The Classroom vs Practice in Health Information

A medical record folder being pulled from the ...

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As M*Modal heads out to Salt Lake City today to attend the 2011 AHIMA Convention and Exhibit, I thought it particularly appropriate to kick off the week with a guest posting from a relatively new member of the M*Modal team and graduate from the University of Pittsburgh’s HIM program, Nathan Gibbon. Today’s HIM students spend a great deal of time learning about the benefits of electronic health information and it is interesting to hear about their experiences in the real world after they graduate.

Nathan Gibbon graduated from the University of Pittsburgh’s HIM program in the spring of 2011, after which he was hired as a healthcare implementation business analyst by M*Modal. Before graduation, Nathan did his six-week clinical at M*Modal working on the identification of information for core measures reporting in documentation. Nathan’s senior project, “Using Natural Language Processing to Improve Reporting of Core Measures for Pneumonia,” completed with fellow Pitt student Dino Mascio also at M*Modal, won first prize at Pitt’s 2011 SHRS Student Advisory Board Poster Competition. So, please welcome guest blogger, Nathan Gibbon.

I attended an excellent Health Information Management program at the University of Pittsburgh. I was taught well, and I enjoyed my time there. In my classes we learned about the Electronic Health Record (EHR) and Electronic Medical Record (EMR), and how they have and will revolutionize the healthcare industry. I learned how the electronic systems will provide ongoing documentation of patient information that doctors will be able to access from all over the world.

Fast forward two years later…I am now working for a company which seamlessly integrates its speech recognition and natural language technologies into healthcare documentation workflows, and which helps to increase adoption and usability of electronic health records. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. These acts saw a plethora of electronic health record systems spring up, along with hospitals spending big money to have the systems implemented.

The textbooks provided for my classes went over workflows, systems analysis, waterfall diagrams, Microsoft Access databases etc….all to help an electronic record system be created, implemented, and used effectively. One of the best experiences the program gave me was the Clinical Experience class. We had four individual clinical experience sessions, one per semester. In this class, the students were sent to a hospital, somewhat of our choosing (I picked one close to my house), and were placed in the Health Information Management Department or Medical Records Department. Not everyone’s facility was the same, but for the majority of us, we had similar experiences. I was shocked to see that this hospital was able to run on such little staff, rushing around a basement floor with paper records. Some records were stored on moveable shelves (that I played with frequently when bored), others were stored on random carts, and others were left on the floor of a dark room. The hospital I was assigned to failed to comply with some standards for housing medical records set by the Joint Commission, (formerly JCAHO). Several of my classmates spoke of their clinical sites in the same manner. The facilities simply did not have the room to house all the medical records – not to mention that paper records deteriorate over a long period of time. From that experience I saw the desperate need for the electronic health record in healthcare. All the space, time, and resources wasted on the paper records could be simplified if they were made into electronic format. I was onboard.

For my final clinical experience, CE4, I requested to be placed at a local health information technology company, Multimodal Technologies (M*Modal). The company provides an on-demand Software as a Service (SaaS) business model (in “the cloud”) and their solutions are all based on a standard for information exchange, HL7 CDA. When I first began my Clinical Experience 4, I thought this company was a competitor of the major EHRs in the healthcare world. However, after a talk with the Chief Technology Officer (CTO), Detlef Koll, I learned otherwise. M*Modal can help to increase adoption of the EHRs which might otherwise be cumbersome for healthcare providers to use. Some hospitals implemented major brands of EHR systems which I was surprised to learn do not communicate with other systems because they do not use a standard format for data exchange. This means there is zero interoperability, something we learned from our textbooks that electronic health records would provide.

In conclusion, the way health information management and electronic health records are described in textbooks does not exactly play out in real world scenarios. The information I learned in school was very helpful, and the benefits of EHRs are real, however, the healthcare environment won’t see those benefits when systems cannot readily communicate with adjacent systems. In conjunction with systems being able to communicate and being able to transfer data, systems should be built specific to what the users really need. This will prove to be a long and difficult process. Software vendors will have to spend many hours studying physicians and healthcare providers in order to understand exactly how they are interacting with the system. But until that work is done, systems will continue to be cumbersome for those that interact with them.

Nathan Gibbon
Healthcare Implementation Business Analyst
M*Modal

Change Ahead for M*Modal and MedQuist

Today’s world is full of change.  In the world of health care, with new discoveries, new treatments, and new technologies found seemingly every day, change may be the only constant.

And so it is with businesses that support health care, where change can lead to the need for migration to new service and product offerings and to corresponding changes in business models.  Consolidations of businesses in the health information service and technology domains often occur as companies seek to increase revenues, take advantage of synergies, or as in the case I’m going to talk about here, to merge two companies with different but complementary talents as part of a growth strategy.

Most of you have probably heard that my employer M*Modal is about to be affected by such a change.  On Monday, July 11,  a merger between M*Modal, a leader in speech recognition and natural language understanding technologies, and MedQuist, a leading provider of medical transcription services and documentation workflow technology, was announced.  It was also announced that Vern Davenport, former CEO of Misys Healthcare and long-time HIT industry leader, will become the CEO of the combined company.

This announcement came as a surprise to many who know us as the small but quickly growing company whose senior executives are the very guys you came to know as industry innovators.  It may not have been a surprise to some, however, who in view of market activity in recent years wondered at M*Modal’s ability to compete against significantly larger companies.

And though we at M*Modal have rather enjoyed being David in a David-and-Goliath-like competitive environment, our leaders understood that now is the time when acceleration of our efforts is needed for our customers.

MedQuist too has been observing changes in the industry and sees value in combining their world-class services with the industry-leading technology that will allow them to offer their customers the best of both worlds – innovative technology offered by people who understand the world in which it will be implemented and used.

What does this mean to M*Modal customers and to its partner relationships?  It means only good things.  To the partners who rely on M*Modal technology to provide services to their customers, it means robust strength.  To the partners who incorporate M*Modal solutions into their technology offerings, it means partnership with a company with greater market presence.  To our health care provider customers, it means greater flexibility and options.  And since M*Modal understands that our customers need us to act fast in response to health care’s changing needs, then perhaps most importantly, this merger means that M*Modal will have the ability to bring solutions to health care faster.

Many of you have been kind enough to ask what this means to me personally.  To be honest, I was surprised at the announcement, and was admittedly concerned.  I mean, anyone who knows me knows that I believe in M*Modal and its vision with my whole heart.  But… after a visit from our future leader, Vern Davenport, my concerns have changed to excitement, hope, and even eagerness.

In speaking with the M*Modal team, he made it clear that this is not a case of one company absorbing another.  To the contrary, he explained that we are two companies joining forces to support health care providers as they continue to adopt electronic health records and as they embark on the transformation to value-based care.   He told us that his role as the CEO of the newly formed company will not be a job for him – it will be a mission.  He said he is here for one reason – to make an impact on health care. Well, for me that was the statement that clinched it.  I’m in.

In short, this new relationship will ensure that M*Modal can continue on its path towards creating a collaborative ecosystem for health information that supports the health care provider and which contributes to health care itself.  We have always strived to serve those who serve the patient – and now we’ll have the ability to do so with even greater impact.

For the immediate future, the two companies will continue to operate separately as all the i’s are dotted and t’s are crossed.  But stay tuned for more!  I’ll be sure to keep you updated…

In the meantime, like me, rest assured that we are not the Starship Enterprise and the Borg (you know, “you will be assimilated. Resistance is futile.”)  Like Jean Luc Picard, current M*Modal CEO Michael Finke and the other M*Modal leaders will continue to lead us as we “boldly go where no one has gone before” into the exciting times ahead.  (CBS Entertainment, 2010)

For more details, here is a link to the formal announcement  http://www.medquist.com/Home/tabid/36/Default.aspx

All my best as always,

Lynn

Still M*Modal

Disclaimer:  All nerdy Star Trek references are mine – not to be blamed on anyone else at MedQuist or M*Modal.

CBS Entertainment. (2010).  Star TrekTM. Retrieved July 14, 2011 from http://www.startrek.com/.

AHDI – M*Modal Continuing Management for Modern Medical Transcription Series – Webinar

US medical groups' adoption of EHR (2005)

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Hello everyone:  It was my very great pleasure today to be the presenter for an AHDI webinar as part of the M*Modal – AHDI Management for Modern Medical Transcription series.

Today’s presentation was titled, “The Continuing Relevance of Medical Transcription in Health Care.”  Here is a pdf of the slides. AHDIWebinar_Transcription_Relevance_20110517

Key points:

Medical transcription:

  1. Is part of HIM.
  2. Can support Meaningful Use, ICD-10 coding, and computer assisted coding (CAC).
  3. Must provide documentation that is valuable and useful.
  4. Must emphasize quality of content over print format and cost.
  5. Supports options and flexibility for increased adoption.
  6. Can be cost-effective without sacrificing MT pay.

Back in the earlier days of speech recognition (and in fact many health care facilities and transcription companies  still follow these practices today), the best practices for speech recognition were much more limiting than they are now.  They tended to be directed at productivity – not towards the cost-effective creation of useful documentation.

Unfortunately, the emphasis on productivity and cost savings caused us to lose sight of what it is that we do – create high-quality, accurate, clinical documentation – and who creates it – the highly skilled, knowledgeable, Career-Minded, Medical Transcriptionist.

I myself stood up in front of a roomful of people at the 2006 AHIMA national conference and gave recommendations such as:

  • Select physicians carefully
  • Select MTs carefully. You will have plenty of volume left for traditional transcription.  Leave your high-producers in transcription and move your low- to mid-range producers to speech rec.
  • Have your MTs perform “as dictated” editing as much as possible.
  • Encourage physicians to adopt best practices for speech recognition.

That was before I came to M*Modal and realized that the right technology allows us to view documentation from a different perspective.  It allows us to get the real value and use out of clinical documents rather than only using them to check off a requirement on a chart completion list.  Luckily even the most stubborn of us can learn fast when we want to.  🙂

Today that list would look more like:

  • Bring on the doctors – let the technology sort out which result in quality sufficient for editing and which do not.
  • Train all of your MTs to edit.  Advanced speech recognition technology will cover a significant portion of the transcription volume.  Transcription IS editing.
  • Pay your highly-skilled, highly productive transcriptionists appropriately as they move into speech.  You cannot deliver the quality of documentation necessary to support requirements for meaningful use, ICD-10, or computer assisted coding, without them.
  • Create the requirements for documentation according to usefulness and quality.  “You get what you say” does not result in documentation that consistently adheres to content or quality needs.
  • The “average % productivity gained” is not the correct metric to use to measure the results of speech recognition; nor is it the correct means to determine a compensation plan.
  • Get your cost savings through a combination of effective use of the technology and workforce and performance management.  Understand that cost benefits come from increased output from fewer staff members – not a high average % increase.  Your increased output will allow you to take on more volume without increasing staff.  If your output increases enough that you can decrease staff, get rid of the “hobby MTs” and reward your Career-Minded MTs for making you more efficient.

Medical transcription must be about delivering high-quality, comprehensive, useful information – not cheap documentation – if it is to stay relevant as an enabler of health information technology.

All the best as always,

Lynn

M*Modal

Throw Away Everything you Thought you Knew About Speech Recognition and Medical Transcription

Fort Lauderdale, Florida

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Hello everyone:  What better way to roll into National Medical Transcriptionist Week than with a trip to lovely Fort Lauderdale to meet with the even lovelier folks of AHDI – Florida!

As always, a visit to this lively, engaged group of dedicated professionals resulted in more discussion than there was time!  And to cap it all off, I had the pleasure of meeting two luminaries in the health information domain, Pat Forbis and Claudia Tessier.  I was greatly humbled to have been part of a speaking schedule that included two women who have been such leaders in our field. I even got to share a bench with Claudia, both of us “iPadding” away.  Very cool to “ipad” sitting next to the leader of the mHealth Initiative!

The theme for AHDI-Florida’s annual meeting was the “Winds of Change”, so what better topics to discuss than the emerging technologies which are having such an impact on our industry, on health information, and on how health care itself is delivered.

The point I most wanted to make in my presentation is that changing technologies do not mean the end of medical transcription.  In fact, if we keep sight of the fact that medical transcription is about the accurate and high-quality creation of meaningful, useful clinical documentation – not the “cheap” creation of something someone only uses to check off requirements on a chart completion list, then transcription can actually be an important enabler for electronic health information.

Unfortunately, the focus in recent years has sometimes been on the wrong things.  We’ve focused so much on cost, on print formats, and on providing customized requirements, that we’ve lost sight of the real value we provide to the health care provider.  Worse, we’ve allowed them to lose sight of our value too.

So let’s throw away everything we thought we knew about transcription, slides here –  Florida_AHDI_20110514 , and look at it in an entirely new light.  Let’s look at it as a way to provide high-quality, comprehensive documentation to support increasing demands for information….produced in a way that happens to be cost-effective.

What can we do?

  1. Make sure everyone knows about the Health Story project, particularly the Health Story, IHE, HL7 Consolidation project.  Learn about it, and share your knowledge with your employer, your customers, your vendors, and your representatives in the U.S. Congress.
  2. Remember how important your highly skilled, highly productive, career-MTs are if you are to be a provider of information that can be used to support Meaningful Use, computer assisted coding, the coming ICD-10 conversion, and the other increased demands for health information that are coming our way.  Feel free to refer here for links to other articles about this topic.
  3. Focus on quality.  Without quality, the rest can’t happen.

Thank you as always to AHDI-Florida for being such gracious hosts and such passionate supporters of high-quality clinical documentation.

And don’t forget to visit Misty and Bethany at M*Modal’s Always Understanding blog for activities all week in honor of National Medical Transcriptionist Week!

All my best as always,

Lynn

M*Modal

Preaching to the Choir at AHDI Florida

Sunrise at Fort Lauderdale Beach

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I must have been a very good girl lately, because here I am again visiting AHDI Florida whose annual meeting is, of course, right on the beautiful beach in Fort Lauderdale.  Pennsylvania has been a bit on the chilly and rainy side, so this feels pretty wonderful!

But my favorite thing about being here is the people of AHDI Florida. It must be all this sunshine, because they are so full of energy!  Their meeting this year is called, “The Winds of Change” and from my previous experiences with this group, they get that change is coming their way – and rather than bemoaning the fact – they are embracing it and making it their own.  In fact, they “get it” so well that in a way I feel like I’m cheating speaking here….I am, in effect, preaching to the choir.  🙂  But since I know the members of this group will take what they hear and will spread the gospel of dictation and transcription as enablers of electronic health information, then I can enjoy the Florida sunshine without guilt.

My presentation is titled Speech Recognition – Throw Away Everything you Thought you Knew.  In this presentation I will ask listeners to throw away a lot of common assumptions about speech recognition and transcription – including a few things I might have told them a few years ago before I joined M*Modal after some experiences with a different vendor.

Because you see – we did it wrong.  The message about speech recognition and transcription has always been about saving money, and that unfortunately has often meant decreasing MT line rates rather than looking at the many other ways the technology can be used to decrease costs. And now look where we are. We are in an era where comprehensive information is a must-have for quality and outcomes reporting, as a driver of automated clinical decision support systems, as a source of data for population health reporting, and as a foundation for technologies such as natural language processing and computer assisted coding.  But instead of promoting the fact that transcription is an excellent source of high-quality, comprehensive information which can adhere to all the content requirements a provider needs to drive other aspect of HIM and health care, we have been focused on productivity.

Many in the industry (not all!) have been focused on providing cheap documentation; not high-value documentation. They’ve been focused on print formats, not content requirements.  And worst of all, they’ve been driving down the value of our skilled medical transcriptionists causing them to leave the industry.  I actually had a service provider tell me during my trip to DC for the Advocacy Summit that hospitals aren’t reluctant to use offshore transcription anymore, not because they realized that the quality could be just as good, but because the types of errors that would have caused the cancellation of a contract ten years ago don’t even get mentioned today. In other words, it is about “cheap”; not about quality.  Folks, I’m here to tell you, the day a provider stops complaining about poor quality is the day they are telling you that you are extraneous, your documentation is not being used for anything important, and you are not long for this world.

As you all know – I don’t care if the transcription is done in the U.S., or in India, or on Mars. I don’t care if it’s being produced through traditional typing, backend speech, or telekinesis. Poor quality documentation is USELESS for all of the purposes that documentation must be used for today – from computer assisted coding to PQRS (formerly PQRI) reporting, to the use of the documentation as a communications tool for members of a patient care team in an ACO or patient-centered medical home, to the reconciliation of problem lists and creation of patient-facing summaries that is required as part of Meaningful Use, and more.  The quality MUST be there – or transcription won’t be.

Unfortunately many speech recognition vendors, and I’m sorry to say, even many transcription service organizations, continue to promote the wrong message – the message of “cheap” documentation, not valuable documentation.  Let me ask you this – if the health care provider is only giving up printed paper documents of inconsistent quality that are not being used for any purpose other than to check-off requirements on a chart completion list, when someone comes along and says, “hey, the docs can do direct-data entry into the EHR so we don’t need transcription anymore,” is the provider going to use, “but we get the transcription so cheap…” as a reason to convince the decision makers that transcription should be kept as a means of documentation?  Not hardly…

Let’s forget everything we thought we knew about speech recognition and transcription and look at it in a new light.  Let’s remember that dictation and transcription can be the accelerator of high-value electronic health information, not something that electronic information can replace.

So – all you folks out there in the choir – can I get an Amen?

All my best as always,
Lynn
M*Modal

A Vision for Truly Meaningful Health Information

The dome of the US Capitol building.

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This article comes on the heels of the AHDI – CDIA Advocacy Summit in Washington, DC, where members of AHDI and CDIA worked together to speak to members of Congress about the value of narrative health information and the part that medical transcription plays in helping to preserve the patient story.  This article is a joint effort from Liora Alschuler, CEO of Lantana Consulting and me, and also appears on Excellence in Health Information.

Physicians have long used narrative documentation as an effective means of information capture.  Dictation in particular is a widely used method of creating clinical reports such as history and physical documents, operative reports, consultation reports, discharge summaries, and progress notes.  In addition to serving as important communication tools, these documents are an excellent source of the information used by providers for HIM, medico-legal, and administrative functions.  These documents can contain the subtleties of the physician thought process in addition to important clinical facts. They contain a level of expressiveness that cannot easily be captured using other methods of information capture.  According to the Health Story Project, the amount of the nation’s total clinical information captured as narrative documents is approximately 60%, with 1.2 billion documents produced in the United States every year (2011).1

Now that it is accepted that electronic health information will lead to more efficient and effective health care, the belief that information must be captured as discrete metadata-tagged elements in order for the data to be semantically interoperable has led to the assumption that narrative forms of documentation are no longer of value.  When physicians lose the option to dictate narrative notes, they typically are asked to enter the data into the EHR manually, using “point-and-click” methods to capture clinical data. But adoption of electronic health records has been slow, largely because of the increased level of effort and time required to enter information into the EHR, and also because care givers do not find the clinical facts available to them through EHR templates to be a sufficient representation of the patient’s health and clinical history.

The Health Story Project (originally CDA4CDT) was founded for the purpose of creating implementation guides for the electronic exchange and use of health information captured in narrative clinical documents.

The Health Story guides address content requirements for the most common document types and create data standards for exchange of information captured within the original “primary source” documentation of the delivery of care. They represent the original capture of key observations and results, as well as data elements required for the electronic record. The component parts are described through CDA templates, the reusable building blocks of Clinical Document Architecture, most of them developed initially for the HL7 Continuity of Care Document (CCD).

Meanwhile, IHE and HITSP were also developing CDA implementation guides which enable and facilitate Meaningful Use requirements, but which led to some duplication and disconnects with the Health Story guides.

A new initiative, the HL7/IHE Health Story Consolidation Project, joins the two efforts. This project creates a standard which provides the ability to capture and encode discrete data elements while also structuring narrative information such that its value is persisted in the electronic health record.

The collaboration between Health Story, IHE, and HL7 will:

  • Republish all eight Health Story guides for the original common document types plus the related/referenced templates from CCD in a single source.
  • Update the templates to meet the requirements of Meaningful Use, augmenting the base CCD requirements to meet the requirements of HITSP C32/C83.
  • Reconcile discrepancies between overlapping templates published by HL7, IHE and HITSP.

This collaboration is a volunteer effort hosted within the ONC’s Standards and Interoperability (S&I) Framework.  If widely adopted, a standard for health information exchange based on this project could resolve many current challenges by enabling the capture, exchange, and use of clinical data in the EHR in a way that is also meaningful and understandable by human caregivers.

The resulting implementation guides will facilitate meaningful use of electronic health information by:

  • Increasing adoption by allowing physicians to document patient encounters using methods that are efficient, effective, and convenient.
  • Improving the usefulness of the data by increasing the likelihood that the required level of specificity and comprehensiveness will be provided.
  • Enabling the expressive information that is relevant to the documentation of patient care but which does not accommodate entry by point-and-click methods of information capture.

This project gives us the best of both worlds by enabling the exchange and use of clinical facts tagged as discrete data elements without losing the narrative information which still remains the most effective tool for communication and collaboration between the human members of the patient care team.

Dr. David Blumenthal, in his introduction to the ONC’s Federal Health Information Technology Strategic Plan 2011 – 2015, refers to electronic health information as the “’lifeblood’ of modern health care” (2011).2 This collaboration between the Health Story, HL7, and IHE take us one step closer to that vision.

All my best as always,

Lynn

M*Modal

1 – Health Story Project.  (2011).  HL7/IHE Health Story Consolidation Project.  Health Story

Project: Integrating narrative notes with the EHR. http://www.healthstory.com/standards/sec/consolidate.htm

2 – Office of the National Coordinator. (2011).  Federal Health Information Technology Strategic

Plan: 2011 – 2015.  David Blumenthal, MD, MPP.  Retrieved April 21, 2011 from http://healthit.hhs.gov/portal/server.pt/document/954074/federal_hit_strategic_plan_public_comment_period

“Improved Patient Care through Quality Health Information”

I usually keep my blog agnostic of M*Modal, and try to make it of interest to anyone in the health information space, regardless of the technology they use. But since the HIMSS conference about a month ago, the resulting follow-up conversations and news from the HIT world made it more apparent to me why I came to work for M*Modal – and why we’re all in this business in the first place. So I thought I’d stray from my own rules a bit.  The blogger’s prerogative.   I also hope to use this as a jumping-off point to an ongoing discussion – what is quality health information?

At HIMSS this year, there was, as you would expect, a tremendous amount of talk about meaningful use, health information exchange, adoption, you name it. The exhibit hall was full of vendors whose products will solve all of a health care provider’s problems. There were “transformative” solutions everywhere you looked.  Since HITECH ARRA announced its meaningful use requirements, HIT has exploded with new products, new technologies, and a scramble to help the provider (or perhaps capitalize on the need to?) achieve compliance.

But as I talked with people who came to the M*Modal booth asking, “what is different about M*Modal”, it forced me to think about that myself. Why is M*Modal different?

My two cents:

  • We aren’t a “vendor”.  Yes, we sell technology. But with our technology comes our people – a partnership. The service we provide can’t be separated from our technology.
  • We aren’t about the revenue cycle. We’re about health care. Yes – documentation plays a big part in revenue cycle management and our technology certainly helps with that – but “Improve your revenue cycle!” isn’t our mission.
  • Our founders have been using the terms “health information universe” and “meaningful clinical document” for years – as evidenced in a slide from an early presentation that is still relevant today. A universe of meaningful clinical documentation has been what M*Modal is about since its inception.
  • We spend hours talking about how to improve the documentation experience for caregivers, and how to use information to build a more collaborative experience for the patient care team and the HIM. We talk to physicians, to HIM professionals, to technology vendors, to transcription service providers, to continuously improve not just their experience using our technology, but their ability to make use of health information in general.
  • Yes, our M*Modal team includes scientists and engineers, but it also includes health information professionals from MTs to transcription managers to coders to CDI specialists to RNs to those of us who have been in the business so long that we’ve done pretty much everything there is to do in HIM.
  • We honestly believe that health information can have an impact on the care of the patient – and on wellness itself. As our CTO Detlef Koll put it in his response to the PCAST report, ‘truly meaningful use of health information has the potential to transform health care.”

Do we have our challenges? Of course – we’re growing fast and we’re crazy busy.  But from the interns who frequent our offices, to our scientists, to our customer service personnel, to the people who keep our data center running, to our administrative and HR staff, to our marketing and business development teams, we’re all part of a team who works every day towards a vision of improved patient care through quality health information.  And at the end of a day, no matter how long, that is really all that matters.

Over the coming weeks, we’ll be talking more about “quality health information” and what that means to business, to health care providers, and most importantly, to the patient.

I look forward to hearing from you about what “quality health information” means from your perspective.

All my best as always,

Lynn

PS:  This post also appears at Excellence in Health Information.

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