Joel Diamond 1/14/09

I love the pick-up line from The Wedding Crashers: "Some people say that we only use 15% of our brains. I say that we only use 15% of our hearts." Interacting with many of my colleagues who have adopted an EMR in their practices, it seems that most of them use only 15% of what should be the system’s capabilities.   

I recently asked a friend of mind why he hasn’t utilized many cool features like e-prescribing and a patient portal. He sheepishly answered, "To tell you the truth, I am just too damn busy. I wish that there could be some way that this technology would just make me feel like I was making a bigger difference in people’s lives and let me spend more quality time with patients."

With this in mind, I read last week’s National Research Council on Healthcare IT report with keen interest (BTW, Mr. HIStalk did a great job of summarizing the report).

The council’s esteemed panel recommended to "organize incentives, roles, workflow, processes and supporting infrastructure to support and respond to opportunities for clinical performance gains. Focus on identifying, prioritizing and managing changes in process and workflow."

Wow … that is so much more impressive than my friend’s quote!

I hope they didn’t spend too much money concluding what every front-line practitioner considers obvious. Let’s face it, most physicians are tremendously dedicated and work long hours. Any down time is spent squeezing precious extra minutes with patients, following up on tests, and calling families. Occasionally, there is even time to do preventive health.

To be fair, I would say that the technical accomplishments to date represent 15% of our needs. Let’s start working on the other 85%.

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

News 1/13/09

From Dr. Old-timer: “Re: Obama’s EMR plans. Do you think that Obama read the National Research Council Report before he suggested that all medical practices are computerized within the next five years? Does he understand that no one is quite sure the overall effect on quality and costs? If I understand the basics of the report correctly, it sounds like we lack adequate functionality in our existing products. So we need better products, need money to build those products, need money in the hands of providers to buy those products … all in the next five years. It will never happen.” Clearly we need to see a roadmap that details how Obama and team plan to get there and how to pay for it. But, I have to agree that five years is a tight timeline. First, I have my doubts that Congress can act quickly. In these post-bank and automotive bailout times, I don’t see anyone agreeing to pass out money without a plan that includes specific goals and plenty of oversight. And don’t forget the privacy folks will want to issue their stamp of approval. If and when Congress passes a plan, who is going to administer the money and to whom? Will vendors need to rewrite software to meet new governmental requirements? It’s all a big mountain to climb.

From Early Adopter: “Re: Practice Fusion. While I am glad Dr. Thakkar found an EMR that works for him, I would never take a similar risk. About 10 years ago I found a slick EMR product developed by a local start-up and got a great deal for being one of their first clients. They, too, were ‘eager’ for my feedback and making the product better. However, two years after going through all the pains of implementation, the company went bust. My current vendor converted all they could, but there are definite gaps. Sure, I like the idea of a free EMR and I don’t mind the ads. I even like ease of use and speed. But I will never again go through the hassle of implementing any software if I am not confident in the vendor’s business model and long term viability.” If you missed Dr. Thakkar’s positive comments on PracticeFusion, you can read them here.

The acting Surgeon General announces the release of a new version of "My Family Health Portrait," yet another personal health record, but this one’s from the government. I think they goofed in putting the password to the Tuesday media conference in the press release for the whole world to see, although I don’t expect too many eavesdroppers to jump on. Given the number of misspellings and grammar errors on the site itself, maybe that’s not surprising.

Two US Senators introduce the Health Information Technology Act of 2009, which they hope will serve as a blueprint for addressing health care issues in the upcoming economic recovery package. The HIT Act would establish grant money for health care providers to purchase (or lease) HIT systems. The grants would target safety-net and rural providers. Maybe it will be more successful than the HIT Acts of 2005, 2006, 2007, and 2008. None of those bills ever passed.

Solo practitioners are being especially hard hit by economic conditions, according to an LA Times report that profiles the failed practice of a primary care practitioner in Beverly Hills. She hasn’t been able to pay herself for almost a year, spent $40,000 of personal savings and $15,000 in credit card debt to keep the practice going, and finally closed the practice to work for a Johns Hopkins-affiliated practice. She said patients stopped coming when the economy went sour and those who did often stiffed her on their co-pays.

Kentucky’s lieutenant governor, who is a physician, says the state will announce a collaboration of three state universities that plans to study whether healthcare IT is a good investment. While some of the state’s interest may be because Kentucky’s incidence of heart disease, obesity, and diabetes is among the top few states, the LG admits that the main plan is to get a piece of the billions the Obama administration may spend on healthcare technology.

Texas Health Resources Organization for Physicians (THRP) and MedSynergies Inc. create a new management services organization called Texas Health MedSynergies (THM) to offer physicians revenue management cycle services and other business functions. Texas Health’s goal is to “enhance engagement between physicians and our hospitals” and give providers more time for patient care. The pricing structure was not disclosed. Will the pricing be attractive enough to make it worthwhile for a physician to consider, or will the doctors prefer to keep their money matters as removed as possible from the hospital?

MGMA announces its Project SwipeIT initiative, aimed at advancing the adoption of standardized patient health insurance ID cards with machine-readable information. MGMA claims the industry wastes as much as $1 billion annually as a result of non-standardized cards. If every retail establishment can read every credit card in our wallet, and every ATM in the world can read our debit cards, how hard could it be to standardize an insurance ID card? As I patient, I roll my eyes every time a doctor’s office has to photocopy it.

Concierge Medicine of Las Vegas chooses PracticeOne.

In addition to shortages in primary care physicians, look for a shortfall of over 1,000 gastroenterologists by 2020. As the demand for colorectal cancer screening grows, so does the demand for gastroenterologists. The shortage could limit the nation’s ability to implement national guidelines for cancer screening.

The 33-physician Michigan Cardiovascular Institute (WI) selects Sage Intergy PM and EHR. 

Long-time Misys Vision client Physician Associates LLC (FL) selects the Allscripts Enterprise EHR solution for its 80-physician practice. The CIO of Physicians Associates calls the decision a “no-brainer” since they liked their Vision product and the Allscripts EHR. (Don’t you know that made Glen smile?) Allscripts also announces that Tully-Wihr Company, in conjunction with Ray Morgan Company, signed an agreement to resell the Allscripts MyWay EHR/PM to 100 physicians. In addition, Excela Health (PA) contracts with Allscripts for its 115 employed physicians. MDRX stock (blue) is looking good against the Nasdaq (red) in the six-month stock price chart above.

MD-IT, a provider of medical documentation services and software for physician offices, closes on $11 million Series B funding from PE firm J. Burke Capital Partners, LLC.

An article in the current Annals of Family Medicine questions whether consumer drug advertising really works. Patients asked doctors about a specific new drug in only 3.5% of visits, far less than the 15.8% found in a similar study five years ago. The researcher isn’t sure if it’s because patients no longer trust drug companies or whether poor and non-English speaking patients decline because of drug cost and lack of advertising exposure, respectively.

A Texas woman sues her doctor for telling her she can’t get a handicapped parking sticker just because her arms and legs go to sleep, the rudeness of which, she claims, caused her to have a heart attack right in his office. A week earlier, she had sued her attorney for being sarcastic with her and the month before, she sued President Bush because mismanagement of the local housing authority may cause her to lose her home. The kicker is her recommendation to the doctor: he should get psychiatric help.

As we start our second full week of HIStalkPractice, we want to thank all you early adopters, especially those taking the time to provide us great feedback. This week, we will roll out our first guest writer, Dr. Joel Diamond, a part-time practice family physician and an experienced EMR user. He also serves as CMIO for healthcare interoperability company dbMotion. We think he is smart and funny and we know you will, too. We are also lining up an EMR implementation guru to provide great advice and commentary on maximizing the use of EMR. In addition, look for upcoming HIT Moments that highlight assorted other physicians and industry gurus. Make sure you have signed up to receive your HIStalkPractice updates – and hang on for the ride!

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News 1/8/09

Doctors in Hawaii will soon be making virtual house calls to patients via America Well’s Web service. Hawaii Medical Service Association, the state’s BCBS provider, will make the service available to everyone in the state. Members pay $10; non-members $45. That’s a good deal for the uninsured, impatient, or busy patient. Not so helpful for the poor and/or elderly who don’t have ready access to a computer and Internet access.

Alabama Medicaid tests a Web-based EMR that gives physicians access to a patient’s prescription information and past doctor visits. So far, 59 sites are using the free service that is part of a $7.6 million project funded with federal dollars.

A California doctor finds a profitable business niche by helping immigrants from India and China give birth to sons, which are culturally preferred over daughters. Instead of the female infanticide sometimes used in those countries, the doctor employs "pre-implantation genetic diagnosis," identifying the sex of fertilized embryos before implanting them. Couples pay up to $18,000 to make sure their child isn’t a girl, which the doctor says is ethical since Canadians prefer girls.

INTEGRIS Health extends its deployment of Allscripts Care Management from two hospitals and 74 physicians to all 13 of its Oklahoma facilities. Allscripts also announces the sale of its Enterprise EHR to the 85 physicians at Medical Specialists of Palm Beaches. Medical Specialists is a longtime user of the Misys Tiger program, which will be integrated with the EHR.

Healthcare IT stocks fell Tuesday after a stock analyst’s prediction that any vendor benefit from the proposed Obama economic stimulus plan won’t show up on their bottom lines for at least 12-18 months. He downgraded shares of Cerner, athenahealth, Allscripts, and Quality Systems. The analyst believes that healthcare IT funding will not exceed $10 billion and much of that will be used for non-EMR purposes, such as infrastructure and a national health network.

Robert Sexton MD, a neonatologist and Vietnam veteran in his 50s, rejoins the Army and heads off to Iraq after a 38-year break, following his sons into the military as a major. "I figured we have less than 1 percent of the American people in the service, and some of those people are going to need a break sometime – and that’s what I aim to do. I’m still physically fit. I thought I could make a contribution."

Children’s National Medical Center (DC) selects eClinicalWorks EMR/PM solution to connect its employed pediatricians to the medical center. Children’s is also implementing eClinicalWorks Electronic Health eXchange to create a community health record. The eCW software will interface with the hospital’s Cerner applications, as well as the Sage Intergy EMR application used at other sites.

The 12 physicians at Horizon Gynecology & Obstetric Associates (GA) choose Sage Intergy PM/EHR. The group has been a Sage client for more than 20 years.

Summa Health Network (OH) offers free software to help physicians participate in P4P programs. Using MDdatacor’s CareInformatix technology, physicians will have access to Web-based software to collect clinical data from various information systems. Clinical data will then be compared with claims-based data. The clinical data will be used to support P4P initiatives.

Whitney M. Young Jr. Health Services (NY) commits to the purchase of a Cerner system following the receipt of a NY Department of Health grant. The community health center is receiving $897,000 from the state.

PracticeOne hires Scott Lentz as CFO. He was previously CFO of Picis.

Physicians at Landstuhl Regional Medical Center (Germany) military hospital master Dragon Medical speech recognition software to document patient medical records. The champion physicians claim the software is faster, more detailed, and more accurate than transcribing. Because of the success, the surgeon general’s office has purchased 10,000 copies of the Dragon Medical software and is distributing it across 42 facilities worldwide.

A Stanford attending physician pushes students and residents to spend less time in front of the monitor charting and examining test results and more time refining their beside, hands-on patient skills. "In short, bedside skills have plummeted in inverse proportion to the available technology," claims Dr. Abraham Verghese.

Physicians are adopting smartphones at a faster rate than the general public, according to a Manhattan Research study. Doctors are incorporating smartphones into their care routines to access drug information, medical calendars, and EMRs. Currently 54% of physicians own a PDA or smartphone, compared to about 20% of physicians using EMRs. Mr. H uses a BlackBerry Bold and Inga an iPhone. As smartphone experts (ahem), we predict the EMR market will boom when applications work as easily as the ones on our phones.

The University of Kentucky’s faculty practice plan implements a charge capture solution from MedAptus.

The Australian Medical Association opposes a physician code of conduct that would prohibit having sex with patients, writing phony sick notes for patients, and turning in incompetent peers, saying it would be a "lawyers’ picnic."

Inga has been a fan of Dr. Sanjay Gupta for awhile, so she is happy to see he is getting a promotion to U.S. surgeon general. Who else recalls that he was once featured as one of People magazine’s “Sexiest Men Alive”?

Is this a sign of the times? A 13-physician cardiology group sells its practice to Concord Hospital (NH,) making it the fifth practice to sell to the hospital in the last two years. The practice’s managing partner said the practice needed to buy an EMR to stay current and the hospital is covering the $250,000 cost. Economic pressures also influenced the transaction.

Earlier this week we published an "HIT Moment" with Mark Anderson, HIT futurist and CEO of AC Group, Inc. If you have suggestions for future interviews, drop us a note. Self-nominations will be accepted.

A retired Washington physician publishes a new book entitled, “The Best of Wits End: Medical Humor at its Brainiest.” The 81-year old Dr. Harold Ellner compiled 450 pages’ worth of jokes that he collected over the years wile writing a medical humor column for a national physician magazine. Available at Amazon.

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An HIT Moment with … Mark Anderson

An HIT Moment with ... is a quick interview with someone we find interesting. Mark Anderson is CEO and healthcare IT futurist with AC Group, Inc.

We saw a number of HIT companies consolidate last year. Do you think the trend will continue?

Yes. With over 370 vendors in the marketplace selling EHR products, the consolidation trend will continue. However, we believe more companies will just close their doors rather than being consolidated. If an EHR vendor does not have at least 2,500 physicians using their product by the end of 2009, we do not believe that can afford to stay in business. Therefore, physicians risk losing their money if they select a vendor with a small EHR footprint. 

Additionally, vendors that are not CCHIT 2008-certified by March 2009 will have a very hard time selling their EHR product. Not that physicians are really requiring CCHIT, but from a marketing campaign standpoint, competitors will scare physicians from purchasing non-CCHIT 2008-certified products.

As the EMR market matures, products seem increasingly similar in terms of features and functions. What should physicians selecting an EMR evaluate beyond features and functions?

Functionality is important, but it should not be the only consideration. When evaluating products, we rank each vendor from a scale of 1 (low) to 5 (high) in each of the following characteristics:

1. EHR product functionality
2. PMS product functionality
3. PHR product functionality
4. Company viability
5. Management
6. Long-term support
7. End user satisfaction
8. Initial pricing
9. Second-year pricing
10. Contracting terms
11. Negotiated contracting terms
12. Performance guarantees
13. Community hub pricing
14. Community hub functionality
15. Initial installation, training, and configuration
16. Overall rating

In the past,your company has been accused of bias when compiling your annual AC Group rankings. How do you respond?

The best way to answer this question is to ask our clients if they think we are biased. What you will get is that we are extremely hard on all of the vendors. 

I have to agree with many of the vendors that our reports back in 2004-2006 were not totally fair since we only provided rankings based on functionality. Vendors receiving high ranking were those with the best functionality, not necessarily the best solution for any one physician.

We listen to the critics and, starting in 2008, we revised our rankings based on the 16 categories listed above. Now functionality only counts 18% of the total vendor ranking.

Starting in 2009, we are ranking vendors based on five levels of sophistication. This means that a physician can use our reports to determine the top nine vendors based on what "type" of EHR product they are looking for. This means that vendors with low cost, ease of use, and maybe not as many functions (level 2 EHR) can be ranked in the top 10 and will not be compared to products that might cost the average provider over $35,000 during the first three years.

Of course, there are always vendors that do not like the ranking system and the ranking that we provide them. Like the BCS college football ranking system, our ranking is partially based on real data and based on our perceptions and the perceptions of our clients.

The toughest part of any evaluation is determining the EHR vendor’s company viability and end user satisfaction of clients. Since 92% of the EHR vendors are private, they do not have to report any data on clients, revenues, and financial viability. This makes it very hard for a practice to evaluate a vendor.  

When it comes to end user satisfaction, if you believe vendor market data, every practice loves their product and they have no issues. When it comes to end user satisfaction, we believe that KLAS has the best data.  Even there, vendors always complain to use that we should not be using a third party study, but that we should only believe what the vendor tells us. Sorry, I am not interested in beach front property in Arizona.

You were an early supporter of RHIO efforts, yet most have struggled financially.  What will it take to make a RHIO or HIE successful long term?

We believe that the RHIOs will be as effective as the CHINs of the 1990s. Very few will create any benefit to the community.  

However, the concept still makes sense. A community of physicians and hospitals must come together to create a community-based EHR that will allow clinically pertinent data to be exchanged within a local community, not a region. Before we can have a region (RHIO), we need local communities. 

Additionally, the community needs to provide multiple EHRs based on provider needs along with an "EHR Lite" for the majority of the providers who want to start slow. 

Finally, the community EHR needs to provide one consolidated PHR for all of the patients who would like to opt in to a community data exchange. Patient demographics and selected clinical information (lab results, eRX, etc) need to flow between treating physicians following the government’s CCD/CDA data exchange standards.

Do you have any predictions for 2009 in terms of industry trends or technology innovations?

The number of EHR failures will continue to increase. Just look at the numbers so far. According to multiple studies, only around 17% of providers have installed an EHR and less than 5% of the providers nationwide are using EHRs for full documentation, clinical orders, clinical decision support, and for outcomes measurements. Additionally, the majority of the EHR vendors provide inadequate training and support when it comes to changing business and clinical processes. The vendors are teaching physicians how to use the software, but most are unaware of the clinical and operational transformation that must occur before true adoption will occur for the masses.

CCHIT will continue to drive EHR purchases. However based on our studies, 67% of providers do not want all of the functionally and the costs and they are not willing to adopt the operational changes required to fully utilize a fully functional CCHIT EHR. The main reason is not the cost, but the operational change that providers perceive the CCHIT product will require. For example, the average provider spends an average of 33 seconds handwriting or dictating their note on a returning patient visit. Since every patient is new the first time they are seen using the EHR, the amount of time required to enter the information averages 295 seconds, an increase of  over 800%. Over the average clinic day, the EHR would require an additional three hours of charting time, basically eliminating all of the benefits that are promised by EHR vendors. However, the problem can be minimized if we change our approach towards pre-populating the EHR with patient data before the provider starts using the EHR.

The next generation EHRs will enter the marketplace — "DRT-enabled EHRs". DRT stands for Discrete Reportable Transcription. A DRT-enabled EHR allows the physician to continue to dictate clinical notes for a specific period of time. The difference is that the DRT-enabled EHR populates discrete data via the transcription, reducing data entry time by 87%. In most cases, dictation is eliminated within the first nine months once the majority of the patients have been seen using a DRT-enabled EHR. Using multiple methods, a DRT-enabled EHR populates up to 95% of clinical data required for the creation of a clinical note, for orders, and for clinical outcome reporting.

Along with DRT technologies, physicians will learn that a majority of clinically pertinent data can be enter without touching the keyboard. We have determined that up to two years of patient lab results can be obtained electronically along with patient medications, diagnostic codes, and numerous other data via upfront data conversions. If we can pre-populate patient data, the transition period can be eased. Additionally, through community data exchanges and PHRs, we estimate that 72% of patient information can be captured without the keyboard.

EHR purchasers will switch from individual practices to community purchasers. From our research, 87% of EHR licenses were sold to individual physicians/practices in 2007. By the end of 2009, we estimate that 43% of EHR licenses will be sold to community-based initiatives including hospital-sponsored community EHR, IPA-sponsored EHRs, and not-for-profit EHR communities. These types of community EHR initiatives  can help reduce upfront costs by 45% and, via a community data exchange, can help reduce data entry time by 68%.

Monday Morning Update 1/5/09

NYC offers $60 million in subsidies for eClinicalworks EMR, with doctors in the poorest neighborhoods receiving the most assistance. One doctor notes how their program may vary from other initiatives around the country: “We know that at these fancy schmancy systems, they can do these things, but here in New York, we’re trying to do this for the storefront in Harlem.”

In another not so “fancy schmancy” part of the world, the Maine Health Access Foundation announces new low-interest loans to promote EMR adoption in primary care medical practices.

"Free EMR" vendor PracticeFusion has always been questionable to us because their announcements seem to invite more "confusion" than "fusion" (i.e. misleading claims of a Google partnership, announcements of rapid growth that didn’t seem all that rapid, the company’s business model of selling de-identified patient data and pushing ads, how to get the records back out if the honeymoon sours) but the company seems to be playing seriously, bringing on management talent and releasing a good-looking 2.0 product (click above to enlarge). I’m starting to feel more convinced, although it’s hard to know how deeply doctors are actually "using" the product instead of just signing up for it because it’s free. That’s true of all vendors, though — the real question is what functions are being used, by whom, and with what result? We’ve yet to run across a real, live PracticeFusion user, so if you know one, let us know. Surely if it’s anything but terrible someone must be using it — it’s free and online.

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The New York Times overviews the Marshfield Clinic’s (WI) use of technology and an EMR. The article discusses the potential EMRs have for improving healthcare, especially as patient data is mined to find patterns (e.g. outcomes) to manage chronic diseases. Marshfield leaders emphasize that measurable ROI is not the key to assessing the EMR’s success. I wonder if the Harlem and Mainer docs agree.

Outgoing HHS Secretary Mike Leavitt’s editorial in the Washington Post that we mentioned last week urges that any government "investments" in healthcare IT be limited to systems that are CCHIT-certified as interoperable. One might argue that the government should not be intervening in the EMR market by trying to pressure vendors to make them interoperable (a theoretical capability) than to pressure providers to actually share information in whatever way the government has in mind and then let them pressure vendors themselves. Just because you own an "interoperable" EMR doesn’t mean that you’ll ever actually exchange data, either because you as a practitioner don’t want to or because there’s no organization technically prepared to accept your information in the first place.

The local paper highlights Tucson physicians who are moving to EMRs. A former EMR resister believes the transition is “hands-down better for the patent because there are much fewer things you miss." He also notes that his productivity dropped from 25 to 10 patients a day during the changeover to NextGen, but has presumably improved since. The administrator admits the ROI is not immediate, though there is immediate improvement in patient quality care.

Forbes quotes a Congressional Budget Office study that says EMRs will save $7 billion over five years. So given the thousands of EMR-using practices out there, doesn’t that constitute a pilot study group that should already be saving those dollars? The problem, of course, is that it isn’t the practices that are saving the money, most likely, so poring over their books would probably show nothing but additional EMR expense since the savings accrue to insurance companies, patients, and employers. The article cites several self-proclaimed experts, none of whom appear to actually practice medicine and, in fact, all of whom make money selling EMRs and related services. The reporters who write these articles always seem to marginalize the concerns and observations of real, practicing doctors, writing them off as irrelevant Luddites when there are fast-talking sales types available who, not surprisingly, sing the praises of whatever they’re selling at the moment.

GE Healthcare releases Centricity Business 4.3. I assume Centricity “Business” is the old IDX software since it is geared to academic medical centers and large practices.

Sermo introduces a new infectious disease monitoring tool called Sermo FluMonitor that allows physicians to report geographically based clinical observations in real time. I’d love to see how the reliability compares to Google’s flu trend tool.

A new report notes the shift from a provider-owned medical record to a record shared and controlled by both the provider and patient. It predicts the EMR market will grow by 14.1% annually through 2012. Of course I remember the days when everyone predicted 30% per year growth, a rate the market never quite achieved.

A UMass study says that medication errors occur in 7% of adult chemotherapy visits and 19% of those of children. The biggest question that lay people and even clinicians often forget to ask is whether the "errors" actually had the potential to cause patient harm without being caught down the line. The authors of this study did ask and found that about half had that potential, with most of them involving failed reconciliation between initial chemo orders and those adjusted for a specific visit. Many of the errors were cause by people in the home preparing and giving doses, not medical professionals. The clinic with the lowest rate of errors, one per 500 visits, used an EMR system with physician order entry.

Financial conditions are hitting physicians: more of them want hospitals to pay them for on-call cover or to hire them outright and fewer of them will attend conferences that involve overnight travel in 2009. Another example: a practice management company for plastic surgeons is laying employees off this week, which might logically be interpreted as meaning that fewer people are willing or able to shell out for cosmetic surgery.

Here’s a significant but tiny news item that the usual healthcare media will probably miss (unless they read it here, of course). A primary care office in Maryland cancels its plan to move to a boutique practice model when the Maryland Insurance Administration, worried about losing more primary care doctors, held hearings to decide whether retainer-based medicine is a form of health insurance that requires additional state regulation. Is it insurance to charge patients a flat yearly fee rather than fee-for-service? My first reaction was an emphatic no, but I can see how there is some gray area that would need to be carefully spelled out in whatever agreement the patient and practice sign. Other than that, it’s still an emphatic no in my book, but I’m not a state insurance bureaucrat. My suspicion is that the state wouldn’t have cared if it was a small group doing it.

Medical bills that have been turned over to a collection agency are keeping many people from qualifying for a mortgage, a mortgage company says, calling it a "huge injustice" that credit scores are hurt even when the debt is fully paid. I’ll go out on a limb to speculate that those mortgage companies who can’t get the money owned to them without turning it over to a collection agency (or who even experience only ‘slow pay’ from debtors) feel it’s entirely right and good that their deadbeats take a credit score hit.

I’ve always found the Zagat restaurant surveys to be pretty reliable. As Zagat expands into healthcare, we’ll see if the results will be as solid. The new Zagat Health Survey tool, offered in partnership with BCBS North Carolina, allows patients to evaluate their physicians on a set of distinct criteria. I wonder if consumers are as willing to rate their doctors as they are a good meal.

This is Inga’s kind of doctor. An Irvine plastic surgeon sets his Botox rates based on the rise and fall of the Dow Jones industrial average ($1/Botox unit for every 1,000 points on the Dow.) On those days his patients open their 401K statements and become depressed by all those losses, they can now find consolation from a little cosmetic refresh.

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