PHR data overload, legal liability concern docs

By: Andis Robeznieks / HITS staff writer Story posted: May 21, 2007 - 10:56 am EDT

Part one of a two-part series

Like a recurring dream about having to take a test they didn’t study for, some physicians view the idea of patients with electronic personal-health records as their own personal nightmare.

Visions of patients handing over a computer disk containing years’ worth of blood-pressure readings taken every four hours along with random recollections of rashes and muscle strains that physicians are required to somehow make sense of and memorize are followed by thoughts of being sued because there was a kernel of important information missed in the deluge.

“That’s why folks like me are terrified of personal health records and what patients will bring to us,” internist Michael Zaroukian said earlier this year during a panel discussion at the Integrating the Healthcare Enterprise Connectathon, an event that brings electronic medical-record vendors together to solve interoperability problems (and sponsored by the Healthcare Information and Management Systems Society, the Radiological Society of North America and the American College of Cardiology).

While Zaroukian, who is chief medical information officer at Michigan State University, is now backing away from the word “terrified,” he still maintains “there are certainly lots of reasons to be concerned.”

The reasons for concern that Zaroukian cites include: the accuracy, completeness, usefulness and volume of the records physicians receive from patients; the hours of uncompensated work it will take to slog through them; and the potential for a misdiagnosis if something important was overlooked.

“In some ways, it’s simply an electronic extrapolation of what we’ve seen in the paper world,” Zaroukian says. “The greater the volume, the more likely it is that relevant data will be lost.”

Zaroukian certainly isn’t the only physician who feels this way.

“He has every reason to be frightened by that, and I don’t see what he is describing as an improvement over someone bringing in an entire paper chart,” says Joseph Heyman, a gynecologist and an American Medical Association trustee. “I don’t blame a physician for worrying about that. I think the beauty of a personal health record is if it’s a snapshot of a patient and their most important demographics—like their current condition, allergies and medications—that’s entirely different from their entire medical history for their entire life.”

Peter Basch, medical director for e-health at MedStar Health in Washington, says “physicians love a (hospital) discharge summary” that gives one to two pages of key points. What they may get from a PHR, however, could be something that has no resemblance to a discharge summary at all.

“Electronic records make it easier to share more information and images, so often what could be included on one page is now included on 10 and 12 pages,” says Basch, an internist who serves on the medical informatics subcommittee of the American College of Physicians.

He says, though imperfect, a quick two- to three-minute oral history taken during an office visit can be more helpful than an extensive PHR.

“It’s like saying to a patient: ‘Tell me about the rash,’ ” Basch says. “Don’t give me a seven-hour history of every rash you’ve had in your life.”

Zaroukian says that while things like patient-recorded blood-pressure readings can be useful, the value is not in each particular entry, but in the average and the range of high and low readings.

He says diabetic patients often give him diaries of insulin doses and pre-breakfast blood-sugar levels recorded in meticulously arranged rows and columns, but—despite their neat appearance—the numbers are not distilled into a useable format.

“You have to skip between rows and try to average the numbers somehow, but it’s impossible,” Zaroukian says. “The data is so poorly organized that it not only does not improve quality, it could contribute to making a bad decision.”

Nevertheless, he says that PHRs could be an important tool in developing a partnership with patients, so he “gently forces” them to use the spreadsheets—either paper or electronic—that he has developed.

“Over time, patients see how their own self-management can be improved, so over time they become more interested in doing so,” Zaroukian says. He adds that the key is to make it easy to record the information in a usable format so the patient-maintained record is not “just a few jewels of data floating in a sea of debris.”

Organization and quality of the data are paramount to making the PHRs useful, says Heyman, who has a solo practice in Amesbury, Mass.

“I think at the AMA, we believe there can be great value to PHRs and they can save physicians and patients a great deal of time, while helping to avoid medication errors and duplicate laboratory tests,” he says. “But there is a risk of ‘garbage in, garbage out,’ and if the record is populated by the patient, there are errors of understanding that can be inputted by the patient.”

Basch says it’s not the PHR alone that will create savings or improvements in care or efficiency, but it could be the tool that helps a motivated patient achieve those results. In fact, all the information included in the popular physician-provided PHR iHealthRecord from Medem, a San Francisco company founded by the AMA and several other medical societies, is entered by the patient (although if patients choose they can have data automatically flow into their PHR as it is entered in their physician’s EMR system).

“Some patients will rise to the occasion, and some won’t,” he says. “But for patients with diabetes, hypertension or congestive heart failure, daily or weekly recordings of blood pressure and weight could result in useful information that could stem chronic conditions from going bad and save a lot of ER visits.”

And, for these patients with chronic conditions, Basch cites key barriers to primary-care physician involvement in helping develop and maintain a patient’s PHR: a lack of reimbursement for coordination of care among specialists; uncertainty over the legal responsibilities of helping a patient maintain a PHR; and knowing what the record contains.

“With personal health records, one of the issues is the core problem of financing healthcare where information management and discussions with patients are poorly reimbursable in the context of an office visit,” he says. “Those are currently seen as an uncompensated burden on physicians.”

Making sense of complicated and unorganized records can require four to five hours of work—whether the records are on paper or in an electronic format—Basch says, but this is accepted in most sectors because “there’s an unwritten rule that a primary-care physician’s time is not relevant and that information management isn’t really work.”

“There’s no payer who will say: ‘Sure, I’ll pay you for your time’; they’ll say ‘Too bad, learn how to do it in 60 seconds,’ ” Basch says.

Steven Waldren, director of the American Academy of Family Physicians’ Center for Health Information Technology, says PHRs haven’t caught the attention of most doctors yet. But for the relatively small portion of physicians who have implemented electronic records, PHRs are known entities and these doctors’ main concern is on workflow.

Establishing PHR data standards—what information to include and in what format—will be important to solving workflow and data-management problems, Waldren says, adding that it’s time for physicians to get familiar with PHRs.

“PHRs are here and will continue to be,” Waldren says. “If the healthcare consumer empowerment trend continues to move in the direction it’s moving, we’ll continue to see growth in the tools available for patients.”

Waldren mentions healthcare decision-support applications as one of the tools patients are going to be using soon, and this prediction is already coming true. Earlier this month, Verizon Communications announced it was offering PHRs to 900,000 of its employees, retirees and their family members, and the system would include alerts that would inform users when their care “may not be consistent with evidence-based medicine.”

See article here: http://www.modernhealthcare.com

Standards rivals’ collaboration could have major impact

By: Joseph Conn / HITS staff writer
Story posted: February 13, 2007 - 10:56 am EDT

The compromise reached between two sometimes rival standards development organizations could have far-reaching implications for the development of a national healthcare information network, experts close to the effort say.

The collaboration, called the Continuity of Care Document, or CCD, is the handiwork of Health Level 7, Ann Arbor, Mich., and ASTM International, Conshohocken, Pa., which jointly announced its release Monday after required formal balloting was completed. Initial development efforts by both organizations was aimed at developing patient care summaries but has since broadened in scope.

The CCD is a melding of HL7’s broader Clinical Document Architecture, or CDA, and the Continuity of Care Record, or CCR, developed by ASTM in collaboration with the Massachusetts Medical Society. Balloting on the much-anticipated CCD began on Dec. 6, 2006, and concluded Jan. 7. It took two ballots to pass muster among HL7 members and other interested parties who reviewed the development, according to Robert Dolin, an Orange County, Calif.-based physician lead for national terminology services for the Kaiser Permanente Medical Group, a member of the HL7 board of directors and the editor-in-chief of CCD for the standards development organization.

Richard Peters, also a physician, is chairman of the ASTM International Committee on Healthcare Informatics and serves as ASTM’s lead in the collaboration on the CCD.

Peters could not be reached for comment by deadline.

“I am the primary editor, and I voted no on it on the first ballot,” Dolin said. “We had enough time so we tightened up all the constraints and the language to use to express the constraints that were a little ambiguous. We went through each section of the CCR and went through it line by line,” he said, making sure it dovetailed with the CCD.

In October 2006, the federally funded Healthcare Information Technology Standards Panel recommended to HHS Secretary Mike Leavitt its first batch of “harmonized” IT standards aimed at facilitating specific healthcare data transmission tasks chosen by HHS. Among those was a recommendation by HITSP that the then-unfinished CCD be adopted for the exchange of certain clinical information, including patient demographics, medications and allergies.

HITSP Chairman John Halamka, the physician chief information officer of Harvard Medical School, in an e-mail called the successful CCD ballot “a very significant development for healthcare IT” and “a milestone in the standards world.”

“HL7 and ASTM worked together seamlessly to incorporate the best of their standards into a work product that will now form the basis of many HITSP Interoperability Specifications,” Halamka said. “CCD was included in the HITSP interoperability specifications submitted to Secretary Leavitt last October. We’ll ensure any updates to CCD are included in our next release of interoperability specifications which will be voted on in May.

Work by ASTM on the electronic CCR flowed out of an initial effort by physicians in Massachusetts to develop a standard, paper-based discharge summary for patients leaving the hospital bound for nursing homes.

Dolin said a similar interest by HL7 members to develop a standard for patient summaries led HL7 to come up with on its own Care Record Summary, or CRS. But the parallel development work of ASTM on the CCR and HL7 on its CRS led to strained relations between adherents of the two standards—what Dolin diplomatically described as “all this politics going on between HL7 and ASTM.” Cooler heads apparently have prevailed and with the collaboration leading to the successful balloting, “CRS is now sunseted by CCD,” Dolin said.

A major event at the IT trade show, Toward the Electronic Patient Record, last May in Dallas, was a demonstration of the CCR by more than a dozen vendors of electronic medical-records systems. At the time, most of the participating vendors could export documents in the CCR format and at least one vendor could import a CCR document and seamlessly place discrete data elements from the record in the fields of the receiving vendor’s EMR.

The demonstration showed the potential of peer-to-peer communication between physicians with different EMR systems.

Peter Waegemann, chief executive officer of the Medical Records Institute, sponsor of the show, said development of the compromise CCD “is really a win-win situation.”

Vendors and users of large IT “legacy” systems that are backers of HL7’s Clinical Document Architecture will gain the most benefit from the CCD because they will be able to use the CCR format in their systems, Waegemann said. But the collaboration with HL7 on the CCD further establishes the CCR, he said.

“Both have a community and both are good for the doctors and everyone else,” Waegemann said.

The American Academy of Family Physician’s Center for Health Information Technology operates an online list of EMR and personal health record system vendors that have committed to using ASTM’s CCR. The list, currently with 31 vendors, also includes the status of their CCR incorporation efforts.

Germany Starts Testing Electronic Health Records

Germany started testing electronic health insurance cards which will eventually contain the patients’ complete health history in digital format. The high-tech card is Germany’s largest IT project.

“From today, 10,000 insurance holders will be receiving the new electronic card, whose functions will be gradually tested in doctors’ offices, pharmacies and hospitals over the next few months,” said Marion Caspers-Merk of the German Ministry of Health on Monday.

 

The new electronic health insurance card, which should be released for general use in 2008, is meant to reduce administrative costs in the health industry and simplify information access for medical workers.

 

In addition to containing the carrier’s photo, which is expected to reduce the abuse of health insurance privileges, the card has an electronic chip that will eventually contain the patient’s complete health record.

 

Digital Revolution

 

“The card is an important step on the path to better medical services for our 82 million citizens,” Caspers-Merk said.

 

The development costs for the high-tech card, which have been estimated to around 1,6 billion euros ($2.1 billion), are expected to be amortized in five years.

 

The Minister of Health in the German state of Schleswig-Holstein called the testing of the electronic health-insurance card “the beginning of the digital revolution in the health sector.”

 

The information recorded on the health-insurance card will be encrypted and legible only by special reading devices. Healthcare providers will be required to purchase the device for 300 euros.

 

Model for personal health records released

Insurance groups move toward long-awaited patient tool

December 13, 2006 (IDG News Service) — Two large health insurance trade groups based in the U.S. have released a model for personal health records, a portable, Web-based tool that includes a customer’s insurance claims, immunization records, medication records and other health information.

America’s Health Insurance Plans (AHIP) and the Blue Cross and Blue Shield Association, whose members provide health insurance to about two thirds of U.S. residents, unveiled the personal health record model Wednesday.

The two groups saw the importance of working together on the project, said Susan Pisano, vice president of communications for AHIP. “This is really an effort that cries out for collaboration,” she said.

President George Bush has pushed for electronic health records to be available to all U.S. residents by 2014. Backers of such records say they will improve the efficiency of the U.S. health-care system and cut down on errors such as drug interaction problems.

Personal health records, or PHRs, “may be one of our most important contributions to helping improve health care,” Ronald Williams chairman, chief executive and president of insurer Aetna Inc., said in a statement.

PHRs are similar to other electronic health records, although they include less specific treatment information. Electronic health records typically are used by health care providers to store and manage detailed clinical information.

Patients will be able to enter information into their PHRs, in addition to information from pharmacies, laboratories and medical providers, the groups said.

The model released Wednesday includes definitions of data elements that should be included in PHRs, such as risk factors, family history, health care facilities and medications taken. The model also includes standards for the PHRs to be portable between insurers and providers, and rules about when insurers can share the information.

Insurers can send the information to a new insurer only after the patient gives consent and has enrolled in the new insurance plan, Pisano said. Those tight sharing rules were designed to address concerns about the PHRs used by insurance underwriters, she said.

The PHR model also set 2008 as the deadline for insurers to incorporate the data elements and adopt the portability standards, she added.

The groups said the U.S. is still “many years” away from a fully interoperable health records system. But Dr. Robert Kolodner, interim national coordinator for health information technology at the U.S. Department of Health and Human Services, praised the groups’ efforts. The new model is a “step forward in the national health IT agenda,” he said in a statement.

Earlier this month, five major corporations — Applied Materials Inc., British Petroleum America Inc., Intel Corp., Pitney Bowes Inc. and Wal-Mart Stores Inc. — announced plans to fund the development of a Web-based system that would allow their employees and retirees to access and maintain personal medical records. The companies said the plan could help them cut health care costs.

PricewaterhouseCoopers Identifies Top Seven Health Industry Trends of ‘07

Predicts Tipping Point for HSAs, Pressure on Pharmaceutical Pricing and More State Action

NEW YORK, Nov. 30 /PRNewswire/ — The year ahead will be a watershed for the health industries, according to PricewaterhouseCoopers LLP, as health savings accounts reach a tipping point, states act where the federal government hasn’t and pressure on pricing amid demand for transparency forces pharmaceutical companies, hospitals and health plans to rethink their strategies. These are among the top issues identified by PricewaterhouseCoopers’ Health Research Institute, which today released its report, “The Top Seven Health Industry Trends of ‘07.”The report also includes findings of a nationwide survey of 1,000 Americans about their perceptions of the U.S. healthcare system. The survey identified significant differences between what the public and industry believe to be key issues, including:

• Nine out of ten Americans (90 percent) believe that greed is a major reason that U.S. healthcare costs are rising, a greater number than those citing drug prices, care for the uninsured, business inefficiencies or malpractice costs.
• Nearly one-quarter (24 percent) of Americans don’t yet believe that having an electronic health record will improve the quality of healthcare, and four in ten consumers (42 percent) are unsure.
• Only one in six (17 percent) agrees that a very important way to reduce the cost of healthcare in the United States is for consumers to share more of the cost, which is the strategy behind high-deductible health plans with Health Savings Accounts. More than half of those surveyed(51 percent) believe that better, more advanced medical technology and diagnostics is the answer.

“Every health organization across the health industries is responding to pressure to reduce costs, meet growing demand and do more, better and faster with less,” said David Chin, MD, partner and leader of PricewaterhouseCoopers’ Health Research Institute. “Our survey, however, found a disconnect between what the American people, policy makers and industry think is wrong with our nation’s health system and how to fix it. It appears that consumers may not appreciate the complexity of healthcare as a business, and therefore the industry’s messages about itself and the challenges it faces are failing to resonate in the court of public opinion. This disconnect must be addressed before real progress can occur.”

PricewaterhouseCoopers has identified the following as the top seven trends in the health industries for 2007, based on its work with leading employers, policymakers, associations, advocacy groups and organizations across the health industries, including hospitals, health systems, physician groups, government and commercial health insurers, pharmaceutical companies and life sciences firms:

1. States Take the Initiative: In the presence of federal gridlock, states are taking the lead on divisive issues such as stem cell research, health insurance coverage for the uninsured and oversight of advertising and promotion by pharmaceutical companies. Responding to local social and fiscal concerns, states are developing innovative insurance programs, forming public-private partnerships to spur innovation and passing legislation to drive greater accountability and transparency from hospitals, physicians and pharmaceutical manufacturers. According to PwC, such state-led initiatives will likely expand in 2007, but the risk is a patchwork quilt of local programs and regulations.
2. 2. Transparency Could be Revealing: The demand for transparency around pricing, quality measures, safety standards and community benefit is being driven by and is supportive of consumer-directed healthcare and pay-for-performance. In 2007, the health industries will focus on becoming more transparent, but government, insurers and employers need to educate consumers about the availability and use of such information. Providers will need to dedicate more resources to reporting, a strategic issue that can no longer be delegated down in the organization.
3. Time to Walk the Talk on Technology: Developing a digital backbone to support electronic health records, interoperability and transparency is a national priority, but the public mandate is unclear and the industry is struggling with the cost and return on the investment. According to PwC’s research, nearly one-quarter (24 percent) of Americans don’t yet believe that having an electronic health record will improve the quality of healthcare, and four in ten consumers (42 percent) are unsure. Progress will take an investment of resources from the government and/or the private sector.
4. Consumers Take the Wheel: The shift toward consumer-driven healthcare as a way to control costs will continue, but the year ahead will be the tipping point for HDHPs and HSAs. Insurers, employers, and to some extent the government have been proceeding in favor of consumer- directed health plans in the absence of strong support from the consumers themselves and from strong data on the results of such changes in benefits. PwC’s consumer research found that only one in seven Americans (17 percent) surveyed by PwC thinks that increased cost-sharing is a “very important” way to reduce healthcare costs. With a critical mass of people now enrolled in these plans, 2007 will be the year to see whether they really have results to offer, and for consumers to weigh in on what they think of them.
5. Price Check for Pharmaceuticals: Forty-two blockbuster drugs will lose their patents in 2007, opening the door to generic equivalents and potentially creating an enormous loss of revenue for brand name pharmaceutical manufacturers. PwC’s consumer survey indicates that the public is quite aware of and sensitive to drug prices, perhaps due to relatively high cost sharing and price transparency of pharmaceuticals, relative to other health services. Nearly three quarters (72 percent) of consumers surveyed said they would be willing to take a generic versus brand–name prescription drug. According to PwC, drug pricing will come under continued pressure from generics, and pharmaceutical companies will have to develop innovative pricing strategies to compete.
6. Obesity is the New Smoking: First smoking, now weight. There is a culture shift around healthy eating sweeping the United States, as evidenced by the number of fast food chains cutting out transfats and U.S. companies introducing health and wellness programs. Two-thirds of U.S. adults are overweight, and obesity’s impact on chronic health problems is stirring healthcare organizations and employers to aggressively promote weight loss. Public attitudes have yet to catch up: While three in five Americans (61 percent) believe health insurance should cost more for smokers, only 40 percent believe it should cost more for those who are overweight because of poor lifestyle habits. In 2007, expect public health campaigns to push the envelope on obesity through wellness programs and financial incentives to lead healthier lifestyles.
7. Small is Big: The competitive landscape will change as healthcare gets smaller, more focused and patient friendly under consumer-directed healthcare. Physicians and hospitals are now competing with retailers, several of whom have announced plans to open mini-health clinics within their walls. Consumers like the idea: Four in ten people surveyed by PwC (42 percent) said they would seek non-emergency care from a retail health clinic. In addition, large general hospitals are seeing competition from increasing numbers of smaller, specialty hospitals, surgery centers and outpatient clinics, the result of regulatory action overturning the specialty hospital ban. There already are 130 specialty hospitals in operation and more under construction, predominantly in the South and West.

“Though there is disagreement about priorities, most everyone agrees that our current health system is ailing and isn’t sustainable without major changes,” said Sandy Lutz, director of PricewaterhouseCoopers’ Health Research Institute. “There are a myriad of issues facing health organizations and opportunities for executives to address them, but they need to also focus on closing the gap between how consumers view the industry and how the industry views itself. Healthcare is a people business and must become more consumer- centric. To be sustainable, health organizations must communicate and connect with their customers through innovative approaches and fresh perspectives - beginning in 2007.”

A copy of The Top Seven Health Industry Trends of ‘07 is available at www.pwc.com/healthcare under “Publication/Thought Leadership.”

Initiative To Make PHRs Interoperable, Portable Among Insurers

By Diana Manos, Senior Editor Healthcare IT News

WASHINGTON – America’s Health Insurance Plans is poised to announce an industry initiative for making personal health records portable from one health insurance company to another.

AHIP will make public the details of an 18-month pilot project with 10 AHIP member companies on December 13. The panel studied ways health insurance companies could assist in making PHRs interoperable. The plan will also recommend minimum elements for all PHRs.

AHIP represents nearly 1,300 member companies providing health insurance coverage to more than 200 million Americans.

“Many of our member companies have already set up PHRs,” said Susan Pisano, AHIP’s vice president of communications. “The main roadblock has been that if a patient left one company and went to another, their records weren’t portable and interoperability was lacking.”

Health insurance companies for the most part have no standard for what PHRs should include, Pisano said. AHIP’s goal has been to identify the essential elements needed in PHRs.

“Companies will still compete on bells and whistles, as they always do, but the focus of the project is core elements,” Pisano said.

The project is part of a partnership with the National Health Council, which shares AHIP’s interest in having PHRs available, portable and usable by consumers, Pisano said.

“Widespread use of [electronic] PHRs can greatly empower the 100 million Americans with chronic disease and allow them to take better control of their health care. Yet only a small segment of the population even knows they exist,” said National Health Council President Myrl Weinberg. ” By working with our members, the voluntary health community, and AHIP we can credibly educate Americans about this resource and encourage its widespread use.”

AHIP has been in consult with IT standards organization, including the American National Standards Institute, “to make sure they know what we’re doing and where we’re headed,” Pisano said. “Our idea is that our work should mesh with whatever ultimately is accomplished in making the whole healthcare system interoperable.”

AHIP anticipates its PHR initiative to be a first step toward use of electronic health information to monitor chronic care patients–representing nearly half of all Americans with healthcare issues–and should present a cost savings, Pisano said.

The plan supports the Nationwide Health Information Network, the government-led project to connect all regional health IT networks into one large interconnected system.

“We want to approach PHR interoperability in a way that’s compatible with the national effort and we feel we’re in a position to make that contribution,” Pisano said.

AHIP is starting with PHRs rather than EHRs because much of the data needed to establish PHRs already is available within health insurance company databases. “We have the information, and consumers and doctors should have it too. This seems like a logical place to start,” Pisano said.

See article at Healthcare IT News

Privacy panel explores identity proofing

By: Joseph Conn / HITS staff writer

A federal policy advisory panel on privacy and security of electronic healthcare information spent a second consecutive session wrestling with the details of how to best identify patients, providers and others who might want access to patient data from electronic medical-records systems, personal health records and messaging systems.

The confidentiality, privacy and security work group of the American Health Information Community met for three hours via teleconference Monday, working mainly on honing a list of draft recommendations for “identity proofing,” ways of verifying a person’s identity before giving access to electronic records systems or messages. Read more on the draft recommendations.

Group members decided to focus their recommendations not on broad privacy policies but on the narrow demands of three other AHIC work groups. Those work groups are: looking to promote the use of electronic health-records systems by making it easier to import laboratory values into the systems; developing technologies to create medication histories and electronically provide basic patient registration information to electronic personal health records; aiming to accelerate the electronic transfer of anonymized patient data from ambulatory care and hospital emergency room environments to public health authorities.

Even so, the privacy work group tentatively approved the wording of some general statements — that all data exchanged through an EHR, PHR or messaging systems it sensitive, and that the work group’s identity-proofing recommendations were not intended to be a comprehensive list, but a set of guiding principles.

The group also reached a consensus on some specific recommendations, including: the Certification Commission for Healthcare Information Technology should incorporate criteria for identity proofing in its testing program for electronic healthcare information systems; physicians converting paper records to electronic in their own practices need not be required to identity-proof those records, but should use identity proofing techniques when moving that information electronically to patients from their EHRs; and that anyone moving patient information from a PHR to a patient should use the recommended identity-proofing techniques.

The group stuck, however, on specific identity-proofing techniques and their applicability to different providers. Generally speaking, the group reached consensus on the notion that when a face-to-face, personal relationship exists between a patient and a provider, identity proofing of medical records in person is the gold standard. But they hung up on the adequacy of identity proofing when there were lesser levels of a relationship between the recordkeeper and the person whose records were being kept, with much discussion centering on PHR systems being offered by insurance companies and other third-party payers.

The group put off deciding on a hierarchy of recommended lesser identity proofing techniques until a later meeting. 

Read entire article at Modern Healthcare