Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and HIPAA for FREE!!

Is FHIR Adoption At A Turning Point, Or Is This Just More Hype?

Posted on October 8, 2018 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.

Over the last few years, healthcare industry players have continued to experiment with the use of HL7 FHIR to solve key interoperability problems.

Perhaps the most recent efforts to do so is the Da Vinci Project, which brings together a group of payers, health IT vendors, and providers dedicated to fostering value-based care with FHIR. The group has begun work on two test cases, one addressing 30-day medication reconciliation and the other coverage requirements discovery.

This wasn’t big news, as it doesn’t seem to be doing anything that new. In fact, few if any of these projects — of which there have been many — have come close to establishing FHIR firmly established as a standard, much less fostering major change in the healthcare industry.

Now, a new analysis by the ONC suggests that we may finally be on the verge of a FHIR breakthrough.

According to ONC’s research, which looked at how health IT developers used FHIR to meet 2015 Edition certification requirements, roughly 32% of the health IT developers certified are using FHIR Release 2, and nearly 51% of health IT developers seem to be using a version of FHIR combined with OAuth 2.0.

While this may not sound very impressive (and at first glance, it didn’t to me), the certified products issued by the top 10 certified health IT developers serve about 82% of hospitals and 64% of clinicians.

Not only that, big tech companies staking out an expanded position in healthcare are leveraging FHIR 2, the ONC notes. For example, Apple is using a FHIR-based client app as part of its healthcare deployment.  Amazon, Alphabet, and Microsoft are working to establish themselves in the healthcare industry as well, and it seems likely that FHIR-based interoperability will come to play a part in their efforts.

In addition, CMS has shown faith in FHIR as well, investing in FHIR through its Blue Button 2.0,  a standards-based API allowing Medicare beneficiaries to connect their claims data to applications, services, and research programs.

That being said, after citing this progress, the agency concedes that FHIR still has a way to go, from standards development implementation, before it becomes the lingua franca of the industry. In other words, ONC’s definition of “turning point” may be a little different than yours or mine. Have I missed something here?

Look, I don’t like being “that guy,” but how encouraging is this really? By my standards at least, FHIR uptake is relatively modest for such a hot idea. For example, compare FHIR adoption of AI technology or blockchain. In some ways, interoperability may be a harder “get” than blockchain or AI in some ways, but one would think it would be further along if it were completely practical. Maybe I’m just a cynic.

Report Says EHR Usability Tests Should Focus On Common Safety Threats

Posted on August 29, 2018 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.

The American Medical Association and health system operator MedStar Health have published a report laying out a set of proposals designed to improve EHR safety. The report, which is also backed by The Pew Charitable Trusts, looks at ways that use of EHR usability can fail to prevent or even lead to patient harm.

As readers will know, to meet certification criteria EHRs currently need to conform with EHR usability requirements established in 2015. Developers need to document how they meet clinician needs and conduct formal usability testing addressing clinicians’ efficiency, effectiveness and satisfaction in using the system.

Unfortunately, the current generation of certification standards don’t focus specifically on high-prevalence safety hazards, which may mean that the process doesn’t address how usable some important EHR features are, the report says. Plus, even the earlier versions didn’t do much in regards to usability.

Over time, of course, both EHR developers and providers have begun to take these issues more seriously, and as the paper points out, are moving beyond the minimum required to meet certification standards.

For example, developers have agreed to review safety incidents with patient safety officers and product users, along with sharing such information across healthcare facilities. Also, providers have taken their own steps in this direction, such as protecting EHR safety surveys or establishing safety teams tasked with identifying EHR-related problems. As we all know, however, there’s a lot more to be done.

To make more progress, the groups suggest, EHR developers need to design more rigorous, safety-focused test cases. While they already need to run such real-world-oriented test cases, which are required for certification, but these studies might not be looking for the right things, the report says.

To be truly useful, these test cases should represent the expected uses of the technology; should represent a clinically-oriented goal with clear measures of success and failure; test known areas of risk and efficiency; and address a defined audience.

The paper also includes a list of criteria developers and providers can use to boost EHR usability and safety across the system’s entire lifecycle. For providers, this includes establishing a culture of safety which will support EHR-based safety efforts; seeing that user needs and product capabilities are aligned; customizing and configuring the system to meet those needs; implementing and maintaining the EHR carefully; and training clinicians to use the product safely and effectively.

Not surprisingly, research on these topics is ongoing, but some providers are more engaged than others. I was interested to see that MedStar Health’s National Center for Human Factors  in Healthcare continues to work with the AMA on these issues. For example, about two years ago the partners released a joint framework designed to rank EHR usability. (The partners also use the framework to rank the usability of several widely-implemented systems, including that Allscripts and McKesson were doing the best job at the time. That was fun.)

I hope to see more work on the links between EHR usability and safety in the future, as well, of course, as feedback on how to address both. We simply don’t spend enough time on this subject.

AMIA Shares Recommendations On Health IT-Friendly Policymaking

Posted on April 17, 2017 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.

The American Medical Informatics Association has released the findings from a new paper addressing health IT policy, including recommendation on how policymakers can support patient access to health data, interoperability for clinicians and patient care-related research and innovation.

As the group accurately notes, the US healthcare system has transformed itself into a digital industry at astonishing speed, largely during the past five years. Nonetheless, many healthcare organizations haven’t unlocked the value of these new tools, in part because their technical infrastructure is largely a collection of disparate systems which don’t work together well.

The paper, which is published in the Journal of the American Medical Informatics Association, offers several policy recommendations intended to help health IT better support value-based health, care and research. The paper argues that governments should implement specific policy to:

  • Enable patients to have better access to clinical data by standardizing data flow
  • Improve access to patient-generated data compiled by mHealth apps and related technologies
  • Engage patients in research by improving ways to alert clinicians and patients about research opportunities, while seeing to it that researchers manage consent effectively
  • Enable patient participation in and contribution to care delivery and health management by harmonizing standards for various classes of patient-generated data
  • Improve interoperability using APIs, which may demand that policymakers require adherence to chosen data standards
  • Develop and implement a documentation-simplification framework to fuel an overhaul of quality measurement, ensure availability of coded EHRs clinical data and support reimbursement requirements redesign
  • Develop and implement an app-vetting process emphasizing safety and effectiveness, to include creating a knowledgebase of trusted sources, possibly as part of clinical practice improvement under MIPS
  • Create a policy framework for research and innovation, to include policies to aid data access for research conducted by HIPAA-covered entities and increase needed data standardization
  • Foster an ecosystem connecting safe, effective and secure health applications

To meet these goals, AMIA issued a set of “Policy Action Items” which address immediate, near-term and future policy initiatives. They include:

  • Clarifying a patient’s HIPAA “right to access” to include a right to all data maintained by a covered entity’s designated record set;
  • Encourage continued adoption of 2015 Edition Certified Health IT, which will allow standards-based APIs published in the public domain to be composed of standard features which can continue to be deployed by providers; and
  • Make effective Common Rule revisions as finalized in the January 19, 2017 issue of the Federal Register

In looking at this material, I noted with interest AMIA’s thinking on the appropriate premises for current health IT policy. The group offered some worthwhile suggestions on how health IT leaders can leverage health data effectively, such as giving patients easy access to their mHealth data and engaging them in the research process.

Given that they overlap with suggestions I’ve seen elsewhere, we may be getting somewhere as an industry. In fact, it seems to me that we’re approaching industry consensus on some issues which, despite seeming relatively straightforward have been the subject of professional disputes.

As I see it, AMIA stands as good a chance as any other healthcare entity at getting these policies implemented. I look forward to seeing how much progress it makes in drawing attention to these issues.

FHIR Product Director Speaks Out On FHIR Hype

Posted on June 6, 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.

To date, all signs suggest that the FHIR standard set has tremendous promise, and that FHIR adoption is growing by leaps and bounds. In fact, one well-connected developer I spoke with recently argues that FHIR will be integrated into ONC’s EHR certification standards by 2017, when MACRA demands its much ballyhooed “widespread interoperability.”

However, like any other new technology or standard, FHIR is susceptible to being over-hyped. And when the one suggesting that FHIR fandom is getting out of control is Grahame Grieve, FHIR product director, his arguments definitely deserve a listen.

In a recent blog post, Grieve notes that the Gartner hype cycle predicts that a new technology will keep generating enthusiasm until it hits the peak of inflated expectations. Only after falling into te trough of disillusionment and climbing the slope of enlightenment does it reach the plateau of productivity, the Gartner model suggests.

Now, a guy who’s driving FHIR’s development could be forgiven for sucking up the praise and excitement around the emerging standard and enjoying the moment. Instead, though, it seems that Grieve thinks people are getting ahead of themselves.

To his way of thinking, the rate of hype speech around FHIR continues to expand. As he sees it, people are “[making] wildly inflated claims about what is possible, (wilfully) misunderstanding the limitations of the technology, and evangelizing the technology for all sorts of ill judged applications.”

As Grieve sees it, the biggest cloud of smoke around FHIR is that it will “solve interoperability.” And, he flatly states, it’s not going to do that, and can’t:

FHIR is two things: a technology, and a culture. I’m proud of both of those things…But people who think that [interoperability] will be solved anytime soon don’t understand the constraints we work under…We have severely limited ability to standardise the practice of healthcare or medicine. We just have to accept them as they are. So we can’t provide prescriptive information models. We can’t force vendors or institutions to do things the same way. We can’t force them to share particular kinds of information at particular times. All we can do is describe a common way to do it, if people want to do it.

The reality is that while FHIR works as a means of sharing information out of an EHR, it can’t force different stakeholders (such as departments, vendors or governments) to cooperate successfully on sharing data, he notes. So while the FHIR culture can help get things done, the FHIR standard — like other standards efforts — is just a tool.

To be sure, FHIR seems to have legs, and efforts like the Argonaut Project — which is working to develop a first-generation FHIR-based API and Core Data Services specification — are likely to keep moving full steam ahead.

But as Grieve sees it, it’s important to keep the pace of FHIR work deliberate and keep fundamentals like solid processes and well-tested specifications in mind: “If we can get that right — and it’s a work in process — then the trough of despair won’t be as deep as it might.”

RIP CCHIT

Posted on October 29, 2014 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.

CCHIT announced that it was ending 10 years of service.

Today, the Certification Commission for Health Information Technology (CCHIT) announced that it is winding down all operations beginning immediately. All customers and business colleagues have been notified, CCHIT staff is assisting in transitions, and all work will be ended by November 14, 2014.

Alisa Ray made these comments in the announcement:

“We are concluding our operations with pride in what has been accomplished”, said Alisa Ray, CCHIT executive director. “For the past decade CCHIT has been the leader in certification services, supported by our loyal volunteers, the contribution of our boards of trustees and commissioners, and our dedicated staff. We have worked effectively in the private and public sectors to advance our mission of accelerating the adoption of robust, interoperable health information technology. We have served hundreds of health IT developers and provided valuable education to our healthcare provider stakeholders.”

“Though CCHIT attained self-sustainability as a private independent certification body and continued to thrive as an authorized ONC testing and certification body, the slowing of the pace of ONC 2014 Edition certification and the unreliable timing of future federal health IT program requirements made program and business planning for new services uncertain. CCHIT’s trustees decided that, in the current environment, operations should be carefully brought to a close”, said Ray.

The announcement also said that CCHIT would be donating its remaining assets to the HIMSS Foundation. Makes sense since HIMSS kind of gave them a partial home the past few months as they tried to save the jobs of the many who worked at CCHIT. Credit should go to Alisa Ray for all she did to try and give those who worked at CCHIT a soft landing.

Long, long time readers of this blog will remember my long blog posts talking about CCHIT and the lack of value that they provided the EHR industry. I believed then and even now that EHR certification was more of a tax on the industry than it was something that provided value to the market. They told me it provided some assurance to the purchaser of the EHR, but I never saw such assurances.

Once EHR certification was made part of meaningful use and the HITECH act, it basically made CCHIT irrelevant. Although, I still think that EHR certification in its current state doesn’t provide value to organizations and I’d love to see it go away. Sadly, there’s some legislation which is pushing the opposite direction.

While I disagreed with CCHIT’s approach to EHR certification and the value they provided, I do think there were good people who worked there that had good intentions even if we disagreed on the approach. I hope they all land somewhere great.

CCHIT to Leave the ONC Certification Business

Posted on January 28, 2014 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.

Update: Multiple people sent me the email that was sent to CCHIT certified EHR vendors that details this decision. In the email, along with what’s detailed below, CCHIT suggests a transition to ICSA Labs for EHR certification and talks about a new allegiance with HIMSS to provide new programs and policy guidance including a series of summits and events to support that work. I’m still waiting for an official response from CCHIT and will update the post if they respond.

Update 2: Here is CCHIT and HIMSS press release about the change and also ICSA Labs comments on the change. Drummond Group also issued this response.

I recently got word from a source close to the EHR certification world (yes, that could be just about any EHR vendor or EHR consultant) that CCHIT is about to announce they are leaving the ONC Certification business. I was told that CCHIT will test those that are already in the pipeline, but will not continue as an ONC EHR certifying body. I’d still classify this as a solid rumor for now (I emailed them for comment, but still haven’t gotten a response. I’ll update the post if I do.), but it comes from a reliable source. Plus, CCHIT did just cancel their weekly webinar series. No point in doing the webinar series if you’re not going to be certifying EHR anymore.

Whether the rumor is true or not, it’s worth considering the EHR Certification bodies and what would happen if any of them decide to not go forward with EHR certification. It will likely have a major impact on the meaningful use program.

I don’t think we should be surprised by this decision if indeed it is the case. CCHIT was started years before ARRA and meaningful use. They were created with a cost structure that was higher because they were charging a lot more for their EHR certification when they started. Once ARRA hit, CCHIT was marginalized and as EHR certification was commoditized and codified, CCHIT became irrelevant. Plus, with three new competitors certifying EHR, the prices for EHR certification dropped dramatically.

Furthermore, I think that all of the EHR certifying bodies are finding that 2014 EHR Certification is much more complex and time consuming than the 2011 certification. Yet the price to certify is basically the same. To me, the economics of the EHR certification business were never good.

Think about the business. Let’s say you get paid about $30,000 per EHR certification. There are only 600 customers (at the time we thought it was closer to 300) for your entire business and many of those don’t even pay the full $30k. Enter in 3 competitors and you’re now sharing a market of less than $18 million or $4.5 million per certifying body. Not to mention the stimulus is for only 5 years with many of the EHR vendors likely to consolidate, stop certifying, or go out of business. Plus, EHR certification is not a high margin business and requires expensive government certification. The economics just aren’t that exciting as an entire business.

This rumor is also interesting when paired with the comments I’ve heard that the EHR certification bodies have a backlog of EHR vendors that are trying to get 2014 certified. They’re having to schedule their testing day months out. If CCHIT gets out of the EHR certification business, then that will only increase the delay in 2014 EHR certifications. I wonder if this will lead to another call for a delay in meaningful use stage 2. Can it be delayed now that some have already started MU stage 2?

I’ve never been a fan of EHR certification. I think it represented a lot of cost and very little value to the EHR industry, doctors and patients. I’ll never forget when I asked Marc Probst, Intermountain CIO and member of the ONC committee that worked on EHR certification, why we needed EHR Certification if people had to show meaningful use of the requirements. If you can show meaningful use of a requirement, then the software can certainly do that requirement, no? He answered, “I lost that battle.”

Whether this rumor is true or not, the next couple months are going to be really interesting months for EHR vendors. How many will get across the 2014 EHR Certification line in time? How many will fail in the process? Will the ONC-CHPL be able to keep up? If CCHIT does leave ONC EHR certification behind, what will they do next? Can CCHIT do something to make themselves relevant again?

EMR Vendors Struggle With Meaningful Use Stage 2

Posted on October 29, 2013 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.

CCHIT head Alisa Ray, clearly, is trying to put it delicately. EMR vendors are “struggling a little bit” when it comes to meeting 2014 criteria. “It  has been a slow start,” Ray told Healthcare IT News.

Usually, hearing this would lead to an inside baseball discussion of vendor operations, which wouldn’t be very exciting. But the thing is, meeting 2014 certification criteria is necessary to allow providers to meet Meaningful Use Stage 2. So vendor struggles in complying with CCHIT’s criteria should concern providers a great deal.

There are three areas of Stage 2 that are proving to be an issue for vendors: clinical quality measures, interoperability and automated measure calculation for reporting metrics, Ray said.

This has led to a real lag in certifications. About 40 companies had listed products with the CCHIT in 2011, but a scant 21 percent of those have stepped up and gotten certified in the 2014 criteria.

According to Ray’s chat with Healthcare IT News, “almost everyone has struggled and been surprised by the complexities” of meeting 2014 standards.  Despite having gone through the process yearly since 2006 with CCHIT, several have had to go through repeated certification trials to meet criteria.

ICSA Labs’ Amit Trivedi, meanwhile, noted that while there were close to 3,000 listings, with many having multiple listings — Cerner alone had 800 — so far there less than 300 on ONC’s Certified Health IT Products list.

There are signs that EMR vendors will catch up, the HIT story suggests. For example, vendors have been working particularly hard to offer Continuity of Care Documents or Direct messaging, a capability providers must demonstrate for Meaningful  Use Stage 2, said Matt Kohler, vice president of Network Infrastructure Services at Surescripts.

But vendors clearly have some serious development challenges ahead if they want to keep up with the pace set by Meaningful Use Stage 2.  If I were a provider reading this, I’d call my vendor right away and see where they were at in the certification process.

Healthcare Groups Want Meaningful Use Evaluated Before Stage 3

Posted on January 16, 2013 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.

Though the final rules for Meaningful Use Stage 3 aren’t due to take effect until 2016, ONC has already made the draft rules available for public comment.  And comments, to be sure, the agency is getting.

While various groups have chosen their own details to critique, the general consensus seems to be that ONC is getting ahead of itself and ought to give Meaningful Use Stage 1 and 2 a good hard look first.

Accordng to a nice summary from iHealthBeat, here’s where some of the major healthcare groups stand:

* The American Hospital Association is recommending that ONC fund a comprehensive evaluation of MU generally, and while it does, hold off on finalizing Stage 3 recommendations.

*  CHIME, too, is asking ONC to evaluate the existing Meaningful Use program to decide whether achieving stage 3 is realistically possible by 2016.

* The Federation of American Hospitals is also arguing that ONC needs to evaluate current Meaningful Use requirements.  Also, in its letter to ONC, the group argues that the existing structure of two years per stage doesn’t cut it.

* The AMA weighed in with its own recommendation that ONC evaluate Meaningful Use as is before moving ahead. It also suggested changing some thresholds to  make them more reachable; greater flexibility in program requirements; change the certification process to address usability; and improve HIT’s capability to share patient data.

Personally, I think the idea of doing an extensive Meaningful Use evalulation sounds like a good one, and I hope ONC actually does so.  When you’re setting new standards that affect so many providers, why not gather some data on how existing standards work?

Final EHR Certification Bodies – Meaningful Use Monday

Posted on July 23, 2012 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.

This seems mostly like a formality, but NIST has published the list of Accredited Testing Laboratories (ATLs), that are qualified to test EHR technology under the Permanent EHR Certification Program. You might remember that the permanent EHR certification program was delayed.

Here are the list of companies that are part of the final EHR certification bodies:

  • Drummond Group
  • Certification Commission for Health Information Technology (CCHIT)
  • ICSA Laboratories, Inc.
  • InfoGard Laboratories, Inc.
  • SLI Global Solutions

All of them are familiar names and ones that have been doing work with EHR certification the whole time. I think this is generally good for consistency of EHR certification. Can you imagine if you’d certified your EHR using one of the bodies and then that body didn’t get approved for the permanent EHR certification. Sure, the criteria are still the same, but there’s some differences in the processes each EHR certification body uses.

As most of you know, I’ve been a long opponent to EHR certification. I think it’s pointless and provides no value to physicians. However, someone in Washington put it in the HITECH legislation, so we’re stuck with the idea of a certified EHR. The good thing is that ONC and CMS have basically rendered it meaningless since every EHR vendor has basically become a certified EHR or will be soon. Of course, that also illustrates how pointless the EHR certification really is.

All in all, the EHR certification bodies are going to be around for a number of years more. I’m not sure if they’ll survive post HITECH. I just wish they were providing something “meaningful” (pun intended.

Few Doctors Ready To Qualify for Meaningful Use

Posted on May 3, 2012 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.

A new study published in Health Affairs has confirmed what I, at least, have suspected for some time about physicians and their EMRs.  The study, which surveyed 3,996 physicians, found that while 91 percent were eligible for Medicare or Medicaid Meaningful Use programs, only 11 percent of those intending to apply had their act together.

Researchers, who analyzed data from the 2011 mail survey supplement to the annual National Ambulatory Medicare Care Survey, found that 51 percent of respondents were planning to apply for MU Stage 1 incentive programs. However, it seems that only 11 percent of doctors planning to apply have a capable enough EMR set-up to support up to two-thirds of Medicare Stage 1 core objectives.

Now, this was not completely unexpected. In the final Stage 1 MU rule, CMS had estimated that 10 to 36 percent of Medicare eligible pros, and 15 to 47 percent of Medicaid eligibles, would end up meeting the agency’s criteria.

And it should be noted, the HealthAffaits authors remind us, that about 124,000 eligibles had registered in 2011, and that CMS had paid out $275 million to 15,000 participants. Also, Medicaid programs paid out about $220 million to about 10,500 physicians.

Still, you can’t bury poor performance like this in a pile of data. Clearly, a program is lacking something important just over 1 in 10 physicians manage to set themselves up for Meaningful Use cash — especially if  they were trying hard to do so.

The problem with news items like these is that they don’t get into what’s holding physicians back. It’s actually a bit disappointing that the HealthAffairs study didn’t offer any red meat on the “Why Can’t Doctors Qualify?” issue, as we all know that talking about problems doesn’t make them go away.  (I do admit that in the world of public policy at least, simply underscoring a problem gives rulemakers ammunition to dig deeper into an issue.)

Still, I’d love to know what you’re seeing out there in terms of unprepared physicians. Are we talking practices that got fast-talked into buying inappropriate or junky technology?  Lack of understanding what they bought?  Slow-moving practices that are on the right track?