News 12/29/09

The Monterey County Health Department Behavioral Health Division completes implementation of the Netsmart Technology’s Avatar EMR. The $2.2 million project connects over 300 users.

Medical coding software developer CrossCurrent seeks $5 to $10 million in new funding to expand operations and extend marketing efforts for its Incisive MD product.

The AMA offers a new online tool that allows physicians to compare different healthcare plans. The information provides detailed data on Aetna’s Aexcel program, Cigna’s Care Network, and UnitedHealthcare’s Premium Designation program.

Justice or silliness? Mississippi’s governor sends a tweet asking constituents to forward ideas on how to trim state expenses. An employee with the University Medical Center follows up with a tweet suggesting the governor not schedule his medical exams after hours, which requires the clinic to pay 15-20 people to stay open late and leads to overtime pay. UMC fires the employee for violating HIPAA laws.

Mayo Clinic also fires a physician and an allied health staff worker for violating privacy policies.

PhEMR (femur) releases a new version of its EMR that includes e-prescribing functionality and lab interoperability. I’ve never heard of the company, but I think their name is sort of clever.

Increasing the use of IT to reduce medication-related errors and improve medication adherence could save billions of dollars and save lives. That’s the conclusion of a new report by the Center for Technology and Aging, which looked at ways IT could help with the medication-use process among older adults. Some of the new technologies explored include medication kiosks, online medication history tools, mobile phone apps, and wireless POC testing devices.

Clafin Medical Equipment agrees to market Aprima Medical Software to new clients, as well as its 10,000 existing customers.

Wuesthoff Health System opens the first of five Florida walk-in health clinics at the Merritt Island Walmart Supercenter, which will run eClinicalWorks software.

Companies like mPay Gateway, Navicure, and FirstPaid admit that physician adoption for their services remain low, but, all are optimistic for the future. The companies specialize in services that speed patient collections through the use of preauthorized credit cards.

GE expands its Stimulus Simplicity program to include new purchases of its Centricity Business solution suite. The program offers 0% payment terms and deferred payments until 2012.

A research organization says that healthcare consolidation can benefit patients because larger practices have deeper pockets for IT systems and other infrastructures. Technologies such as EMR and better payment systems provide increased efficiencies and result in better customer service. Analysts expect solo and small practice physicians to continue moving to larger groups, especially as payments are squeezed and providers require more capital for practice upgrades.

I’m only semi-working this week since there isn’t much going on in HIT-land and because I’ve escaped to a remote location. It’s quite rustic (I left all the stilettos and designer sweaters at home). I sent Mr. H a picture of my lodgings and he quickly assessed it un-Inga-like. I say that there is nothing like a few nights on a bed with low sheet thread count to appreciate home.

E-mail Inga.

HIStalk Practice Interviews William Zurhellen

William Zurhellen, MD, FAAP is a pediatrician at Putnam Valley Pediatrics PC of Putnam Valley, NY.

Provide me a bit of background on your practice.

This is a two-pediatrician private practice in Putnam Valley, New York, which is a suburb of metropolitan New York, about 45 minutes to an hour north of New York City. It was established in 1975 by me. It’s a community-based, ambulatory general pediatric practice.

I understand you’re using a homegrown EMR. What’s the history there?

I developed an interest in computers way back when the Tandy Model 1 came out. I started writing what was then BASIC from Dartmouth, BASIC programs for that. We wrote a financial program in 1984 and immunization program in 1987 and then launched what would be our current EHR in 1999. It’s had revisions, but the basic format has been the same for 20 years.

Are you the only practice using it or has it been used other places?

There are several other practices that are still using it, although each practice had the right from Y2K on to essentially alter it themselves. In other words, it was a research project on our part and we had other pediatricians — it’s only pediatrics — who wanted to use it. So we installed it for them and set it up for them and then they manage it. It’s self-managed.

So it does general functions like the prescription writing, tracks immunizations, all that?

It does prescription writing. However, with the changes in New York state law, we can’t use it any more because it required the use of micro-printing. Of course, removing the e-prescribing, the goal is to eventually merge an e-prescribing software with it.

More likely, when the right new system comes along that works as well or better than ours, then we will probably migrate to that,  only because the only support for our system is me and I’m 63. I don’t want to be supporting the software when I’m 85.

I understand you’re a member of a CCHIT work group.

I’m part of the Child Health expert panel.

I’m assuming your homegrown EHR is not CCHIT-certified?

No. There’s no intent at this point to have to go and qualify for ourselves because there’s no point in spending $30 to $40 thousand on a regular basis to certify ours.

Do you think CCHIT certification should be a requirement to qualify for government funding?

That’s a big, heavy-duty topic. I think government funding is going to help others purchase EHR technology because I think cost and price is a major issue. I think the government needs to be able to set specifics to prevent people from buying a $10 piece of software that does one thing and say, “We have an EHR.” The only current way to do that is either for the government to come out and spell out things that it must be able to do, but then it has CCHIT that’s already doing it. So, I think it’s reasonable to do that.

On the other hand, I’m not sure, and this is just my personal opinion, that the current software out there is what we all need in the first place.

In other words, there’s not the perfect software?

I wouldn’t buy any one of them right now. That’s because I think most current vendor software offerings are really designed around pay-for-performance and documentation to get paid. I’m a firm believer that electronic health records should be designed to improve the health outcomes of the patient and that payment is a derivative of that, but none of the current systems really track outcomes or healthcare.

Until we retool, in a sense, and prioritize the software in such a way that when you build up a five-, or ten-, or twenty-year database of patient function, you can look at it and see if this type of care enhanced or didn’t enhance the patient’s clinical outcome. There’s never been any evidence that pay-for-performance has any quality impact on any health outcomes, in the long run, on individual patients.

Does your software do that type of tracking, reporting, capturing?

To a certain extent, yes. Not as much as I’d like, but I’m limited by the fact that we’re using UNIX and twenty-year-old data structured software.

And no plans to do a rewrite?

Not at this point. I would rather buy something or acquire something that’s going to be supported by someone other than myself personally. So there will come a time for a transition. But if I wanted to, yeah, I’d sit down and take a year or two years off and write something and become a vendor myself. But no, I’m not interested in that.

Has the promise of money through ARRA and other pay-for-performance programs changed your focus at all in terms of technology adoption?

No, because I think the basic original tenet of trying to move medicine into the electronic world is incorrect. I’m not sure how they’re doing it is correct. The entire ARRA is a trade for information. We’ll give you money to put in records, but in return, we want you to supply us with performance data. Performance does not equal quality.

How is your current EMR helping you do research?

It helps us run the practice, and that by itself is the research. It allows us to track patients, follow health reminders — it pops up when we have pre-indicated that we needed it — it sorts, selects patients based on criteria that we set.

The problem is that, for example, if you were talking about children with asthma, there’s really no great case-mix or outcome definition that’s standardized. Not only that, most information systems are based on tracking an encounter, not an episode of care. That is, if a child has an asthma attack that goes on for two weeks and you try A, you try B, and you finally get it under control, you need to look at that whole episode, not just today’s office visit, last week’s office visit; because then the human being has to manually build a picture of an episode, whereas it could be built into information systems.

How are you inputting information?

Keyboard.

Do you have PCs in every exam room?

Well it’s UNIX-based, so we have a central server, and we have Wyse 350 terminals in every room. It’s all working off the same system. Everybody uses it to run our financial, our scheduling, our messaging; all the background services of the practice.

What would you say if a doctor came to you and said, “I want to go write my own software like you did?”

Twenty years ago, great idea. These days, no — it’s a lot more complicated than that. I mean, a person could, but my own feeling is — and this is speaking as a pediatrician — I’m not a great fan of the idea of what people consider, currently, interoperability. Interoperability, conceptually right now, is the ability to exchange bits of information between one system or another.

If I take care of a child for twelve years and they moved to a friend’s practice in California, it doesn’t do any good for long-term records to send him a snapshot or bits of information. That person should have access to that child’s record in the form that I put it in so he can continue to build on it. That is, whether you call it interoperability or exchange, it’s a different concept because right now people are talking about CCRs, where you can exchange certain amounts of information from on to the other.

It still parses it and summarizes it, so it’s no better than a patient record now where I might have a full chart. Then when the chart moves, I send a summary of the problem list and immunizations. That’s great, but it doesn’t supply any background data on the patient over a year, so it’s not useful in terms of looking at outcomes in healthcare management.

My own feeling is that if we could get a single data structure and let vendors compete on the user interface, then all records would be compatible with all others. For example, say I pick NextGen for my office and I install NextGen. Say, five years from now, NextGen wants to raise its yearly maintenance to $30,000. I have no choice but to pay it because if I said, “No, I’m not going to go. I’m going to switch to Vendor X.” Well, Vendor X can’t access the data structure. They’d have to write a completely new conversion program to take all the data from NextGen and convert it into a format that they can use. That costs money.

Or, if a vender decided, “Hey, it’s not worth it anymore. I’m selling out,” or discontinuing, a doctor’s going to be left up the creek with a set of records with no support anymore because it’s not interchangeable. That’s probably, more than money, at least in pediatrics, the biggest hold-back — the fact that obsolescence and being dependent on a single vendor is not a nice situation for anyone to be in.

What if every TV station had their own proprietary mechanism of sending out TV screens so you got a computer that would get NBC, but it wouldn’t get ABC? It’s the same thing, that there’s no real standardization.

I think that if we address the issue of true standardization, whether you did it on site or did it as a centralized data structure, the patient should have a patient record that starts prenatally and goes through life, and shouldn’t have 15 different ones in different sites.

I mean, we’re talking about healthcare now, not getting paid. That’s what I meant earlier by the current systems are designed for an individual physician or an individual practice and focus on documentation for payment. That’s not quality, not from a patient perspective.

Last question here – your opinion on why EMR adoption is so low?

I think money plays a role in it. Standardization plays a role in it, for fear of, “I’m going to be left holding the bag if somebody decides not to support my system any more.” And if I’m dependent on a single vendor, then I can no longer say, “Well I’m not going to pay the bill any more. You’re much too high for what you’re doing.”? Well, then I’m outta here. You can’t do that when you’re dependent on a single type of software system. There’s no other industry that operates on the same basis.

If you have an inventory system done by one company and you want to switch to SAP, bang — there’s a certain amount of standardization on it. So I think doctors are afraid. There are 315 different systems out there, all running. They may work individually well, but you can’t exchange them.

We’re talking about the ambulatory sector, you see. Most primary care physicians are used to the idea of exchanging a document with an orthopedist and getting a document back from an orthopedist. But within the ambulatory sector, pediatricians want to be able to send the patient’s chart to the new pediatrician, not just a note. I think interoperability’s been taken as any system is equivalent to any other one, when in reality, you don’t operate that way. The child’s entire health record should go.

If a woman had breast cancer and had been getting three years of chemotherapy out of Sloan-Kettering and then she moves to Phoenix, what do they do? Send just a summary document? They have to send the entire treatment summary, and it has to be usable and readable by the receiving system.

So, I think part of the holdup is the absolute cost. I think part of the holdup is the fact that there’s no real perception of what real interoperability or exchangeability or standardization is. I don’t think the vendors are interested in, in my own experience, in talking to the EHRA, or what used to be EHRVA. They’re making quite a bit of money selling systems that are documentation to get paid.

They’re not looking at changing, unless we change the perspective that the purpose of the EHR is not for the physician, it’s for the patient. Well, pediatricians are different than anybody else. We’re the only ones taught to manage patients and practice true preventive care. So these elements, the fact that it has to be designed for quality care, the information has to be mobile. That’s much more critical to us than it seems to be for adult physicians. That’s just us – we’re different.

HIStalk Practice Interviews Scott Decker

Scott Decker is president of NextGen Healthcare.

Do you believe that the HITECH Act will deliver the goods, both in terms of improving care and lowering costs through technology and for stimulating the economy?

I think those are two fairly dramatically different issues. I think it certainly is doing more than has been done in the 20 years I’ve been in the industry in getting attention brought to the value of automating electronic medical records and the processes and communication between systems. I think it’s still a little too early to tell. While the entire industry expects that it’s going to be the catalyst and it’s finally going to get everybody moving, it’s still too early to tell.

If it does what it’s intended to, which is get electronic health records in the hands of the vast majority of the physicians and vast majority of the hospitals doing physician order entry, I absolutely believe it’s going to deliver on higher quality care. I think that’s been intuitive to everybody in the industry for a long time, that if information shared across caregivers — I don’t think anybody, obviously, thought that wouldn’t improve patient care. So with that caveat, if everything happens the way the stimulus is intended to happen, yes, I think it’ll absolutely help improve care.

As far as being a stimulus, if everybody starts automating, I think you’ll see a short-term increase in healthcare IT spend. I don’t know that I’d consider that an economic stimulus. It certainly is a segment stimulus and certainly good for healthcare IT vendors. I don’t know if it’s the best use of dollars to stimulate our overall economy.

Do you think the technology’s also going to help lower cost in healthcare?

You go back once again to the intuitive things which are — will it take care of when people get testing and does it help improve the administrative flow? I think a lot of those things are going to happen fairly short term. I don’t know if it’s a major mover in the next five years on lowering costs.

In fact, it may actually increase costs in the next five years as everybody has to go through all this implementation work. Over time, I think if quality improves, lower costs go with that. I think we’ll actually see a short-term increase in costs and I think the long term is a 10- to 20-year horizon before you start to see improved overall cost in healthcare because of this initiative.

Do you have a sense of how many doctors will forego that HITECH incentives and stick with the electronic or paper systems they’re already using?

We don’t have a sense on that, so let’s just assume that 20%, maybe, of physicians have electronic health records. We definitely think this will be an accelerator. We definitely think it won’t force everybody to go off. I think it’s going to get up to the same point we would have gotten to anyhow, I just think it’s going to get up to it faster. Maybe the ultimate is 75 or 80% of physicians.

Two years ago, if we would have talked about this, you probably would have agreed it’s going to take 10 to 15 years. Maybe now we’ve changed the time horizon back to five to 10 years. I mean you still talk to them and say, “This isn’t enough to make it worthwhile.” Now maybe the pain at the end of this curve will be strong enough that even those will have to move, but I think there’s definitely a set who are still saying this isn’t enough to change my position on the value.

The HITECH legislation is aimed primarily at general medicine EMRs. Do you see anything changing for specialists?

I think if it’s successful in the primary care side in and of itself, it’ll help specialists, especially in the flow of information. You already have higher penetration of EHR on the specialty side. Those were certainly some of the more early adopters.

I have heard talk, people even revisiting the stimulus to say, “Do we need to put more incentive into the bill to apply to specialties?” I think yes, they are going to benefit maybe more than they currently perceive. Some of that’s direct, and I think some of its indirect; i.e. just the connectivity of primary care folks as they get online, I think, is going to be a benefit to them.

Hospitals and regional extension centers may eventually have a larger than expected role in which physicians implement which systems. Was that a surprise, and has NextGen’s strategy changed at all because of it?

It was definitely a bit of a surprise. I think we, and some of our peers in the industry, didn’t necessarily expect that move and maybe even scratch our head a little bit at “is that the best way to spend the money to help accelerate this”; i.e. put a middleman in the market between vendors and physicians, especially organizations that don’t exist today, that doesn’t necessarily have a lot of experience and skills implementing and deploying EHR.

But with all that said, it is what it is and yes, it has changed, rather dramatically, our strategy because it has the potential of being a key channel to getting physicians up and running. So we’re very aggressive in our planning on how to best work with the RECs and making sure they’re successful.

Clearly with hospitals, I see them much more aggressive in the last six months, also, in really solidifying their strategies on going after EHR. I was just at CHIME a couple months ago and did probably three focus groups, probably talked to 50-75 CIOs, and almost to a CIO, it’s now their top strategy. One of their top two strategies is now the deployment of EHR, certainly for owned physicians and a vast majority of the cases, to the community physicians having some sort of offering through the health system. So yes, we definitely stepped up the time we’re spending in the hospital segment and think that’s also a key distribution point.

Connectivity solutions include both HIEs and vendor-specific options, technology such as that offered by Epic. What should customers look for in planning for the future?

They definitely need what I would call a more generic HIE offering rather than a vendor-specific. I guess I would relate that comment more to our conversations with health systems, so it’s backlit from that side first. I mean, they need a solution that’s committed to connectivity, and I think everybody has come to the conclusion that you can’t dictate to your community a single EHR solution or even two or three.

Where I think connectivity is not even just about hospitals, it’s the physician communication — the physician and the hospitals, hospital to physician, and physician to physician. The health system probably ought to put in a system that facilitates that. Why need a multivendor platform to do that?

From the physician office side, you need to make sure your vendor has an open architecture and standard that’s going to easily communicate with a neutral HIE platform.

By the way, I wasn’t ruling out the fact that your vendor might have a neutral platform. So for instance, at NextGen, we invested heavily in building an HIE product. The number one criterion was it has to be open standard/open vendor model. Our clients are using a NextGen HIE solution to accomplish what I described as they need to be changing.

One of the things on the inpatient side that we’re seeing is that many vendors have seen customers satisfaction metrics drop after a big sales pitch because the vendor wasn’t able to scale up to hold all the hands of those new clients trying to implement simultaneously. Do you think that we’re perhaps creating a lot of unhappy customers because that HITECH window is so small?

Yes. I think everybody believes if things take off as we are anticipating they are, there are definitely going to be organizations that have trouble scaling. Just like you asked me what the criteria that clients ought to be looking for when they choose HIEs, probably this is an even more important one — whether to resource it to the company you’re looking at to help you with your EHR, and assuming the demand’s going to be through the roof.

What organizations are probably best prepared to scale with that and are going to be able to give you a quality installation and service and training — I think that’s going to become more and more an important criterion for selection.

Anything else you want to share about NextGen?

We’re obviously invested heavily on all the fronts you tapped on. We focused really heavily in the last 12 months on making sure we are prepared to address that scale issue. We’ve always been very focused on customer satisfaction. I think this just puts more pressure than we’ve ever had on making sure we’ve pre-invested to make sure we continue to deliver quality product implementation and clients at the end of it. You need a company that can scale, and there are fewer and fewer of us out there in the industry, I think, today.

The other thing we’ve invested really heavily on is this whole concept of HIE or interconnectivity. We’re pretty excited about the portfolio we now have between having an EHR and an EPM. They’re all on a single database that’s tied into an HIE that also has a patient connectivity piece to it so that we can really tackle what we think is going to be the ultimate game here, which is going to go quickly beyond just “how do I get my practice up and running EHR,” but “how do I get my practice up and running in a connected community.” I think that’s going to be the big game as the standards start raising. We’re real excited about what we have on that side and what we’ve already been able to do through the clients on building up that model.

News 12/22/09

MedLink International joins the ranks of EHR companies offering a guarantee that its “qualified” EHR products will meet meaningful use guidelines, even though though the final guidelines have yet to be published.

I am sure I am not the only one who is ready for the release of the final meaningful use definitions so we stop hearing everyone give an “expert” opinion of what will and won’t be included. Then we will be able to focus on hearing all the “expert” explanations on what it all means. If you are planning to attend HIMSS and aren’t already sick of the topic, there’s a one-day Physicians’ IT Symposium looks pretty good. Hopefully the individual sessions will be more inspired than the symposium’s title: “What it Means to be a Meaningful User.”

CCHIT announces that it has certified a total of 14 products under its Certified 2011 Comprehensive and Preliminary ARRA 2011 programs.

The CIO of the 300-physician Springfield Clinic (IL) claims its Allscripts EMR plus a patient kiosk system netted a $4.5 million ROI in the first year, thanks to staff reductions and reduced transcription costs.

Medical tourism numbers are down almost 30% compared to a couple of years ago. The decline is blamed on the recession, high travel costs, and overall discomfort with the idea of traveling to strange places for care that might not meet US standards.

A market research publisher says the 2009 EMR market will hit $13.8 billion, which is less the market’s full potential. To beef up adoption, vendors and health systems will need to provide additional financial incentives to financially strapped solo and small practice physicians who can’t afford the upfront costs or EMRs.

Karen Pletz, president and CEO of the Kansas City University of Medicine and Biosciences, was fired last week with no explanation from the school. During her ten-year tenure, Pletz has been credited with increasing endowments to $70 million and improving medical board passing rates to 100%.

Practice Fusion claims its user base grew 400% in 2009 and now includes more than 25,000 EHR medical professionals.

Practice EMR vendor DoctorsPartner offers the Sushoo independent HIE, free for DoctorsPartner customers or $2,500 upfront and $80 per month otherwise.

OptumHealth, a division of UnitedHealth Group, plans to offer virtual doctor visits nationwide next year. NowClinic will be available for $45, regardless of whether or not a patient is insured. The visit includes a 10-minute appointment with a physician who can file prescriptions, except for controlled substances. Providers will eventually be able to view patient medical histories.

PricewaterhouseCoopers’ Health Research Institute predicts healthcare cost controls as the top health industry issue for 2010. Also in the sector’s forecast: growth in technology and telecommunication; more hospital-employed physicians as providers seek greater stability and electronic connectivity; and greater emphasis on fraud and mistakes.

The Minneapolis paper highlights mPay Gateway, which offers a Web-based healthcare software credit card payment system. The four-year-old company serves 1,500 providers and predicts 2009 revenues of $300,000. mPay Gateway’s biggest distribution partner is Allscripts, which added 700 providers in 2009. We interviewed CEO Brian Beutner a few weeks ago.

The US Patent Office issues a patent to Practice Velocity for it PIVoT urgent care EMR. The company CEO says, “The patent recognizes the uniqueness of PiVoT and this gives the protection of the US Government for the intellectual property rights of Practice Velocity.” Sounds good, though I couldn’t comment on whether the product is truly unique or if the company is simply employing an unusual marketing ploy.

On the rise: business management programs designed specifically for physicians and other clinicians. Doctors can lug their backpacks across campus at such universities as Vanderbilt, the University of Pennsylvania’s Wharton School of Business, Harvard, and Duke.

I plan to take a bit of time off over the holiday, so maybe I’ll have time to download this new iPhone app. Death Panel tests users knowledge of healthcare reform in a quiz format. Can’t think of what would be more fun then snuggling in front of the fire with a glass of wine and musing over healthcare policy.

 Ho-ho-ho!

Intelligent Healthcare Information Integration 12/19/09

Feeding Those Who’ve Already Supped

From Healthcare IT News, Diana Manos, December 2, 2009:

Health and Human Services Secretary Kathleen Sebelius and David Blumenthal, MD, the National Coordinator for Health Information Technology, have announced $235 million in grants supporting non-profit organizations and local governments that can exemplify the positive impact of healthcare IT on population health.

From Grants.gov, Recovery Act – Beacon Community Cooperative Agreement Program :

Selected communities must already be national leaders in the advancement of health IT, workflow redesign and care coordination, or quality monitoring and feedback. In addition, successful communities must have advanced rates of electronic health record (EHR) adoption and health information exchange (HIE), and the readiness to incorporate health IT to advance community-level care coordination and quality monitoring and feedback.

Seriously? The way to advance healthcare for communities, to help “communities to build and strengthen their health information technology (health IT) infrastructure and exchange capabilities to demonstrate the vision of the future where hospitals, clinicians and patients are meaningful users of health IT…,” is to give more money to those folks who already have money and support? They’re saying the answer lies in encouraging those things that have trudgingly brought us to our current quagmire of NHIN limbo?

This then implies that those 2,000 or so small communities across the U.S. with their associated small community hospitals where 60-70% of American’s receive their healthcare, most of whom have little to no HIT and little to no HIT funding support, are again left standing beside the table, starving, watching those who already have been tossing down giblets and gravy get fed yet again. All the while, there they stand, hunger pangs piercing their bellies, as they watch another course of fat and feast go to those who’ve already eaten while the hungry wonder where they might catch a cast off crumb or two.

No consideration for a new way to advance community healthcare integration? No promotion of novel thinking and innovation for community HIT? No “let’s encourage some disruptive shake-up for this semi-stagnant industry” to encourage new adopters and new connectors?

Maybe in my little foxhole here on the frontlines I’ve missed something, but darned if it makes any sense to me to take ARRA monies and consistently push all of them out to the “already haves.” If they already “had it” sufficiently, wouldn’t we already be seeing the integrative fruits of their labors? With so few really grand success stories in the world of CHINs and RHIOs and HIEs, what is the logic that says throwing more free (i.e., taxpayer) money at them will provide them their long sought spark?

Kathleen, David, I hereby offer my two-cent suggestion: There are lots of small communities who could use that money and I know of several disruptively innovative, out-of-the-container thinkers who might really send HIT integration to new levels for all us little guys if somebody would provide them a seat at the banquet. (They eat very little and would even help with the dishes.) How about a helping hand for the “have nots”?

From the (hungry) trenches…

“I’ll be more enthusiastic about encouraging thinking outside the box when there’s evidence of any thinking going on inside it.”  – Terry Pratchett

PS – Thanks, Shabbir.

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached throughhttp://madisonpediatric.com or doc@madisonpediatric.com.