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CommonWell and Healthcare Interoperability

Posted on June 27, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

2016 June - CommonWell and Healthcare Interoperability-headshots

For our next Healthcare Scene interview, we’ll be sitting down with Scott Stuewe, Director at Cerner Network and Daniel Cane, CEO & Co-Founder at Modernizing Medicine on Wednesday, June 29, 2016 at 3 PM ET (Noon PT). Cerner was one of the Founding Members of CommonWell and Modernizing Medicine just announced they were joining CommonWell. No doubt these diverse perspectives will provide an engaging discussion about the work CommonWell is doing to improve healthcare data sharing.

You can join my live conversation with Scott Stuewe and Daniel Cane and even add your own comments to the discussion or ask them questions. All you need to do to watch live is visit this blog post on Wednesday, June 29, 2016 at 3 PM ET (Noon PT) and watch the video embed at the bottom of the post or you can subscribe to the blab directly. We’re hoping to include as many people in the conversation as possible. The discussion will be recorded as well and available on this post after the interview.

As we usually do with these interviews, we’ll be doing a more formal interview with Scott Stuewe and Daniel Cane for the first ~30 minutes of this conversation. Then, we’ll open up the floor for others to ask questions or join us on camera. CommonWell has become a big player in the healthcare interoperability space with most of the major EHR vendors involved, so we’re excited to learn more about what’s happening with CommonWell.

If you’d like to see the archives of Healthcare Scene’s past interviews, you can find and subscribe to all of Healthcare Scene’s interviews on YouTube.

Dallas Children’s Health and Sickle Cell Patients: Cobbling Together a Sound Solution

Posted on June 23, 2016 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

Sickle cell anemia (SCA) is a genetic, red blood cell condition, which damages cell walls impeding their passage through capillaries. Episodic, it is often extremely painful. It can damage organs, cause infections, strokes or joint problems. These episodes or SCA crises can be prompted by any number of environmental or personal factors.

In the US, African Americans are most commonly susceptible to SCA, but other groups can have it as well. SCA presents a variety of management problems in the best of circumstances. As is often the case, management is made even more difficult when the patient is a child. That’s what Children’s Health of Dallas, Texas, one of the nation’s oldest and largest pediatric treatment facilities faced two years ago. Children’s Health, sixty five percent of whose patients are on Medicaid, operates a large, intensive SCA management program as the anchor institution of the NIH funded Southwestern Comprehensive Sickle Cell Center.

Children’s Health problem wasn’t with its inpatient care or with its outpatient clinics. Rather, it was keeping a child’s parents and doctors up to date on developments. Along with the SCA clinical staff, Children’s Chief Information Officer, Pamela Arora, and Information Management and Exchange Director, Katherine Lusk, tackled the problem. They came up with a solution using all off the shelf technology.

Their solution? Provide each child’s caregiver with a free Verizon smartphone. Each night, they extracted the child’s information from EPIC and sent it to Microsoft’s free, vendor-neutral HealthVault PHR. This gave the child’s doctor and parents an easy ability to stay current with the child’s treatment. Notably, Children’s was able to put the solution together quickly with minimal staff and without extensive development.

That was two years ago. Since then, EPIC’s Lucy PHR has supplanted the project. However, Katherine Lusk who described the project to me is still proud of what they did. Even though the project has been replaced, it’s worth noting as an important example. It shows that not all HIE projects must be costly, time-consuming or resource intense to be successful.

Children’s SCA project points out the value of these system development factors:

  • Clear, understood goal
  • Precise understanding of users and their needs
  • Small focused team
  • Searching for off the shelf solutions
  • Staying focused and preventing scope creep

Each of these proved critical to Children’s success. Not every project lends itself to this approach, but Children’s experience is worth keeping in mind as a useful and repeatable model of meeting an immediate need with a simple, direct approach.

Note: I first heard of Children’s project at John’s Atlanta conference. ONC’s Peter Ashkenaz mentioned it as a notable project that had not gained media attention. I owe him a thanks for pointing me to Katherine Lusk.

E-Patient Update: Apple Offers iPhone EMR Access

Posted on June 22, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Over the last few years, Apple has steadily beefed up the health data access provided by its iPhone operating system, in ways that have made some sense. But depending on how consumers react, its latest effort may have the biggest impact of all of its data sharing efforts to date.

In its latest mobile operating system, Apple is allowing users to store their EMR data directly in its Health app, using the HL7 CCD standard. And while this isn’t a huge step forward for interoperability, it does give e-patients like me a greater sense of control, which is definitely a good thing.

In recent years, Apple has made increasingly sophisticated efforts to unify healthcare data. Perhaps the highest profile effort is the summer 2014 launch of HealthKit, a healthcare data integration platform whose features include connecting consumer-generated data with traditional clinical sources such as the Epic EMR.

Meanwhile, it has steadily added capabilities to the Health app, which launched with iOS 8. Since then, it has been encouraging consumers to manage health data on their phone using HealthKit-enabled apps like the Epic MyChart patient portal app. The new EMR data retrieval function is available in the iOS 10 version of Health.

According to Apple blog 9to5Mac, consumers can import the CCD data from Mail, Safari and other applications as well as into Health. When consumers add the CCD file to Health, the app opens and providers a quick preview of the document’s data, including the healthcare provider’s name, patient’s name and document owner’s name. It also identifies the document’s custodian. Once downloaded, the device stores the document in encrypted form, indefinitely.

Also, when a user confirms that they want to save the record to the Health app, the CCD info is added to a list of all of the health record documents stored in the app, making it easier to identify the entire scope of what a user has stored.

Looked at one way, the addition of medical record storage capabilities to the latest iOS release may not seem like a big deal. After all, I’ve been downloading broad swaths of my healthcare data from the Epic MyChart app for a couple of years now, and it hasn’t rocked my world. The document MyChart produces can be useful, but it’s not easily shareable. How will it change patients’  lives to store multiple records on their cell phone, their tablet or heaven help us, their Apple Watch?

On the surface, the answer is almost certainly “not much,” but I think there’s more to this than meets the eye. Yes, this solution doesn’t sound particularly elegant, nor especially useful for patients who want to share data with clinicians. My guess is that at first, most consumers will download a few records and forget that they’re available.

However, Apple brings something unique to the table. It has what may be the best-integrated consumer technology base on the planet, and can still claim a large, fanatical following for its products. If it trains up its user base to demand EMR data, they might trigger a cultural shift in what data patients expect to have available. And that could prove to be a powerful force for change.

Practice Fusion Settles FTC Charges Over “Deceptive” Consumer Marketing

Posted on June 20, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In what may be a first for the EMR industry, ambulatory EMR vendor Practice Fusion has settled Federal Trade Commission charges that it misled consumers as part of a campaign to gather reviews for its doctors.

Under the terms of the settlement, Practice Fusion agreed to refrain from making deceptive statements about the privacy and confidentiality of the information it collects from consumers. It also promised that if it planned to make any consumer information publicly available, it would offer a clear and conspicuous notice of its plans before it went ahead, and get affirmative consent from those consumers before using their information.

Prior to getting entangled in these issues, Practice Fusion had launched Patient Fusion, a portal allowing patients whose providers used its EMR to download their health information, transmit that information to another provider or send and receive messages from their providers.

The problem targeted by the FTC began in 2012, when Practice Fusion was preparing to expand Patient Fusion to include a public directory allowing enrollees to search for doctors, read reviews and request appointments. To support the rollout, the company began sending emails to patients of providers who used Practice Fusion’s EMR, asking patients to review their provider. In theory, this was probably a clever move, as the reviews would have given Practice Fusion-using practices greater social credibility.

The problem was, however, that the request was marketed deceptively, the FTC found. Rather than admitting that this was an EMR marketing effort, Practice Fusion’s email messages appeared to come from patients’ doctors. And the patients were never informed that the information would be made public. And worse, a pre-checked “Keep this review anonymous” only withheld the patient’s name, leaving information in the text box visible.

So patients, who thought they were communicating privately with their physicians, shared a great deal of private and personal health information. Many entered their full name or phone number in a text box provided as part of the survey. Others shared intimate health information, including on consumer who asked for dosing information for “my Xanax prescription,” and another who asked for help with a suicidally depressed child.

The highly sensitive nature of some patient comments didn’t get much attention until a year later, when EMR and HIPAA broke the story and then Forbes published a follow up article on the subject. After the articles appeared, Practice Fusion put automated procedures in place to block the publication of reviews in which consumers entered personal information.

In the future, Practice Fusion is barred from misrepresenting the extent to which it uses, maintains and protects the privacy or confidentiality of data it collects. Also, it may not publicly display the reviews it collected from consumers during the time period covered by the complaint.

There’s many lessons to be gleaned from this case, but the most obvious seems to be that misleading communications that impact patients are a complete no-no. According to an FTC blog item on the case, they also include that health IT companies should never bury key facts in a dense privacy policy, and that disclosures should use the same eye-catching methods they use for marketing, such as striking graphics, bold colors, big print and prominent placement.

Long Standing EHR Issues That Remain Unaddressed

Posted on June 17, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Dr. Jayne has presented a pretty great voice of reason in her blog posts about the realities of being a doctor in the meaningful use era. In a recent post she offered this comment which I’ve heard from many doctors:

And while we as physicians are having to cope with arduous workflows as a result of the regulations, there are advancements that would really benefit us that remain unaddressed.

I realize that EHR vendors have to prioritize requests from users. Plus, they have to deal with massive government regulation which has made it hard to prioritize user requests over government regulations. However, I know from the end user standpoint Dr. Jayne’s comment about the advancements that could be made in an EHR that still haven’t been added creates a really awful feeling.

Dr. Jayne also added this sad observation:

We’re forced to gather loads of information that could be put to good use but isn’t. For example, we collect information on race, ethnicity, religious preference, language preference, sexual orientation, and more. In many cases, it’s not used to further clinical care. It would have been great to have a prompt to ask about religious fasting the other night when I was treating a patient with profound dehydration. Although it occurred to me to ask, it didn’t occur to my patient care technician or to the resident I was supervising.

The optimistic side of me says that comments like this are a very good thing. 5-10 years ago, doctors wouldn’t have even thought to request this kind of feature. All they wanted to do was automate the paper charts. So, it’s progress that now we’re talking about ways we can incorporate the data in an EHR at the point of care in a much more effective way.

Now if EHR vendors can just be given the flexibility to work on these challenging problems instead of a list of prescriptive goverment regulations which just add to the burden of doctors as opposed to creating magical experiences.

Government Involvement in Healthcare IT – How Meaningful Use Went Wrong

Posted on June 15, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I have about 150 draft blog posts on EMR and EHR. Most of them are ideas for future posts. Unfortunately, I get so many new ideas, a lot of the drafts remain draft blog posts for long periods of time. I probably should create a better process for tracking my blog post ideas, but this was worked so far. Plus, it’s fun to go back and see what past ideas I had for posts and then think about how things have changed or whether that insight has stood the test of time.

This post is an example of that and the draft blog post contained a tweet that Greg Meyer shared during a #HITsm Twitter chat back in December 2014. Here’s the tweet:

No doubt Greg’s tweet resonated with me back in 2014 and still resonates with me today. In meaningful use, the government got way too deep into the how and caused all sorts of unintended consequences. We’d be in a much better position if the government would have just defined the measures and functions and not how you actually got there.

What’s interesting is that this is more or less what I’ve been hearing from Andy Slavitt in regards to MACRA. I’m not sure CMS has executed this vision well, but it’s at least hopeful that their leader is espousing a similar approach to what Greg describes above.

I’d also point out an insight I believe I first heard from Dr. Michael Koriwchak. He espoused the principle that CMS shouldn’t require the collection of any data which it wasn’t going to actually use. Think about how meaningful use would have been totally different if they’d employed this rule. What value is there to healthcare if we collect a whole bunch of data that’s never actually used to improve care?

Do you think CMS will get this right with MACRA? Share your thoughts in the comments.

Fixing Small Stress Inducing Moments Creates Magic

Posted on June 13, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I thought this was a really genius perspective that I heard at the WEDI Annual conference. Or at least it was the thought that was inspired at the conference. I think the speaker was referencing various apps like Uber or Lyft and how they took a whole set of small, individually stress inducing moments and solved them.

Using that example, it was stressful to wonder when the cab would come, it’s stressful to know if the cab will take credit cards, it’s stressful to know if the cab is taking a longer route to make you pay more, etc etc etc. None of these individually was all that stressful but combined they made for a pretty stressful experience. Uber and Lyft were able to look at all of those minor individual stresses and make a great customer experience by removing them.

It’s worth pointing out that these companies likely needed to solve more than one stress for their app to be successful. If they’d only solved one small stress, they likely wouldn’t be as popular today as they have been.

Now let’s apply this to healthcare IT. Ironically, I think many would argue that EHRs have taken a bunch of small stresses and turned them into large stresses. That’s the pessimistic viewpoint. Although, it’s pretty hard to argue that most EHR software has taken the stress out of the medical documentation experience. Is it any wonder that so many doctors hate EHR?

I guess I’m pretty pessimistic that EHR vendors will change and start taking the little stresses out of the healthcare experience. A few EHR vendors have done better than others but most of them are making so much money doing what they’re doing, they’re unlikely to change course. Does that mean we give up hope?

Not me. I’m optimistic about technology’s ability to make healthcare better. I just don’t think it’s going to come from EHR vendors. Instead, it’s going to come from entrepreneurs who do create magical experiences that take the small stresses out of a doctor’s or patient’s day. They may tie into the EHR, but they’ll build it separately.

What do you think? Where have you seen solutions that solve the “small” stresses in healthcare? We could use more “magic”.

New Effort Would Focus HIE Data Around Patients

Posted on June 7, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In theory, doctors should be able to pull up all data available on a patient located within any networks to which they have access. In other words, not only should they be able to see any data on Patient A within the EMR where A’s care is documented, but also retrieve data on A from within any HIEs which connect with the EMR. But the reality is, that’s not always the case (in fact, it’s rarely the case).

To help weave together patient data strung across various HIEs, three exchanges have teamed up to pilot test the idea of a patient-centered data home (PCDH). While many health leaders have looked at the idea of putting patients in charge of their own data, largely by adding to or correcting existing records, getting patients involved in curating such data has been difficult at best.

In this model, Arizona Health-e Connection, western Colorado’s Quality Health Network and the Utah Health Information Network are testing a method of data sharing in which the other HIEs would be notified if the patient undergoes an episode of care within their network.

The alert confirms the availability and specific location of the patient’s clinical data, reports Healthcare Informatics. Providers will then be able to access real-time information on that patient across network lines by initiating a simple query. Unlike in other models of HIE data management, all clinical data in a PCDH will become part of a comprehensive longitudinal patient record, which will be located in the HIE where the patient resides.

The PCDH’s data sharing model works as follows:

  • A group of HIEs set up a PCDH exchange, sharing all the zip codes within the geographic boundaries that their exchanges serve.
  • Once the zip codes are shared, the HIEs set up an automated notification process which detects when there is information on the patient’s home HIE that is available for sharing.
  • If a patient is seen outside of their home territory, say in a hospital emergency department, the event triggers an automated alert which is sent to the hospital’s HIE.
  • The hospital’s HIE queries the patient’s home HIE, which responds that there is information available on that patient.
  • At that point providers from both HIEs and query and pull information back and forth. The patient’s home HIE pulls information on the patient’s out-of-area encounter into their longitudinal record.

The notion of a PCDH is being developed by the Strategic Health Information Exchange Collaborative, a 37-member HIE trade group to which the Utah, Arizona and Colorado exchanges belong.

Developing a PCDH model is part of a 10-year roadmap for interoperability and a “learning health system” which will offer centralized consent management and health records for patients, as well as providing national enterprises with data access. The trade group expects to see several more of its members test out PCDHs, including participants in Arkansas, Oklahoma, Indiana, Kentucky and Tennessee.

According to the Collaborative, other attempts at building patient records across networks have failed because they are built around individual organizations, geographies such as state boundaries, single EHR vendors or single payers. The PCDH model, for its part, can bring information on individual patients together seamlessly without disrupting local data governance or business models, demanding new technical infrastructure or violating the rights of local stakeholders, the group says.

Like other relatively lightweight data sharing models (such as the Direct Project) the PCDH offers an initial take on what is likely to be a far more complex problem. But it seems like a good idea nonetheless.

Specialty-Focused EHRs Re-Entering The Picture

Posted on June 6, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Over time, I’ve read a great deal on whether specialist clinicians should invest in EHRs designed for their area of practice or not. One school of thought seems to be that specialists can do just fine by buying broadly-based systems and implementing practice-specific templates, a move which also offers them a longer list of EHRs from which they can choose. Another, meanwhile, is that EHRs designed for use by all clinicians can undercut practice efficiency by forcing specialist workflow into a one-size-fits-all straightjacket.

But the arguments in favor of specialized EHRs seem to be taking hold of late. According to the latest data from Black Book, specialist surgical and medical practices have been switching over to specialty-driven EHRs in overwhelming numbers during the first half of this year. Its researchers found that during the first and second quarter of 2016, 86% of the 11,300 specialty practices it surveyed were in favor of switching from generalist to specialist EHRs.

According to the research firm, 93% of specialists surveyed felt that templates available in specialty EHRs offered a substantial benefit to patients who needed individualized documentation, especially in practices that see a high volume of predictable diagnoses.

If that’s the case, why did so many specialists start out with generalized EHRs?  Eighty-nine percent of respondents said that they bought the non-specialist EHR they had because they were focused on meeting Meaningful Use deadlines, which left them too little time to vet their original EHR vendor sufficiently.

Lately, however, specialist practices have decided that generic EHRs just aren’t workable, Black Book found. Nearly all respondents (92%) said that given their workflow needs, they could not afford to spend time need to shape all-purpose systems to their needs. When they switched over to purchasing a specialty-driven EHR, on the other hand, specialists found it much easier to support ultra-specific practice needs and generate revenue, Black Book reported.

That being said, specialists also switched from generalized EHRs to practice-specific systems for reasons other than clinical efficiency. Black Book found that 29% of specialists make the change because they felt their current, generic EHR was not achieving market success, raising the possibility that the vendor would not be able to support their growth and might not even be stable enough to trust.

Specialists may also be switching over because the systems serving their clinical niche have improved. Black Book researchers note that back in 2010, 80% of specialist physicians felt that specialized EHRs were not configurable or flexible enough to meet their needs. So it’s no surprise that they chose to go to with more robust multi-use and primary care systems, argues Black Book’s Doug Brown.

Now, however, specialized EHRs perform much better, it seems. In particular, improvements in implementations, updates, usability and customization have boosted satisfaction of specialist EHRs from 13% meeting or exceeding expectations in 2012 to 84% in the second quarter of 2016.

Still, practices that buy specialty EHRs do make some significant trade-offs, researchers said. Specifically, 88% of specialists said they were concerned about a lack of interoperability with other providers, particularly inpatient facilities. Respondents reported that specialty-specific EHRs aren’t fitting well within hospital network and regional health information exchanges, imposing a considerable disadvantage over large multispecialty EHRs.

And not surprisingly, investing in a replacement specialty EHR has proven to be a financial burden for specialist practices, Black Book concluded. Forty-eight percent of all specialty practices switching EHRs between June 2014 and April 2016 said that making such investment has put the practice in an unstable financial position, the research firm found.

My general sense from reading this research is that specialist practices have good reasons to replace their generalized EHR with a specialist EHR these days, as such products appear to have matured greatly in recent years. However, these practices had better be ready to deploy their new systems quickly and effectively, or the financial problems they’ll inherit will outweigh the benefits of the switchover.

Physician Burnout Graphic

Posted on June 3, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This was a really impactful graphic that seemed perfect for a Friday post on Physician Burnout:
Physician Burn Out Graphic

Thanks Rasu for sharing it.

Here’s the list of physician burnout items for those following along at home:

  • Patient Generated Data
  • Quality Metrics
  • Other Health Professionals
  • Telemedicine
  • Lack of Genomic Knowledge
  • Reimbursement
  • Retail Based Clinics
  • EHR Frustration
  • Transparency Office Notes
  • Algorithms
  • Super and Cloud Computing
  • Scorecards
  • Online Health Social Networks
  • Patient Satisfaction
  • Online Reviews; Getting Yelped
  • Relative Value Units

Was there something left off the list? Do we really need to add any more to the list to understand why physicians are getting burnt out? Do you see any relief on the horizon?