Meaningful Use Case Study 3

7/30/2019 Meaningful Use Case Study 3

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Electronic Health Record in Evans Medical Group

Robert Lamberts, MD.

Having been a strong proponent/evangelist for electronic health records for at least 7years, I have come to believe that EHR is too difficult for many physicians to do, and toocomplicated for most to do well. We have been at the task for nearly 7 years, and I haveyet to feel we are doing it well. The task of medicine is too complex, and the medicalrecord too central to that task for computerization to not happen without significant pain.

The only thing that has sustained us through the pain is the belief that this is an essentialstep in the re-forming of healthcare that must come for the system to survive in the not-so-distant future. My personal frustration with the way that medicine is done both as abusiness and as a service to the patients, along with my intimate knowledge of my ownshortcomings have driven me to drive our practice to become computerized.

Buying in

I became interested in computerized medical records in residency. I went to IndianaUniversity for my residency in Internal Medicine and Pediatrics, graduating in 1994.There I was exposed to the work of Clem McDonald and the Regenstrief medical recordsystem. While the system was nowhere near what we have available today, it made useof the technology current at the time to help me organize and improve the care of mypatients. In the outpatient setting, I had access to all labs, x-rays, dictated documents, andeven EKGs. In the hospital, I could get a patients outpatient medication list, have quickaccess to previous hospital notes, and even input order sets (CPOE, about 10 years aheadof its time). I did not realize at the time just how unique this situation was.

Moving to suburban Augusta Georgia, I quickly saw how far ahead things had been inIndiana. Some hospitals had no access to labs on computers. The ones that did haveaccess had non-intuitive interfaces with no ability to view more than a single piece ofdata. In the office, I had no access to labs, x-rays, or hospital reports except as paperdocuments. Not only was I feeling the insecurity of becoming the final medical decision-maker for my patients, but also that of losing access to the data I had become soaccustomed to having. I had to make decisions without good information, and it mademe frustrated.

I had joined another Med/Peds physician in a practice that was owned by a local hospital.The idea at that time was: let the hospital run your practice so you can focus just onmedicine. The hospital was, in turn, owned by Columbia/HCA, so we were part of alarge corporate strategy of corporate practice ownership. The truth of the matter was thatwe were owned by the hospital to help aid in their contracting with the insurance

companies. Our value was not to be a well-run practice, but rather a set of names on asheet of paper that would give the corporation more leverage in negotiation. This becameapparent when I tried to push for efficiencies including computerized records. There waslittle chance that a hospital that did not even value computers for inpatient medicine wasgoing to foot the bill for an outpatient system. In frustration, we left the hospital andbought our practice back from them.


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One of the first things we did when we got out was to look into EHR systems. BesidesRegenstrief, I had also been influenced by my brother-in-law, a physician in NorthCarolina who had been instrumental in developing an EHR in their practice. I sent mypartner to see what they were doing and he came back totally sold on the idea. I alsoattended a meeting through the American College of Physicians regarding computers in

medicine, and the speaker strongly encouraged me to look at the system fromMedicaLogic.

Just at the time we became interested and able to buy an EHR, Blue Cross of Georgia wasalso becoming interested. They had been a channel partner for Medical Managersbilling software, and saw EHR as an opportunity for them to help manage care. Wetalked, and a deal was struck we would purchase MedicaLogics new EHR, Logician,through them in exchange for serving as a beta-test site for their service and trainingpeople. We would also get a discount on this service.

The question has always come up as to how we could afford an EHR. When we

purchased the first installation of Logician, it cost us over $70,000 for two physicians.To many this was (and still is) too steep of a barrier to cross, but for us, the financialdecision was simple. A loan of this size would amount to a payment of $2,000 permonth. Given that we each see patients approximately 20 days per month, this wouldmean that we had to earn an extra $100 per day. This amounted to seeing two extrapatients per day, or one per physician. If we each saw two extra patients per day, itwould give us a 200% return on investment. We did realize that there were otherbenefits, such as reduced transcriptions, decreased chart-pulls, but we felt that this washard to calculate in advance (and unnecessary, since the logic of increasing volume wasso clear to us). Since then, we have never tried to justify the cost to ourselves.

Being a beta-test site is to say that the experts probably dont know much more thanyou do. We were a beta-test site for the training and installation of Logician by the armof Blue Cross of Georgia known as the Network Group. Since we had no hands-onexperience with EHR, we were naive to the importance of that kind of experience inthose who install your system and train you in it. Additionally, Logician was a newprogram, replacing the previous MedicaLogic product known as ClinicaLogic, so eventhe true experts did not have a real deep understanding of the product. All this beingsaid, we went live on Logician in July of 1996, had a party, and started to putinformation into the system. I thought we had come to the end of the road, but instead itwas just beginning.

Making it workThe first version of Logician left little room for customization. We could customize thecontent through the use of text templates, but this would not put data into the databasethat could be gotten out in later notes. The forms made by MedicaLogic to input the datawere not to our liking, as they did not fit into our workflow, so we paid them to make aform that would help us get the data where we wanted. We did not have computers in therooms, so we made templates on paper that pulled the data from the database and gave us


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the information we needed during the visit. We would change information on the paperand have one of our assistants input the data at a later time. For more complex text, wedictated and had the transcriptionist input directly into the program.

When I first went to the Logician User group meeting in May of 1997, I expected to

finally see how to use the program as I wanted. I felt like we had jury-rigged a solutionthat compensated for what was lacking in the program, but surely there was somethingwe were missing. I was surprised to find that not only was there no right way to usethe system, but we were actually at the forefront of users in how we were making it workin our practice. I found myself answering more questions than getting answers. That wasthe moment I realized that, despite predictions to the contrary, medicine was a very longway from becoming computerized. If I was a vanguard user, the situation must not bevery good.

Still, I did make some good contacts, and came to appreciate the people of MedicaLogicand their desire to improve their product. Their intent was not to put out a finished

product and force us to use it, but rather to see how a basic product is used and shape itbased on the feedback from the users. I think that this philosophy on their part is a largepart of the reason that their product is still in use today. Clinicians need to be at the heartof product design and redesign. Clinicians should not be viewed as consultants to theengineers, but rather the engineers should understand that the clinician must be central tothe shape and direction of their product. I left the meeting feeling that, although theproduct was not yet easy to use, the companys intent was to make it easy to use.

The first major step in making the EHR more than just a repository of chart notes camewhen the company gave users the tool for customizing the form templates. TheEncounter Form Editor was a program designed by the programmers at MedicaLogic tomake clinical content in a graphical interface that allowed data to go directly into thedatabase. I quickly became proficient at it and made numerous forms for our practice.This enabled us to become increasingly efficient with the use of Logician and caused thedata in Logician to become more usable.

Since that data would be most useful if it was available in the exam room, we attemptedmany ways to get the information in there. We were already using data from the databaseprinted out and carried with us into the exam room. This did not allow us to change orinteract with the data at the time of care. To fix this problem, we tried using laptops overthe network using radio-frequency LAN, and even tried using a precursor of the TabletPC called a Cruise Pad. The laptops were too slow, however, and the Cruise Pad didnot allow easy input of narrative text. We finally decided upon using Thin Clientterminals in the exam rooms over a Citrix platform. We did this in 1998, and are stillusing some of these terminals today.

Finally getting the clinical information in the exam room in a form that would allow it toeffect real-time decisions was a major step toward becoming truly computerized. It wasthis process that taught me that the real impact of EHR would not be as a record-keepingdevice, but as an interactive database. I began to imagine having 100% immunization


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rates, top-quality disease management, and being able to share that information with bothpayors and patients. I became a passionate apologist for EHR, not as a nice product thatwould help physicians, but instead as a tool to change the basic way that medicine ispracticed. Patients could finally know the quality of the care they are receiving (or notreceiving) and good physicians could be recognized for their quality. Truthfully, I saw

physicians using EHR to take disease management and managed care out of thehands of the insurance companies and contracting directly with corporations. One of mygoals became to put the insurance companies out of business. This process has been alot slower than I would have liked.

Selling it to others

Being as passionate as I was, and being able to make changes without going through acommittee, our small practice shot to the forefront of users of Logician. Because of this,I was voted onto the board of the Logician User Group, and served as President from

1999-2000. I am still not quite sure why we got so much attention there are manyphysicians as bright and passionate as I am. Whatever the reason, I have enjoyed thechance to share my vision and articulate the importance of viewing EHR as more thanjust a record-keeper, but instead as an instrument of system change.

Sometimes it is hard to see why your passion is not shared by others. When we firststarted on Logician, the Network Group used me to give talks promoting it to theirmembers. I felt like our logic was not complicated and the case for EHR strong, soothers should be like my partner and quickly become believers. Reality was different,however, and there was very little interest generated out of my talks. Many physiciansexpressed excitement over the concept of EHR, but it made little impact on actual sales.

I also encountered resistance in my own practice. Steve, my original partner with whomI had decided on committing to EHR, left the practice to be a missionary in Africa. Wereplaced him with two other physicians, one Med/Peds and one Pediatrician.Implementation of change with Steve was simple: I made the changes and he agreed withthem. The two new physicians were not so easy. When I made the change to ThinClients in the exam rooms, I did not consult them, I just made the change. This causedmajor problems. To me it seemed obvious and natural that we would want to interactwith the computer in the exam room, but to them it was an intrusion on their doctor-patient relationship. While I saw it as an opportunity to move further toward beingpaperless and to do better work, they saw it as a major change in their status quo

done without their consultation.

It took me a long time to understand that I was the unusual one, not them. My newcolleagues reactions mirrored that of the physicians to whom I have given talks. Theythought the idea of EHR was OK, but they were not dissatisfied enough with the currentway of doing things that they saw any point in radical changes. My original partner wasa very easygoing person who seemed to buy in to my ideas quickly. It was critical that hewas this way, because I dont know if I would have moved forward with the project if he


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were not. My new colleagues were interested more in doing well within a normal officesetting than going beyond normal. To one of them, the difference between us wasirreconcilable, and she left our practice after 2 years. The other physician, my currentpartner, was able to adapt to me and my passions. I was also able to adapt to him and seehis reluctance as an opportunity to know how to win over the average physician. We

have since added another physician, and are in the process of adding at least one more. Ihave done my best to avoid force-feeding change to them, but rather change in responseto their needs and requests.

Another way in which I have been able to move forward with increased implementationhas been by leading by example. I no longer give evangelist speeches about EHR, butinstead am trying to woo other physicians to EHR by doing it so well in our office thatthey cannot help but want to use it. I use the same technique in causing change in ouroffice. When I come up with an idea, I often use it on my own for a while until I provethat it works better than the old way. If I can show my colleagues that it works betterthan the old way and truly makes life easier, they have no problem changing.

Reality

Making EHR work in a private practice primary care office has been difficult. Much ofthis difficulty comes from the fact that I have been responsible for running the businessof the practice, but have no idea how to do that. Physicians in private practice are smallbusiness owners. They are responsible for paying their employees, paying bills, keepingtheir customers happy, and (hopefully) making a profit. In the past, physicians could getby with running the business badly because the margins were high. As those marginshave gone down, there is increasing pressure to employ good business practice and

increasing consequence for not doing so. To add to the problem, most physicians arevery confident that if they are good at being a doctor, they must have what it takes to runa business. I am no exception to this stereotype.

In the past 7 years, we have added 3 full-time physicians, 1 part-time physician, and 2midlevels. We have lost 2 physicians (my original partner to Africa, and our Pediatricianto frustration). We have also lost 2 midlevels (for more benign reasons). This turnover,along with some poor initial business choices we made have made the past number ofyears very difficult financially. There was a long stretch where we went month-to-month, paying bills as the money came in, and hopefully getting paid. I was the soleowner of the practice until a year ago, so I took the brunt of this difficult financial time.

People would tell me I was doing a good job running the practice, but it did not comfortme when I did not get paid.

Despite this fact, we have become profitable, and have continued to increase ourimplementation of Logician in the practice. As the practice grew, we continued toincrease our investment in both hardware and software. Our overhead rate is consistentwith that of other physicians in our situation (55-60%). We have provided much of ourown technical support, installing new upgrades ourselves and troubleshooting problems


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with the help of technical support. My office manager has had to double as an EHRproject manager and technical person, although she has no formal computer training.

The truth of the matter is that we are a normal practice in many ways. Early adoptionamong integrated delivery networks is much higher than in small private practices, due

mainly to the fact that IDNs can look at the big picture and force their physicians tochange. I tried this approach, and it nearly cost me my practice. In reality, smallpractices are struggling, and to make EHR work, there must be significant incentive tomotivate the investment of time and money.

Where we are now

At the present time, we have 3 full-time and 1 part-time physician and are adding on bythe years end. Despite having fewer providers, we are seeing nearly 25% more patientsthan we were a year ago. In December we plan on to move to a larger office.

We are running on a mix of 2-tiered fat clients and citrix thin clients, all on an NTnetwork. We have recently moved back toward using laptop computers with wirelessLAN as well as a trial with a Tablet PC workstation. Since we are moving, we are usingthe current situation to assess whether the time is good for us to once again redesign ourworkflow and take the computer out of the exam room, replacing it with a wirelessdevice. To do so, we will likely adopt an input technology to allow patients to inputinformation directly into their charts (either by a web interface, an optical pen, or opticalscanning of a paper questionnaire).

We interface with our practice management system, taking demographics from the PMS

and putting them into our EHR. We are looking into various solutions to allow EHR datato cause billing in our PMS and omit the paper Superbill. We also interface with a majorLab in our area, importing lab results as discreet data directly into the patients database.

Encounter data is input into the chart via questionnaires filled out by the patient and inputby the nurses. They are mainly using forms designed by me using the Encounter FormEditor. Clinical information is also input by the clinician in the exam room, either bytyping while the patient talks, using structured data (radio buttons, drop-down lists, etc.),or typing after the encounter. We have not used a transcriptionist in nearly 6 years.

If a patient requires a medication, we prescribe on Logician, printing out the prescription

and giving it to the patient. If a consult is required, we send a flag to our referralcoordinator and she handles the various aspects of the referral process, includingscheduling the appointment, calling the patient to confirm the appointment, and gettingwhatever authorizations are necessary. We use the orders feature on Logician whenordering labs or radiology tests. We have gotten the local labs and radiology departmentsto accept our printed form as a lab requisition (we had to modify it to meet all of theirrequirements). This allows us to link problems on the patients problem list with the


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ordered test, and makes the authorization process easier. Patient education is providedusing handouts within Logician and handouts we have made ourselves.

Phone call management, although still a major problem, is much easier using our EHR.We have a custom form for phone calls that contains our own protocols as to how to

handle various medical situations. This allows nursing to handle a significant percent ofthe phone calls without getting approval from the physician. The chart is alwaysavailable and the patients medication list is usually accurate. Careful monitoring ofnarcotic medication is much easier since all prescriptions are input into Logician.

Interfacing with the paper world continues to be a challenge. Dealing with theabundance of illegible old records from patients previous physicians provides thegreatest challenge. We presently pick out what studies and notes need to be included inthe record and have them scanned in. We are also scanning in all consults, hospitaldictations, procedure notes, and radiology reports. We have minimized expense by usinga high school student to scan in the documents and using an OCR program to convert

them to rich text format, and copying them in to the patients charts. Generally, thedocument is saved as free text, but information that is pertinent to patient management oroutcomes measures (such as mammograms, diabetic eye visits, and DEXA scans), theinformation is also entered into the database using a form that I have made for thispurpose.

Future directions

Recent improvements in our cash flow have made further investment in the systempossible. Each investment is measured carefully for return on investment. Our most

pressing problems involve situations created by our move in December. Before wemove, we must have decided whether we will put a computer in every exam room or gowith another solution. I am presently investigating the use of Tablet PCs with Wi-Fitechnology. This requires some redesign of the clinical content forms to minimize theneed for free text. It also requires investigation and eventual investment in one of thepatient input modalities previously mentioned.

Document management is also a problem, in that we want to minimize the space neededfor storage of paper documents. The slow process of using OCR is also a motivation toget this project running. There are several solutions available, and we plan onimplementing one by the end of the summer.

Patient communication is a problem in any office, and use of our EHR with a secure e-mail solution may greatly reduce the strain of this problem. Patient requests for refills orappointments can easily be handled via e-mail. Secure e-mail provides a means fordealing with simple medical problems, as well has handling more complex problemsonce a method of reimbursement is agreed upon. We have several vendors for doing thiswhich will integrate with our EHR, making patient communications part of the patient


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record without the need for conversion. This will also allow us to send lab resultssecurely to the patients as well as mass e-mailing for targeted populations.

So much of our energy has been directed toward patient care that we have not had thechance to get a web page. Once interfaces are in place with secure e-mail, the

opportunity to get a web presence will be there, and we can quickly make theinformation more robust, hooking in to the secure site where patients can get test resultsas well as send us messages. We also have an opportunity to adopt a direct patientscheduling solution that would allow our patients to make their own appointments.

The problem is not that we do not have options, but instead must decide between manygood options. Deciding which one will have the greatest impact on quality of care,service, and on cash flow will determine which direction we go in first. We are seriouslyconsidering hiring our own full-time IT employee who could help us implement thesesolutions as well as help me write clinical content.

Improving Outcomes

Upon realizing that EHR was more than just a medical record but also a database, wehave made attempts at measuring and improving quality. Our first attempt was to targetPneumovax immunization in people over age 65. Through a simple search, we were ableto increase our immunization rates to over 90%.

Childhood immunizations have been a good opportunity to measure and maximizeoutcomes, as well as increase business. Our record allows us not only to assureimmunizations being up to date on patients who come to the office, but also to find those

behind on immunizations who have not come in for care.

We now regularly search the database for all patients who are overdue for shots. Anexample search would be: show me all of the patients who are 3 months old, have not hadtheir first DTaP, and do not have a scheduled appointment. Patients on the list arecontacted and scheduled for appointments.

We are also calling patients who are due for other well-care services. Children between18 months and 4 years of age require regular visits, but do not require immunizations.We are now pulling up lists of patients who are coming up on specific birthdays who donot have appointments. They are contacted and scheduled for to be seen. This gives

good care for the patients and increases our patient volume.

A recent survey of our practice by the Vaccines for Children program of the State ofGeorgia showed us to be 98% compliant with accurate and appropriate documentation.The reviewers told us that they have never seen rates near this good and subsequentlysent us a certificate honoring this achievement.


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We have also started looking for patients over age 65 in need of physical exams, diabeticswithout visits in the past 6 months, and hypertensive patients without visits in the past 9months. We are using monetary incentives of patient volume to motivate our staff toaggressively go after these patients. We have not been doing this long enough to seewhat its effect on outcomes will be, but clearly it offers better care for the patients while

improving our bottom line. It has also served to involve our entire office staff in the ideaof disease management.

We are also improving our quality by using increasingly robust clinical content. ClinicalContent Consultants, LLC (some Logician User Group colleagues of mine) have designedcustom clinical content that uses the latest disease management tools and the most currentmedical evidence to greatly enhance the quality of care. Their forms call on the patientinformation as well as current care recommendations to guide care for the patient.Cholesterol is managed through the latest NCEP guidelines. JNC-6 blood pressurerecommendations are given for hypertensive patients. Cardiac risk is calculated usingpatient data plugged into the Framingham cardiac risk formula.

These forms have not only improved our own understanding and care of patients, theyhave also been very good tools for patient education. When I show patients their cardiacrisk with and without cigarettes, the impact can be significantly more than a stern dontsmoke from me. Perhaps the most significant impact has been on my management ofblood pressure. In the past, a patient over 65 with a blood pressure of 145/80 would notcatch my attention. Through the use of the CCC clinical content, I have discovered theimpact that lowering the blood pressure to 118/70 has on cardiac risk (sometimes cuttingit in half). I now routinely beckon the patient over to the computer and have them seetheir risk go down with the improvement of the blood pressure. Now, instead of me justthrowing another pill at them, they understand why we want good blood pressure control.More than one patient has told me that they are very impressed with the computerprogram that showed them this information.

While we are looking for improving our outcomes, I much prefer looking at it asimproving quality. We want to know we are doing our job well, and want to find ways todo it better. The impact may be felt in our reimbursement (although I have yet to see thisas a reality), but the biggest impact will be felt by our patients.

Value

It is hard to quantify the value of the EHR to our practice. When we instituted Logician,we were a small practice that had recently taken over self-management. We have verylittle pre-Logician data against which to compare our current status. We can, however,list some of our more noteworthy accomplishments:

1. We are now essentially paperless we have not had specific charts made up forour patients since 1998.

2. We have expanded our EHR use consistently despite significant providerturnover, increased patient volume, and periods of low cash flow


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3. Buy-in by both physicians and office staff has significantly and consistentlyincreased

4. We have utilized the system to bring in more patients improving the quality ofcare and the cash flow for the business.

5. Our chart audits by insurance companies have consistently gotten the highestgrades possible and often effusive praise from the reviewer.6. Patient volume continues to increase and satisfaction, when measured, hasremained high.

7. We have increase profitability and income for primary care physicians in a timewhere incomes are decreasing.

We anticipate capturing more hard data now that we are fiscally stable and showingconsistent growth. We also are looking toward expansion of the practice to multiplesites. The advantage of being on an EHR is very great in this circumstance thesecondary location need not have an area for chart storage, and all phone messaging canbe handled at the primary location. We are seriously considering using this to start a

clinic for indigent patients in downtown Augusta.

Lessons Learned

Many of the lessons learned concern the business in general, but many also are specific tothe use of EHR.

1. Invest in a system that will not become legacy. While we were fortunate in thisregard, other practices were not so fortunate. It is very important that there begood support and an active user base. What is hot technology now will be out

of date in a short time, so it is more important to find a company that will supportyour product than the specific features of the product.

2. Find a company that allows customization of content this has been one of themajor keys to our success. We have worked hard at making forms to fit ourworkflow, and have not had to adjust as much to the EHR as it has had to adjustto us.

3. Find a company that has a fairly good product development cycle. One of thebest things we found to combat frustration with the product was to be able toanticipate improvements. MedicaLogic was very good at including our specificsuggestions in their upgrades, and this would happen within a reasonable amountof time.

4. Little Bang installation this is a concept discussed very much by the LogicianUser Group. The idea is to implement only a small amount of the EHR at a timeso that the impact on workflow is minimal. Once the providers are given a tooland told not to use a lot of it, they generally are anxious to increase their adoption.This is true at the beginning of adoption, but also very important in ongoingadoption of new parts of EHR. With our implementation of the CCC diseasemanagement forms, we just made them available. Once physicians began usingthem and trumpeting the benefit, others were soon to follow.


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5. Do not force feed changes, but rather first do it well yourself. If there issignificant advantage to the change, you can demonstrate that advantage andadoption will be much less traumatic. This also allows you to work the bugsout of any improvements you have (which are usually the things that cause theless enthusiastic users to become frustrated).

6.

Changes that may seem small often have a large trickle down effect. When Iused to change forms without consulting others, it would often have much biggerchanges to the workflow than expected. Changing a form may result in adifferent person inputting data and significantly change that persons jobdescription. We now do not allow changes to happen unless we have discussedthem and tried them in a smaller part of the practice to make sure there is not toogreat of an effect.

7. Use the less enthusiastic users as your benchmark of adoption. It is easy to getadoption of enthusiasts, but if you can design tools that appeal to the leastenthusiastic users, you will have much better success overall (dont take this ideatoo far, however, because some just probably need to work somewhere else).

Conclusion

To discuss EHR in our practice is to discuss our practice. Our computerized records areso central to our practice that it is impossible to think of our practice without them. Theyhave clearly improved our workflow, patient volume, and quality. Using Logician, ourpractice has become a successful business in an era of increasing physician frustration.

Much is made of the problems with the healthcare system. The payment system not onlyneglects paying for quality, it pays more for poor quality than it does for good quality (as

it takes longer to do good work than bad). While I think that it is essential for there to bereform that targets quality (and I will obviously welcome such change), I now think it ispossible to excel in the current system and still make a better income. The efficiency of awell-designed workflow can use the benefits of a good database interface to make quickwork of disease management, preventive medicine, and best medical evidence. I dontthink it wise to sit and wait for change, but rather to use current tools to win the battle onthe current battleground.

Implementing an EHR in a practice is very difficult work. For the average physician tohave any chance at doing it successfully there must be enough incentive to make thedifficulty worthwhile. While this may (and should) happen through reform that focuses

on paying for quality, this may also happen through the successful utilization of EHR inthe current system.

No one knows what a truly computerized office would look like. We are one of the morecomputerized offices around, but I know just how far we are from full implementation.Full implementation would involve direct patient input into the EHR, secure clinicalmessaging that would interact with the health record, automated alerts to patients missingcare, robust interface with other systems, top-line technology, and a community of like-


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minded providers. Full implementation would create what has been termed frictionlessmedicine where the mundane would be done automatically, leaving the personal andhuman side of medicine to the humans practicing medicine. Instead of making healthcareless human, it would enhance the time available for the hand-holding, for the listening,the good patient interaction which is the reason many of us went into medicine.

So what of our decision to adopt EHR? I cannot imagine practicing without it. The onlyway for me to survive without Logician would be to not care as much as I do. While Istill have plenty of frustrations, I have what most other physicians do not have: hope thatthings are going to get better.

Meaningful Use Case Study 3

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