An HIT Moment with … Vatsal Thakkar

An HIT Moment with ... is a quick interview with someone we find interesting. Vatsal Thakkar, MD is EMR Consultant and Assistant Professor of Psychiatry, NYU School of Medicine.

What’s good and bad about currently available EMRs for private practice physicians?

The bad is an easy answer:  the cost and complexity and commitment. The old model in EMR systems is that we pay huge fees upfront to acquire a static system which is basically housed on our premises. Then, we have to pay for maintenance and upgrades. It basically requires doctors’ offices to hire IT staff, so this model was typically only feasible for large practices or large organizations, like the outpatient offices associated with a hospital.

Even with all of the expense, it was not necessarily cost-effective, because the costs of training, maintaining, and upgrading ate away at any benefits. Security was another matter — having an on-site site EMR was not much safer than having an on-site records room. It was still susceptible to disasters and malice.

The good news is that we are entering the Google-ification of all things Internet. What I mean by this is that services are now being offered across the board which are low-cost, low-commitment, low-complexity. They are scalable and this means that the barriers of entry are falling. 

I myself started my solo practice with an EMR system which was very low cost ($50 per month), designed for my specialty (psychiatry), and was Web-based and involved no contracts. Therefore, the entry costs were very minimal. Within a year, I decided that system was not for me because it was slow and did not adapt well to my workflow and practice. 

A company I had kept my eye on was Practice Fusion. They were offering what looked to be an easy-to-use system which was ad-supported and therefore free. However, the reason I switched was because I liked the EMR better and it actually made me more efficient in my workflow. The fact that it was free was icing on the cake. 

Transitioning EMRs is no picnic, but I hired a grad student to help me download all of the old records to encrypted PDF files. The vendor was willing to get me a copy of my data, but I wanted to take this step to be ultra-safe. Ten years ago, or even five years ago, if I had opened a private practice, I would have had no affordable option to use an EMR — I’d be stuck writing in physical charts. This wouldn’t work for me because I have two offices and the lack of 24/7 access to records could have been a deal-breaker.

What functions are you using of Practice Fusion and how well does it work?

I am using many if not most of the functions of Practice Fusion. I use it to schedule patients, document office visits, phone calls, even e-mails from patients. I also use to internally as a secure way to message my assistant — it’s like tying an e-mail to a patient’s chart as a back-and-forth exchange among staff. When the communication is done, it gets saved as a chart document. 

Finally, one of my favorite functions is that I use Practice Fusion to keep a detailed medication history and prescription log, and to print prescriptions. In New York, we have to write one medication per prescription on special security paper, which can be tough on the hand when doing it manually. With Practice Fusion, I can just point and click to print refills. If a dose needs to be changed, that is also a very easy modification. Then, each printed Rx is automatically a part of the chart which I can easily refer to in the future. 

Practice Fusion also has an advanced insurance database for patients by region and there are add-on services for billing which integrate directly into the application to help streamline workflow. I am not using these because I don’t interface with insurance companies in my private practice.

Recently they have added document image uploading abilities so that old paper charts can be scanned and entered into Practice Fusion. I believe they are also working a deal with various nationwide labs to integrate lab ordering and results entry directly from/to the EMR interface.

With free EMRs like PracticeFusion and open source products available, is it really cost that’s holding doctors back from using them and should federal money be used to buy CCHIT-certified commercial products for doctors?

Cost is one of the issues. There is also an equipment issue because even with a free EMR, offices will need PCs, monitors, Internet access, and someone to take care of the machines (anti-virus and firewall, etc.)

Time and complexity is another issue. Transitioning to an EMR for a physician can be akin to changing a tire on an Indy racecar while it is still lapping. In some cases, it can be like changing all four tires while the car is lapping. It takes a lot of time, energy, planning, and devotion to successfully implement an EMR, especially for a group of doctors where there will be different styles and different opinions.

Finally, the last reason would be one that relates to human nature. We don’t like change. Things are always more comfortable the way they are. I would add that in terms of sheer speed and utility of documenting information, which is the core purpose of any medical record system analog or digital, there are few things that are as quick or reliable as writing with pen and paper. Pen and paper are easily available, don’t require electricity or an Internet connection, don’t require special training, don’t have outages, and so on and so on. 

I think the EMR industry should bridge the gap better by trying to simulate pen and paper. This could be done with tablet PCs or digital clipboards like the Digimemo L2. Or perhaps there will be a future device — I personally would love to see the Amazon Kindle adopt tablet functionality. That would be the perfect marriage of great screen for text, low power consumption, and thin and light device. Data could be transferred wirelessly or by cable for security. 

As a psychiatrist, how would you analyze the situation of doctors being blamed by outsiders for not embracing automation, for resisting the use of best practices and outcomes data, and for seldom participating in data sharing projects at a local and regional level?

Doctors usually have two goals: to provide good care to patients and to make money doing it. Some doctors value one of those tenets more than the other, but usually it’s in some sort of balance. There isn’t a level-headed doctor who would refuse automation if it was guaranteed to advance those two tenets. 

The problem has been that there has been a promise of better care and lowering costs, but not the guarantee. In addition, doctors have been told, "You must invest $20,000-$50,000 now and you will reap the rewards in 2-5 years." As a doctor, I have absolutely no obligation whatsoever to do anything purely in society’s best interest! I hope to do things in my best interests which I hope will also help society. 

It’s important to think about workflow — think 20 years ago — whether a physician was rounding at the hospital or seeing office patients, he or she was writing all the time — by the bedside, at the nurse’s station, etc. This writing, in the form of progress notes and orders, was then finalized in a spare moment between patients and the physician moved on. 

I so often see that administrators and non-clinical personnel don’t see that the introduction of a computer workstation and monitor is a change in workflow, but it can be a huge one. Now all of the note and order writing has to occur as discrete segments of time. Even if the doctor took notes in the patient’s room, those handwritten notes have to be re-entered into the computer. If the physician is doing this 20 times a day or more, even if it adds five minutes per patient, that adds up to over 1 ½ hours per day, which seriously affects quality of life or income generation (but usually both). 

When I was involved with implementing a campus-wide EMR system at Vanderbilt University Medical Center, no one had thought of the simple act of typing. Most of us under 40 (especially those under 30) have usually learned how to type as a natural means of communication. But what about those who were still hunting and pecking at the keyboard? There was no provision for getting someone typing lessons, which is the result of a less-than-perfect strategy. The end product is that the notes suffer because if I was posed with the decision of cutting corners on my note-writing vs. being an hour and a half late to go home every day, guess what — I have a wife and a toddler at home … I’m skimping on my notes.

In general, I hate to say that I have often seen the quality of medical documentation go down with the advent of the EMR. One scourge is the concept of insert pre-written text. It is meant as a means of speeding things up, but unfortunately what happens is that sometimes progress notes become fantasy documents that have little connection to reality. Or they all look and sound the same. The practice of medicine is a thoughtful, nuanced craft (even within the concept of practice protocols and guidelines) and that information has to be accurately conveyed in the medical record.

Best practices and outcomes data: in general, physicians should pay attention to these things. One of the problems is that these guidelines often develop prematurely and then have to changed or even reversed. So I think that most physicians should follow guidelines which have the best evidence-base backing them and in general this will improve quality of care and outcomes.

Participating in data-sharing projects also falls under the "better for society than for me or my practice." Therefore, without incentives, this is not going to automatically happen.

As a psychiatrist, using an EMR works for me because I have an office-based practice and I am a good typist. Another essential feature for me has been a wireless, whisper-quiet keyboard (Microsoft makes some good ones). This has allowed me to unobtrusively type a rough note while making eye contact with my patient. Sometimes I’ll have the wireless keyboard in my lap as I leisurely sit and face my patient and it seems to work for my practice.

What are your thoughts on patient privacy when it comes to electronic systems, data sharing, and vendors who manage and possibly sell patient information?

Of course I have had my concerns. With the introduction of federal guidelines (HIPAA) I am assured in the very least that if there is a confidentiality violation, someone can be held accountable, whether it’s a doctor, an EMR vendor, or a third party. 

I believe there are guidelines on how the data servers on an EMR can be set up and run. Everything has to be encrypted while traveling the Internet. In the end, if banks and even the IRS can use web access functionality, I think we are okay to do the same. 

The phrase "selling patient information" sounds very harsh but is a bit misleading. It is not legal to sell any identifiable patient data without consent of the patient. However, HIPAA stipulates that certain de-identified data can be disclosed or sold. The plus side of this may be better quality returns through the analysis of aggregate data. For example, it could be learned that a certain drug is causing complication X in certain patients. This data could be ascertained in real time. 

I don’t see a downside for patients other than a psychological one: the fact of knowing that their private information may be contributing to the healthcare data marketplace out in the world somewhere. For physicians, I think it could be worse. I’m sure this can and will be used by government agencies and perhaps drug companies to see who is recommending more tests (and therefore using more healthcare resources), who is prescribing which medications (potentially a huge draw for pharmaceutical marketing), and who is abiding by appropriate treatment guidelines. As you can see, not all of these are bad (i.e., the last one).  For now, I am content with the ease and efficiency that it affords me and I think that we as an industry and as a society will adequately deal with the issues as they come up. But it will probably be a bumpy ride.

News 2/12/09

US physicians utilize EMRs at lower rates than several other advanced nations, including the Netherlands, New Zealand, the UK, Australia, and Germany. As of 2006, 28% of US physicians used EMRs and 15% received alerts from them to provide patients with test results. The Netherlands had 98% utilization.

Greenwood Pediatrics (CO) chooses Eclipsys PeakPractice as its new PM/EHR solution. The 10-doctor group opted for the former MediNotes product over a hospital-subsidized Epic solution.

A new KLAS research report claims that more hospitals are looking for aggregation solutions that provide a more complete view of medical records and documentation. Such solutions would help clinicians improve patient safety. The report names six vendors that account for 85% of contracted deployments, with MEDSEEK owning the largest installed base. KLAS concludes the solutions from Microsoft and dbMotion are the most functional. The other top vendors include Medicity, PatientKeeper and CareFx.

Clinicians override more than 90% of drug interaction alerts and 77% of drug allergy alerts, according to a study that concludes electronic alerts as deployed today are more of an annoyance than a valuable tool.

A Princeton economics professor calculates that Americans age 15 and older spent an average of 1.1 hours a week obtaining healthcare in 2007. The figure includes travel time to see the doctor, waiting to see the doctor, the examination, taking medication, obtaining care for others, and paying medical bills. He concludes national healthcare costs are underestimated by 11% by not counting waiting time.

A study finds that found most Medicare programs designed to improve the care of chronically ill patients failed to reduce hospitalizations and save costs. Thirteen of the 15 CMS demonstration programs that included patient education, monitoring, and tracking wellness measures failed to influence hospital stays, while none of the 15 reduced Medicare cost.

Lawson Software announces that MedicalEdge Healthcare Group has licensed Lawson QuickStep Healthcare, HR Management, and BI suites. The Dallas-based practice management group supports over 1,000 providers.

Think all that economic stimulus talk is sincere and well-intentioned? This lobbyist isn’t satisfied that compromise rollbacks reduced the HIT portion of the kitty from $23.9 billion to "only" $21 billion. "Sometimes you have to lose the battle to win the war. We want to see the Senate pass this agreement and we will work during the negotiations this week to restore some of these savings." His lobbying firm lists no healthcare IT-specific vendor clients, just big hitters like Cisco, HP, IBM, Microsoft, etc. so they must be planning to get themselves stimulated.

Regional Cardiology Associates Medical Group (CA) selects the SRS hybrid EMR for its six-office, 22-provider practice.

The AMA joins other doctor and consumer groups in suing Aetna and Cigna, claiming the insurance companies intentionally rigged the data they contributed to the Ingenix "usual and customary" out-of-network rate calculator, thereby lowering physician payments. The insurance companies pout: "We’re disappointed the medical community has chosen to litigate on top of already pending consumer litigation on the same topic," said an Aetna spokesperson.

When Good Doctors Go Bad, Episode 1: the orthopedic surgeon of baseball star Barry Bonds and an upcoming witness in Bonds’ steroid trial is the subject of a restraining order filed by Dr. Michael Eiffert in a spat that took place in California hospital. Eiffert told a reporter that the surgeon exhibited "roid rage" behavior consistent with steroid-induced anger, but later clarified that he had no way to know whether the surgeon was juiced. The surgeon made a comment to Eiffert by telephone, prompting Eiffert to call him a "ding dong who was giving alcohol to a patient," referring to an incident in which the surgeon was accused of making in-hospital cocktails for a patient Eiffert was treating for alcoholism. According to Eiffert’s statement, the surgeon held him to a wall by the neck, threatening, "I’ll kill you. I’ll crush you. You don’t know who I am. I’ll kick your ass. And don’t ever call me a ding dong again." I can’t say for sure it’s the same one, but Michael Eiffert, MD is president of Palo Alto-based MyHealth Inc., and holder of a 2003 patent (warning: PDF) on computer-based patient treatment and monitoring plan.

A former office manager in Maryland faces charges for allegedly stealing over $100,000 from her OB/GYN employer via unauthorized credit card charges and outright theft of cash.

Now that the Senate has passed their version of the economic stimulus package, lawmakers must resolve differences between the House and Senate versions. Within the healthcare IT portion, some of the major differences include:

• The Senate bill would provide about $21 billion for health IT, while the House bill would provide about $20 billion;
• The Senate bill includes less stringent patient privacy provisions and directs HHS to issue rules addressing the disclosure of patient information, while the House bill includes provisions limiting the sale of patient data and the sending of fundraising solicitations without patient consent; and
• The Senate bill allocates about $3 billion for the Office of the National Coordinator for Health IT, while the House version includes $2 billion for ONC.

The Allscripts-Misys Healthcare board of directors approves the repurchase of up to $150 million in common stock over the next two years. Under the buy-back plan, Misys PLC has agreed to sell Allscripts the number of shares required to maintain its current stake in the company. Allscripts also announced it plans to sell its Medication Services business.

Unity Physicians Group (IN) lays off 38 people and closes its call center. Unity provides staffing at several emergency departments in Bloomington, owns and runs six urgent care centers, provides billing services for physicians, and hosts software applications. A company news release says the restructuring was undertaken to “make it more efficient and lower its operating expenses.”

A man accused of stealing a University of Utah backup tape from a courier’s car receives a one year jail sentence.

E-mail Inga.
E-mail Mr. HIStalk.

Joel Diamond 2/11/09

You know that you’re getting old when your kids laugh at your original iPod, calling it an antique. It’s only six years old. My original EMR is a little older than that.

Now that I’m merging practices, I’ll be transitioning to a new EMR. Although it’s probably just the natural progression of being an early adopter, moving to my second EMR adds to my angst about aging in a modern world.  

Learning a new system has been a bit humbling. I can recall the days of my first implementation and the frustration of being out of my groove while caring for sick patients. We are after all, creatures of habit, and transitioning EMRs is not that dissimilar to moving from paper to computer. It also reminds me of the inefficient work-arounds that one accepts over the years.

Sometimes the effort needed to make change seems greater than, what in reality, is merely a minor adjustment in workflow. Designing templates again from this fresh perspective is great, and for those of you who haven’t tried this, I can assure you that the creative process is invigorating. 

Overall, I would report that the good news when learning a new system is that the learning curve is much more manageable. This is mostly due to the fact that, aside from some minor differences in the user interface and some new bells and whistles, the overall user experience has not changed much in all these years. I guess, though, that this is also the bad news.

Contrast the change in the iPod user’s experience over a shorter period of time. In 2004, the first iPod Mini came out, soon followed by the iPod photo (in color!). The tiny IPOD shuffle came out just a year later, which was soon followed by the iPod Nano. The current iPod  Touch was announced in September, 2007.

The popularity of the iPod is clearly due to its continuing emphasis on aesthetics, while making sure that it fits into users’ varied activities and changing lifestyles. Basically, a cool interface, with an ability to easily download endless new apps, has tremendous appeal. Furthermore, the ITunes software lets users seamlessly transfer data between systems.

Now without carrying the analogy too far, can you say the same about  your EMR?

The truth is that as far as gadgets go, EMRs are still geeky and haven’t attained the coolness factor associated with BlackBerries and iPhones. When EMR vendors can reflect the same consumerist mentality, we’ll need far fewer incentives to promote adoption.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh Medical Center, and a practicing physician at UPMC.

News 2/10/09

A reader forwarded a letter supposedly sent by PNC Bank in Pittsburgh that indicates that it will shut down its Xpack electronic claims and transaction management system this summer.

Dr. Trent Pierce, chairman of the Arkansas State Medical Board and apparent car bomb victim, appears to be on the mend, although still in critical condition. Authorities don’t yet have a motive or suspects.

If you are interested in what you may have missed at last week’s TEPR meeting, check out Nick van Terheyden’s post on HIStalk. Though attendance was down over previous years, Nick did find a few bright spots, including the opening session:  "The opening sessions were great, and like or not Adam Bosworth’s views on where to spend the $50 billion stimulus, he had a compelling story that was not about technology investment (surprising for an acknowledged pioneer of XML) but centered on incenting behavioral change in the US population to stop the epidemic increase in American waists. But it was the Illness in the Age of “e” hosted by Danny Sands from Cisco and his patient Dave deBronkart that stole the show."

Greenway Medical Technologies and Navicure announce that both are expanding their offerings to include more integrated solutions and services. Sounds like a solid match, given that both are "Best in KLAS" award winners in their respective areas.

A bookkeeper being paid $100K a year by a six-doctor ophthalmology group and left alone to manage their payroll pleads guilty to stealing $783,000 from them by paying herself for 165 worked hours per week. According to court records, "the doctors did not get deeply involved in the financial aspects of the practice."

Penn School of Medicine researchers find that patient information stored in electronic medical records can have new analytical formulas applied that allows generalizing drug efficacy studies to a generalized population, not just those who participate in clinical trials. The study was performed using a UK research database, the extent of which won’t be available in the US for several years.

EMR vendor Bizmatics partners with PhyLogic, a national billing service and revenue cycle management company. The collaboration allows both Bizmatics and PhyLogic to offer and integrated EMR and PM solution.

The Detroit paper details the growth of eVisits and other online medical tools in Michigan. Henry Ford Health System reportedly conducted an impressive 30,000 eVisits last year. Insurance companies are reimbursing doctors between $20 and $30 a visit.

Outer Cape Health Services (located on the tip of Cape Cod) lays off eight employees in a cost-cutting measure. The laid off workers include both full and part-time clinical employees managers,  and support service personnel.  The medical group employs more than 100 people.

Marshfield Clinic (WI) selects SAP Business Objects XI intelligence system. Marshfield plans to use the BI tool to improve patient care and to analyze internal business operations.

iTMP Technology introduces new technology that will allow an iPhone or iPod to double as a heart monitor.  The $150 SMHEART LINK is a wireless bridge that collects data from sensors, such as heart rate monitors, and sends it to the smartphone via Wi-Fi. It appears they are targeting the fitness world, but it will interesting to see if it is accurate enough for clinical use.

Nuance Communications, makers of Dragon Naturally Speaking and dictation/transcription systms, announces Q1 results: revenue up 11%, EPS -$0.10 vs. -$0.08.

Lawyers are getting electronic medical records before many doctors. We’ve written about them before: a company’s new site that allows personal injury lawyers to obtain medical records directly from participating doctors.

What will be the effect of IBM’s announcement that it’s launching new technology to automatically import data from medical devices into PHRs and EHRs?  It definitely indicates that IBM is wanted to grow its healthcare footprint. It also provides more proof that the tele-health and remote monitoring market is growing.

A patient who failed to pay Carle Clinic’s six-figure medical bills by filing bankruptcy and then incurring another $30,000 unpaid bill for defibrillator implantation is upset that he’s not welcome back, calling the private practice "money-hungry" for declining to treat his other conditions. The nonprofit Carle Foundation Hospital wrote off what he owed it, so he offered the clinic $50 a month toward the $30,000 with no interest charges, which would require 50 years to pay off (he’d be in his early 100s by then). He says that’s all he can afford out of the $36,000 a year he and his wife make. So what do you do?

This Computerworld article highlights some of the struggles of rolling out an electronic health record. No surprise here, but younger doctors prefer using technology and older docs prefer doing things manually.  A bit more surprising was the admission from the director of IS at Midland Memorial Hospital that they paid doctors $1,000 each to participate in EHR training. Midland uses Medsphere’s OpenVista system, so I guess when you go with free software you can afford to pay doctors to use it.

Here is an interesting practice model discussed at last week’s TEPR meeting. Greenfield Health (OR) has designed its practice to be patient-centered, both physically and operationally. The practice has invested heavily in IT (EMR, PHR, e-mail) and patients can walk right in and see a physician or staff member without sitting in a waiting room. The practice takes Medicare and most commercial insurance. And, Greenfield Health charges a retainer fee of $250-$650 a year per patient to ensure the practice remains small. The practice also has a consulting service on the side.

E-mail Inga.
E-mail Mr. HIStalk.

Intelligent Healthcare Information Integration 2/6/09

Go Big by Thinking Small

I don’t know about you, but this whole economic meltdown has me worried. I’m worried for my family, for my little local hospital, for my little rural community, for my practice and the families we serve, for the future of healthcare …

OK, ‘nuff said about my anxieties. On to a solution or two.

(I hate whining. That’s for depressing, “poor me” chats over a beer or three. As the testosterone-laden male that I am, I want to know the problem, sure, but mostly I want to know how we go about fixing it. So, now, where’s my toolbox?)

Speaking of my tools, history is one of my greatest wrenches. Utilizing the lessons hard won from days gone by, I believe you avoid silly missteps and can tighten up many a loose nut which you might otherwise miss. (Please hold your “loose nuts” comments until the end.) I also believe many “advanced” minds often overlook the power of historical context and reference.

Currently, I am praying daily that the new Obama administration folks don’t neglect their history lessons as they approach the absolutely monumental challenges before them. Recent HIT efforts/failures and the Great Depression can provide clues to some serious answers for our current healthcare, environmental, and even economic woes, if we heed their warnings. With this in mind, I’d like to offer them an absolutely brilliant solution designed to:

1. Deliver the 70% of the population currently being ignored by most HIT projects;
2. Enable the NHIN goal for all Americans, utilizing a tool we already have;
3. Minimize the impact of more technology upon the already strained electrical power grid;
4. Provide jobs and lower healthcare costs;
5. Stimulate PHR participation while providing a tax break to all, and;
6. Eliminate all forms of STDs from the entire planet.

Yes, just stretching it a bit on that last one, but drop dead serious about the rest. Kidding? Nope. Not even a little. While the naysayers out there will poo-poo such grandiose proclamations, if the rest of you will willingly suspend disbelief for a moment, I will explain, very succinctly, after two short points.

First, small communities and their associated community hospitals provide care for some 70% or so of the U.S. population. They have been virtually ignored by the past 25 years of HIT development. They’ve been awaiting the trickle down from big medical center/large regional/big money projects. It has been a long, boring wait with no brass ring in sight. And now, the global economic crisis threatens them even more.

Second, the big boys and their big-money mindsets are notoriously neglectful of the little people. Their big projects often don’t provide down-scalable answers that work well for smaller markets. However, as many a grassroots phenomena illustrates (recent evidence: Obama campaign), starting with an answer from the little folks can absolutely engender big, even huge results for everyone.

Consider this:

1. Begin to build the national health information database using a system we already have. If they’re already planning to provide a tax break, build in an incentive for extra bucks for those who opt in and provide some basic demographics and maybe allergy history to a national healthcare database. Why not use the IRS? Who has more info on everyone already? (OK, CIA aside). They already have a national electronic input form; all you’d need is something similar to the check box they use for donating a dollar to the presidential campaign.
2. Develop a small community HIT mindset. Start with a system designed for the end user, a basic EHR/PHR combo that provides end user satisfaction and doesn’t try to compete with the big boys doing everything for everybody. Push this inward toward the hospital and outward toward the community at the same time allowing everyone in the community to go through the growing pains together. People are empowered by, and engaged with, their communities; use this to provide mass motivation to all of a given community’s doctors, hospitals, and individuals — all together, all at once. Patient-centered, but community-driven.
3. Use open source as much as possible. Save taxpayer dollars. (Sorry, all my HIT vendor friends).
4. Associate green technology with HIT deployment. Every new computer component in every doc’s office, home, or hospital is going to add to the already overburdened power grid, not to mention add to electric bills we all have trouble paying. Offer incentives to add a solar panel or micro wind turbine for each new system, residential or commercial. It may not lower your heating costs, but it could offset any increase in power consumption.
5. Use small business incentives to develop small community employment to deploy, train, and service these new technologies. Provide jobs for people to help us ‘technologize’ healthcare, contain our energy demand, and create the real NHIN from the grasses’ roots up.

Large problems need gigantic answers. But that doesn’t mean it has to be from or for the giants. Little guys, in little communities, eventually all working together can generate an unstoppable force.

Don’t just throw money at the big boys. Go big by thinking small.

Dr. Gregg Alexander is a grunt-in-the-trenches physician and admitted geek. He runs an innovative, high-tech, rural pediatric practice in London, OH, and can be reached at doc@madisonpediatric.com.