Cenegenics Builds Resilient Cisco Network to Support Its Growing Practice

It is easier to have just one specific vendor, especially for the switching gear, because there is a lot you have to worry about.”
– Dror Nisenbaum, IT Manager, Cenegenics

Pressures of Growth on IT

Dror Nisenbaum, IT Manager at Cenegenics, clearly remembers his first day of work. He arrived at eight o’clock in the morning, sat down and the phone rang before he could take the first sip of coffee. It was a disgruntled user who had been waiting a month to fix an IT problem. Nisenbaum walked him through a solution right there on the phone. The user was pleasantly surprised and relieved, while for Nisenbaum it was a not-so-subtle hint of the road ahead. In fact, after spending four intense months working through the IT support backlog, he turned his attention to the challenge of redesigning and rebuilding the network and other IT infrastructure to support the company’s fast growth.

Cenegenics, based in Las Vegas, Nevada, is the largest age management practice with 20 medical centers in the United States serving more than 20,000 patients. Age management emphasizes prevention, as opposed to treating disease, and employs nutrition, exercise, supplements and hormone treatment under the care of a physician to maximize the quality of life for its patients as they age. Cenegenics is well known for ads showing one of its physicians, Dr. Jeff Life, a 72-year old man with the toned body of a youthful muscle builder.

Cenegenics experienced many years of rapid growth. From 2006 to 2012, it expanded from 3 medical centers in Las Vegas, Boca Raton and the Carolinas to 20 medical centers throughout the United States. The number of corporate staff at its headquarters in Las Vegas quadrupled. By any measure, the practice was successful and growing.

However, the expansion and growth put a strain on its aging IT infrastructure. Ten years ago, Cenegenics had a flat network with HP equipment supporting its users and applications. They added a voice over IP (VOIP) system. The VOIP provider installed Cisco networking equipment with power over Ethernet (POE) support, so they had two networks connected via uplinks, one for data and the other for voice. Unfortunately, the features and configurations were inconsistent and many problems arose. Phones did not power up if connected to the HP switches, and computers would not acquire the right IP addresses if connected to the Cisco switches. There were many dropped calls because the HP switches did not support QoS. Data storms flared up on a couple of occasions because of misconfigurations between the networks. The IT contractor who managed Cenegenic’s network was an HP reseller trained to support HP networking equipment, but not Cisco. They had to manufacture artificial phone problems and call the VOIP provider to get Cisco support. “It was very difficult. It was the perfect storm,” said Nisenbaum.

After the support backlog was finally under control and response times were reasonable, Nisenbaum focused on diagramming and labeling the entire network, including switches, cables, distribution points and servers. “I had to redo all of the wiring closets because it looked like a spaghetti ball,” he said. The jumble of cables and switches was so confusing they resorted to pulling cables after business hours and walking to the adjacent suite to see which device turned off. The result of the effort was a diagram that provided a comprehensive view of the infrastructure and identified the single points of failure.

Building a Consolidated, Highly Resilient Network

Next they developed a plan for a consolidated, highly-available, virtualized infrastructure. It included two Cisco Catalyst 3560-X switches as the core of the network and a Cisco 3945 Integrated Services Router to replace a SonicWALL router and one other that were too small for the expanded user load. The two 3560-X switches had redundant power supplies and were paired up for failover. Six existing Cisco Catalyst 3560s would serve as edge switches. Connections around the headquarters building would have four strands trunked in pairs to make a redundant fiber ring. Pipes between suites in the building would carry not more than one fiber optic cable to eliminate the risk of a severed pipe disrupting communication. The design also included three powerful Dell servers with dual six-core processors running VMware and a Dell EqualLogic iSCSI SAN with dual controllers connected via the 3560-X core switches.

Nisenbaum felt strongly that the network should be consolidated on Cisco equipment, not a mixed-vendor environment. “It is easier to have just one specific vendor, especially for the switching gear, because there is a lot you have to worry about,” he said. Nisenbaum is Cisco-certified and very comfortable using their equipment. Though he had some experience with HP and SonicWALL equipment, he thought some of their configuration procedures were unnecessarily complicated. “Having multiple vendors brings so much complexity… I wanted to consolidate everything to one vendor, so I can train my employees and make sure the team we have in place can manage it all.”

The plan was presented to Cenegenics’ executive board. The project cost was in the six figures, a substantial investment for a company of that size. Nisenbaum’s approach was to show them all the points of failure in their existing infrastructure. “If any of these devices goes down, this is the catastrophic effect. How much is it going to cost you per day if this doesn’t work? That was my pitch. I came in six months after one of their servers crashed and they were down for almost a week. What I was saying was very fresh in their minds,” he said. The board decided to approve and fund the project.

I can sum it up with one statement:  I can sleep at night.”
– Dror Nisenbaum

Uptime Makes Everyone Happy

Installation of the new equipment took four months because some aspects of the transition had to be handled carefully to avoid disrupting users. Today the company’s applications and users run on the rebuilt and highly resilient network as well as server and storage infrastructure. It has been 16 months since a server went down. While individual components have failed and had to be replaced, such as a GBIC on a switch, the redundancy of the design ensured that users did not experience downtime. Executives and staff are pleased because they can focus on running the practice and serving patients with a stable IT infrastructure supporting them.

Asked about how he feels about the situation now, Nisenbaum replied, “I can sum it up with one statement: I can sleep at night. When I had all the aging hardware and there was such a support backlog, I didn’t have a personal life. Now that things have slowed down, it gives me the ability to see how I can improve Cenegenics as a whole.”

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 Copyright © 2012 Apropos LLC. All rights reserved.

At Banfield Pet Hospital, PACS and Telemedicine Bridge the Distance across Its Hospital Network

We needed a way to consolidate this image data and make it universally available across our distributed network of hospitals.”
– Dan Baldock, Senior VP and CIO, Banfield Pet Hospital

Banfield Pet Hospital was challenged by all of its digital x-ray and ultrasound images stored locally at each of 500 disparate locations across the country. They had no way to share those images among all of the 780 Banfield pet hospitals. There was no backup or disaster recovery plan in place, so the medical data was at risk of loss if a hard drive failed. Telemedicine (getting a second opinion from a radiologist working remotely) was slow, expensive, and many veterinarians were not taking advantage of the service to improve patient care. “We needed a way to consolidate this image data and make it universally available across our distributed network of hospitals,” said Dan Baldock, Senior VP and CIO of Banfield Pet Hospital.

Banfield Pet Hospital is a network of 780 veterinary hospitals located throughout the United States. Banfield partners with PetSmart, the nation’s largest pet-related retailer, and operates pet hospitals inside PetSmart stores.

First Step: Centralize and Protect Digital Images

To solve these challenges, Banfield implemented a centralized PACS system (Picture Archiving and Communication System) at its headquarters in Portland, Oregon. They selected the open source software ClearCanvas as both the back-end archiving system and as the front-end viewer. Banfield had the support of the team at ClearCanvas and leveraged their existing in-house resources and expertise to develop and deploy the system. The only additional staff they needed to hire was a single PACS Administrator to aid in the setup and ongoing administration of the system.

Banfield set up the infrastructure for all 500 digital x-ray and ultrasound machines across the country to transmit images over a WAN to their centralized servers for long-term storage. They set up redundant, mirrored server and storage infrastructure with daily and monthly backup processes to protect the data. In addition, once that data was centralized, they implemented a disaster recovery plan for failover to a remote site in Arizona. Now the medical imaging data (x-ray and ultrasound images) is protected and readily accessible.

Data centralization also allowed Banfield to implement nationwide image sharing. Many clients are very mobile across the country. The hospital has countless stories of truckers that drive nationwide with their pets or snowbirds that go south with their pets for the winter. Having the ability for images taken at any Banfield hospital to be viewed with the click of a button at any other Banfield hospital has improved dramatically the continuity of care their veterinarians could provide.

Second Step: Telemedicine

With the foundational PACS system in place, Banfield then implemented a robust tele­medicine system. To do this, they custom-built a RIS system (Radiology Information System) to track the requests for telemedicine consults, allow the radiologist or other specialist to view the cases, and communicate the consultation results back to the requesting veterinarian and team. They partnered with various veterinarian telemedicine vendors, even designing a custom integration with one to send cases that could be read in their existing system.

By building this RIS system, they were able to improve the turnaround time of telemedicine consultation results getting back to the hospital to an average of 30 minutes for STAT cases (emergency cases) and 90 minutes for routine cases. Historically the turnaround time was hours to days. This made an enormous impact at the point of care for the veterinarians and their clients and patients to have a specialist give a second opinion as needed on a case to improve the treatment decision-making process.

In the end, Banfield was able to save millions of dollars in the first few years by selecting the ClearCanvas technology and leveraging their existing resources. Since the initial imple­mentation, they have also expanded the PACS system to include digital dental x-ray images after adding 60+ digital dental x-ray units to its hospitals. The system was built to be very scalable so they could add different types of imaging equipment and allow for the growth of new hospitals. Banfield has been opening about 50 new hospitals per year and will continue to do so. They are also in the process of implementing another feature, DICOM CD burn, using another ClearCanvas product. “The solution we chose has really allowed us to grow in many directions,” added Baldock.

Next Step: Integration with EMR

The future for PACS, RIS, telemedicine and all imaging systems at Banfield Pet Hospital holds even greater promise. The next step is to integrate the imaging systems with Banfield’s proprietary EMR (electronic medical record system) called PetWare. The goal will be to integrate images that reside in ClearCanvas PACS and radiology telemedicine consultation results directly into the EMR. The solution will also allow them to integrate images into their client/patient portal system, so clients can view their pets’ images.

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 Copyright © 2011 Apropos LLC. All rights reserved.

St. Luke’s Radiology Group Accelerates Reporting with Speech Recognition Technology

As the IT group, you can do a good job with the technology, but it is the cultural change, the enthusiastic adoption by doctors and staff, that really makes it a success.
– Adrienne Edens, Chief Information Officer, St. Luke’s Health System

Toward Timely Transcription

As part of a new consolidated PACS installation for archiving digital images, St. Luke’s Health System wanted to implement a speech recognition technology for its radiology group to accelerate reporting and facilitate more responsive patient care. At the time, the turnaround time for manually transcribing a radiologist’s dictation averaged seven hours. Patients had to wait that much longer for the results of an x-ray or other medical image. “The goal of speech recognition was to eliminate transcription and shorten this process,” said Adrienne Edens, Chief Information Officer for St. Luke’s.

St. Luke’s Health System is an Idaho-based, not-for-profit health care provider for southern and central Idaho, northern Nevada and eastern Oregon. It operates medical centers in Boise, Meridian, Magic Valley, McCall and Wood River as well as more than 70 clinics. St. Luke’s Boise Medical Center is Idaho’s largest hospital, and St. Luke’s Children’s Hospital is the only children’s hospital in the state.

St. Luke’s medical imaging process involved several steps. When a physician ordered a medical image, a technician performed the scan and sent the image to a radiologist for diagnosis. The radiologist dictated an audio report that was forwarded to the transcriptionists. After the text version came back, the radiologist approved it and the official report and diagnosis went to the referring physician and became part of the patient’s medical record.

Manual transcription was the most time-consuming step. If automated speech recognition could mitigate or even eliminate the need for it, the overall time to deliver a diagnosis could be reduced dramatically.

Speech Recognition Development

Speech recognition technology has been in development for decades. Programming a computer to recognize and decipher human speech is particularly complex and challenging. While the accuracy rate has improved over time, progress has been slow and incremental. Today, the technology has advanced to a point where it is a viable for certain applications. “Even in the last couple of years the technology has come a long way,” said Dan Talley, IT Service Team Leader for St. Luke’s.

Collaborative Approach

St. Luke’s took a collaborative approach for reviewing options and approving a speech recognition system. All stakeholders had a seat at the table: the IT group who would manage it, the hospital administrators who oversaw budgeting and compliance, and the radiologists who would ultimately use the system as part of their jobs. They also enlisted Santa Rosa Consulting, an IT and management consulting firm for the healthcare industry, to provide guidance and expertise in this area.

From the beginning, the radiologists were active proponents of a speech recognition system. “It was not administration saying we needed the system, or even IT. The radiologists were the most enthusiastic advocates,” said Edens.

RadWhere from Nuance Healthcare

After considering several speech recognition solutions, the project team chose RadWhere from Nuance Healthcare. RadWhere is a speech recognition solution with reporting and workflow management designed specifically for radiology. The software transcribes a radiologist’s dictation in real-time, thereby speeding up report writing. It includes templates and macros based on procedure codes for structuring the reports. RadWhere’s workflow engine also automatically routes documents through the creation, review and delivery process.

To roll out the system, the IT group installed software on the radiologists’ workstations and the primary RadWhere application on a host server that is replicated to a remote site for disaster recovery. If a failure occurs at the local site, the system will fail over and continue to provide service to the radiology group. Furthermore, each user had to “train” the system to understand his or her voice by speaking scripts into the computer.

The radiologists were quick to incorporate the new system into their routine. “Normally these types of projects are phased in slowly, but in this case, radiology no longer needed transcriptionists after only two weeks,” said Talley.

It felt great to experience such an improvement, especially after being a part of this project.
– Dan Talley, IT Service Team Leader, St. Luke’s Health System

More Responsive Patient Care For Less

As a result of the fast adoption, the benefits to St. Luke’s and its patients accrued quickly. The average turnaround time for radiology reports dropped from 7 hours to about 30 minutes. St. Luke’s is saving $450,000 per year in radiology transcription costs for the Treasure Valley alone (Boise, Meridian and surrounding areas). Most significantly, patients receive faster and more responsive care.

Talley gave a personal example. His elderly mother had fallen down occasionally in the past, and Talley would take her to the hospital for an x-ray. Typically they had to wait hours for the results, but the last time this happened, after the speech recognition system was in place, the x-ray and diagnosis came back in only 20 minutes. “It felt great to experience such an improvement, especially after being a part of this project,” he said.

Edens added, “We are thrilled and wish all of our IT projects went this well. We give the radiologists credit for the success. As the IT group, you can do a good job with the technology, but it is the cultural change, the enthusiastic adoption by doctors and staff, that really makes it a success.”

Based on the success of the RadWhere system, St. Luke’s is looking at standardizing on Nuance technology for all of its medical speech recognition applications.

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 Copyright © 2011 Apropos LLC. All rights reserved.

For Idaho Clinic, Secure Messaging Means HIPAA Compliance and Better Patient Care

John Cotten

With secure messaging, when the nurse or provider sends out a message, the patient
gets it.”

– John Cotten, IT Director,
Family Medicine Residency of Idaho

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HIPAA Mandates Secure Electronic Communication

“Starting in February of this year, the next revision of HIPAA came out – the high-tech policy that required any kind of unsecure electronic communication to be encrypted and secure. In other words, you can’t e-mail your patients,” said John Cotten, IT Director at Family Medicine Residency of Idaho (FMRI). In response to this new federal HIPAA requirement, the clinic decided to adopt secure messaging. This technology would enable health care providers and nurses to send medical information like lab results to patients securely by e-mail.

Family Medicine Residency of Idaho, based in Boise, trains medical school graduates to become family physicians. The clinic associated with FMRI is called the Family Medicine Health Center. It provides a range of health services with an emphasis on affordable care for underserved groups.

Another benefit of secure messaging is streamlined patient communication. “Traditionally in a doctor’s office, when lab results come in for a patient, the nurse will try to call up a patient and let them know what the doctor said. And a lot of times they are playing phone tag. With secure messaging, when the nurse or provider sends out a message, the patient gets it. There is no phone tag and no interpretation of what the provider may have said. It’s pretty black and white – here are your results and here is what we recommend,” said Cotten.

GE Centricity Secure Messaging and Patient Portal

Cotten attended a user conference where he previewed the GE Centricity Secure Messaging and Patient Portal solutions. FMRI already used GE Centricity Electronic Medical Record (EMR) in its clinic. The Secure Messaging and Patient Portal solutions, originally developed and sourced from the vendor Kryptiq, were integrated with Centricity EMR and resold under the GE brand. Therefore it would be easy to drop them into the clinic’s existing IT infrastructure.

Cotten presented this solution to the staff. Dr. Justin Glass, one of the doctors at the clinic, happened to be looking at a grant that would cover an IT healthcare solution like this, so they included it in the application. The grant was approved and they went ahead with the deployment. It was a fairly easy sell to management because of the new HIPAA mandate for secure electronic communication.

The clinic configured the system for robust security to ensure the privacy of a patient’s medical record. When a new patient visits, he or she receives a one-time PIN for the portal. The patient goes online and registers, providing some key information to verify their identity. At this point the patient is set up for secure messaging. When a provider wants to send the patient information, such as the results of a cholesterol screen, the patient will receive an e-mail with a link to the portal. The patient clicks on the link, logs in and views the results and recommendations. If a patient does not log in and view the information within a certain number of days, the system alerts the nurse or provider so they can follow up by other means.

“Of course, with any technology, you can do a lot of things with it. What really drives a technology is the policies and procedures that you put in place at your practice,” said Cotten. Providers can control how and if information is presented through secure messaging. They might allow a patient to see a full test result or choose just to say, “Everything is normal. Check back in six months.” Sometimes presenting too much complex information which is subject to interpretation may be confusing. And for sensitive information, they might forego e-mail altogether and contact the patient in person.

Providers also have the option to allow the patients to respond by e-mail, and some at the clinic take advantage of this feature for back-and-forth communication. It facilitates more responsive patient care. “One of our providers is a huge proponent of the system, and he decided to allow some of the patients to respond to him. In one case, a patient responded to an e-mail and said, ‘I’m having pain in my leg…’ The nurse was able to see that information, track down the provider and see if they had taken care of it. If not, find another provider to take a look at it. So from a patient standpoint, it was great patient care,” he said.

Another benefit is that messages become part of a patient’s electronic medical record. The next provider that works with a patient can see the record and know exactly what was communicated. This provides more detail than summary notes.

Managing Change

As with any new healthcare technology, it is challenging to train and encourage people to use it. “A lot of technologies aren’t going to make their jobs easier right off the bat. At first it seems like one more thing to do,” he said. But in the end secure messaging reduces the amount of time spent with unanswered patient calls and playing phone tag. The clinic’s approach is to educate about the benefits and the ultimate goal of the technology. For instance, Cotten sent a message to the staff about how secure messaging will help nurses and providers focus on the patient that is here and in front them while still getting the message to the patient that they have already seen. In another words, a tool for efficiency and better patient care.

The patients themselves were leery at first about giving their e-mail addresses to the clinic because they did not want to be spammed. Once they realized it was so their provider could communicate with them, they became more enthusiastic. Many people prefer to communicate by e-mail today.

Building on the Patient Portal

The clinic uses Centricity Patient Portal only for secure messaging at this time, though it has the potential to do much more. The software can show a patient’s full medical record, including historical details. So FMRI is currently studying how it might build upon this solution in the future. According to Cotten, while the technical aspects are straightforward, the real work is in understanding the impact on providers, nurses and patients and developing appropriate policies and procedures around the technology. It always comes down to the human impact.

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 Copyright © 2010 Apropos LLC. All rights reserved.

Oliver Family Healthcare Finds Electronic Health Records Are a Win for Patients and Clinic

I really felt the future was going to be electronic health records.”
– Dr. Greg Oliver, Oliver Family Healthcare

Out With the Old – Paper Charts

Dr. Greg Oliver, head of Oliver Family Healthcare in Indianapolis, Indiana, was early to see the benefit of electronic health records for health care providers. “I had been in practice the first twelve years of my career and then I sold my practice to a hospital and went to work for them,” said Dr. Oliver. As medical director for multiple clinics, he kept abreast of new technologies for computerized healthcare. “I thought the future was going to be electronic health records from what I was reading. So the hospital gave me the assignment to try to find a product for all their clinics. I narrowed it down to a couple of products, and about that time, the hospital decided not to go forward with it due to costs.”

When this project stalled, Oliver saw an opportunity to buy back the family practice and run it more efficiently using new IT systems. “I decided to go back into private practice for several reasons,” he said, “but one was I really felt the future was going to be electronic health records.” The hospital allowed him to keep the practice in the same location since it was a larger referrer to the hospital.  He and a nurse practitioner worked together to go back into private practice.

Having used charts for so many years, Oliver knew the limitations and costs of a paper-based system. “There wasn’t a day that went by where one of my staff didn’t say the unfortunate thing, ‘Your chart is lost.’ I’d always tell a patient that it’s really not lost. It’s here. Someone just can’t find it,” he said. Electronic health records seemed a more reliable and cost-effective solution. “I knew that it was expensive to handle charts and keep them stored. I just thought this has to be cheaper to do, which it definitely was. We were doing transcription at the time, and I wanted to save on transcription costs.”

At the time, he did not anticipate that electronic health records would add significantly to the quality of patient care. “That wasn’t really one of the things I thought I would gain from it. That now turns out to be one of the greatest benefits of it,” he said.

In With the New – Electronic Health Records

Oliver chose Allscripts Professional EHR for electronic health records and Allscripts Professional PM for practice management (known at the time as the A4 HealthMatics System and HealthMatics Ntierprise). After considering many aspects of the competitive solutions, one feature in particular made Allscripts stand out: “The reason I chose that over the other was it seemed to provide a very easy-to-use physician interface with a computer,” he said.

Dr. Oliver took an aggressive approach to rolling out the new system. He and the nurse practitioner took a week’s vacation from their hospital employment and traveled to Allscripts’ offices in North Carolina to learn the new system and make customizations to the software. After returning, they trained the staff and made preparations. On July 1, 2003, they went live with the new system and started the private practice on the same day. “We had a trainer from Allscripts here on site with us. The first day we went live in our practice we saw 60 people. They told us we shouldn’t do that. I know a lot of practices will say, ‘Stay with your charts and just do three or five on the system.’ We just went live,” he said.

In advance of a scheduled appointment, a worker entered key details into a patient’s electronic record. They also carried the patient’s chart into the room in case it was needed. Oliver continued, “I remember being in an exam room and telling a patient, ‘Hang on, I don’t know what I’m doing here,’ and would walk out. The trainer would say do this, this and this. And I would go back in the room and take care of it. The first few days we were in the office very early, six-thirty or seven a.m., and didn’t leave until probably nine or ten p.m. But very quickly within that first week, having seen hundreds of patients on the new system, we were rolling. It was fine. So my thought on it was if there’s going to be pain, let’s get it over with quickly, and it turned out, I don’t think we had a lot of pain.”

By the end of the year, they rarely needed the paper charts, and by the end of the second year, they no longer used them.  The old charts were stored for compliance purposes and for rare instances when they need to see an old test result.

More Efficient, More Productive, Better Care

The Allscripts Professional EHR and Professional PM solutions helped the practice to operate more efficiently and cost-effectively and improved patient care. Merely having access to timely, reliable records and reports enabled medical workers and staff to accomplish more each day. They were able to see more patients. At the end of the day, every patient visit was ready to send to the insurance companies. Collections were much higher than before, and revenues also climbed. The system notified patients automatically to schedule routine exams and tests, such as for hypertension, diabetes and high cholesterol. “Not only has it increased our ability to get the patients in for things that we think are important for their healthcare, but because of that, it increases our revenue also,” said Oliver.

More recently, Oliver Family Healthcare implemented online visits. For current patients experiencing minor issues, they can go to the website, enter symptoms and request an online visit. This generates an email that is sent to the on-call doctor’s iPhone. The doctor views the patient request, symptoms and medical history from their iPhone or PC. With this information, the doctor can address the health issue, send a prescription, request the patient come into the office the next day or refer to an emergency room. The benefit to patients is they can access their own doctor who is aware of their medical history from home. They do not have to drive to a walk-in clinic. From Oliver Family Healthcare’s perspective, the online visits are chargeable, though only if they can address the problem, and not if it requires further evaluation or a referral. The patient visit is also documented and becomes part of their medical history. “So we have implemented that in the last couple months,” said Oliver, “and without an electronic health record, you couldn’t do that.”

Just jump in, you’ll be okay. Because there is no way that with a paper chart you can take as good care of a patient as you can with an electronic health record.”
– Dr. Greg Oliver

Advice for Healthcare Providers

When asked for his advice to other medical practices and clinics that may be considering electronic health records, Dr. Oliver responded: “I would tell anybody, especially a small practice, just jump in, you’ll be okay. Because there is no way that with a paper chart you can take as good care of a patient as you can with an electronic record. And most of it is because you can’t do anything with the data that’s in a chart in a file. This software is doing things and inviting patients to come back for their regular screenings and checkups and blood tests while I’m sleeping. It’s doing this automatically. There is no way you can practice that type of medicine with a paper chart. Is there an expense to getting involved? Yes. But we noticed that for the last five years, our practice revenue has gone up between twenty-five and thirty percent every year. A lot of is just because we strategically look at how we can ladder technologies in our practice and link them to our electronic health records and practice management system to, number one, take better care of the patient and, number two, become more efficient over time and be able to capitalize financially on our ability to take better care of our patients.”

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 Copyright © 2009 Apropos LLC. All rights reserved.