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November 7, 2010  9:41 PM

Checklist for EHR data migration



Posted by: RedaChouffani

As we continue to see more and more certified products from the ONC on (http://onc-chpl.force.com/ehrcert), many early adopters of EMR are facing a serious challenge. They are at a crossroad where they have to make the choice between either upgrading their current system to a certified version, or completely replace the existing system with a new one.

For the organizations that are engaging in a full system replacement, they are faced with a full fledged electronic medical records conversion.

At this stage, many of the mature EHR systems do provide with data extraction and export capabilities. But the challenge is always what steps to take to ensure a successful data conversion from one system to another. There are some important steps to take to ensure a successful migration:

 

Define the data that will be converted and migrated:

One of the critical steps to start the process of data conversion is to first identify the scope of the project. This would require the participation of several departments to ensure that all the data that is critical to patient care is in fact being migrated. Some of the data that would be discussed during these round table meetings are:

Lab results

Radiology documents and results

Patient Mediations

Scanned patient documents (business office as well as clinical)

Immunization Records

Allergy list

Progress Notes, Consults, letters, Reports and other clinical documentation

ECG and vitals

Patient Demographics

Billing or general account information

Identify the data format:

The next step would be to identify what information will need to be discrete data and which one will stay as unstructured data. During this step the conversion team will be able to identify the level of complexity for the conversion. For example, some labs maybe in one system as simple ASCII files or simple text files, but the organization may need to have lab results in the flowsheet which would mean that the data must be in a discrete format, and that may mean some additional data manipulation.

Identify what is the best route for the best outcome

With many of the EHR products in the market under pressures to add interoperability to their solutions, this makes the conversion process a little easier for many. By having the ability with most mature system to export and import data by using the widely used HL7 standards, it would mean that most of the burden would be placed on areas relating to the cross referencing the different clinical vocabularies between the two systems. The only piece of data that may add some challenges to the conversion process would be the unstructured data such as Images, PDFs, Tiff files and any other

In house or outsourced data conversion

When converting data from one system to another, it is important to review all your options. In many cases the interface team at the hospital organization or mid size practice would be an expert in the “old” system, which means they would know the best way of extracting the data. But when it comes to the new system, this stage would require working closely with the new EHR vendor or a third party reseller who has plenty of experience with other conversions. This will help identify what would be the best format for the extracted data as well as what capabilities the new system has in terms of importuning electronic patient medical records.

Test, test and test:

Once a road map is defined for the data migration or conversion, it is useful to perform test conversions early on and review the converted information by several of the clinical departments that will be utilizing the new system. This will ensure that all the information did convert as expected, and that everyone is on the same page.

 

Clearly technology helps care givers save lives, and that means that ensuring the patient data is safeguarded and properly maintained regardless of the system it resides on. When migrating millions of records, it is critical to have checks and balances throughout the entire cycle of the conversion. By using the already defined interfaces from both system, and involving everyone in the process, this will ensure a smooth and success data migration.

October 31, 2010  3:17 PM

Top 10 skills for a successful leader in healthcare technology Part 2



Posted by: RedaChouffani

Continued:

4.Be curious and don’t be afraid to take calculated risks:This is a tricky one. If you ask anyone who knows me, they will tell you that I will be the first one to pickup a new tool, a new programming language or engage into a new concept of doing things. I like to take risks and try new things. But that comes with its own risks. New technologies can be buggy, and not as reliable as previously established products. But nevertheless, one should not be afraid of learning, evaluating, implementing new concepts and following their gut feeling on a new way of thinking. Just as long as it is a calculated risk, discussed openly, tested, and proven in a small controlled environment. After all, innovation does not come from thinking inside the box.

5.delegate delegate and delegate :One of the most difficult things in IT is to have the ability to trust someone else with specific tasks that you may not be confirmable having them perform. But when you have a million things to-do, adding more to your task list will most likely set you up for failure. So, it is important to learn to delegate and enable others to learn and accept that they may not do it perfectly the first time, but eventually as you have learned, they will as well and with your mentoring and support the outcome might just surprise you and win their few people along the way.

 

 

6.Time Management:In order to ensure that you don’t fall into the reactive nature of IT, you need to plan your workdays, projects and what needs to be accomplished accordingly. This will ensure that you are in fact focusing on the right things and not just simply going from fire to fire. To begin getting organized and properly balancing your day, you will need to use some of the available time management tools. Then, create or use an existing process to identify and categorize the IT requests based on priorities and deadlines. If you are in the helpdesk, these may already be pre defined, but it would not hurt to have your own list and methodology in place. There are several great resources available about best practices in the IT support arena in the ITIL (Google it).

7.Think with a Business Mind not just a technical one:In this area, you don’t need to become a financial expert or stock market guru. You simply need to recognize the value of projects you are involved in, or recommending. From learning the soft/hard ROI of the specific product, to knowing how IT can save costs and increase revenue. While healthcare may be moving toward payments based patient outcomes instead of procedure based fees, it is important more than ever to recognize and implement the projects that will bring true value to the environment. There are many available resources that can assist you in learning what projects payoff and what products are nothing more than nice toys to have.

 

8.Get the task done that’s at hand:This is somewhat of a controversial matter. Many of the successful individual that I have worked with and interviewed in the past, the 8 to 5 is just not in their vocabulary. When there is a task that needs to be done, they will see it through. Some have argued that these individual may not have a life, however, these are the same people that I see at soccer practice and spending quality time with their family instead despite their long working hours. They are just know how to manage their time and choose not to spend hours watching mindless reality shows or meaningless television. If you want to impress your boss or executive, then you need to be the kind of person that sees a project through as well as gets the job done.

 

9.Learn to be a sales person:Everyday that you are at work, you are trying to persuade someone with something. Whether it is trying to persuade your team on a product or idea that you believe will help the organization or simply trying to explain the outcome of a project to the board. You have to possess a level of sales skills that will help you get the point across. This includes your image from how you dress, to how you choose your words in conversation or emails. If you have a great idea and you know that it is going to improve a certain process, but you cant get anyone to get on board, then you are not presenting it correctly, and you need to sharpen your sales skills to sell it better. Despite the stigma on the work “Sales person”, many of successful leaders have a lot in common with business development folks and they know how to sell themselves.

10. The ability to think strategically and see the big pictureIf you are one of those individuals that falls asleep during the organizational quarterly or yearly meetings then you need to wake up and pay attention. Have a strong understanding of where the organization wants to be and ensure that everything you do is in fact in line with what the leadership is looking for. It may get boring at times, but without a deep understanding of the relationship between what you do and what the goals are, you will have a disconnect and may never get the opportunity to engage in meaningful conversations with your leaders.

 

 

As I work with new comers in the technology field, I see tremendous potential and untapped talent. And for many individuals who are aggressive and focused on their success some of the above items are just a sample of what can assist them in achieving their goals. There are many incredible resources out there that provide greater insight and great advise on what to do and how to do it. Some of the material that I think are a must have read are:

“The execution”, “From good to Great”, “The seven habits of highly effective people”, “”The outlines”, “How to influence and make friends”, “The IT transformation”, and many more..


October 30, 2010  9:09 PM

Top 10 skills for a successful leader in healthcare technology Part 1



Posted by: RedaChouffani
HIT, IT leaders

Whether it is during a tough economy, or a thriving one, a successful career is something that many look forward to. Some obsess about it, and others simply wish for it but never go after it. But it is important to recognize what it takes to become successful.

To achieve success in any career we are always reminded of the following: how much you put in, how well you communicate, and if you possess the skill set that is required to accomplish the tasks. In today’s market, healthcare has become one of the hottest and fastest growing arenas for IT. While some may assume that IT is the same across all types of businesses, it is far from being the truth. Healthcare is a complex environment and requires comprehensive understanding of technology, standards and domain expertise. Many IT folks that have been in the field long enough are beginning to wonder about what are some of the things that are needed to turn them into a valuable asset to their organization or what is it that they should do in order to accelerate their career.

Based on many years of working with very successful and talented individuals in the healthcare, ranging from software architects, CIOs, to healthcare technologists, it was very clear that there are few common qualities that distingue these successful careers and individuals from the rest of the IT pack. The following is a list of 10 recommendations and qualities that would help create a successful career in the Healthcare industry:

1. Healthcare Domain Expertise:It is critical to have a deep understanding of the healthcare domain. By making the effort to understand the environment you will have the ability to carry on conversations with the different departments, understand their pain points and gain the ability to identify inefficiencies in order to apply specific solutions. This knowledge can be acquired by simply interacting with the individuals and asking them questions on what they do, and how they interact with the different applications that are being supported. Read healthcare magazines and blogs. Stay current with laws impacting the healthcare as well as news on technologies and devices used in the medical field.c

2.Communication skills:Communication is key to a successful career and for an IT leader. And this has been the buzz word for many years and years, and the subject of many publications. Communication is considered by many of my peers as the one of the “Core” skills for successful leaders. So, in order to sharpen this skill, one must focus on the following areas:

Listening: (Listen with the intend to learn the other person’s point of view, pain points and what they mean). The best advise that was given to me was to repeat what the other person said to ensure you understand what they meant and that you have acknowledged them).

 

Be a mentor: This is a valuable quality to have and you will easily identify a good leader by seeing who takes time to mentor others. In working with some very talented individuals who have the ability to identify the problem in a short amount of time and still be humble about their ability is just priceless. But what amazes me more, is the ability for some of these successful individuals to be a mentor and a teacher. This is something that many leaders possess and is what differentiates a leader from a manager.

 

Empathy: In IT, we work with people and machines, and sometimes what we might think is not important to us, for the people we support it may mean their job or the inability to perform it. So, when interacting with any individual in the organization no matter what the situation is, we must have empathy and be able to relate to what they are going through. In order to exercise this, you can think of using some of the following words when in conversation: “I can see how not being able to print the patient lab results can cause frustration for you and the physicians, I am going to do my best to ensure that this is addressed”.

Emotional detachment: This is something that can be seen in few individuals in some organizations. The mistake is made when they bring their personal problems to work and allow it to influence their interactions inside the office. It is almost guaranteed that most of the successful technology leaders do not bring their dirty laundry to work with them. If you are finding yourself coming to work after an argument and responding with “I am just not having a good day, i have some arguments with my wife, and I just don’t think I can concentrate today on my work!”. This is a sign that you need to focus on learning how to disconnect from your personal problems and focus on your work. Do not let those emotions influence how you interact and respond to people at work and continue to care for others.

 Respect others and treat everyone dignity: One of the top reasons people leave their jobs is simply due to how their managers treat them. So, in order for someone to be a successful healthcare IT leader, they must treat everyone with respect and dignity. This means no gossip, if you are saying something about someone, say only what you would say to their face. Also, be helpful and do your best to assist others. There maybe times when you may not be able to assist them, but be honest and discuss with them and possibly set some up time later to assist with a task.

 

3.Continued learning:When I was growing up, I saw my dad reading magazines, newspapers and books all the time. At that point, I though to myself what a waist of time. But, I have realized since that learning is very important at all ages. Especially when you are staying up to date with healthcare regulations, as well as technology and your soft skills. This will help you engage in conversations with your peers and provide you with a better understanding of your domain. You will be amazed what an hour of reading or learning a day can do to your career. Whether you decide to wake up earlier in the morning, or take a weekend class, or even listen to an audio book during your commute.


October 24, 2010  9:03 PM

Simple steps to streamline Vitals capturing



Posted by: RedaChouffani

It is no news that the implementation of an EHR does add more workflow for everyone in the organization initially.  And as we continue to identify new ways to streamline the workflows in the clinical department, it is has to ignore how some simple tasks do require time that may not be necessary.

Currently, almost every medical organization gathers vitals at almost every date of service. And now with meaningful use requiring clinical staff to track patient vitals electronically, some  are considering ways of how to use digital vitals capture systems, and do away with a nurse having to manually enter the data into the chart or on paper.  Even though it may not be lots of data to enter, it is easy to see how such devices can speed up the data capturing process.  Several products are available in the market place from vendors like MidMark and Welch Allyn that provide wireless/wired medical devices that can interface with some of the commonly used EHR products in the market.  This simple integration can reduce the time to capture vitals that is commonly associated with the need for clinical staff to read thermometers, blood pressure gauges and other commonly used equipment.

For larger organizations, some of these devices are a must, especially for patients where the readings on blood pressure, pulse rate and body temperature must be done more frequently.

In addition, with the rise of chronic disease, aging population that requires in some cases close monitoring to ensure immediate medical intervention telehealth has a great opportunity to improve health of many patients.

We will continue to see more adoption of these devices, interoperability is still one of the biggest challenges that vendors will face.  There have been several alliances amongst manufactures and health organizations that are working toward create standardization and ensure interoperability.


October 22, 2010  11:42 PM

How does Medicare plan on tackling its projected rising costs and burden on tax payers



Posted by: RedaChouffani

I ist no news that our country suffers from a terrifying and undeniably large deficit. This number continues to grow, and as outlined by the congressional budget office (Center on budget and policy Priorities), Medicare and other health programs are estimated to cause the exponential growth.

So what is our government to do in order to balance the budget and take control of the situation. It is hard to identify from political debates and interviews what solutions will be utilized to reduce or control Medicare costs in the next decades, and especially ones that can truly be proven models based on pilots.

 

First, if we look closely at the overall goals of the America Recovery and Reinvestment Act (ARRA), we are certain to find the direction the incentives are looking to accomplish. Starting by “Invest in health care and other essential public services to ensure the long-term economic health of our nation”, and also to “encourage health information technology”. There are additional goals that have been outlined, but for this article we will focus on just these two. The reason these two are important, is simply that they provide the carrot at the end of the stick to enable Medicare and some of the other health services to make the shift toward a much sustainable healthcare system.

 

 

One of the first indicators of such a shift for CMS to ensure the long-term economic health of our nation, is the move away from traditional fee-for-service programs that most everyone is participating on today. The new direction is called Accountable Care Organization (ACO). This is a group of healthcare providers that agree to be accountable for the quality, cost, and overall care of the Medicare beneficiaries. This direction will ultimately encourage improved outcome measures which would ultimately reduce the overall costs to CMS. The savings anticipated from an ACO structure are coming from the reduction of hospitalizations, unnecessary use of specialists and diagnostic services, plus improving outcomes on patients with chronic illnesses. These programs are planned to start in January of 2012, and are already receiving criticism as HHS has not defined many of the criteria.

 

However, this initiative would most likely require the ACO participating physicians to ensure the use of better communication tool to coordinate care of patients. Which takes us to the next aspect of this.

The move to an ACO would ultimately require the use of an EMR system that will enable data exchange and coordination and care amongst physicians that may not be affiliated with the the same the same hospital system.

 

The next piece of discussion comes for a recently published article in the NY Times by David Leonhardt titled “Proving Innovation in Medicare”. In this piece, David touches on an example of how Medicare may reduce costs by only paying for the technology that in fact does improve patient’s health. The plan is to provide new treatments three years to prove that they worked better than the cheaper alternative treatment. The idea behind this is to ensure that Medicare is not payment for new expensive treatment that is not proven to be a much more effective one. This would in turn reduce waste or unnecessary unjustified treatment.

 

The fact of the reality is that with the growing rate of uninsured, the current healthcare reform and growing numbers of baby boomers, CMS is facing serious challenges. And while reimbursement levels are not where they should be, CMS still has long ways to go to ensure it can sustain its public service and ensure that health care providers can still keep their doors open and provide care of their patients. As we look at the changing coming our way, we must keep an open mind about the changes and why some of them are unavoidable.


October 17, 2010  9:27 PM

Top 5 reasons why a healthcare organization should consider a Kiosk



Posted by: RedaChouffani
Uncategorized

In my previous blog post, I focused on identifying why health care Kiosks are expensive and complex. However despite that, they can be a source of revenue and free up additional resources in the organization.  Here we will describe the top 5 reasons some groups should implement Kiosks for patient self service:

1.Patient satisfaction:
As a patient and parent of a patient, I have to admit that wait time and paperwork are some of the things that influence my experience at the medical practice. A Kiosk would typically provide a faster way to check-in without waiting in line as well as enabling a patient to enter the data using point click and/or keyboard. This would eliminate the need for clipboards and pens and paper.

2.Capture revenue:
During the check-in process and with a insurance eligibility functionality of some Kiosks, an organization can capture the payments for patient co-pays as well as payment on their balance owed.
In addition to co-pays, having the kiosk verify insurance information will ensure that all claims are not denied and that will ensure that no revenue is lost due to not filling claims or disputed ones.

3.Improve resource utilization:
In many organizations, the front desk staff are responsible for checking in patients, taking their co-pays , providing the patient with the clipboards, and answering some of the patient requests such as copies of medical records. With a self service Kiosk, patients can interact with a computer through a touch or keyboard and mouse.  This would eliminate the wait for a front desk staff member for basic assistance. This means that now the front desk can provide assistance to the rest of the patients that are not able to efficiently use the Kiosk and also any other requests that are out of the scope of the Kiosk’s ability.

4.Reduce paper forms:
In most medical organizations that have gone paperless or “paper-less” they realize that many of the documents that are outside the clinical department are still paper format.  This means that in order to be completely paperless all patient consent forms, medical history must be captured electronically, or scanned in.  Web portals are becoming a good source of digital documents from the patients, and Kiosks are bring that same value.

5.Provide patient value-add through self service:
Some of the Kiosks in the market provide additional services such as a copy of patient medical records in a USB flash card.  It also provides an option for patients to make payments on their open balance and future appointments.

While there are additional advantages to utilizing a Kiosk in a medical organization, it is important to note that many of those are and can be customized to the spercific organizational challanges and needs.


October 15, 2010  9:29 PM

Top 5 reasons why healthcare Kiosks are expensive and complex



Posted by: RedaChouffani

In a non health care settings, Kiosks are widely used.  From airports to hotel check outs.  In health care adoption has been slow.  But with organizations facing tighter budgets and looking at cutting costs, a Kiosk would be an attractive solution to reduce front desk staff and automate some of the processing at check-in.But the reality is that in most cases, some of functionality needed in the health care arena would be more complex than the ones seen in train stations and other public areas.

There are several reasons that contribute to the slow adoption of Kiosks.  Ranging from the high capital investment needed up front to the lack of patient usability.  Following are the top 5 reasons why Kiosk are more expensive and complex:

Lack of open architecture in EHR: A Kiosk is meant to facilitate and also electronically capture data by allow self service for the patients.  Unfortunately that information such as Medical History and payments can not be automatically be pushed or captured by most EHR packages.  Some vendors have relationships with some KIOSK providers, but still leaves a majority of them without integration or interoperability capability.

Costs:
In many cases a kiosk will integrate several different hardware devices, ranging from biometric identity, credit card reader, digital cameras and touchscreen.  This increases the cost of a single unit.  In addition the software inside the kiosk would require an interface engine.  When shopping for these devices and without understanding the value of the product, the price can overshadow the value that many of these devices can bring to the table.

Lack of patient adoption:
Clearly we have seen that some of the elderly choose the traditional route and fill their medical history by paper, it is difficult to justify to the practice that potentially a small percentage of their patients will even attempt to utilize the device to capture information such as their demographics, medical history and other details of their health.

Data requirements:
Unlike an airport kiosk that only requires to identify you, and few clicks to checks the bags in, a medical Kiosk can require the entry of lots of data.  Example: medical History, chief complaint, consent forms, specialty medical questionnaire and of course all the other requirements such as payments and appointment details.

Complexity of systems:
From a technology stand point, this device most definitely contains the most integrations.  This system not only has to communicate with the different hardware devices connected to it, but it also must be able to exchange information and perform the some of the following tasks:

Process Patient Demographics by interfacing to the PMS through XML or HL7     (sometimes ODBC).
Process credit card payments and use web services or model to get authorization
Capture digital signature and merge it with the organization’s forms
Check patient eligibility with payers using X12  270/271
Post payments to the PMS using XML 232 format.

Ultimately as any other project, a kiosk is an investment, and it will need to show real results.  Wether it is from reducing the resource utilization for basic patient needs, or simply improving patient satisfaction.  The organization will need to consider several things to ensure it maximizes the success of the project, from Location of the devices, ease of use, interoperability, and beneficial to the group.


October 10, 2010  10:33 PM

Medicare and some of the changes coming with 2011



Posted by: RedaChouffani
Medicare

The end of 2010 is nearing, and many organizations are reflecting on all the successes and challenges they had during the year.   Many of which were changes beyond their control that had significant impact on their business.  These changes ranged from a difficult economy to new federal mandates.  But for many, all the adjustments that are being done in Medicare may present the biggest concerns yet.

 

Some of the interesting areas that will be part of the New Year 2011 that will go in effect for Medicare are as follows:

Physician Compare Website:

After seeing Hospital Compare web site that compares different hospital organizations (about 4681 based on my latest data download) http://www.hospitalcompare.hhs.gov/.   we will be seeing a similar posting of information online.  This would provide information on physicians enrolled in the Medicare program and other eligible professionals who participated in PQRI.

 

Preventive Benefits:

 Medicare will begin to cover all of Annual wellness visit providing a personalized prevention plan for beneficiaries of Medicare Part B, and with no co-pays or deductible for the prevention plan services. (Sec. 4103, H.R. 3590).

 

10% Bonus payment for surgeons and primary care:

Expands access to primary care doctors and general surgeons providing services in areas where there are physician shortages by providing them with a 10 percent Medicare payment bonus for five years (Sec. 5501, H.R. 3590).

 

Payment cuts for physician-related services:

Currently the biggest threat to healthcare organizations across the nation is the payment cuts planned in January 2011 (-23.5%).  The rule also includes an additional 6.1% under the SGR (sustainable growth rate formula.  Of course everyone is waiting to see if congress would vote to freeze the cuts or delay them.

Several of these changes will have some major impact on organizations, and especially hospitals who already suffer from a disproportionate Medicare/Medicaid Payment to cost, will see additional cuts to their reimbursement.  This would most likely drive their costs up, or reduce even further their margins.  One thing certain and that is, whether it is an IDN, hospital or a small practice, many will see a significant impact that will require creative solutions to lessen the negative consequences.

 

 

 

 


October 9, 2010  9:14 PM

OpenSource EHR VistA



Posted by: RedaChouffani
In the 70‘s, a group of individuals working in the federal government recognized that there is a need for basic functionality that is required in order to manage health information (Patient Information Management, Laboratory, Pharmacy, Radiology, Notes, etc). At first, an application called Decentralized Hospital Computer Program (DHCP) was the original name was developed.

As the application evolved over time, several modules were added and continue to be added. Ranging from Imaging, Pharmacy and laboratory.

The basic architecture continued to be the same over 20 years, and has been ported into different products such as CHCS in 1988. Currently the following agencies are actively using DHCP or now called VistA: DOD, VA, Indian health service.

MUMPS was the programming language and database used for VistA. This language was very advanced in its time. But as technology evolved, there has been a greater demand for more integration. Whether it is the interfacing of VistA to a billing system, or two hospitals attempting to exchange records. Several new technologies have been implemented since the invention of the Internet, and that meant that VistA needed to be adapted to allow for communication over new protocols and communication methods such as: Web services.

As the application has been adopted by different entities, the solution has been adapted to several different platforms including: WorldVistA, OpenVista, vxVistA

As technology continues to develop, and programming languages evolve, there has been a clear need for better user interfaces as well as strong object oriented languages. In response to those changes, many open source initiatives have been started and enabled VistA to have web interfaces by Using web MUMPS gateways. Also several other solutions are available such as EsiBojects, Cache ObjectScript which allow for the use of modern object-oriented tools.

Many healthcare entities have voiced concerns on need for billing modules to be added to VistA to make it a bit more attractive in the EHR market place. Fortunatly, there have been organizations that have extended teh functionality of the opensource VistA such as Medsphere. One question on every one’s mind is when is the VA or Medsphere going to certify its product according to the certification process outlined by the ONC.

 


October 3, 2010  9:15 PM

Free Vocabulary translation engine for HHS



Posted by: RedaChouffani
HHS, Kaiser

Kaiser one of the largest non profit health plans in the US for many years has been responsible for the development of a core Convergent Medical Terminology CMT system that has been privately used in their HealthConnect solution. This kp asset that has been serving as a common repository for terminology translation. Ranging from SNOMED CT, DICOM, RxNORM, NIC, NOC, NANDA,LOINC for labs to First Data Bank drug terminology.

Their role has become even greater as many HIEs are seeking interoperability and vocabulary translation to enable common languages from ICD9/10, Procedures with CPT, and other HL7 vocabulary concepts. Of course one of the core services that differentiates Kaiser CMT from the rest of vocabulary repositories is the ability to use logic-based definitiones to identify matches for specific content.

On September 29th, 2010 Kaiser Permanente announced that it will make their CMT solution available to a wide rande of Healthcare IT developers and users to speed the implementation of EHR associated with the ARRA. This was a significant donation from the Kaiser to HHS. The CMT concepts have been developed over the years and has created a significant semi-automated translation from clinician documentation to administrative billing codes and crossing from labs, radiology, immunizations, pharmacy as well as EKG.

 


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