DOCtalk with Dr. Gregg 2/2/15

HIE: Finding Successes

Health information exchange (HIE) is the Holy Grail for all that is HIT. All the EHRs and self-monitoring devices and big data collection tools in the world really come to nothing if we don’t have sharing of this digitally collected data, right? What good is EHR data without data sharing? Isn’t that essentially the same as what we had before – offices and institutions filled with paper charts chock full of data with which nobody could do much of anything because it was in a gazillion different silos that had no significant interconnectivity?

To be sure, EHRs and Fitbits and other data collection tools are just as essential as the data exchange, for without them there’d be no data to be shared. But, health data collection and its sharing are like the two sides of a single coin. And a coin with but one side is just a slug.

The real purpose of Meaningful Use, Regional Extension Centers, and all that associated jazz was to drive forward a foundation upon which to build, to cast the first side of the coin, to lay the framework for the next step. That next step is the flip side of the coin, the interchange of all that collected data … sharing … true health information exchange.

Unfortunately, many of the public and semi-public HIEs, especially the broad-based and/or statewide HIE systems that were begun across the country to share said data are failing, and failing hard. (This generally excludes private HIEs created by hospitals or localized health systems that are mostly doing OK because their reason for existence is built upon a localized need and unique business model.) Without continuing grant dollars to support the public/semi-public HIEs’ less-than-capitalistic business models, many are taking a nosedive, likely into oblivion.

And, to be honest, that was the intention.

No, the intention wasn’t to create a bunch of money-sucking, doomed-to-fail exchanges. The intent was to create the growth medium, a nationwide test bed if you will, for deriving a few winners, a few flowering models of success among the weeds of failure. At least that’s what I was told back in the early days of HITECH and RECs and MU by one of those so-called “highly placed governmental sources.” He (or she) said that the feds knew that many a Regional Extension Center and/or HIE would essentially fail, that most would survive only as long as the soft money lasted. They knew that they were generating a bunch of loss leaders, so to speak, but also knew – or at least hoped – that a few successes would blossom. The goal was to create a sufficiently fertilized environ to generate a few winners, a few role models that could hopefully be cloned and replanted atop the tilled-under graves of those expected-to-die organizations. (Personally, I can’t verify the truth of that thought process or say whether those intentions were ever spoken openly amongst the feds, but it does seem fitting with what has transpired since.)

If that broad “test bed” model was in fact true, it’s those successes it engendered upon which the whole future of HIE depends. If those so-far-proven models continue to thrive, and if they can be extended or replicated across the rest of the country, and if they can execute successful inter-HIE connectivity just as successfully as they did within their own intra-HIE networks, then a true national “Holy Grail” health information exchange might be realized.

Healthcare Informatics recently ran a piece entitled “Top Ten Tech Trends: "Survivor: Edition HIE"– Can Statewide HIEs Achieve Sustainability?” that briefly discussed a few of the successful HIEs – those in Colorado, Maine, Michigan, and Ohio. To get a flavor of the blossoms that are growing from the federal HIE garden, it’s worth the read. (Full disclosure: I’m on the board for the Ohio HIE, Clinisync. Also, the article quotes Clinisync’s CEO, Dan Paoletti, a friend and one of the finest human beings I’ve ever known, so I’m probably biased in my recommendation of this read.)

Who knows what the final nationwide HIE will eventually look like? But, it is coming. Many might say it’s premature, but I believe the tipping point has passed and we’re now on the uninterruptible path toward true and total health information exchange. It may seem like it is a ways off, but I’m betting the Holy Grail is closer than most people think.

From the trenches…

“If you have no critics, you’ll likely have no success.” – Malcolm X

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership.

Contacts

Jennifer,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

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News 1/29/15

Top News

CVS Health announces clinical affiliations with the LSU Health Network (LA) and Shawnee Mission Health (KS). LSU and Shawnee patients will have access to clinical support, medication counseling, chronic-disease monitoring, and wellness programs at CVS/pharmacy stores and MinuteClinics. CVS Health, in turn, will provide prescription and visit data to the health systems via EHR and information systems integration. In addition, physicians affiliated with the participating health systems will collaborate with MinuteClinic nurse practitioners to work closely on joint clinical programs and care coordination activities.

HIStalk Practice Announcements and Requests

Several HIStalk team members have enjoyed sunny skies for most of this week, while others have experienced the hopefully waning Northeastern blizzards first-hand. No matter the conditions, the HIStalk sites continue to publish faithfully, knowing that many of our readers are working tirelessly from home even though their offices may officially be closed. It strikes me as a bit sad that today’s workforce no longer has the luxury of taking adult snow days. Jesse Singal of New York Magazine explains his snow-day discontent rather eloquently: “In a world that forces us to inhabit our roles as workers ever more intimately — one in which time actually off from work has been shrinking for decades, where it’s easy to forget that there’s more to life than what it says on our business cards — snow days were one of the few remaining excuses not to be a worker for a little while. I’m going to miss them, even if I haven’t really had much time to think about it.”

Announcements and Implementations

Atlanta-based Premedex launches its Chronic Care Management Solution Suite to help physician practices more efficiently manage the operational and financial tasks associated with caring for patients with chronic diseases.

Quest Diagnostics partners with the CDC to improve hepatitis diagnosis and treatment. As part of the collaboration, Quest will provide CDC researchers with access to its Health Trends database of de-identified clinical testing hepatitis data. A primary goal will be to identify and monitor trends in hepatitis B and C viral infection in pregnant women, and to characterize those patients by demographics and type of physician.

PatientPoint partners with Ion Solutions to offer its PracticeWire and Exam Room Tablet education and engagement solutions to Ion’s national network of oncology practices.

Eastern Idaho IPA chooses Valence Health’s vElect contract administration system to allow physicians to compare fee schedules to Medicare benchmarks in selecting and declining payer contracts.

MedConnect selects clinical interface terminology from Intelligent Medical Objects for its EHR.

Georgia’s GRAChie HIE – founded by Cerner, GRHealth, and Navicent Health — reports increased numbers of data sources and system usage.

The Apple Watch will begin shipping in April, perhaps just in time for HIMSS giveaways. It will be interesting to see how many Apple fans pony up $349 for the privilege of standing in line at Apple stores on the as-yet-unspecified date. Surely it won’t be on April 15.

Acquisitions, Funding, Business, and Stock

Portland, OR-based Clinicient secures $7 million in debt funding from Silicon Valley Bank. The line of working capital will be used to enhance its EHR, PM, and revenue cycle solutions for outpatient rehabilitation therapists.

Government and Politics

New CMS data reveal that only 15 percent of eligible providers have attested for Meaningful Use Stage 2. Of those, 47 percent did not actually meet Stage 2 in 2014, but instead took advantage of a hardship exemption and attested to Stage 1. The majority of that group used EHRs certified in 2011, while 28 percent used 2014-certified EHR technology.

Health insurance exchange enrollees total 9.5 million, a good bit above the administration’s hoped-for goal of 9.1 million. That number still has opportunity to climb with 18 more days to go until the February 15 enrollment deadline. Florida and California have led the pack, with a total of 2.5 million citizens enrolled.

Speaking of government services, the American Customer Satisfaction Index shows that the nation’s satisfaction with federal government services continues to decline. This year’s score of 64.4 is the lowest it’s been since the Index was first published in 1999. HHS had its second consecutive decline in citizen satisfaction, falling from 69 in 2012 to 62 in 2014. Only Internet service providers scored lower than the government when compared to other verticals.

Other

Good news for quantified selfers, and telehealth and wearables fans in the Southeast: Google Fiber is coming to Atlanta, Nashville, Charlotte, and Raleigh-Durham within the next 18 months. They are among the nine cities Google announced nearly a year ago as being considered for the gigabit fiber-to-the-home service. It’s worth noting that Georgia and Tennessee have legislated parity for private coverage of telemedicine services, according to the American Telemedicine Association, while North Carolina doesn’t seem to have taken up the issue.

The local paper highlights Avhana Health, a Baltimore-based startup focused on building a better electronic checklist for physicians. After graduating from the DreamIt Health Incubator last year, the company went on to work with the HHS Office of Population Affairs testing integration standards. It’s now looking to test its system with physicians.

Fast Company sheds light on the intersection of corporate wellness programs and precision medicine, ultimately concluding that targeted initiatives fueled by analytics are the key to creating healthier employees and reducing corporate healthcare expenses.

Sponsor Updates

• Clockwise.MD is nominated as a finalist in the inaugural Georgia’s Top Startup Awards.
• Jaffer Traish of Culbert Healthcare Solutions writes about data sharing.

Contacts

Jennifer,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

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News 1/27/15

Top News

HHS Secretary Sylvia Burwell unveils a new plan and timeline for moving healthcare providers from a fee-for-service model to a value-based reimbursement model. Goals include getting 50 percent of all Medicare provider payments switched over to alternative payment models by 2018, and for nearly all Medicare fee-for-service payments to be tied to quality and value by the same year. Burwell also announced the formation of the Health Care Payment Learning & Action Network, calling on providers, consumers, employers, payers, industry, and other government agencies to help HHS keep to its aggressive timelines.

Acquisitions, Funding, Business, and Stocks

New Jersey-based MaxMD receives clearance from the Minnesota Department of Health to operate as a Health Data Intermediary in the state, meaning that providers there now have access to its Direct Messaging services. (On a whim, I looked up Minnesota’s state motto. “L’etoile du Nord” dates back to 1861, though “the Land of 10,000 Lakes” is far more well known.)

This article digs into telemedicine company Doctor on Demand’s revenue model, breaking down the cut it takes from patient fees and employer utilization. The San Francisco-based company also brings in revenue from its white-label offering for health systems. Given that it raised $21 million late last year, I’ll be interested to see how its MGMA booth compares to its HIMSS booth.

Emdeon is considering an IPO, sources say. The earnings multiples of recent sector deals suggest a valuation of $5.4 to $6.6 billion, which would create huge profits for the two private equity firms that took Emdeon private in 2011 for $3 billion.

The local business paper profiles the healthcare technology investment plans of GE Ventures, which has 17 healthcare-related companies in its portfolio. The firm typically invests in five HIT companies each year, to the tune of between $3 million and $8 million apiece. “The sort of companies we’re looking for are divided into three verticals across health care,” explains Alex de Winter, director, “Minimally invasive medical devices, healthcare IT and services and precision medicine, which got a shoutout from Obama, clinical diagnostics, and life sciences instrumentation.”

Announcements and Implementations

Three-hundred fifty Kaiser Permanente ambulatory clinics receive the Stage 7 Ambulatory Award from HIMSS Analytics. The award recognizes the organization’s use of its HealthConnect EHR, the largest non-governmental EHR in the world.

Florida Cancer Specialists & Research Institute selects Athenahealth’s revenue cycle and PM services as part of a pilot program in which the new technology will be rolled out in phases to 300 providers.

Community Eye Center Optometry (CA) selects the VersaSuite EHR and PM system.

EHNAC announces new versions of criteria for 15 accreditation programs. Applicant candidates beginning the accreditation process in this year will adhere to the updated criteria versions for accreditation and/or re-accreditation.

Government and Politics

CMS adds star ratings to its Dialysis Facility Compare website. The annually updated ratings summarize performance and quality, joining similar rating systems used for Physician Compare and Nursing Home Compare.

Telehealth already seems to be the healthcare business buzzword of 2015, and we’re only 27 days in. The Federation of State Medical Boards launches LicensePortability.org to track the progress of the Interstate Medical Licensure Compact in state legislatures. (Nine states have already introduced it this year.) Originally introduced in September 2014, the compact proposes legislation that would speed up the process of issuing licenses for physicians who wish to practice in multiple states, in turn making it significantly easier for telemedicine companies to operate to their fullest potential.

Teladoc continues to make news as its services get shut out of Texas and Arkansas due to medical board concerns over patient-physician relationships. The company, based in Dallas of all places, went so far as to sue the Texas Medical Board (for the second time) for its declaration earlier this month of an emergency rule requiring physicians to meet patients "face-to-face" before prescribing them a controlled drug. “There is no imminent peril,” the company’s complaint states. “There is no emergency. There is only a state agency ignoring its legal limitations in a blatant attempt to get its way.” Teladoc does not operate in Idaho for similar reasons.

The state of Colorado’s House Health, Insurance, and Environment Committee approves a bill that would expand the use of telemedicine across the state. If approved, the bill would prevent payers from requiring in-person care if consulting, monitoring, and other care could be as effectively administered at a distance.

HRSA Administrator Mary Wakefield, RN tours the South Dakota facilities of telemedicine network Avera, which provides remote care to rural populations via its growing e-Care network. “We have so many parts of the United States that are under served,” explains Wakefield, “that are what we call health profession shortage areas. [Avera e-Care] is, over time, part of the solution I think to that problem.”

HHS reduces the outbound flow of personal consumer data from Healthcare.gov to third-party sites, caving to public outcry over the revelation that the exchange was delivering personal registrant details including age, ZIP code, and income to websites related to advertising, and data mining for marketing and performance metrics. The agency had previously contended that the outside companies used the data only to analyze and improve Healthcare.gov.

Research and Innovation

The American Society of Clinical Oncology partners with SAP to develop CancerLinQ, a computer network that will help cancer doctors make treatment decisions for their patients based on the outcomes of comparable patients. ASCO expects to roll the first version of CancerLinQ out by the end of 2015 to 15 oncology practices that are contributing half a million patient records to the big data project.

This article highlights the parameters the VA has set around its two-year, $16 million Watson pilot project. They include initially operating in a safe-harbor environment where simulated patient encounters will be run using real clinical data, assessing the ability of the system to perform clinical semantic searches of the EHR and clinical literature, and assessing its ability to generate problem lists from the EHR.

Other

Silicon Valley-based Doximity launches an interactive map highlighting physician compensation trends and salaries across 48 specialties, plus potential career opportunities in rural areas with shortages. Dr. Jayne, who seems to be considering career options at the moment, may want to think about going rural: Doximity data indicates that physicians in rural areas see an average of $1,500 more in salary each year compared to those in urban areas.

Those interested in historical clinical career data may want to check out ONC’s updated Health IT Dashboard, which now includes state and county estimates for the number of MDs, PCPs, NPs, and PAs from 2011 to 2013.

Sponsor Updates

• Healthwise wins gold and silver Web Health Awards for its health education videos.
• E-MDs CEO David Winn pens a new article entitled, “Time to Let the Air Out of the Tires on ICD-10.”

Contacts

Jennifer,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

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Readers Write: Good News, Physicians. Patients Do Want to Access Online Portals

Good News, Physicians: Patients Do Want to Access Online Portals
by Tamara St. Claire

Americans are generally interested in participating in online patient portals. In Xerox’s annual survey on the usage of EHRs, more than half of respondents who don’t already use portals (57 percent), said they would be more interested and proactive in their personal healthcare if they had online access to their medical records. I personally love using the portal provided by my doctor, particularly to view test results without scheduling another in-person appointment.

This motivation is good news for providers, many of whom are working on the Meaningful Use Stage 2 view, download, and transmit requirement. Aside from MUS2, there are many benefits to patient engagement that help providers as they strive to deliver quality care in a patient-centric healthcare system.

Many patients simply aren’t hearing from their physicians about the option to access portals. Thirty five percent of Americans surveyed said they were unaware that they existed. Another 31 percent said their physician had never spoken to them about patient portals. When we look at some of the best practices out there, we see that having that conversation multiple times along the patient’s path through the office is most effective. People view the physician as the trusted voice, so it’s really important for physicians to engage in that conversation in the exam room.

However, the survey also highlighted patient preferences that were somewhat divided along generational lines, with Millennials and Baby Boomers reporting different ideas about what they like to see and do when it comes to online engagement. Personalizing the discussion is key to helping providers overcome engagement challenges and increasing patient engagement long term.

For example, our survey found that Baby Boomers are really interested in using portals on a transactional basis. For them, the utility of a patient portal is about efficiency. They want to be able to schedule appointments, view test results, ask questions, and order refills. Providers can motivate Boomers to use a portal to get answers to questions more quickly, and order refills – without ever picking up the phone.

On the other hand, we found that Millennials want to see information and resources in a portal that are individualized for them. Forty four percent of patients aged 18 to 34 said they wanted to view tailored recommendations or learn more about other services their healthcare provider has available. They also prefer the convenience of doing so on a mobile device. Therefore, engaging Millennials is about providing them with an individualized experience that suits their lifestyle, whether that’s through smartphones, tablets, or other devices.

This year, providers seeking MUS2 will be required to succeed during a full, 365-day MU reporting period, compared to just a 90-day reporting period in 2014. Patient engagement must be a top priority for providers – both for this reason, and because a knowledgeable and active patient is ultimately a healthier patient, demonstrated by the fact that 59 percent of respondents who already are using portals feel they are now more interested and proactive in their personal healthcare.

Tamara St. Claire is Chief Innovation Officer of Xerox Commercial Healthcare of Norwalk, CT.

Contacts

Jennifer,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

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News 1/22/15

Top News

A group of 35 industry associations including CHIME, the AMA, AAFP, and MGMA urge ONC National Coordinator Karen DeSalvo, MD to make the following changes to EHR certification in a bid for improved patient safety:

1. Decouple EHR certification from the Meaningful Use program;
2. Re-consider alternative software testing methods;
3. Establish greater transparency and uniformity on UCD testing and process results;
4. Incorporate exception handling into EHR certification;
5. Develop C-CDA guidance and tests to support exchange;
6. Seek further stakeholder feedback; and
7. Increase education on EHR implementation

The authors explain that, “We believe the Meaningful Use certification requirements are contributing to EHR system problems, and we are worried about the downstream effects on patient safety. Physician informaticists and vendors have reported to us that MU certification has become the priority in health information technology design at the expense of meeting physician customers’ needs, patient safety, and product innovation.”

Announcements and Implementations

Missouri Health Connection receives a $375,000 grant from the Healthcare Foundation of Greater Kansas City to connect EHRs at Swope Health Services, Samuel U. Rodgers Health Center, and KC Care Clinic to the Missouri HIE. Additional funding from St. Luke’s Health System (MO and KS) will be used for EHR upgrades, which will affect 68,000 patients at 17 clinics.

Non-profit community healthcare provider ARcare installs i2iTracks, a population health management and analytics product from i2i systems, at 37 facilities. ARcare received the HIMSS Analytics Stage 7 Ambulatory Award last summer. I had the opportunity to interview ARcare CIO Greg Wolverton shortly thereafter.

Akasha Center for Integrative Medicine (CA) selects Open Source Health Inc., which provides digital patient engagement solutions for women, to advise it on the development of a cloud-based EHR for integrative health and personalized medicine. (If you need to take a break from the hustle and bustle of healthcare IT for a few minutes, check out the Akasha website, which plays extremely soothing sounds of nature upon opening.) 

ExamMed launches a healthcare technology platform that includes video, EHR, patient portal, “smart” coding, and physician network and referrals. The new tool also includes MedCoins, which act as forms of credit patients can put towards services or gift to family members.

Custom PC Programming’s DoseTracer inventory and payment tracking software for pharmaceuticals joins the Greenway Health Marketplace.

Zotec Partners introduces ZARi, a new analytical reporting interface for radiologists.

GE Healthcare and NextGen earn EHNAC’s first practice management system accreditation.

Acquisitions, Funding, Business, and Stock

Medical diagnostic device company Welch Allyn acquires Hubble Telemedical, which specializes in remote diabetic retinopathy screening and analysis in primary care settings. The deal is the second acquisition in six weeks for Welch Allyn, which acquired remote vital-signs monitoring company HealthInterlink late last year.

Smart jewelry startup Ringly raises $5.1 million in Series A funding led by Adreessen Horowitz, bringing its total funding to $6.1 million. While the investment probably won’t affect product development in time for this Valentine’s Day (it’s still working to fill pre-orders from Christmas), the company does plan to use it to add new features to its collection, build partnerships with fashion brands and designers, and hire additional staff for its New York City office. 

Kaiser Permanente becomes the “Official Health Care Partner” of the NBA, WNBA, NBA D-League, and USA Basketball. It is the provider’s first national partnership with a professional sports league. Through the partnership, Kaiser and the NBA will conduct 14 community health and wellness events in NBA markets, as well as an annual Health and Wellness Forum.

Government and Politics

Media reports suggest that ONC National Coordinator Karen DeSalvo, MD has appointed board certified Ob/Gyn Michael James McCoy, MD as its first chief health information officer, effective January 26. As CHIO, McCoy will develop clinical policy and serve as the department’s leading expert on interoperability. He will report directly to DeSalvo. His ties to Atlanta, Georgia (recently voted by HIStalk readers as the nation’s capital of healthcare IT) run deep. He received his degrees from Georgia State University and the Medical College of Georgia, and worked in various physician leadership roles at healthcare facilities in Gwinnett County. His vendor experience includes executive positions at Allscripts, Xerox, Physician Technology Services, and digiChart.

The Pew Charitable Trusts, Geisinger Health System (PA), Intermountain Healthcare (UT), The Leapfrog Group, and seven other industry organizations write to HHS Secretary Sylvia Burwell strongly urging the government to mandate a field for unique identification numbers of medical devices in EHRs so that they can be better tracked and recalled. They believe this objective will support Meaningful Use Stage 3 priorities including better clinical decision support, care coordination, and patient engagement.

The local paper covers the Texas Department of Criminal Justice’s use of telemedicine within its prison system to curb healthcare costs, which have climbed steeply in the last several years due to the state’s aging inmate population. While telemedicine has saved the department $780 million from 1994 to 2008, it does have its detractors. “I see the potential for danger where, for example, psychiatric care is not given in person and a doctor doesn’t see the cuts on the person’s arm and the next day they commit suicide,” says Wayne Yang with the Texas Civil Rights Project. “Telehealth could save money, but it could hurt health care.”

The White House releases details on the new precision medicine program President Obama announced during his State of the Union Address. The program will work to individualize treatment plans through advances in genetic research, medical imaging, and health information technology.

Research and Innovation

Mobile health service HealthTap releases its first report ranking apps by physician recommendations. The report includes apps in 30 health categories such as pregnancy, heart health, and weight loss. Top apps include Fooducate (I can vouch for this as being great if you are just starting to pay attention to nutrition labels.), Glucose Buddy, First Aid – American Red Cross, Sleep Cycle Alarm Clock, and Stroke Riskometer.

An American Well survey conducted by Harris Corp. finds that 64 percent of respondents are willing to have virtual visits via telemedicine, with slightly fewer indicating virtual visits should cost less than in-office visits. The majority of the 2,019 consumers surveyed chose video as their preferred method of telemedicine. While these sorts of surveys tend to be fairly self-serving, it’s worth noting that 70 percent would rather have an online video visit than an in-office visit to obtain primary care prescriptions – yet another indication that the primary care business model will have to change to meet consumer demands for convenience, access, and affordability.

Other

The American Telemedicine Association seeks nominations for its annual President’s Awards for the Advancement of Telemedicine. Nominations are due February 15. Winners in three categories – Health Delivery Quality and Innovation, Leadership, and Remote Health Care – will be presented at ATA’s annual meeting in May.

Cerner will co-host a virtual career fair with the VFW February 18 from 10 a.m. to 3 p.m. CT. to connect service members and their family members with job openings at the company. Veterans can qualify for such positions as system engineer, technical support analyst, implementation consultant, nurse, and a variety of operational roles. They can even use the online military decoder tool at Cerner’s website to match their enlisted position with suggested roles within the company. Cerner is also working to help modernize the VFW’s IT infrastructure, and evaluate the creation of a patient portal for VFW members.

A North Carolina OB-GYN says physicians should use computers and not vice-versa, urging his peers to look at the patient instead of the screen. “The folks who sold us these systems talked about all the wonderful things EMR can do … One might assume the EMR would excise the tumor, lower the blood glucose and stop the hallucinations. The problem is that the EMR really should not ‘do’ anything. Patients tell us their concerns. Practitioners do their best to listen and perform the appropriate evaluation, with or without technology … everything we need to know about our patients is in their face, in their voice, and in their eyes.”

Sponsor Updates

• ADP AdvancedMD offers tips on leveraging practice data to view key performance indicators in a new blog.
• ABCNews.com lists Clockwise.md amongst other companies making a name for themselves developing online booking software.

Contacts

Jennifer,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

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