News 6/3/10

The Retina Group of Washington (DC) selects the SRS hybrid EMR for its 20 specialists.

MED3OOO founder Pat Hampson is profiled in Smart Business. He advocates a culture based on strong relationships to foster growth. He suggests that employers value and recognize the contributions of each individual, nurture two-way employee communication, and empower employees. His approach seems to have worked since he started out 15 years ago: the company employs 1,760 and earned $137 million in revenue last year.

Practice Fusion and Kareo launch an integrated EHR/PM solution that includes Practice Fusion’s web-based EHR and Kareo’s medical billing software. Both companies will market the products.

Medical billing and A/R management company Medigistics selects CPU’s MED/FM Medical Billing and Practice Management software. The company provides services for over 300 physicians and CRNAs.

Over 40% of private practice physicians are connected to hospital systems, according to a new Beacon Partners study. The most common connection is via a patient/physician portal (35%), followed by a  results reporting interface (20%). Half the hospitals and practices surveyed have had to cut back on IT investments due to the economic climate and reduced access to credit markets.

The Ohio General Assembly passes legislation to establish 44 existing primary care practices as training centers for patient-centered medical homes. They will be reimbursed up to 75% of  their costs for HIT products, including EHRs, HIEs, e-prescribing, and decision support tools.

CHHIT extends full 2011 certification to Allscripts Professional EHR 9.1 and Medicat 2011 10.0. That’s a total of 19 products, if you are counting.

I haven’t mentioned any stats on HIStalk Practice in awhile, but traffic and subscribers continue to grow steadily. May readership increased 11% over last year and our subscriber base has jumped 28% since the beginning of the year. Confirmed e-mail subscriber count is now 774. Thanks to everyone who takes the time to read and sharing the site with your friends. And of course, a big thanks to our sponsors for their great support!

US Oncology announces its new iKnowMed platform for community oncologists. In 2004, US Oncology purchased iKnowMed and its oncology-specific EHR and has since added a revenue cycle management inventory management component.

In what appears to be a fairly comprehensive review of the HITECH Act’s implementation status, Manatt Health Solutions concludes that many eligible health providers will have difficulty achieving proposed Meaningful Use criteria. This is especially true for small and rural practices and certain community health centers. As a result, EHR adoption rates will be less than anticipated. The report is also critical of the HITECH’s approach to interoperability, saying it is unlikely to yield quality improvements and cost efficiency gains. Other key points:

• There need for stronger policies that would encourage practices to follow evidence-based treatment guidelines for improving patient health outcomes.
• All currently excluded health care providers need to be included in the program to enable true coordination of care across all care settings.
• Regional Extension Centers may face sustainability and operational challenges; alternative approaches should be developed to ensure ongoing EHR adoption and implementation support.

E-mail Inga.

News 6/1/10

From: Apple Doc “Re: iPad. Is Sage/Intergy going to be iPad compatible? That would be good news for us few with new iPads.” I asked the folks at Sage and a spokesperson provided this response: “Using Microsoft Remote Desktop Service or Citrix XenApp, Sage Healthcare software can be used from many different devices, including iPad. We began testing immediately upon the release of the iPad, and will continue testing for the next several weeks.”

mPay Gateway secures an additional $1.55 million in funding from new and existing investors.

Healthcare South (MA) selects Allscripts EHR/PM for its nine pediatric and family practice offices.

Sevocity offers regional extension centers and educational organizations free access to its Internet-based EHR, setting up as a demo clinic for up to 20 users and requiring them to have nothing more than PC with Internet access.

AHRQ releases a report on practice-based EMR usability and concludes that vendors are not performing adequate usability testing, following user-centered design principles, nor getting real usability experts involved in product design. Mr. H provides a great summary here.

The American Academy of Professional Coders names Daniel Schwebach VP of practice management initiatives. Schwebach most recently served as a manger with Pricewaterhouse Coopers, overseeing daily practice operations for over 400 faculty physicians.

Spurred by physician shortages and improvements in technology, the interactive telemedicine business is now growing almost 10% annually. The $3.9 billion industry includes home monitoring devices, teleconferencing, e-mail interactions, and healthcare applications on smartphones. Of course now that more insurers are agreeing to reimburse providers for many of these services, look for more physicians jumping onboard.

Enforcement of the Red Flags Rule is pushed yet again. The FTC set December 31, 2010 as the new deadline, giving Congress time to consider legislation that would affect the scope of covered entities. One proposed bill would exempt healthcare practices with 20 or fewer employees.

NextGen parent Quality Systems reports Q4 numbers: revenue up 19%, EPS $0.45 vs. $0.40, falling short of consensus earnings expectations of $0.49.

E-mail Inga.

Intelligent Healthcare Information Integration 5/30/10

Boomers’ Usurpers

We Baby Boomers have long thought we invented pretty much everything. If we didn’t actually invent sliced bread, we at least identified which side needed to be buttered. From the cultural and sexual revolutions of the Sixties with our hippie dippie, free love, free speech, flower power, no plastic, “Who needs more ‘stuff,’ man?” anti-establishmentarianism to the Eighties’ New Materialism where our mantra did a one-eighty to “Whoever ends up with the most stuff wins” to the New Right, Silent Majority, neo-conservatism, Family Values of the late 20th and early 21st centuries, we have always felt empowered to promote “our” values as “the” values.

God bless ‘em, our kids seem to have figured out to ignore our inflated mass sense of self importance.

While computers did come into their own on our watch, the powers of mass social networking were, whether we Boomers want to admit it or not, discovered and developed by our prodigy. They MySpaced out, friended up, and YouTubed down the mighty River Internet. They even seem to have evolved the species with a new developmental feature, TTA (Text Thumb Ambidexterity.)

OK, they blazed the trail, but B.B.s don’t like being out-maneuvered on social movements. So, we’ve jumped aboard the Facebook, et al, bandwagon full force. We’re all a-Twitter as we StumbleUpon Classmates who are LinkedIn to Slashdot and who Digg Xanga as we Friendfeed LiveJournal entries from Bebo that were Tagged on Ning as we Hi5 each other over that Delicious Last.fm recommendation once we’ve Reddit. A study on Pingdom posted in February showed a full 32 percent of social networking site users are undeniable Boomers with another 25 percent of users being from the Boomer “cusp” (ages 35 to 44).

So, Boomers and their close associates are hitting the Web hard for social interaction. Granted, it’s those Boomer-cusp Middle-Agers (who were 20-somethings when the Web truly hit World Wide “wowness” in the 1990s) who are leading all packs for online sociability. But, they’re kin, not kids, to us full-bore Boomers. Together, we account for more social internetting than our tech-brained children.

But, dagnabbit, them young whippersnappers are up to their rascally shenanigans again. After they scooped us with social media savvy, they are now securing their online profiles much more aggressively than we. The recent Pew Research Center report, “Managing Your Online Profile,” finds that Boomers are far more lax about managing their Web “face” and less likely to guard their privacy and manage their online security than those 18- to 29-year-old rapscallions. How dare they outperform us again!

Well, gang, we better get a grip or these young punks are going to trot us out to the old revolutionaries’ pasture right quick. We need to take heed, secure up, and get our Web acts together or they’re going to out-revolutionize us again. We obviously followed the lead of the kids to Web-based socialization. It looks like they’re scooping us on the need to look both ways as we cross the Information Highway, too.

Eh? What’s that you say, sonny? I need to watch my healthcare data as it goes digital, too? Clementine, call Dr. Peel…I think I need to have my “privates” examined.

Now, where’d I leave my cane?

From the crotchety, old trenches…

“Civilization is the progress toward a society of privacy. The savage’s whole existence is public, ruled by the laws of his tribe. Civilization is the process of setting man free from men.” – Ayn Rand

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.

HIT Vendor Executives – Advice for Dr. David Blumenthal

We asked several EMR and consulting executives the following question:

If you could give national coordinator David Blumenthal one piece of advice, what would it be?

Evan Steele, CEO, SRSoft

My advice to David Blumenthal would be to think about EMR adoption more intently from the physician’s perspective. What is needed to truly facilitate the purchase and successful implementation of EMRs is what I have termed “EMR Reform” — a plan that would provide physicians with the unbiased information they need to make an informed EMR purchase decision.

The barriers to EMR adoption will not be overcome by the mere promise of $44,000 because the true barrier to adoption is the historically high rate of implementation failure. Physicians are rightfully gun-shy and will not be coerced into purchasing technology if that technology will not work for them, regardless of the incentive. If the government wants to stem the tide of failures and achieve its goal of increased EMR adoption, it should focus on protecting physicians from purchasing products that are not right for their practice and on making it easy for them to identify the products that are.

EMR reform would include the following three components, which I have described in detail in an EMR Straight Talk blog post, EMR Reform: A Plan to Spur Adoption:

1. Increase product quality and usability through competitive benchmarking. Give practices the tools to objectively compare efficiency and give vendors an incentive to create more usable products.
2. Provide transparency by issuing audited vendor report cards. Base the report cards on implementation success (by specialty), rather than on certification requirements.
3. Establish an EMR Lemon Law. Remove the purchase risk by allowing providers to return EMR licenses if they do not perform as promised.

EMR Reform would go a long way towards leveling the playing field and restoring the balance between vendors and physicians. This is the only way to instill physician confidence and encourage widespread adoption.

Betty Otter-Nickerson, President, Sage Healthcare

Sage is largely in agreement with the Notice for Proposed Rulemaking (NPRM) and the interim final rule (IFR) that David Blumenthal released which calls for separates testing and certification of EHR systems as reasonable first steps toward the goals outlined under HITECH.

Though some in the practice physician community feel meaningful use is just another hoop they must jump through in an effort to retrieve incentive dollars, we have been educating providers and working with them to overcome their fear and trepidation by explaining the dramatic improvement in quality of care and the enormous public health benefits that will come as a result of implementing health information technology and EHRs.

To that end, however, we continue to convey to providers that if they wait too long, they are likely to be in a situation where they will have to meet the Stage 1, 2 and 3 requirements of meaningful use in a more compressed timeframe, which could ultimately prove very challenging.

At the same time, as we have expressed in our open comments, we feel that Dr. Blumenthal should consider softening the “all or nothing” approach of the NPRM so as to encourage maximum adoption during Stage 1, and to ensure that the final rule is more easily achievable for all physicians. We are concerned that if the bar is set too high, too few physicians may attempt to achieve meaningful use. This could deter overall improvement of quality care and the public health.

Jim Bodenbender, President, RelayHealth Connectivity Solutions

The investments our country is making toward a more efficient, quality-focused healthcare system are commendable. The focus on foundational technologies is important because many of our country’s greatest healthcare assets are small, community-based private practices.These small practices are hesitant to adopt technology for a number of reasons, particularly cost, return on investment, and the vast variety of products available. Thus in order to quickly expand clinical connectivity throughout our healthcare system, we must focus on community-level interoperable connectivity.

In mid-May, you stated that “…all of our efforts must be grounded in a common foundation of standards, technical specifications and policies.” One need only look at how states are deploying HIE-targeted federal funds to agree with this statement. A “common foundation…of policies” would bring more consistency and certainty to the expansion of healthcare connectivity.

The variability among the states in supporting HIE will likely delay the anticipated benefits and, in many cases, may result in programs that will not be sustainable. The large variation of standards, technical specifications and policies ensure that a significant portion of the funds intended for HIE are used for ancillary services in an attempt to develop strategies, select solutions and provide oversight – thus slowing the expansion of clinical integration, eroding the funds available for the acquisition of technology, and thwarting the forward momentum our healthcare system is trying to achieve.

Additionally, while the secure exchange of healthcare information is imperative, we mustn’t lose sight of the fact that for information to be valuable, it must be actionable. While the ability to share and view information is helpful and will surely help reduce testing redundancies and improve a provider’s view of a patient’s total healthcare picture, making information actionable will enable the workflow and cost efficiencies – and value – that will expand provider adoption.

Throughout the entire process, the focus of connectivity efforts must remain firmly on the patient and the related benefits in doing so. One might surmise that a major reason for our healthcare systems’ current inefficiencies is that the patient is disengaged from his or her own healthcare. Putting the patient at the center of healthcare connectivity and encouraging consumer engagement into the process will assure that we can create a more effective, fiscally sustainable healthcare system.

Finally, privacy and security are imperative to the process. To ensure that we build the most securely connected system possible, we must standardize the implementation, application and enforcement of HIPAA regulations across the nation and in doing so we must give consideration to the technologies that are evolving to provide the most comprehensive capabilities to support health information exchange. Nationwide consistency with regards to HIPAA will ensure that all patients are afforded the most stringent protections available – without hindering the expansion of connectivity.

Dr. Blumenthal, you also said, “Ultimately, simple exchange will be part of a package of broader functions that allows any provider, and ultimately consumers, to exchange information over the internet, enabled by NHIN standards, services and policies.” We couldn’t agree more…and “simple exchange” will expansively occur when community-level interoperable connectivity is the focus of our efforts.

Tee Green, President and CEO, Greenway Medical Technologies, Inc.

My respectful advice for ONC Director Dr. David Blumenthal and certainly every stakeholder with a hand in the formation and evolution of Meaningful Use is to construct its future on foundations of standards-based — and therefore manageable — functionality, interoperability and reporting seen thus far with Stage 1 criteria.

What I mean by that are the foundations created and recommended by the Health Information Technology Standards Panel (HITSP) and Integrating the Healthcare Enterprise (IHE), which were largely in alignment with existing electronic health record (EHR) certification criteria and therefore existing EHR functionality.

Together these foundations can lead to an understandable and achievable Stage One setting, crystallized by the majority of thoughtful public comment and anticipated in final form in the coming month. This is the course to follow for Stages 2 and 3 as this public-private collaboration continues on its mission to improve care coordination and healthcare outcomes nationally while reducing costs and clinical errors.

It is important for administrators like Director Blumenthal to keep in the forefront of their minds that for the creation of a true national health information network, small practices critical to this venture do not have large IT budgets, layers of CIO and IT staff, and must rely on the expertise and functionality created within EHRs to meet — and be trusted to meet — the Meaningful Use functionality, interoperability and quality reporting standards.

Small practices that may not participate within an REC, for example, cannot be expected to fully write and support multiple interface expansions to keep up with unexpected or lofty criteria beyond what is presently expected. As expertise from bodies like HITSP, IHE, the National Quality Forum (NQF) and other supporting entities hopefully evolve meaningful use, Director Blumenthal should take — and I am satisfied has taken — public comment to heart and will not exorbitantly add to EHR implementation, interoperability, and support costs.

It is well understood that the future stages of Meaningful Use will heighten and advance functionality, interoperability, and reporting demands, but those steps can be equally built upon recommended standards. Unexpected deviations would cause eligible professionals and their organizations to play a costly game of catch up, which could dampen the acceptance and enthusiasm Meaningful Use is increasingly showing.

Building future Meaningful Use stages — their functionality, interoperability, and reporting criteria — on the standards-based foundations hopefully found in Stage 1 will continue to attract all stakeholders into the program.

Michael Stearns, MD, President and CEO, e-MDs, Inc.

I would suggest to Dr. Blumenthal that, if statute allows, timelines for the RECs to reach their goals be extended so that the period in which they receive the 90/10 funding does not expire prematurely.

As the Meaningful Use definitions and certification process have yet to be finalized, many providers have delayed their EHR purchasing decisions. This has the potential to create a sudden increase in the demand for EHR vendor services that could create an implementation and training backlog. The RECs are dependent upon the vendors for implementations so these delays could unfairly penalize them even if they are effective in encouraging physicians to invest in EHR software.

Peter McClennen, President, North America, dbMotion

This is a controversial position, given the amount of work to be done by many to meet the basic tenants of Meaningful Use, but I would advise him to stick to his guns. Dr. Blumenthal needs to continue to reinforce the goals of the program and the timelines for success. Many people are lobbying that the bar needs to be set significantly lower — that connected healthcare is an unrealistic goal based upon the current state of disintegration of our healthcare system. Those voices are likely to get louder as we enter the tougher years of 2013 and 2015 from the original Meaningful Use charter.

I express this opinion while having a true appreciation for the work in front of us and the stakes at hand. I know that in some cases, fiscal viability of entities will be tied to achieving Meaningful Use and that not every entity that sets out to meet the guidelines will succeed in the given timeframe. However, we cannot afford to do this twice, so we need to make sure we get the largest impact for the stimulus dollars resulting in a truly connected healthcare system.

What we need most from Dr. Blumenthal now is unwavering leadership. If we revisit the goals of the program we will create “lowest common denominator solutions” that do not result in an adequately connected healthcare system. It’s time to turn from goals to actions to achieve the goals.

Right now, it is critical to have tremendous leadership to meet the challenge. I believe stellar leadership is setting high expectations and then helping people meet them. We can help people meet them by amplifying some of the tactics used to date — highlight the winners, setup programs to knock down barriers to success and never waiver on the goals.  As we all know deep down, the time is now to get down to the hard work of connecting healthcare.

Glen Tullman, CEO, Allscripts

While I would have some personal thoughts to share with Dr. Blumenthal, I think that it would be more important in my role as chief executive officer of the nation’s largest electronic health record and practice management company to share the concerns of our 160,000 physician clients and the other healthcare providers we serve in over 800 hospitals and 9,000 post-acute organizations.

They consistently tell us three things:

FINALIZE THE IFR ASAP!

First, they want the ONC to release the Certification IFR as soon as possible. Once that is public, all of the ARRA processes can be finalized — the certification bodies can be accredited, vendors can proceed with product certification, and physicians can implement the systems. Until that is done, many physicians are simply waiting, which is exactly the opposite of the desired outcome the legislation was meant to produce.

Speed is imperative. Many physicians remain skeptical that the ARRA money will be available, and most are confused about the details of the program. If we want to prove to the skeptics that ARRA is for real and the money is flowing, then it’s critical that as many physicians as possible be ready to collect the incentives early in 2011. If enough physicians receive incentives next year, then their peers who are hesitating today will finally have the motivation to move forward. If, on the other hand, only a handful of physicians take advantage of the 2011 payout, then the whole program could be at risk and, along with it, the health of America’s patients and America’s healthcare system.

PROVIDE CLEAR DIRECTION TO RECS

Second, based on discussions I’ve had with leaders of RECs across the nation, I would say that many of them are confused about Meaningful Use, certification and the whole complex of issues associated with ARRA, as well as what programs are most effective in driving EHR adoption. As a result, there is wide disparity in the models that the different RECs are implementing.

While disparity is OK, confusion is not. The uncertainty about how they should proceed is slowing the RECs down and limiting their ability to hit the mandated guidelines in their grants. This appeared to be even more true after the meeting held for the RECs in Washington DC last week. The RECs were looking for direction and didn’t receive enough clarification. In fact, a number of them called to tell us they were instructed not to spend any money or sign any contracts yet!

Dr. Blumenthal could help by ensuring that CMS provides the RECs with clear, consistent guidelines to help clarify this program. If we are serious about providing primary care physicians across the US with help in selecting and implementing an EHR, then we had better ensure that the folks who are doing the hard work of helping them have the tools they need to succeed.

HIGHLIGHT REAL PRACTICES USING AFFORDABLE SYSTEMS

Third, and perhaps most important, our clients consistently tell us that many of the physicians, practice administrators, and others in the field that have successfully deployed electronic health records in ways that can be replicated (affordable systems that work today at small and mid-size practices and even larger groups) are not included in the process.

The ARRA program is not about Kaiser.

Kaiser was working well before the Stimulus and delivers great care; I expect it will continue to do so. But their model is not one that can be replicated or afforded by the 50 percent of physicians who work in small practices, nor those in most larger groups.

Why not ask the major vendors in the target markets (Allscripts, eClinicalWorks, NextGen and Greenway) to invite their key clients to a conference hosted by Dr. Blumenthal wherein they give their feedback and ideas? The vendors don’t have to attend. Let their most successful clients have a forum to share ideas and successes and then publicize them. Open the process up and we all win when the nation sees that the future of healthcare is already here today in our best physician practices. It’s not about software. It’s about leadership.

(See www.allscripts.com/go for hundreds of examples and best demonstrated practices of physician practices effectively deploying EHRs).

FORCE THE VENDORS TO CONNECT; PUNISH THOSE WHO DO NOT

So, that’s what our clients are saying. I will add one personal suggestion: Dr. Blumenthal should actively be meeting with all of the vendors and pushing them to interface, integrate and build the “Connected System of Health” that we all want and need.

There are still large vendors who are fighting connectivity and refusing to share patient information. This hurts patients and raises costs. Dr. Blumenthal should be actively highlighting vendors who are working together and challenging those who are not. We need to focus on delivering One Patient Record across every healthcare setting, independent of the system being used, not the outdated “everyone will use one system idea.” And we need to get there quickly.

Dr. Blumenthal has a large job and an even larger responsibility that goes beyond programs to include leadership.  We wish him success on both the program and leadership fronts and stand ready to help in any way we can.

News 5/27/10

From Anonymous: “Re: EMR bug. Major vendor releases a version of clinical software with a bug that causes patient assessment information to be saved on another patient’s chart. End users have no way of knowing which assessment is correct and/or where the lost information is located. Support comments: ‘I apologize, but … the developers did not create the utility to drill down to specifics and us at Client Support have no way of helping the client as much as we would like, to identify the correct assessment or modification. If your agency utilizes (a) warehouse, you could query the answers from the assessment. Other than that, there is no other way.’ I’m no Deborah Peel, but come on! This is scary. Have other end users experienced this sort of problem? I remember seeing something similar in an EMR 8-9 years ago, but in today’s environment, I find this shocking.”  Readers? I agree that it’s scary and we should be far better than this by now. I can hear the rants of the FDA advocates as I type.

Humana and BCBS-RI top the 2010 PayerView Rankings, an annual report that examines how well health insurers are paying physicians. The data, which is pulled from athenahealth’s athenaCollector platform, indicates insurance companies are paying physicians an average seven days faster than last year, and denying 12-18% fewer claims. Humana led in the major payer segment, though BCBS-RI was the highest ranked overall payer. The rankings are based on insurers’ financial performance, administrative performance, and transaction efficacy. Full list here.

HIT vendors continue to announce the availability of their applications on the iPad. EMR and medical transcription service provider MxSecure is the latest to jump on the iPad bandwagon, saying its MxChart EMR systems is now iPad compatible. Before long, we’ll be better off compiling lists of applications that won’t run on the iPad.

Another hot trend: vendors offering special finance programs to help providers add EHR in time to achieve Meaningful Use objectives. NextGen announces an option for new practices to signing up for EHR over the next month: deferred payments until 2011 and pay zero interest for two years.

Here is some technology all my doctors need. MedWait Time is a Web-based tool that allows patients to check to see if their doctor is behind schedule. Up to two hours before their appointment, patients can see if their doctor is running late, and if necessary, receive instructions for a new arrival time. This detail can be accessed via the Web or as a text message. The service is reasonable $50 a month, but, requires that staff manually update wait-time information. Sounds like a great marketing tool for practices.

Speaking of doctor office visits, I accompanied a family member on a visit last week and stealthily took this photo. The practice was computer-less over the weekend while their old EMR was converted to GE Centricity. Monday morning I spoke to a receptionist, who shared that things were going well, though the staff was still trying to figure out how to navigate patients’ charts.

Davis County Hospital (IA), Paynesville Area Hospital (MN), and Renville County Hospital and Clinic (MN) select McKesson’s Practice Partner Patient Records EHR and PM for their employed and affiliated physicians.

CCHIT extends 2011 Ambulatory EHR certification to a few new products, including meridianEMR version 4.2, NeoMed EHR 3.0, Nortec EHR 7.0.

A local paper reports that patient electronic medical records were temporarily unavailable at the local OSF Medical Group offices. I wonder if the general public really cares, or if it was just a slow news day? In any case, a spokesperson says no care was compromised and the cause was undetermined. OSF runs Epic.

OmniMD signs a co-branding partnership agreement with BalineMD, giving BalineMD the opportunity to market OmniMD products. Meanwhile, Tech Data Corporation signs up as the latest reseller for gloStream, a developer of  EMR and PM systems.

The 72-year old former president of American Lung Association of Washington is accused of prescription fraud and his medical license is suspended. Police say the doctor was writing prescriptions for a 22-year-old woman who was not his patient in exchange for sexual contact. Pathetically sad.

Use of EMR systems may help physicians determine if patients are filling prescriptions, according to one author of a recent Harvard Medical School study. The researchers found that at least 20% of first-time patient prescriptions were never filled, but, suggest the use of technology could improve prescription adherence.

We’ll soon be posting the latest responses to HIT Vendor Executive question. The question: If you could give David Blumenthal one piece of advice, what would it be? You can bet a few of the answers are colorful!

E-mail Inga.