News 4/28/09

From Practice management guy: "Re: pitching products in the age of ARRA. While it’s true that providers are heavily focused on EMR right now, they are also more worried than ever with declining reimbursements and the growing trend for higher deductibles and bigger co-pays. As a practice management vendor, we are seeing practices ask for for more tools to manage the patient A/R, especially on the front end. To be competitive, vendors need to have an option to verify insurance up front and on the fly. The tools must also calculate the expected patient responsible portion. Welcome to the world of consumer-driven healthcare!"

From Eve: "Re: Medzio. It’s actually A.D.A.M., Inc. (www.adam.com) who launched the Medzio Health Network and Medzio iPhone application. A.D.A.M.’s development team developed the application, built the partner network, and submitted the app for approval in App Store. The participating partners – LIVESTRONG.com, Health 2.0, HelloHealth, etc. were recruited by A.D.A.M. to build out the Medzio Health Network." Got it.

Hopefully Fujitsu’s new EMR is more user-friendly than its name. Fujitsu’s new HOPE/EGMAIN-GX V2 is the company’s latest EMR software release, presumably designed to run on Fujitsu’s mobile devices. Good luck trying to find out more information on the software because we couldn’t find any details on Fujitsu’s website, nor anywhere else (at least any places that were written in English).

In an article highlighting the use of EMR in Tennessee’s Tri-city region, the president and founder of Holston Medical Group claims EMR saves his practice saves over $800,000 a year in transcription costs. Dr. Jerry Miller led the transition to EMR 13 years ago and claims the conversion took a lot of work and expense, but was worth it.

The burnout rate among surgeons ranges from 30 to 38% and stems from such factors as enormous workloads, family life stress, and grief over unsatisfactory outcomes. Younger surgeons and female surgeons are especially at risk.

Thanks to the Internet, information on swine flu is spreading faster than the actual disease.The CDC is tweeting updates (twitter.com/cdcemergency) and posting podcasts. The WHO and HHS are also providing regular updates that include the number of confirmed cases by state. If you are a visual  person, try the Google Maps site that displays confirmed outbreaks by location. Or, if you prefer your data aggregated from multiple sources, Healthmap is your best bet.

Clearinghouse vendor Navicure releases a new software version that includes such features as denials management, aging analysis, and interactive graphs.

Forbes profiles Steve Schelhammer, a former teacher and yearbook salesman who formed disease management company Accordant Health Services, sold it for $100 million, and is now CEO of Phytel, which analyzes EMR data to find non-compliant patients and sends them messages asking them to schedule a visit. Practices pay for the service, but benefit from increased visits.

The AHRQ contracts with Rand Corporation to develop a toolset for implementing e-prescribing. The goal is to boost e-prescribing adoption rates by providing physicians a how-to guide, including advice on the most appropriate workflows.The estimated cost of the project is $120,000.

Scriptnetics, the makers of Medscribbler Open Source EMR software, has met the Microsoft Platform Test requirements for SQL Server 2005. Scriptnetics claims that Medscribbler Open Source was the first EMR to be designed for the handwriting capabilities of the Tablet PC. The software looks to be a "lite" EMR; that is, it doesn’t have all the features of a full EMR and is limited to two clinicians and two administrative people in a single practice. However, Scriptnetics also offers a "Pro" and "Enterprise" version of the software, which presumably you can upgrade to if you outgrow the free version. It’s probably not a bad model for Scriptnetics, assuming the free version is decent enough to earn a doctor’s loyalty. And, it’s likely an attractive alternative for clinicians on a shoe-string budget, especially if the top concern is automation and not necessarily qualifying for ARRA funds.

Thinking of Miami brings up images of beautiful beaches, cool architecture, exotic foods, and Medicare fraud. Case in point: a recent HHS study finds that south Florida is home to only 2% of the the nation’s Medicare beneficiaries, yet accounts for 17% of the Medicare’s total spending on inhalation drugs. The government blames fraud. Also noted in this article from the local paper is the story of a dermatologist who wrote $620,000 in false prescriptions for expensive inhalation drugs. A local pharmacy paid the doctor a $100 kickback per prescription. These are probably not the kind of things the visitor’s bureau talks much about.

SRSsoft announces that the 23-provider group OrthoNeuro (OH) is installing the SRS hybrid EMR solution. OrthoNeuro’s CEO is quoted as saying that a "CCHIT-certified EMR would drastically interfere" with their high-volume practice. SRS is taking a strong anti-CCHIT stance and it will be interesting to see how their strategy plays out. Also interesting: Evan Steele, the company’s CEO (and occasional poster to HIStalk and HIStalkPractice) recently mentioned on his blog that he has been nominated to the HIT Standards Committee, the group charged with defining the EHR certification criteria. Hope he makes it because it would be fun to see if he is able to mix things up a bit.

E-mail Inga.

News 4/23/09

MED3OOO announces that Family HealthCare Network (CA) plans to implement InteGreat EHR for 90 physicians across 11 community-based ambulatory care clinics.

Surescripts releases a report claiming that 17% of office-based prescribers are now using e-prescribing tools.This is up from 12% in 2008 and 6% in 2007. The company notes that in the first three months of 2009, active prescribers have jumped from 74,000 to 103,000. More pharmacies are also on board, with 76% of community pharmacies and six of the largest mail-order pharmacies now connected for prescription routing. Could this be a sign that we have reached the tipping point?

Eclipsys announces a new release of its PeakPractice PM/EMR aimed at ambulatory surgery centers.

Health Choice Network is implementing Sage Intergy CHC and EHR at 26 community health centers across the country.

Medzio releases a new, free mobile phone application for use on the iPhone. Features include basic first aid information, locations of the nearest medical facilities, and  interactive health information. Inga downloaded the application to her iPhone and found it to be very intuitive and easy to navigate. The first aid covers everything from spider bites to more seriously emergencies, such as heart attacks. Inga especially liked the “Sewing a wound closed” series, complete with graphics and step-by-step instructions (sure to be a big hit at her next dinner party.) She also says the application accurately located the nearest emergency medical facilities, but was disappointed that the only area pharmacies listed were the national chains. Will the tool necessarily help doctors? Not really, but it might help their patients determine what constitutes an emergency.

Nuance Communications releases the results of a study showing how real-time speech recognition software can accelerate the transition to and adoption of EHRs. Nuance, which sells the Dragon Medical software, claims that 81% of surveyed physicians say Dragon improved the quality of their notes, 81% say it reduced transcription costs, and 69% say it made EHR use faster. If you are a clinician using Dragon with your EHR, let us know if you agree with the findings.

When it comes to electronic medical records, what does the public think? A new study finds that most Americans believe EMRs would improve quality of care, reduce medical errors, and facilitate the coordination of care. However, most fear that EMRs won’t save them or the country money, and, fear for the privacy of their records. When you think about it, aren’t these findings similar to what most doctors have been saying for years? In other words, don’t most providers believe in EMRs’ potential to improve care, but don’t believe it will save them any money, and, fear patient records could be compromised?

Medical Present Value releases a combined patient estimate calculator and eligibility and benefits verification tool for physician offices.The application provides practices with real-time eligibility verification, plus determines the patient’s out-of-pocket responsibility.

Pondering: if you are a company like MPV, selling a non-clinical that does not appear to benefit from the ARRA stimulus funds, are you currently finding providers less interested in your products? In other words, are buyers primarily focused on EMR solutions, and ignoring the business side for now? At HIMSS we heard several companies making a pitch along these lines: We has a new solution to help doctors increase revenues, just in time for them to spend that extra money on EMR. Is that the right pitch?

Ordinarily, the announcement of a new billing service would not be deemed very newsworthy. However, we like the name (Dr. America Billing) almost as much as the Inga-esque Avatar logo.

The American Medical Association signs a five-year contract with Compuware Covisint to provide a Web portal for its 240,000 members.The portal will provide physicians information on various products, services, and resources for improved practice efficiency, including the adoption of HIT and EHRs. E-prescribing company DrFirst says they are the first company to announce they’re working with the AMA on the project, which is expected to launch in early 2010.

Last year almost one in every 1,000 doctors received serious disciplinary actions by state medical boards. Alaska was the top-ranking state for disciplining physicians with 6.5 actions per 1,000 doctors. That compares to the most lenient state, Minnesota, which took action on fewer than one in a thousand.

Will this Minnesota doctor be disciplined? Or simply sued? A patient has surgery to remove his appendix and is sent home. Two days later he is re-admitted after the surgeon realizes he had mistakenly removed a piece of fat instead. By the time the second surgery is performed, the appendix burst, complications ensued, and the patient remained in the hospital for 11 days.

At an age when many physicians are contemplating retirement, 65-year old Dr. Bill Haggerson of North Carolina returns to military service to care for injured American soldiers. Haggerson, who spent 20 years in the Navy, was inspired to re-up with the military after his son was deployed to Iraq in 2002. Last September he closed his private practice and spent seven months in Iraq. He is now leaving for a one year stint in Afghanistan. Definitely our nomination for Hero of the Week.

Joel Diamond 4/22/09

Why We Need Natural Language Processing

Chief Complaint: “Are my testicles black?”
Operative Note: “The patient was brought to the operating suite. She was propped and raped in the usual fashion.”

Granted, these anecdotes came from colleagues using much earlier versions of voice processing software, but they show the inherent need for voice understanding.

Oh, I forgot to tell you the actual dictation:

Chief Complaint: “Are my tests all back?”
Operative Note: “She was prepped and draped in the usual fashion.”

Most long-time EMR users will agree. For documenting the ROS and physical exam, drop-down lists and templates, particularly when the users have customized them around their own workflow, have proven to be incredible time-savers. The problem is that History of Present Illness and Assessment/Plan are best expressed using free text. Moreover, these are the most critical parts of the record, as they  reflect nuances and thought process associated with the true art of medicine. 

Since my typing skills have improved drastically, I continue to express these areas with significant detail. To me, the thought of using voice recognition software just seems like a less efficient move from dictation. I know that there are many of you out there who have enjoyed tremendous cost savings and efficiencies, particularly with the vastly improved newer versions of this technology, but I’m holding out for something better.

Natural Language Processing (NLP) is a method that transforms text into structured data.In essence, it understands text. Clearly our growing requirements for reporting and analytics will make this technology essential, yet it continues to be discussed mostly in academic circles. Significant advances have been made in this technology and I believe that incorporation would enhance EMR adoption. Without it, I worry that we will continue to add unstructured (i.e. unusable) data into the collective medical record.

I would love for other readers to comment on this subject. (Equally important: my immature and irreverent side would love to hear more anecdotal voice-processing gaffes like the ones above).

 

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

News 4/21/09

Walgreen pharmacies fill a record 3.1 million electronic prescriptions in March, which is a 211% increase over the previous year. Still, this number represents only about 15% of all eligible prescriptions.

A Colorado doctor is found guilty of practicing medicine in California without a state license after prescribing an antidepressant over the Internet to a patient who later committed suicide. The patient had completed an online questionnaire, but the two never talked directly. The doctor has been sentenced to nine months in jail. His attorney says that, “Telemedicine is now dead,” since it is not feasible for physicians to be licensed in every state. Nice grandstanding, Mr. Attorney. Perhaps the conviction was for practicing without a license, but isn’t the bigger issue that the doctor was providing inadequate patient care, presumably with limited oversight?

McKesson kicks off its 11th annual McKesson Community Days, a program to bring employees together to participate in large-scale volunteer projects. Over 14,000 McKesson volunteers are creating care packages for hospitalized veterans at VA medical centers. The packages included a hand-written note of thanks, along with a fleece blanket and personal care items. Well done.

The administrator of the 16-physician Florida Heart Associates claims its transition to EMR has been worth the effort and cost because doctors are spending less time at work and reimbursements are up. The group took 12 to 18 months to review EMR systems and spent about $600,000 initially. After a two and half year transition, the group is now paperless. The administrator estimates the group now spends $11,000 to $14,000 a year per physician for support and updates. No word on which software they use, though it was supposedly developed by cardiologists.

Lee Memorial Health System (FL) and area doctors discuss interoperability and the exchange of patient data, a conversation that will undoubtedly be repeated in medical communities across the country in coming months. Even with the potential for federal funds, some community physicians are hesitant to partner with the health system and utilize Lee Memorial’s Epic system. Others wonder how they’ll be able to tie their existing EMR with the hospital’s system and who will pay for the connection. Everyone sees the value of connecting patient data, but today most communities lack a clear plan to make it happen.

Since launching its e-Prescribe Tennessee effort in December, the Tennessee Office of e-Health Initiatives has awarded $14.6 million in grants to 1,830 Tennessee providers. The $2,500 to $3,500 grants subsidize the cost of the required e-prescribing hardware and software.

A jailed Arkansas physician accused of illegally possessing of hand grenades sues state medical board members for persecution. Dr. Randeep Mann, who names both present and former board members in the suit, claims he was persecuted over the past six years, at least in part because he is Hindu from India rather than white, Christian, and native-born. Mann has been in jail since March 6 when he was arrested on firearm charges.

Federal agents raid two Indiana medical offices and three physician homes in connection with a Medicare fraud investigation. The raids follow a lengthy HHS investigation of two doctors affiliated with Doctor’s Hospital in Bremen. The physicians are suspected of billing fraud, improper referrals, and illegal kickbacks to physicians.

Sharp Community Medical Group (SCMG) in California announces that its first physician is live on the SCMG CONNECT EHR system. SCMG is working to establish a shared, single patient record for its 600 independent primary care physicians.

Top military doctors in Iraq aren’t happy with its new tracking system for wounded soldiers. The new system, Theater Medical Data Store (TMDS) replaced Joint Patient Tracking Application (JPAT). One of the main complaints involves data loading time (a minimum of three hours to load from the field and into servers in Virginia, and then to the physicians at medical centers in Germany.) Also a concern are the multiple information links for each patient, which make easy interpretation difficult. An army vascular surgeon sounds like his civilian counterparts: “I know JPTA is dead, but our current system is not functional. As we do more with less putting the administrative burdens on the doctors is ludicrous.”

A University of Texas School of Public Health study finds that the uninsured in Harris County are visiting hospital EDs for minor illnesses less often because of improved access to primary care programs and clinics. Over a three-year period, Harris County hospitals saw a 5.5% decline in the percentage of primary care-related visits to EDs by the uninsured. Diverting these patients to clinics saves an estimated $10 million per year.

Cardiac Science Corporation completes certification to connect its HeartCentrix ECG connectivity software to the Sage Intergy EHR.

The FTC issues a proposed rule requiring PHR vendors and related entities to notify consumers when their identifiable health data has been breached. Public comment is open until June 1.

The Vermont legislature explores the use of smart cards for health insurance, medical billing, and EMRs.

A Chinese man accidentally swallows a pair of nail scissors he was using as a toothpick. Doctors surgically removed the scissors, which had entered the man’s esophagus. If this had happened in America, you know this guy would have been asked to be the next spokesperson for Oral-B toothbrushes.

E-mail Inga.

Intelligent Healthcare Information Integration 4/17/09

Two Thirds of the NHIN by 2010 (or, Not Your Daddy’s CHIN)

The Nationwide Health Information Network. By 2014. That’s the timeframe we’ve all heard about since GWB, Michael Leavitt, David Brailer, et al, began the ball rolling from a governmental initiative perspective about five years ago. So, half the time has passed and we’re halfway there, right?

OK, it seems Sisyphus had an easier time reaching the mountaintop with his boulder than we’re having with this NHIN rock. It has been more than 25 years since some pretty smart people saw the advantages of using electronic brains to assist with the collection, manipulation, and dissemination of healthcare information. Yes, we have seen the pioneers and the early adopters join in the uphill shove, but we are currently so far away from any sort of national healthcare data sharing that it is almost comical. (Have you ever tried to aggregate old records for a patient who has seen three doctors, two ERs, an urgent care, and a couple of health departments in the past few years?)

So, on to Step 3 of the “Official Grunt-in-the-Trenches Complete U.S. Healthcare System Overhaul and National Health Information Network in Five Easy Steps Disruptive Innovation Package.”

Is it really possible to achieve 70% of the NHIN by 2010? (Well, maybe 2011, but NHIN and 2010 have a better rhythm!)

Yes. Period.

I know, I know. Many with far bigger brains than my little peanut tell us the interoperability difficulties, the interfaces required, the rules, and the regulations are almost insurmountable with our current systems. And, maybe … maybe they are correct. With “our current systems” maybe there is no hope. But, have you ever noticed how many times throughout history that the prominent intelligentsia got it wrong? Have you noticed how many times those who discuss why things can’t be achieved are eclipsed in the historical record by those who say, “Why not?”

Well, here goes my next shot at “Why not?” and – hey, it could happen – a historical footnote. (For the first shot, see Step 2.)

We have been focused upon building these big center systems – the RHIOs, HIEs, and their ilk – and then figuring out how to connect all these silos, these disparate giant Sequoias of information. Well, first, did I miss something? Don’t we have connectivity? Doesn’t this massive information exchange system already exist as a little thing called the Internet? (Internets, according to some.) So, if you and I can exchange information – as we are right now, regardless of where you are – how is it that we need these massive health information exchange projects to send data across town? Is health information somehow different? Does the exchange of health data involve some unique form of electrons or a specialized set of zeroes and ones compared to lay data? Doesn’t seem to be a problem for first cousin Finance.

Why not…consider a different approach to both linking healthcare professionals and motivating participation in the Grand Healthcare Digitization Project, participation of both providers and the general population? Does the fact that we have already invested oodles of money in current projects preclude the thought trail which veers sharply away from the current, overly beaten track?

Why not … convince health systems and providers to understand that patient health data is not “owned” by anyone except the patient, that sharing that info is not counterproductive to corporate profits but rather contributive, once all are duly linked?

Why not … start building a system less filled with silos, less federated, and begin endorsing truly integrative designs, designs which take advantage of the connectivity we already have and utilize that connectivity to motivate usage?

What I’m saying is, there are certain systems and/or design elements already available which could integrate and inspire usage and adoption of both providers and public. We are not focusing upon them, at least in part, because of earlier (and some current) failures of integrative-type systems. (CHINs, RHIOs, etc.) Regrettably, those systems had some grossly neglectful design flaws: they were built upon financially unsustainable models and/or they did not take basic human motivations into sufficient consideration.

Here’s the skinny on attaining 60-70% of the NHIN (OK, it’s a somewhat chubby skinny):

a) Small communities and their associated small community hospitals serve an estimated 60-70% of the U.S. population. (See where this is going?)

b) Let’s utilize the power of “community,” a strong force within small towns, to help inspire adoption and conquer the learning curve necessary for this “paradigm shift.” (Sorry…I hate such corporate-speak clichés, too.) Enabled consumers and ancillary medical services providers – EMS, police, fire, sheriffs, home health, hospice, health departments, school nurses, etc. – will entice physicians to adoption by their creation of a need to which the docs can respond, this response being something of a forté for most clinicians. (Commercials with the local fire chief and Little Timmy or Grandma Gertie, who were saved because emergency responders had access to important health data at critical moments will drive digital participation far more than, “Look, see how many demographic or health history boxes we have for you to fill out.” Enabled patients will begin to ply their caregivers for participation with community-based digital care basics.)

c) The “Promised Land” of EHR/PHR use involves all of the tremendous information, subsequent insights, availability, and integration said info will provide. But, we delay our journey by focusing upon all of the wonders to come. Small bites, small sips – that is what consumers and physicians need to start along the path out of the Paper-filled Desert. Don’t blind them with the overwhelming roar of the “Voice of the ‘Almighty’ EHR.”Rather, allow all us Moseses to hear the Word and feed the people those portions which they can tolerate as we attempt to lead them out of the paper-filled desert. (Read this as: Institute small, valuable tools in modular form that can provide immediate, real life value and then build upon this foundation with additional modules providing increasing value in tolerable, stepped progressions.)

d) Using the tools mentioned in Step 2 – an end user-friendly system with simple, familiar tools and goops of support and education, along with an open, but secure, design that is inclusive (read: non-proprietary or, at the very least, one that works and plays well with others) – we establish a local non-profit governance organization to oversee and insure local concerns. (A for-profit corporation to help establish and support these local 501(c)3s would likely be more fleet-footed than a governmental oversight org.

e) Within each community, while we enable bridging the digital divide in these typically less technologically advanced populations, we would create a minimum of 10 to 20 new jobs (20 X 2,000 = 40,000 new jobs) for support and education services. We would also enable small hospitals to retain employees, a current, major challenge. (Our local hospital recently had to let 50 people go: 50 X 2,000 = a possible 100,000 jobs saved.)

f) Utilizing a combination of tools, such as the Health Record Bank, so pleasantly detailed at HIMSS by Drs. Deborah Peel and Bill Yasnoff, along with the Integrated Health Record (IHR,) as discussed in Step 2, we could create a patient-centric, patient-controlled, community-driven healthcare model which, with one of the available integration/exchange engines – for instance Medicity’s Care Collaboration Platform – would allow for a truly inclusive, integrated healthcare community system. All could participate, including new and legacy systems.

g) Such community systems, based upon designs specifically for small communities, would not provide Mayo-esque, Rolls Royce-type digital healthcare magic. They would, nonetheless, provide what small communities actually need: the initial Honda Civic version that may have few bells or whistles but can get us from paper (here) to electronic (there) healthcare – or at least down the first part of the journey. Once small communities have given up their horse-and-buggy (paper full) systems, they will be able to actually share basic healthcare data seamlessly, as their systems’ similarities will allow such sharing, and we can add new modular enhancements as people become more and more comfortable with their new mode of healthcare data transportation (less paper.)

h) Small communities rarely have competing hospitals. Sharing data between such communities would not engage the “it’s my data, you can’t have it” seen within larger centers. With appropriate consent and protections, sharing across the biggest HIE pipeline (the Internet) between small communities would only boost information access, enable less costly care provision, and promote small center usage by consumers who can receive higher quality care closer to home.

To recap (i.e., the skinny skinny):

• Most folks get care outside of giant centers in small communities and their associated community hospitals (60-70% of NHIN)
• Design specifically for small communities (i.e., no ill-fitting trickle down)
• Graduated, modular development (no “drink from the fire hose”)
• Immediate, real world value to inspire participation (school & home health & nursing home & hospice telemedicine services, care reminder services, real “saved lives” via first responders now)
• Patient-centric, community-driven (LOADS of support/education, opt-in only, local governance)
• Community to community connectivity with Aspen-like interrelatedness (compared to our current siloed Sequoia-like systems)
• User-friendly, customizable, intuitive, simple, familiar tools (think cell phone apps, JAVA, Flash, video, “fun” elements, community kiosks, local education sessions by locals, door-to-door help and support)
• Utilize “natural human motivations” to inspire co-adoption and conquer learning curves (en masse, in community, we are more inspired, more driven)

I promised at least a Tweet about funding and sustainability. So…

Funding? – Obama.

Sustainability? – A permanent Obama aristocracy.

Seriously, yes, we could certainly receive a tremendous bang for a chunk of the Obama bucks. (60-70% of the NHIN using less than 1/3 of the ~$38 billion already planned – e.g., projected costs are far less than 5 million per community X 2,000 communities = <10 billion) Anybody else know of a system or design which could attain two thirds of the NHIN for such a bargain basement, fire sale price?

Sustainability must be derived from a variety, a community, of sources. Just as the community can help drive adoption, so, too, can the community model drive a diversity of ongoing income sources. Besides having EHR vendors pony up some of the development costs for products destined to enhance their ongoing revenue streams, others should participate in supporting this communal sandbox: local employers, local hospitals and physicians via savings and enhanced earnings, HRB service fees, community-based grants via the aforementioned local non-profit, insurance company rebates and support, local levies, and, of course, the traditional small town bake sales and fish fries. Yes, yes, just kidding on those last two, but the point is, with a coordinated effort and a seriously detailed plan, sustainability can be obtained using the same community-based mindset. (It is difficult to detail this adequately within the constraints of a blog…er…”News & Opinion” site. No dis intended, Mr. H!)

Finally, the runway model skinny:

• Start with the basics in small test tube environs, provide adequate growth media, let the system grow along natural growth lines, allow Aspen-like spread and interrelatedness (maybe we should call the system, Pando?) deriving scale via reproducibility, and “allow” all of the beneficiaries to feed and water it ongoing.

As I said, I know there are many really smart people out there who are going to point out the bazillion reasons why this can’t work. Personally, I’ve never found intelligence to be a substitute for initiative. Those who depend upon nay-saying and “why you can’ts” tend only to limit; I more prefer to heed the call of the “Why Nots.”

Still to come:

Step 4: Equalizing the Playing Field (“Open” is not a Four Letter Word; Systems That’d Suit)
Step 5: Verdant Health (Lush, Full, Eco-friendly, Yet More Jobs – “Green” in Every Sense)

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 through http://madisonpediatric.com or doc@madisonpediatric.com.