumps everything and that can be good or bad.

A culture of innovation is great, because it spurs more innovation. A culture of being closed. A culture of fear. A culture of bureaucracy. Those can all be extremely damaging and stifle innovation and change that could improve healthcare.

I want to be careful to say that I’m not advocating a culture of recklessness. Culture can be taken too far either direction. However, I know very few people in healthcare who are reckless and I know a lot of people in healthcare who are paralyzed by a culture of fear.

Take a second to think about your culture and the impact for good and bad it has on your and your organization’s choices.

The Power of WeChat for Chinese Health Trackers

Posted on March 24, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been meaning to write this post ever since CES at the start of this year. It was one of the most impressive and interesting things I saw at CES. However, it requires a real international perspective to understand the impact of the story. Hopefully I can flesh it out for you.

While at CES I ran into a company called Lifesense (All in Chinese). I almost didn’t stop at their booth because their booth was in Chinese, but I did recognize the pictures they had and the guy at the booth came out and said hi. I try to respectful so I stopped and talked for a minute.

At first appearance I just thought they were one of the hundreds of copy cat companies I’d seen all over the Fitness area of CES. They had a fitness tracker, a scale, a blood pressure cuff, etc. I guess in some ways they were/are a copy cat company since none of those things made them special (at least nothing I could see). However, it turned out that there was more than meets the eye and there was a reason their booth and website were in Chinese.

Turns out that Lifesense was only in China. They had no US presence (although, he thought that one day they might). As someone who’s always curious I wondered how well their health tracking products had done in China. He then recounted to me that they were lucky to be major partners with WeChat and so they’d had tremendous success in the Chinese market.

This is where I got most interested. For those not familiar with WeChat, it’s the go to IM/SMS/Facebook Messenger/SnapChat/Kik/Whatsapp/etc app for China. Everyone in China is pretty much on WeChat. Plus, unlike the companies that I just listed WeChat also has a built in commerce platform and engine for running third party apps. It’s amazing to think that an IM platform could be so powerful, but WeChat has shown that it can be. You literally can order Pizza or an Uber from within WeChat.

With that in mind, building a health tracking platform on WeChat solves so many of the challenges that US based fitness tracking applications have going against them. Take for example the experience with Fitbit. You can connect with your friends and “compete” against them to see who takes the most steps. However, it can be a pain to get all of your friends on the Fitbit platform so you can compete. Plus, this doesn’t even take into account that your friend has to have a Fitbit device.

Turns out that since Lifesense has built their Fitness tracking on WeChat, they can already connect you to all your other friends that are tracking their fitness with no work on your part. That feature literally just comes built in with WeChat. That’s so incredibly powerful since the social element to health is so important.

The problem in the US is that we don’t have a WeChat. There are a lot of platforms that are trying to do what WeChat’s done in China in the US, but they still have a long ways to go. Plus, it’s hard to imagine them ever becoming the dominant force that WeChat is in China.

As usual, I think there’s lots that we can learn from other countries. I think that’s the case with simple integrations like WeChat that open up all sorts of easy doors to improving health.

Here are some screenshots of the LifeSense app in WeChat for those that are interested to see how the app looks on top of WeChat:

The Easiest Form of Healthcare Information Blocking – Charge for It

Posted on March 23, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve watched the discussion around information blocking in healthcare with a lot of interest. I’ve seen many people (including the government) talk about how information blocking is a major issue in healthcare and that we need to do something to solve the problem of information blocking. I’ve read other organizations who have searched for information blocking and say they can’t find it and that people are overstating the issue of information blocking.

I do think that some people overstate how big of an issue information blocking is, but I know that it’s a problem. Sometimes the information blocking is done purposefully, but other times it’s happening without much thought as to why they should or shouldn’t take part in information sharing.

As I’ve watched this discussion evolve and the drive towards interoperability I’ve realized that what’s happening in interoperability today could very well be the easiest and most legal form of information blocking that exists: charge for the information.

When I look into the future of information sharing, I can see EHR vendors salivating at these new found revenue streams associated with data sharing. Sure, it will only be pennies or fractions of a penny to share each record. However, when you spread that across millions and millions of records those fractions of a penny really start to add up.

When I look at the interoperability options that are being built today, these options are going to be able to charge for access to this data in a very granular way. All the data sharing is easily tracked and if it’s being tracked it can easily be charged for. I expect large healthcare organizations are going to have to start creating entire budgets dedicated to the cost of interoperability.

Once this happens smaller healthcare organizations are going to be blocked out of accessing the data. However, they won’t be literally blocked out of accessing the data like they are now. Instead, they’ll have access to the data, but the cost to access the data will be so much that they’ll be unable to access the data due to the high costs.

If you’re someone who’s a fan of information blocking, this is the perfect solution. No one can tell you that they couldn’t get access to the data, because they could get access to the data. All they had to do was pay for it. The fact that they couldn’t afford to access the data is a different issue. I expect this day will come sooner than we think.

Five Gray Areas of HIPAA You Can’t Ignore

Posted on March 22, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Scrypt, Inc. has released a guide called ‘Five gray areas of HIPAA you can’t ignore.’ With the phase 2 HIPAA audits looming, I know a lot of organizations that need to step up their HIPAA game. Unfortunately many organizations are practicing the “ignorance is bliss” approach to HIPAA compliance. Ask someone who’s been through a HIPAA audit how well ignorance worked for them as a defense. Short answer: It doesn’t.

Here’s a little graphic from Scrypt that highlights briefly the 5 “grey” areas that are covered in their guide:

5 Gray Areas of HIPAA Infographic

How Do We Really Move the Needle in Healthcare IT?

Posted on March 21, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Lately, I’ve become more and more interested in what will really move the needle in healthcare IT. Plus, I’ve been thinking through how most health IT companies approach their solutions and how the methods we’ve been using for years are failing so many patients in healthcare. As part of this analysis I’ve been discovering a need for healthcare IT companies to spend more time and focus on the behavioral side of things than they do today.

Much of my thinking has been influenced by Melissa McCool and her work creating her company, STI Innovations. Plus, this thinking was extended in a number of conversations at HIMSS including my meeting with Wanda Health. While Wanda Health uses things like machine learning and healthcare analytics, I was most interested by their efforts to actually influence the behaviors of patients. These companies are making efforts to understand the unique needs of each patient and their situation so they can engage them in a way that will actually achieve the desired result.

This type of approach is dramatically different than so many healthcare IT companies out there. I believe most healthcare IT companies currently take 2 approaches to building a company: Process Automation and Trial and Error.

Process Automation Companies
This class of healthcare IT company is one that wants to use technology to make a healthcare process more efficient. That’s not to say that they do make that process more efficient. Just that their goal is to make the process more efficient. Sometimes all that they actually do is make the process electronic. They don’t necessarily achieve the efficiency goal. However, the best ones do make healthcare more efficient. Most EHR vendors fit into this category of company, but there are hundreds of other health IT companies that just want to use technology to make your life a little more efficient.

There’s nothing wrong with these companies. More efficiency is a great thing that can have all sorts of great tangential impacts. However, this is very different than a company that’s focused on actually improving the care that’s provided patients. What happens sometimes with process automation companies is that they back their way into doing more than just process automation. Their main goal when they start isn’t to improve patient care, but they often back into that goal as their system matures. We all hope this is what will happen with EHR vendors. It’s happening with some of them already, but not nearly as quick as most of us would like.

Trial and Error Companies
A trial and error healthcare IT company is one that believes some use of technology will improve care, so they build a product and try it out and see what happens. This type of company has been extremely successful in the general silicon valley startup world. They create a hypothesis, try it out, adjust their hypothesis, try it out again, and so forth.

The trial and error style company will sometimes back into something that’s clinically relevant. As they go through this trial and error process, they’ll discover that whatever they were doing might improve things for 20% of people in their trial. So, they double down on those 20% and see how they can expand that 20% to 30% by tweaking what they were already doing.

What’s usually missing with the trial and error approach is that once they find the 20%, they just try and suck the life out of that 20%. They don’t worry about the other 80% that didn’t respond. 20% (or whatever the specific number) is enough for them to improve the status quo and so they build a business around that 20% improvement and generally don’t think about the other 80%.

Once again the Trial and Error companies may back themselves into a solution that works well for patients. Sometimes they hit magical numbers, but they’re usually backing into the solution rather than really working to understand the problem and creating a solution that fixes the wide variety of problems that exist across the majority of patients. This category of companies is likely why someone came up with the term pilotitus on Twitter to describe healthcare’s propensity to do lots of pilots, but stop there.

Really Moving the Needle
I’ve become more and more convinced that if we really want to move the needle on healthcare, we have to take a different approach than the two described above. Sure, the new approach will include some process automation and there will be some trial and error involved. However, to really move the needle in healthcare I think we need to do a much better job understanding the unique patient needs and why the 80% of patients aren’t responding to the technology and methodologies that are currently being thrown at them.

I can say this with some authority since I am a techguy by background (and on Twitter). In technology we often get pretty lazy and don’t dive into the details of why the technology’s not helping. This requires a deep understanding of behavioral science that most tech people don’t want to tackle. It’s much easier to just automate something or to try something and see if it works. It’s much harder to understand the underpinnings of patient and provider decision making so you can craft a product that actually improves that decision making.

I’ll make the reverse analogy. If you’re a programmer, you know that not all programmers are created equal. You have the newbie programmers that make something work and you have the expert programmers that design something in such an elegant way that it can handle anything that’s thrown at it with incredible efficiency. Right now our technology solutions in healthcare feel like a bunch of newbies that make something work. We need more tech companies to dive into the deep and become experts on behavior change if we want to see healthcare IT companies taking things to the next level. Otherwise, like in programming we’re going to have so much accrued technical debt that it’s going to be hard to unravel the situation.

One final word of caution. While we need more companies that invest in this type of deep understanding of healthcare’s challenges, we also need healthcare organizations that are willing to buy and work with these companies. That takes some bravery from both the companies who want to solve hard problems and the healthcare organizations that aren’t just looking for the quick fix.

Health IT Humor – Fun Friday

Posted on March 18, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It’s Friday and most of you are watching March Madness instead of working anyway (or you wish you were if you’re not). So, let’s have a little fun this Friday that you can enjoy during commercial breaks.
Cost of Healthcare
This cartoon really hits home after traveling this week. There is a certain irony there.

Patient Advocate
I think this is how it feels for many doctors. However, it gives the wrong impression of the involved and engaged patient. Although, as a husband of a wife who’s found the long list of life threatening illnesses, this hits home. I wonder when we’ll find that balance.

Physician Handwriting - Electronic
As an official #HITNerd, after reading the first line of this cartoon I was getting excited that the doctor was sending the email. Then, I was disappointed for a moment that it was a physician handwriting joke. However, I do love a good physician handwriting joke.

Have a great weekend!