Marianne McGee on what a lot of people in healthcare informatics are wondering: what are the challenges to being recognized for “Meaningful Use” of Electronic Health Records?

I suspect I am not the only one who depends on Marianne McGee to keep me in the know about the evolving knowledge about how the “meaningful use” criterion are going to be fully established, reviewed, and operationalized. I would like to know as much as she or John Halamka but I have a dissertation to finish!

from http://www.informationweek.com/blog/main/archives/2010/04/top_10_meaningf.html

Meaningful use criteria will come into effect in three incremental stages. Stage one starts in 2011, followed by stage two in 2013, and stage three in 2015. Healthcare providers have until end of 2014 to achieve any of the stages, but the more stages they achieve before 2015 the bigger the payout in meaningful use bonuses they’ll get. (By 2015, penalties will begin kicking in for non-compliance.)

Right now, it’s estimated that fewer than 6% of the nation’s healthcare providers have health IT–such as e-health records and computerized physician order entry systems–in place to meet even stage-one meaningful use requirements, said Walt Zywiak, a CSC principal researcher in an interview with InformationWeek.

1. Capture the data–that includes collecting and entering data in a structured formats so that data can be sorted and selected for reporting purposes, said Zwiak.

2. Establish effective workflows to reinforce data entry, including medication reconciliation. For instance, “often, an organization’s workflow needs to be modified to make sure data is entered,” while patients are being cared for, whether it’s vital signs like blood pressure or allergy updates, said Zywiak.

3. Drive provider involvement in adoption of the EHR. “The primary users of these systems need a say” in what’s selected, said Zwiak.

4. Computer-based provider order entry (CPOE). “In ambulatory settings, 80% of orders, including tests, referrals and medication prescriptions, will need to be entered electronically,” he said.

5. Start e-prescribing. “Do this as soon as possible,” he said.

6. Develop a process for managing clinical decision support. This could include different clinical reminders for individual doctors in the same multi-specialty practice. For instance, a primary care doctor might need different alerts than a dermatologist caring for the same diabetic patient.

7. Implement patient health information exchange workflows. As a healthcare provider, “you’ve got to provide patients access with information–but will you do this via a patient portal or through a [third party] personal-health record” site, such as Google Health, said Zwiak.

8. Formulate a provider health information exchange strategy. “How will you exchange patient summary data with hospitals, specialists?,” he said.

9. Ensure privacy and security compliance. “Most primary care organizations haven’t been on an EHR, so they think of HIPAA in terms of protecting paper-based information,” he said.

10. Initiate EHR-based quality performance measurement support. “You’ll need to report quality measures to Medicare and Medicaid,” he said.

a year later, the details of “meaningful use” are coming into focus

Almost one year ago, the President signed the HITECH Act: “Health Information Technology for Economic and Clinical Health” as part of ARRA, the “American Recovery and Reinvestment Act.” This part of the stimulus bill is intended to incentivize the migration away from legacy paper health records and non-standard health records towards electronic health records (EHRs), via incentive payments to physicians of up to $44,000, starting next year.

Since the passage of ARRA, there has been much speculation and some tentative analysis of how the criteria for “meaningful use” of EHR/EMR will play out. With the recent announcements by the Feds, the details are at last becoming more-or-less apparent. There is still the period of review and input from stakeholders and the public, so there may be some changes, but at this point the basic operational definitions can be characterized. My friends at Software Advice.com put together a very useful summary and representation of how the suits at CMS and ONC are making sense of the “meaningful use” provision:

“In the table below, we’ve combined the meaningful use objectives for both eligible professionals (physicians) and hospitals for the Stage 1 adoption year, the required EHR technology criteria to accomplish those objectives and what criteria the government will use to measure meaningful use.

CMS defines “meaningful use” as using an EHR for the objectives listed in the first column. The objectives fall under these general topics:

* Improving quality, safety, efficiency, care coordination, population and public health;
* Reducing health disparities;
* Engaging patients and their families; and,
* Ensuring adequate privacy and security protections for personal health information

For the first time, CMS has also outlined specific measurements for how the government will determine if an EHR is being used in a meaningful manner for the Stage 1 (2011) adoption year. Updated definitions of meaningful use for Stage 2 (2013) and Stage 3 (2015) EHR adoption periods will be released in the year before those periods begin.

This table outlines what Stage 1 objectives define meaningful use, what software features are necessary to accomplish those objectives and what criteria the government will use to measure meaningful use. EP refers to eligible professional.

For the full article, see http://www.softwareadvice.com/articles/medical/the-stimulus-bill-and-meaningful-use-of-qualified-emrs-1031209/

“meaningful use” criterion for EHR/EMR’s proposed

The Feds are moving forward with operationalizing “meaningful use”, as CMS and ONC have now put out an official statement proposing a definition. After many months of speculation, it appears the Healthcare IT world is much closer to knowing just what hospitals and clinical practices need to do to get their chunk of the ARRA stimulus money. It is possible that the comments from interested parties may substantially modify what is being proposed here, of course:

from http://www.hhs.gov/news/press/2009pres/12/20091230a.html

“The proposed rule would define the term “meaningful EHR user” as an eligible professional or eligible hospital that, during the specified reporting period, demonstrates meaningful use of certified EHR technology in a form and manner consistent with certain objectives and measures presented in the regulation. These objectives and measures would include use of certified EHR technology in a manner that improves quality, safety, and efficiency of health care delivery, reduces health care disparities, engages patients and families, improves care coordination, improves population and public health, and ensures adequate privacy and security protections for personal health information.

The proposed rule would define meaningful use for the Medicare EHR incentive programs. It proposes one definition that would apply to eligible professionals participating in the Medicare fee-for-service and the Medicare Advantage EHR incentive programs as well as a proposed definition that would apply to eligible hospitals and critical access hospitals. These definitions also would serve as the minimum standard for eligible professionals and eligible hospitals participating in the Medicaid EHR incentive program. The rule proposes that states could request CMS approval to implement additional meaningful use measures, as appropriate, but could not request approval of fewer or less rigorous meaningful use measures than required by the rule.

This rule proposes a phased approach to implement the proposed requirements for demonstrating meaningful use. This approach would initially establish reasonable criteria for meaningful use based on currently available technological capabilities and providers’ practice experience. CMS will establish stricter and more extensive criteria for demonstrating meaningful use over time, as anticipated developments in technology and providers’ capabilities occur.

CMS provides a 60-day comment period on the proposed rule. “The definition and requirements for demonstrating meaningful use of EHR technology are proposals. CMS welcomes and will give serious consideration to comments that improve our proposal while achieving the goals Congress established for the EHR incentive programs,” Frizzera said.”

how important is Dell’s EHR/EMR project?

I just read that Dell is offering something called the Affiliated Physicians EMR Solution

Possibly reflecting my background as much more of a software than a hardware person, I am not at all sure how much of a game changer this is. Dell is a mighty force in the IT world, no doubt about that. I think there is a pretty obvious logic that medical offices could benefit from a standardized, modularized, low-cost integrated server solution with (say) Linux as the OS and MySQL or MS SQLServer handling queries generated by interacting with an EHR/EMR user-end application.

But while Dell has a proven track record in delivering low-cost solutions, I am not sure why they are an obvious fit for an EHR/EMR solution. Is it because they can sell cheap servers? But why have the server farm at the office at all? Why not run it on the “cloud” at a server farm somewhere? Is Dell wanting more of the hosted applications market? If that is the game, then the medical offices are not necessarily interacting with the hardware provider in any meaningful way, so much as outsourcing their EHR/EMR needs to a hosting company or Software as a Service company.

Of course ensuring HIPAA compliance is no trivial matter, but still…can Dell offer an on-site solution that is better than off-site hosted ones? Physicians typically have more money than time. Maybe the economies of scale involved here with Dell’s plan make it ultimately cheaper to host these mission-critical, data intensive applications yourself?

Maybe Dell is morphing from a hardware company to more of a services company? IBM has made a bundle dropping (relatively) low-margin hardware sales for higher-margin services and support. Nice work if you can get it. I suppose this is part of the strategy for righting the company after going through some difficult quarters even before the recession hit.

According to dell.com

“Together, Dell and participating hospitals are eliminating long-standing barriers to EMR adoption for small and medium medical practices: cost, complexity and interoperability. Dell’s Affiliated Physician EMR Solution lets hospitals sponsor their affiliated physicians with an EMR solution that is interoperable with the hospital’s own health information systems. The solution includes industry-leading EMR and practice management software, hardware systems, and a complete service and support portfolio. Financing options minimize physician up-front and out-of-pocket expenses until ARRA reimbursement starts.

Healthcare providers who adopt EMR and achieve “meaningful use” by 2011 are eligible to receive the maximum reimbursements of up to $44,000 in Medicare or $66,000 in Medicaid from the American Recovery and Reinvestment Act. Reimbursements decline every year thereafter until 2015. Physicians who do not achieve meaningful use by 2015 risk Medicare and Medicaid penalties.

Hospitals:
While many hospitals offer their affiliated physicians “access” to the hospitals’ health information systems, this still doesn’t manage the totality of patient care. In order for true coordinated care to exist, physicians and their patients must be connected with hospitals before admission. By sponsoring this EMR program, your hospital will be building this connection. Together with Dell, your hospital plays a pivotal role in supporting physicians with the ability to accelerate the use of health information technology, improve patient safety, and reduce healthcare costs.

Affiliated Physicians:
The question isn’t if you’re going to transition to electronic medical records (EMR). It’s when. But, faced with all of the decisions and regulations, getting from here to there can seem daunting. That’s where Dell comes in. Dell has created a comprehensive solution that simplifies EMR adoption and management, allowing you to focus on your mission of improving patient care”

The Austin American Statesmen has an article that reads like a press release:

“Health care is a valuable new target sector for Dell. The company has relied increasingly on sales to government in recent quarters to make up for big drops in computer spending by large corporations.

Dell said its early partners in the electronic records program include Tufts Medical Center in Boston and the Memorial Hermann Healthcare System in Houston.

Tufts, along with the New England Quality Care Alliance industry group, worked with Dell to design the program.

Dr. Jamie Coffin, Dell’s vice president for health care and life sciences, said Dell’s program helps attack the digital divide in the medical system where hospitals and affiliated doctors do a poor job of sharing patient records.

“Patient information that is locked away in paper records, electronic medical records solutions that are beyond the reach of most physician practices,” Coffin said. “Hospitals and physicians share patients, but not patient information. With our hospital partners, we are knocking down (electronic medical records) barriers.”

Analyst Judy Hanover with IDC said Dell has introduced one of the first comprehensive solutions for hospitals and affiliated doctors.

Elecronic medical records technology “has existed fore nearly 20 years, but cost, complexity and other barriers have kept it beyond the reach of physician practices and many hospitals, the front line of our health care system,” Hanover said.

Dell spokesman Cathy Hargett said her company believes it is important for hospitals to be the lead partner in such systems so that affiliated doctors can invest in compatible records systems.

The computer maker is plans to work with a variety of software vendors including eClinicalWorks to deliver the applications that hospitals and doctors want to use. Dell will provide a variety of services to help hospitals and doctors practices to set up such systems – including financing, needs assessment, work flow consulting, system configuration, software installation, training and support’

Discussing ARRA’s “meaningful use” provision: how to define it?

Picking through the July print edition of Healthcare Informatics, and surfing the blog, I see the debate by analysts over what constitutes “meaningful use” of Electronic Health Records/Electronic Medical Records is reaching a crescendo.  “Meaningful use” refers to the criterion for accessing some of the massive funds allocated by the American Recovery and Reinvestment Act for development and implementation of Electronic Health Records/Electronic Medical Records. As Woodward and Bernstein (allegedly) said: “follow the money“.

There is lots of good discussion and fine-grained debate over the definitions and implications of the “meaningful use” provision at http://www.meaningfuluse.org/ . I see at Health Data Management.com a nice summary:

“The federal HIT Policy Committee has approved revised recommendations of a workgroup for an initial definition of “meaningful use” of electronic health records systems. Among the changes made in the recommendations are refinements in computerized physician order entry criteria and a shorter timeline for implementing personal health records.

The definition is important because providers must demonstrate meaningful use of EHRs to qualify for Medicare and Medicaid incentive payments starting in 2011 under the economic stimulus law. The recommendations now go to the Office of the National Coordinator for Health Information Technology and other units of the Department of Health and Human Services. HHS officials will use the recommendations for guidance as they develop rules to implement the incentive programs. A proposed rule is expected by the end of this year.

The policy committee’s Workgroup on Meaningful Use recommends that 2011 criteria apply not just to 2011, but also to a provider organization’s first adoption year. That means if a provider cannot be ready for incentive payments until 2012 or 2013, the organization still will start with 2011 criteria. In other words, 2011 criteria would be considered Adoption Year 1 criteria.

Consequently, 2013 criteria would be in effect in 2013 or in an organization’s third adoption year.

The workgroup’s adopted definition of meaningful use is a matrix of more than two dozen requirements that have been revised to some degree since it first was unveiled a month ago. The workgroup made several clarifications, particularly in the area of requirements for adoption of CPOE. But many of the details remain to be fleshed out during the administrative rules process.”

Meanwhile, over at Modern Medicine, an analyst writes:

“The first public draft of the “meaningful use” definition, the linchpin of the $44,000, five-year Medicare incentive for improving electronic health record adoption, includes too many requirements for physicians to comply by the 2011 deadline, according to a healthcare technology analyst.

“The bar has been set too high, and the recommendations put forth will be virtually impossible to implement within the aggressive time schedule of the HITECH Act,” says John Moore, managing partner of Chilmark Research of Cambridge, Massachusetts, in reference to the EHR incentive legislation. “Simply put, it appears that not enough attention was paid to the processes/workflow changes that are required as part of a successful HIT rollout to meet these recommendations.”

Uwe E. Reinhardt: healthcare comparative effectiveness analysis and cost-effectiveness analysis

from http://economix.blogs.nytimes.com/2009/03/13/cost-effectiveness-analysis-and-us-health-care/

With so much brouhaha over what should be thought of as basic operations research for health care, it may be well to explore what “comparative effectiveness analysis” is, and how it is related to what is known as “cost-effectiveness analysis.”

The sketch below describes the basic structure of “comparative effectiveness analysis.”

It is assumed that researchers compare two therapies aimed at the same medical condition. The researchers try to determine which of these therapies can be judged “better” in terms of the positive and negative consequences associated with them. In principle, the clinical practice guidelines promulgated by medical specialty societies to help physicians with their daily treatment decisions should be based on this type of carefully structured comparative effectiveness research.

Source: Uwe Reinhardt A diagram of comparative effectiveness analysis.

Alas, in practice most of the currently promulgated guidelines lack that kind of rigorous scientific foundation. For example, as the science reporter Ronald Winslow recently reported in The Wall Street Journal “just 11 percent of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing, according to new research.”

That circumstance alone justifies spending billions more than we traditionally have on operations research for an industry that now absorbs $2.5 trillion or close to 17 percent of our gross domestic product. Why anyone would oppose that kind of research challenges one’s imagination.

Early drafts of the economic stimulus bill, however, referred not only to “comparative effectiveness research,” which keeps the analysis strictly in the clinical realm, but also to “comparative cost-effectiveness analysis,” which brings economics into the inquiry. That analysis seeks to establish which of several alternative therapeutic strategies capable of achieving a given therapeutic goal is the least-cost strategy. It seems a sensible form of inquiry in a nation that is dismayed over the rising cost of its health care.

Indeed, in recent years most industrialized nations have begun to subject clinical practices in their health systems to this type of analysis, as have private insurers in the United States (see, for example, the American Journal of Managed Care).

In Congress, however, the word “cost” in this connection remains anathema. This is despite the fact that that same Congress rings its hands in despair over the millions of American families priced out by the ever-rising cost of health care, and over the bigger chunk of the federal budget taken up by Medicare and Medicare.

So, in the end, the offensive term “cost-effectiveness analysis” was stricken from the bill.

The opposition to cost-effectiveness analysis in health care comes from two distinct groups that work closely together and reinforce one another.

The first group includes individuals or enterprises that book other people’s health-care spending as their own health-care income.

The manufacturers of pharmaceutical and biotechnology products or of medical devices are often found in that group, even though in some instances the greater economic transparency provided by cost-effectiveness analysis might help them market their health products or health services. Also in this group are physicians who thrive economically from highly resource-intensive medical treatments, even if some of its components are of only marginal clinical benefit.

The second group among the opponents of cost-effectiveness analysis includes individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.

Ephraim Schwartz: Financial and technology issues make Obama’s EHR push not so easy to execute

from www.infoworld.com/article/09/03/11/10FE-electronic-medical-records_1.html

Up until now, the benefits of electronic medical records that have occurred accrue to just about everybody — patients, employers, state and federal governments, and medical insurers — but the actual health care providers. Doctors get the least benefits, especially in small practice groups (those with fewer than five physicians) that make up most medical practices.

But even those who might benefit from electronic health records don’t, says Homer Chin, associate medical director for clinical information systems at Kaiser Permanente Northwest. Why? Because there is little incentive to share information, the core of an electronic health record (EHR; also called an EMR for “electronic medical record”). For example, hospitals make money by doing tests. But once EHRs are up and running, a doctor ordering a test electronically might immediately receive an alert saying the test was unnecessary because the patient had the same test or procedure at another location. “There is not much revenue and profitability in putting in an EHR. There is little financial incentive,” Chin says.

An ironic consequence of EHRs is that, by helping raise the quality of health care, they penalize doctors and other medical providers for success, says Wes Rischel, a vice president at Gartner. The bottom line: Doctors will see fewer patients.

Beyond the income factor, the high cost of EHR systems today — not only the systems, but the setup and training — also dissuades adoption by doctors, especially those in small groups. Physicians have been unwilling to invest anywhere from $20,000 to $50,000 in an EHR system where the economic benefits tend to go to someone else. Today’s EHR systems are not as easy to use as they could be, so there is a large learning curve required, Chin says: “There is something intuitive about paper chart and prescription pad.”

Recognizing these factors, the stimulus package tackles these financial challenges head on by offering money to health care providers. Hospitals submitting via EHR systems to Medicare and Medicaid will receive up to $6 million a year in additional payments for sending data electronically. This incentive will remove much of the adoption inertia seen so far, says Richard Archer, a principal in the health care IT advisory practice a KPMG.

<snip>

But now Microsoft, Google, and AOL founder Steve Case’s Revolution Health are looking at entering the health care information exchange market. All three offer individuals a personal health record, which puts the patient in control of his medical information. But the business aspect is in giving health care providers access to a person’s complete health record from a single site.

There are two major questions around the reliance on health records from these providers, say industry analysts. One is whether users will trust a for-profit organization to care for the most personal kind of information. The second is whether each of us can be trusted to manage and keep such a life-and-death record up to date or if it’s safer to leave that responsibility to organizations whose only job it is to keep the health data updated.

The prognosis for EHRs
EHR providers are, not surprisingly, bullish on the future of EHR efforts. Greg Mancusi-Ungaro, a senior director at Exigen Systems, says deploying an EHR system is just like implementing any big enterprise application, only the enterprise in this case is bigger and the stakes are higher. “The technology exists today and despite the fact that we lack some core standards, we are enabling the development of a flexible infrastructure to stay in tune with requirements. I can visualize a successful national system,” he says.

As Kaiser’s Chin points out, there is a convergence occurring around health care technology regarding how to share it and use it to assist delivery of services and treatment. But the challenge of orchestrating and satisfying so many stakeholders remains. Plus, even if the solutions are mandated rather than eventually negotiated, the task of gathering the many pieces that are still in flux, then integrating them remains a complex technical and process task.

Over time, both industry representatives and analysts expect that every U.S. citizen will have an EHR available nationwide. But to make it happen will require a great deal of cooperation, innovation, and an investment in health-oriented IT. This shift will likely start at a less ambitious level than the political rhetoric suggests, with local practitioners sharing patient information in a local health care ecosystem.

5 guiding principles for spending EHR stimulus funds wisely

John Halamka, MD,  on Making Smart Investments In Health Information Technology: Core Principles

http://content.healthaffairs.org/cgi/reprint/28/2/w385.pdf

Over the past five years, thousands of public- and private-sector employees, many volunteering their time, have worked to advance the cause of interoperable, certified, secure electronic health records. As new federal funds become available, should we invest right away or wait for technology and policy perfection? Do we leverage the accomplishments of existing national organizations, or do we start from scratch? The time to invest is now, building on the organizations we already have. To ensure wise investment, I suggest guiding principles assembled from the input of hundreds of providers, patients, payers, vendors, government employees, and standards-development organizations.

No other industry has had such a mismatch between the sophistication of the technology being introduced and the lack of technological sophistication on the part of those who are supposed to manage it. Placing servers in clinicians’ offices and expecting office staff to back up, secure, and maintain technology is likely to be expensive, frustrating, and highly risky. Investments in EHRs should focus on achieving economies of scale through the funding of regional, hospital based, or vendor-hosted “software as a service” providers that provide Web-based/remotely accessible solutions that require very minimal new technology in clinicians’ offices.

Will the Obama EHR/EMR plan enable government surveillance?

from  www.amconmag.com/article/2009/mar/09/00009/

“At this point, fewer than 20 percent of the nation’s physicians have gone full-speed on computerization. Obama’s plan offers between $44,000 and $64,000 to doctors who computerize patient records and up to $11 million per hospital. “On the stick side of the equation,” the Wall Street Journal reported, “the measure includes Medicare payment penalties for physicians and hospitals that are not using electronic health records by 2014.” If records are digitized on the federal dime, it will be far easier for politicians to claim the resulting information.

But the feds have no technological silver bullet to distribute to docs across the land. David Kibbe, a top technology adviser to the American Academy of Family Physicians, warned Obama in an open letter late last year that existing medical software is often poorly designed and does a miserable job of exchanging information. Kibbe declared, “If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.”

Marc Roberts, a Harvard professor of political economy and health policy, notes, “Many healthcare systems are now intentionally building medical record systems that are nonstandardized and noncompatible so they can own and control the data.”

In the same way that George W. Bush bragged about the percentage increase in homeownership, President Obama will be able to boast about the increase in doctors’ offices using electronic records. It didn’t seem to matter to Bush that many of the new federally subsidized homeowners went bankrupt, and it may not matter to Obama that the federally controlled health-record system is bound to be a trainwreck.”

CEO of athena Health: a Federal “Marshall Plan” for Electronic Medical Records will fail

http://histalk2.com/2008/12/22/histalk-interviews-jonathan-bush-ceo-president-and-chair-of-athenahealth/

Money quotes from Athena Health CEO:

“In life and society, the goal of government is to set the rules of the road for companies. If the government intervenes and actually becomes a participant, there’s all kinds of adverse skewing that’s going to go on.

Certainly this is a world class case in point. If we end up with a Marshall Plan for EMRs, we will subsidize the approach to this that has not worked, that is certainly, among the readers of your site, clearly known to be a failed approach. We’ll keep those established players, those dominant buffoon gigundo companies, alive a little bit longer. It really feels like subsidizing General Motors. Who else would help save America from having access to cars that nobody wants?

I really feel that way about these big EMR, clinical, software-only business model companies. Nobody wants them. They’re being told that they should have them, but in their hearts, if you look at their Id, they don’t want them.”

I don’t want the Obama investment in healthcare to end up looking like the Congressional investment in General Motors, which is to say I don’t want really, really bad, dead things that ought to die sooner to be kept alive longer by a well-meaning federal government. I want software companies to die as quickly as is humane.

If the federal government gets in there and starts handing out free subsidies, then the providers of the world have to say, “Well, gee, I know it sucks, but if it’s free, does it suck that much, or maybe I should give it one more swing?” That’s what scares me to death. That’s why the interview with Wall Street Journal and with Fox and anybody else who will talk to me, including you. To make sure the Obama folks hear us saying, “Please don’t kill the emerging technologies by subsidizing the established and dying technologies in order to have something to do.”

Q-Is the track record of doctors and hospitals who have already implemented the available technology good enough that we should be subsidizing more of the same?

The hyperbole is almost ringing as you ask. You’re the ultimate insider and I know that you know that the answer is no.

The folks who have installed this stuff are experiencing negative ROI. That’s why the RAND Institute came out with the study that showed that it’s 19% slower to have an EMR. There’s no pay-for-performance revenue to cover that 19% slowness. None of the supply chain is connected to EMRs, so all the laboratories and specialists and X-ray machines and PET scanners and mammogram machines aren’t connected to EMRs. There’s an incremental administrative cost in keeping the EMR current by typing results into the chart from these other sources of medical information.

Everybody knows in their heart of hearts that without a massive increase in pay-for-performance … it’s not really even performance at this point, it’s really pay-for-data … without a massive increase in pay-for-data in hopes that will prime the pump and we’ll figure out how the data maps to performance later. I’m sitting here looking at a row of plastic white yachts in Boca Raton and I’m thinking, “What is the definition of a yacht? A hole in the water into which one pours money.” I think of EMRs a lot like that … data yachts.