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A Missed Opportunity For Telemedicine Vendors

Posted on June 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.

Today, most direct-to-consumer telemedicine companies operate on a very simple model.

You pay for a visit up front. You talk to the doctor via video, the doctor issues as a prescription if needed and you sign off. Thanks to the availability of e-prescribing options, it’s likely your medication will be waiting for you when you get to the pharmacy.

In my experience, the whole process often takes 45 minutes or less. This beats the heck out of having to wait in line at an urgent care center or worse, the emergency department.

But what about caring for chronic illnesses that can’t be managed by a drive-by virtual visit? Can telemedicine vendors play a role here? Maybe so.

We already know that combining telemedicine with remote monitoring devices can be very effective. In fact, some health systems have gone all-in on virtual chronic care management.

One fascinating example is the $54 million Mercy Virtual Care Center, which describes itself as a “hospital without beds.” The Center, which has a few hundred employees, monitors more than 3,800 remote patients; sponsors a telehealth stroke program offering neurology services to EDs nationwide; manages a team of virtual hospitalists caring for patient around-the-clock using virtual visit tools; and runs Mercy SafeWatch, which the Center says is the largest single-hub electronic intensive care unit in the U.S.

Another example of such hospital-based programs is Intermountain Healthcare’s ConnectCare Pro, which brings together 35 telehealth programs and more than 500 clinicians. Its purpose is to supplement existing staffers and offer specialized services in rural communities where some of the services aren’t available.

Given the success of programs that maintain complex patients remotely, I think a private telemedicine company managing chronic care services might work as well. While hospitals have financial reasons to keep such care in-house, I believe an outside vendor could profit in other ways. That’s especially the case given the emergence of wearable trackers and smartwatches, which are far cheaper than the specialized tools needed in the past.

One likely buyer for this service would be health plans.

I’ve heard some complain publicly that in essence, telemedicine coverage just encourages patients to access care more often, which defeats the purpose of using it to lower healthcare costs. However, if an outside vendor offered to manage patients with chronic illnesses, it might be a more attractive proposition.

After all, health plans are understandably wringing their hands over the staggering cost of maintaining the health of millions of diabetics. In 2017, for example, the average medical expense for people diagnosed with diabetes was about $16,750 per year, with $9,600 due to diabetes. If health plans could lay the cost off to a specialized telemedicine vendor, some real savings might be possible.

Of course, being a telemedicine-based chronic care management company would be far different than offering direct-to-consumer telemedicine services on an occasional basis. The vendor would have to have comprehensive health data management tools, an army of case managers, tight relationships with clinicians and a boatload of remote monitoring devices on hand. None of this would come cheaply.

Still, while I haven’t fully run the numbers, my guess is that this could be a sustainable business model. It’s worth a try.

HL7 Releases New FHIR Update

Posted on April 3, 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.

HL7 has announced the release of a new version of FHIR designed to link it with real-world concepts and players in healthcare, marking the third of five planned updates. It’s also issuing the first release of the US Core Implementation Guide.

FHIR release 3 was produced with the cooperation of hundreds of contributors, and the final product incorporates the input of more than 2,400 suggested changes, according to project director Grahame Grieve. The release is known as STU3 (Standard for Trial Use, release 3).

Key changes to the standard include additional support for clinical quality measures and clinical decision support, as well as broader functionality to cover key clinical workflows.

In addition, the new FHIR version includes incremental improvements and increased maturity of the RESTful API, further development of terminology services and new support for financial management. It also defined an RDF format, as well as how FHIR relates to linked data.

HL7 is already gearing up for the release of FHIR’s next version. It plans to publish the first draft of version 4 for comment in December 2017 and review comments on the draft. It will then have a ballot on the version, in April 2018, and publish the new standard by October 2018.

Among those contributing to the development of FHIR is the Argonaut project, which brings together major US EHR vendors to drive industry adoption of FHIR forward. Grieve calls the project a “particularly important” part of the FHIR community, though it’s hard to tell how far along its vendor members have come with the standard so far.

To date, few EHR vendors have offered concrete support for FHIR, but that’s changing gradually. For example, in early 2016 Cerner released an online sandbox for developers designed to help them interact with its platform. And earlier this month, Epic announced the launch of a new program, helping physician practices to build customized apps using FHIR.

In addition to the vendors, which include athenahealth, Cerner, Epic, MEDITECH and McKesson, several large providers are participating. Beth Israel Deaconess Medical Center, Intermountain Healthcare, the Mayo Clinic and Partners HealthCare System are on board, as well as the SMART team at the Boston Children’s Hospital Informatics Program.

Meanwhile, the progress of developing and improving FHIR will continue.  For release 4 of FHIR, the participants will focus on record-keeping and data exchange for the healthcare process. This will encompass clinical data such as allergies, problems and care plans; diagnostic data such observations, reports and imaging studies; medication functions such as order, dispense and administration; workflow features like task, appointment schedule and referral; and financial data such as claims, accounts and coverage.

Eventually, when release 5 of FHIR becomes available, developers should be able to help clinicians reason about the healthcare process, the organization says.

ONC Announces Winners Of FHIR App Challenge

Posted on August 3, 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.

The ONC has announced the first wave of winners of two app challenges, both of which called for competitors to use FHIR standards and open APIs.

As I’ve noted previously, I’m skeptical that market forces can solve our industry’s broad interoperability problems, even if they’re supported and channeled by a neutral intermediary like ONC. But there’s little doubt that FHIR has the potential to provide some of the benefits of interoperability, as we’ll see below.

Winners of Phase 1 of the agency’s Consumer Health Data Aggregator Challenge, each of whom will receive a $15,000 award, included the following:

  • Green Circle Health’s platform is designed to provide a comprehensive family health dashboard covering the Common Clinical Data Set, using FHIR to transfer patient information. This app will also integrate patient-generated health data from connected devices such as wearables and sensors.
  • The Prevvy Family Health Assistant by HealthCentrix offers tools for managing a family’s health and wellness, as well as targeted data exchange. Prevvy uses both FHIR and Direct messaging with EMRs certified for Meaningful Use Stage 2.
  • Medyear’s mobile app uses FHIR to merge patient records from multiple sources, making them accessible through a single interface. It displays real-time EMR updates via a social media-style feed, as well as functions intended to make it simple to message or call clinicians.
  • The Locket app by MetroStar Systems pulls patient data from different EMRs together onto a single mobile device. Other Locket capabilities include paper-free check in and appointment scheduling and reminders.

ONC also announced winners of the Provider User Experience Challenge, each of whom will also get a $15,000 award. This part of the contest was dedicated to promoting the use of FHIR as well, but participants were asked to show how they could enhance providers’ EMR experience, specifically by making clinical workflows more intuitive, specific to clinical specialty and actionable, by making data accessible to apps through APIs. Winners include the following:

  • The Herald platform by Herald Health uses FHIR to highlight patient information most needed by clinicians. By integrating FHIT, Herald will offer alerts based on real-time EMR data.
  • PHRASE (Population Health Risk Assessment Support Engine) Health is creating a clinical decision support platform designed to better manage emerging illnesses, integrating more external data sources into the process of identifying at-risk patients and enabling the two-way exchange of information between providers and public health entities.
  • A partnership between the University of Utah Health Care, Intermountain Healthcare and Duke Health System is providing clinical decision support for timely diagnosis and management of newborn bilirubin according to evidence-based practice. The partners will integrate the app across each member’s EMR.
  • WellSheet has created a web application using machine learning and natural language processing to prioritize important information during a patient visit. Its algorithm simplifies workflows incorporating multiple data sources, including those enabled by FHIR. It then presents information in a single screen.

As I see it, the two contests don’t necessarily need to be run on separate tracks. After all, providers need aggregate data and consumers need prioritized, easy-to-navigate platforms. But either way, this effort seems to have been productive. I’m eager to see the winners of the next phase.

Securing IoT Devices Calls For New Ways Of Doing Business

Posted on June 8, 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.

While new Internet-connected devices can expose healthcare organizations to security threats in much the same way as a desktop PC or laptop, they aren’t always procured, monitored or maintained the same way. This can lead to potentially major ePHI breaches, as one renowned health system recently found out.

According a piece in SearchHealtlhIT, executives at Intermountain Healthcare recently went through something of a panic when connected audiology device went missing. According to Intermountain CISO Karl West, the device had come into the hospital via a different channel than most of the system’s other devices. For that reason, West told the site, his team couldn’t verify what operating system the audiology device had, how it had come into the hospital and what its lifecycle management status was.

Not only did Intermountain lack some key configuration and operating system data on the device, they didn’t know how to prevent the exposure of stored patient information the device had on board. And because the data was persistent over time, the audiology device had information on multiple patients — in fact, every patient that had used the device. When the device was eventually located, was discovered that it held two-and-a-half years worth of stored patient data.

After this incident, West realized that Intermountain needed to improve on how it managed Internet of Things devices. Specifically, the team decided that simply taking inventory of all devices and applications was far from sufficient to protect the security of IoT medical devices.

To prevent such problems from occurring again, West and his team created a data dictionary, designed to let them know where data originates, how it moves and where it resides. The group is also documenting what each IoT device’s transmission capabilities are, West told SearchHealthIT.

A huge vulnerability

Unfortunately, Intermountain isn’t the first and won’t be the last health system to face problems in managing IoT device security. Such devices can be a huge vulnerability, as they are seldom documented and maintained in the same way that traditional network devices are. In fact, this lack of oversight is almost a given when you consider where they come from.

Sure, some connected devices arrive via traditional medical device channels — such as, for example, connected infusion pumps — but a growing number of network-connected devices are coming through consumer channels. For example, though the problem is well understood these days, healthcare organizations continue to grapple with security issues created by staff-owned smart phones and tablets.

The next wave of smart, connected devices may pose even bigger problems. While operating systems running mobile devices are well understood, and can be maintained and secured using enterprise-level processes,  new connected devices are throwing the entire healthcare industry a curveball.  After all, the smart watch a patient brings into your facility doesn’t turn up on your procurement schedule, may use nonstandard software and its operating system and applications may not be patched. And that’s just one example.

Redesigning processes

While there’s no single solution to this rapidly-growing problem, one thing seems to be clear. As the Intermountain example demonstrates, healthcare organizations must redefine their processes for tracking and securing devices in the face of the IoT security threat.

First and foremost, medical device teams and the IT department must come together to create a comprehensive connected device strategy. Both teams need to know what devices are using the network, how and why. And whatever policy is set for managing IoT devices has to embrace everyone. This is no time for a turf war — it’s time to hunker down and manage this serious threat.

Efforts like Intermountain’s may not work for every organization, but the key is to take a step forward. As the number of IoT network nodes grow to a nearly infinite level, healthcare organizations will have to re-think their entire philosophy on how and why networked devices should interact. Otherwise, a catastrophic breach is nearly guaranteed.

HL7 Backs Effort To Boost Patient Data Exchange

Posted on December 8, 2014 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.

Standards group Health Level Seven has kicked off a new project intended to increase the adoption of tech standards designed to improve electronic patient data exchange. The initiative, the Argonaut Project, includes just five EMR vendors and four provider organizations, but it seems to have some interesting and substantial goals.

Participating vendors include Athenahealth, Cerner, Epic, McKesson and MEDITECH, while providers include Beth Israel Deaconess Medical Center, Intermoutain  Healthcare, Mayo Clinic and Partners HealthCare. In an interesting twist, the group also includes SMART, Boston Children’s Hospital Informatics Program’s federally-funded mobile app development project. (How often does mobile get a seat at the table when interoperability is being discussed?) And consulting firm the Advisory Board Company is also involved.

Unlike the activity around the much-bruited CommonWell Alliance, which still feels like vaporware to industry watchers like myself, this project seems to have a solid technical footing. On the recommendation of a group of science advisors known as JASON, the group is working at creating a public API to advance EMR interoperability.

The springboard for its efforts is HL7’s Fast Healthcare Interoperability Resources. HL7’s FHir is a RESTful API, an approach which, the standards group notes, makes it easier to share data not only across traditional networks and EMR-sharing modular components, but also to mobile devices, web-based applications and cloud communications.

According to JASON’s David McCallie, Cerner’s president of medical informatics, the group has an intriguing goal. Members’ intent is to develop a health IT operating system such as those used by Apple and Android mobile devices. Once that was created, providers could then use both built-in apps resident in the OS and others created by independent developers. While the devices a “health IT OS” would have to embrace would be far more diverse than those run by Android or iOS, the concept is still a fascinating one.

It’s also neat to hear that the collective has committed itself to a fairly aggressive timeline, promising to accelerate current FHIT development to provide hands-on FHIR profiles and implementation guides to the healthcare world by spring of next year.

Lest I seem too critical of CommonWell, which has been soldiering along for quite some time now, it’s onlyt fair to note that its goals are, if anything, even more ambitious than the Argonauts’. CommonWell hopes to accomplish nothing less than managing a single identity for every person/patient, locating the person’s records in the network and managing consent. And CommonWell member Cerner recently announced that it would provide CommonWell services to its clients for free until Jan. 1, 2018.

But as things stand, I’d wager that the Argonauts (I love that name!) will get more done, more quickly. I’m truly eager to see what emerges from their efforts.

Intermountain Uses EMR To Share Radiation Exposure

Posted on May 24, 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.

It’s a well-known and worrisome trend that patients are receiving potentially harmful doses of  radiation from tests such as CT scans. Generally speaking, though, neither patients nor clinicians know exactly how much radiation exposure an individual has received.

At Intermountain Healthcare, however,  they’re hoping to change this state of affairs. The Salt Lake City-based health system of 22 hospitals and 185 clinics is launching what the Wall Street Journal says is the first major effort to measure and report patients’ cumulative radiation exposure.

Intermountain’s effort is focused on the tests that produce the highest amount of radiation, including CT scans, nuclear medicine scans and interventional radiology exams of the heart, the WSJ reports.  As part of an effort to educate clinicians and patients about medical radiation, both will be able to access data on patient exposure levels through Intermountain’s EMR.

The idea behind listing a patient’s radiation exposure is to encourage both clinician and patient to consider the risks and benefits of a particular test and at times, avoid the test if the needed information can be obtained with a radiation-free test, the WSJ piece says.

In a typical year, Intermountain’s patients receive 220,000 CT scans and radiology procedures, so data that helps patient and doctor consider alternatives could conceivably have a meaningful effect, clinicians there say.

Intermountain is not the only hospital system to focus on tracking radiation doses. For example, Hospital Corporation of America, the largest for-profit hospital system, is kicking off a new “Radiation Right” campaign tracking patient doses, the newspaper reports. But it does seem to be the only chain sharing the data with patients via an EMR.

Realistically, these efforts are still in their infancy, as researchers don’t know how much of a cumulative dose of radiation directly increases cancer risk. Still, this does seem like an excellent use of the EMR as a collaborative tool engaging patients in making better-informed health decisions.

Utah Hospital Helps Parents of Babies in NICUs Be More Involved

Posted on May 6, 2013 I Written By

Katie Clark is originally from Colorado and currently lives in Utah with her husband and son. She writes primarily for Smart Phone Health Care, but contributes to several Health Care Scene blogs, including EMR Thoughts, EMR and EHR, and EMR and HIPAA. She enjoys learning about Health IT and mHealth, and finding ways to improve her own health along the way.

Right after I posted about the Cedars-Sinai Medical Center using FaceTime to connect moms to their babies in the NICU, I saw this article about an Intermountain hospital in Utah doing something similar.

Utah Valley Regional Medical Center, a hospital in Provo, Utah, has equipped all of the NICU beds with three cameras. These will give parents 24 hour access to a live video of their baby.

This hit home because, well, I live right across from the hospital this article talks about, and my son spent eight days there when he was just two weeks old. While we were allowed to be in his room with him the entire time, if he’d been in the NICU, this would have been wonderful to have. And, if we stay in Utah, and we had a baby who had to stay in the NICU, we may benefit from this. This is part of the redesign of the NICU department at UVRMC.

Stephen Minton, MD, is overseeing this project. He is a neonatologist at Intermountain Healthcare, and in an interview he emphasized the importance of communication with parents who have infants in the NICU. He has been at this particular NICU unit since 1979, cared for 26,000 babies, and in all that time never had a lawsuit filed against him. He said that this is not because he didn’t make mistakes, but because of how he interacts with the parents:

It’s really unusual in critical care medicine to go quite that long [without a lawsuit.] The reason is because I communicate with parents, and so they understand what you’re really trying to do. That’s really all what people want. They want to be involved, and they want to feel like they have a voice and that you care.

Minton believes that implementing these cameras will allow the parents to be involved even more, and have a better understanding of the care their infant is receiving.  They can see what is being done at all times, and communicate with the attending physician.

UVRMC isn’t the first hospital to implement this type of technology, but it is definitely one of the first. I hope to see more hospitals doing something like this in the future, and perhaps extend it to other areas in the hospital.

New Friend Request…From the Family Doctor?

Posted on May 11, 2012 I Written By

Katie Clark is originally from Colorado and currently lives in Utah with her husband and son. She writes primarily for Smart Phone Health Care, but contributes to several Health Care Scene blogs, including EMR Thoughts, EMR and EHR, and EMR and HIPAA. She enjoys learning about Health IT and mHealth, and finding ways to improve her own health along the way.

It seems like every company, person, or product has a Facebook page nowadays. I’m not complaining — I actually really like being able to connect through Facebook. Several months ago, I noticed quite a few pages for hospitals or doctors popping up, and I even “liked” a few of them myself. After “liking” them, I didn’t think much of it, until one day I saw an update from one, Intermountain Moms. Apparently, every week, “Nurse Dani” answers the questions of moms everywhere. Simply write a question under the status update, and she answers it.

I thought this was pretty neat. In fact, I asked my own question. It was something that I felt silly calling my son’s pediatrician about but was worrying me. Within a matter of minutes, Nurse Dani responded to my question. Not only did she put my nerves to rest, but she was so kind in answering. It felt like I was talking to an old friend. As I read the rest of her responses to other mom’s questions, the same respect was given. And while I’m not about to start text messaging my nurses and doctors (so not ready for that kind of relationship), I think it’s nice that more health professionals are getting involved with their patients through social networking.

According to an article on US News, doctors across the country are connecting through Facebook, Twitter, and FourSquare. Apparently, there is a website called TwitterDoctors.net, which is essentially a place where doctors who “tweet” register their names and make it easy for patients to find them. This article talks about how different doctors are implementing social networking into their websites. Here is a little bit of what the author said:

Some doctors are latching onto social media to issue real-time alerts and reminders, a unarguably valuable service for time-pressed patients. Stream cites colleagues who tweet when they’re running late for appointments, for instance, so patients know they needn’t rush to the office. Others post hours for flu shot clinics and encourage patients not to overlook the vaccine.

To me, I think this is great. I would love to have these types of updates readily available. Who likes waiting at the doctor’s office? Recently, when we took my son to his well-child appointment, we waited an hour in the waiting room. Or being able to post my concerns or questions and receive instant feedback, especially concerning menial topics that are worrying me but may not warrant a doctor’s visit?

I can see some downsides to this though. The professional relationship between doctors, nurses, etc. with their patients might become a bit blurry. There should definitely be limits. Like, should patients and their doctors be actual Facebook friends? When I graduated from high school, I remember becoming friends with some of my former teachers. They refused to add students that were currently still in school, and I can see why. Once someone in a position of trust (i.e., a teacher or doctor) becomes more intimately invovled in one of their student’s or patient’s life, things can get weird.

But in general, as I’ve already said, I love that practitioners are becoming involved in social networking. Like it or not, that’s the way the world is going, and I think it would be wise for doctor’s to know at least the simple parts of social networking (and maybe hire a tech-savvy office assistant to manage the Facebook page).  As the article I previously mentioned quotes Kevin Pho, a medical blogger, saying:

These are powerful, tremendously influential tools. Doctors should be taking advantage of the opportunity.”

So what do you think? Is it a good thing that doctors and hospitals are getting involved with patients through social networks, or is it making the doctor-patient relationship too casual?

Intermountain Healthcare and GE Healthcare: A Partnership in Care

Posted on October 7, 2011 I Written By

GE Healthcare partners with Intermountain Healthcare to develop state of the art IT solutions aimed at improving patient outcomes while reducing costs in an increasingly complex healthcare environment.

 

 

Watch the video here.

Marc Probst Talks About Meaningful Use

Posted on August 1, 2009 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.

A relatively new reader of EMR and HIPAA, Michael Archuleta, sent me his notes from the Utah Medical Group Managers Association 6/25/09 where the keynote speaker was Marc Probst. For those that don’t know, Marc Probst is the CIO of Intermountain Healthcare (IHC). IHC is huge in Utah and I think it does pretty well in a number of surrounding states as well. Plus, Marc Probst is also a member of the HIT Policy Committee. You may remember that I’ve talked about Marc Probst on EMR and HIPAA a few times before.

Anyway, I found some of the points that Michael captured interesting. I guess in the end I was interested to hear what Marc Probst was telling people. Michael Archuleta’s notes are as follows (published with permission and the emphasis added was mine to highlight some interesting parts):

Mark Probst – Intermountain Health Care – government wants to invest 42 billion in IT healthcare. IHC has 500,000 enrollees, 28,000 employees. 600 physicians. They are a unique integrated health care organization. Feels Obama framed the problem (related to health care, in previous nights TV pitch) well, and wants his plan in by Oct 09. Referred to how IHC is the lowest cost per capita.

Probst has met with 3 congressman and 20 government staffers. Using Mayo Clinic as a benchmark, could save 30 pct in chronic illnesses. There are 300,000 uninsured Utahns.

Four stages of an EMR. Third stage was commercial products. Stage four will have broad adoption of solutions. Second increased knowledge. Third is introduction of clinical decision support. A stage 3 EMR could save a 300 bed hosp at least 11M.

At LDS hospital there were 581 adverse drug events in 1990 and in 2004 there are only 270 . Their stats showed that waiting to 39 weeks (for OB delivery) was best for infants and reduced neonatal admissions. The docs said they knew this already and didn’t induce unnecessarily. But when showing them the data, they were in fact inducing. The same stats showed improved outcome with acute respiratory stress.

150 people are working on a new EMR system (for IHC) with GE and people from India. A complete clinical information system has automation (taking common tasks and automating it like voice, scanning, bar codes. Helps you with inventory management and pricing. Provides automated data entry with hot texting.), connectivity (using a network. Allows doctors to see and share information and this brings more specialists into the picture.), decision support (prompts and alerts for obvious things. Advanced decision support like glucose management and need to push the human mind.), data mining (using historical data to identify patterns and to test hypotheses).

Commercial systems were good at automation and connectivity but were weak on decision support. IHC was good in that area so they decided to build their own hybrid.

Rather than rip and replace, they aggregate, view, analyze, alert and then gradually replace existing systems.

The government HIT policy committee: Meaningful use says that to get money you need a certified system and have meaningful use. There must be a certification and an adoption. Must have the ability to do health information exchange. Time frames are aggressive: They originally thought they had until October to define requirements and then were told by the Obama administration that it was moved up to July 16. It will move from policy to a standards committee.

The intent and commitment of the people involved on the HIT committee is to do the right thing.

Questions from the floor: Doesn’t HIPAA preclude the ability to share information? In his opinion it allows for protection.

How do we get our voices heard? Have to get involved with AMA.

What is meaningful use? Capture discreet data like BMI, weight. Then there is an adoption process.

How will costs go down? If other things are in place, then we will minimize duplications. We may be connected but we can’t talk.

What about CCHIT? It is unclear what their role will be. IHC, for instance, is a hybrid of best of systems. Who would certify us?