Meaningful use workgroup
Download
1 / 48

Meaningful Use Workgroup - PowerPoint PPT Presentation


  • 123 Views
  • Uploaded on

Meaningful Use Workgroup. Paul Tang, Chair George Hripcsak, Co-Chair. December 20, 2013. Meaningful Use Workgroup Members. J . Marc Overhage , Siemens Healthcare Patricia Sengstack , Bon Secours Health Systems Charlene Underwood, Siemens Michael Zaroukian, Sparrow Health System

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Meaningful Use Workgroup' - alexa-ratliff


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Meaningful use workgroup

Meaningful Use Workgroup

Paul Tang, Chair

George Hripcsak, Co-Chair

December 20, 2013


Meaningful use workgroup members
Meaningful Use Workgroup Members

J. Marc Overhage, Siemens Healthcare

Patricia Sengstack, Bon Secours Health Systems

Charlene Underwood, Siemens

Michael Zaroukian, Sparrow Health System

Amy Zimmerman, Rhode Island Office of Health & Human Services

Federal Ex officios

Tim Cromwell, Department of Veterans Affairs

Joe Francis , Veterans Administration

Greg Pace, Social Security Administration

Martin Rice, HRSA

Robert Tagalicod, Centers for Medicare & Medicaid Services, HHS

Chairs

  • Paul Tang , Palo Alto Medical Foundation

  • George Hripcsak, Columbia University

    Members

  • David Bates , Brigham and Women’s Hospital

  • Christine Bechtel , National Partnership for Women & Families

  • Neil Calman, The Institute for Family Health

  • Arthur Davidson, Denver Public Health Department

  • Paul Egerman, Businessman/Entrepreneur

  • Marty Fattig, Nemaha County Hospital Auburn, Nebraska

  • Leslie Kelly Hall, Healthwise

  • David Lansky, Pacific Business Group on Health

  • Deven McGraw , Center for Democracy & Technology



Review of Population and Public Health Objectives Stage 3 MU

Arthur Davidson, MD, MSPH

Meaningful Use Workgroup

December 20, 2013


Agenda
Agenda

  • Review Stage 1 Public/Population Health Meaningful Use Measures

  • Review Public Health Efforts Regarding Standards and Interoperability Framework Components

  • Review of proposed Stage 3 Meaningful Use Measures


Hospital 1st v 2nd v 3rd year ph menu objective performance
Hospital 1st v. 2nd v. 3rd yearPH Menu Objective Performance

Source: CMS Presentation – Rob Anthony, December 4, 2013


Update on current measures immunization elr ss
Update on Current Measures: - Immunization, ELR, SS

  • Immunization

    • New guide provides improvements

    • Progress with providers is better

    • ONC test criteria are making interoperability better

    • PH moving toward accepting data coming form certified products

    • Next version (Feb 2014) of Implementation Guide (IG) will include bi-directional w/ History and forecast back to provider

  • Electronic Laboratory Reporting (ELR)

    • New version of IG is available to HL7 members and includes many improvements

  • Syndromic Surveillance (SS)

    • Successful centralized infrastructure utilizing BioSense

    • http://www.hl7.org/dstucomments/showdetail.cfm?dstuid=104


Electronic laboratory reporting elr pattern of adherence to standards
Electronic Laboratory Reporting (ELR) – Pattern of Adherence to Standards

  • Public Health has consistently made efforts to abide by standards and in turn minimize impact on clinical partners

  • Proof of PH’s commitment to build on standards and processes used for other use cases,.

    • ELR Release 1 (HL7 Version 2.5.1: ORU^R01)1was built on the HISTP Lab-to-EHR Implementation Guide

    • ELR Release 2 is the current profile for Electronic Laboratory Reporting to Public Health (MU Stage 1 and 2).

    • Public health has demonstrated readiness for standards and will credibly achieve that for Stage 3.

http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/opi/infectious%20disease%20surveillance/v251_IG_LB_LABRPTPH_R1_INFORM_2010FEB.ashx


Key principle for ph stage 3 mu
Key Principle for PH Stage 3 MU Adherence to Standards

  • Adhere to Standards and Interoperability Framework Components Whenever Feasible


Cancer Reporting Adherence to Standards

  • Stage 3 MU Cancer Implementation Guide (IG) should move to consolidated clinical document architecture (c-CDA) because:

    • EHR vendors are required to use this format for Transition of Care documents in Stage 2 MU

    • eliminates burden of supporting two different formats for cancer reporting

    • c-CDA has harmonized and improved templates across multiple sources

    • cancer program is ready to move to this new standard


Cancer c-CDA: Next Steps Adherence to Standards

  • Align Cancer IG sections with c-CDA sections (high level completed)

  • Add a new document-level template c-CDA R2: "Ambulatory Healthcare Provider Cancer Event Report”

  • Add Cancer Diagnosis Section to c-CDA

  • Perform Gap and Overlap analysis of entries, data elements, attributes, and value sets

  • Put new document through HL7 ballot process

    Timeline

    • High level gap analysis performed in November 2013

    • Detailed gap/overlap analysis work starting in January 2014

    • Ballot in May 2014


Public health and c cda progression for some areas
Public Health and c-CDA Adherence to Standards- Progression for some areas

2012

2013

2014+

Pertussis (NY State)

EHDI (N. Dakota)

Cancer Registry

Pertussis (San Diego)

EHDI (Oregon)

Tuberculosis (Delaware)


Electronic Healthcare Associated Infection (HAI) Detection and Reporting: Supporting Patient Safety

CDC

Reporting system

publishes facility-specific

HAI data

  • Specifications:

  • eMeasures

  • Decision rules

  • Computer code

Healthcare

Reporting system provides protocol and algorithm

Public

Health

Publicly Reported HAI data

Executable expressions of detection and case reporting algorithms

Reporting protocol for HAI

CMS

  • CDA transmission:

  • Manual upload

  • Automated send

NHSN

CDC

Programs

HeD

Electronic HAI Report

Clinical

Document

Architecture

(CDA)

  • Electronic

  • systems:

  • EHR

  • Pharmacy

  • ADT

  • Lab

Additional rules applied to populate full HAI report

HAI detection rules applied to patient-specific data

Healthcare Facility


Progress : What’s been completed and Reporting:

CDA/SDC for Public Health Pilot Projects

Public Health Reporting Architecture

Continuity of Care Document (CCD)

(pre-population data)

Public Health Infrastructure

Or

Health Information Exchange (HIE)

CDA-based

Case Reports:

Tuberculossis

Pertussis

Newborn Hearing Screening Outcome Report

Provider

Public Health

Electronic

Health Record

System

Information Systems:

Surveillance Systems

EHDI System

Public Health Information Systems

Delaware Electronic Reporting Surveillance System (DERSS)

New Your State Universal Public Health Node (UPHN)

San Diego County

(Atlas Public Health)

Oregon EHDI System

(Filemaker)

North Dakota EHDI System

(OZ Systems)

EHR Vendors

Core Solutions

Connexin

Allscripts

(Test Harness)

Epic 2012

(Test Harness)

Public Health Infrastructure

(Orion Rhapsody)

HIE

(OZ Systems)

  • Request Form

  • 2. Provide pre-population data

Form Manager

Form Manager

Form Filler

3. Pre-populated Report Form

Form Receiver

Form Receiver

4. Populated Report Form

Content Creator

Content Creator

  • Send–Receive

  • CDA Report

Content Consumer

15

Sources: Communicable Disease CDA Pilot Project Report. 2012. URL: https://wiki.phdsc.org/index.php/CDA

EHDI CDA Pilot Project Report. 2013. URL: https://wiki.phdsc.org/index.php/EHDI-Pilot


Communicable Disease Reporting and Reporting:

– CDA/SDC Pilot in NYC and WI

Current Progress (as December 2, 2013) – Finalize Testing in Vendor Environment

  • Key Outcomes

  • Shift in tradition al public health case report (PHCR) use case

    • Leverage existing standard (i.e., CCD -> cCDA)

  • Light-weight service for EMR vendors to connect to various jurisdiction reporting end-points

    • Minimize development in EMR System

  • Extensibility/ portability to other EMR vendors

  • State and LHD can configure forms based on reporting and business needs specific to jurisdiction

  • Electronic Medical Record (EMR) Vendor Test Environ-ment

    (i.e., EPIC)

    NYC and WI Public Health Infrastructure

    Continuity of Care Document (CCD)

    Reporting Module/Form Manager

    • Parse

    • Retrieve Form

    • Pre-populate web form

    4. Send URL with pre-populated web form

    Electronic Disease Surveillance System

    5. Physician/ICP submits addition information directly to system

    Next Steps – Identify, Recruit, and Implement in Hospital using EPIC EMR System

    State/Local Surveillance System


    • Public Health Tiger Team

      • Community based effort to identify, develop, and implement SDC Public Health Pilots

    • Proposed Public Health Pilots

      • EHDI

      • Cancer Reporting

      • Case Reporting

        http://wiki.siframework.org/Public+Health+Tiger+Team+Meeting+Archives

    17


    Health eDecisions and Reporting:

    - Use Cases

    • Use Case 1: standard format for sharing CDS knowledge artifacts

      • Rules, order sets and documentation templates

      • Goal: CDS knowledge authored in standard format can be imported and used in any EHR system

    • Use Case 2: standard interface for accessing CDS Web services

      • Goal: CDS capability encapsulated using standard interface can be integrated with any EHR system

    19


    Health edecisions use case 1 cds artifact sharing
    Health and Reporting: eDecisions– Use Case 1 (CDS Artifact Sharing)

    Use Case 1 Focuses on three artifact types:

    Event Condition Action Rules

    Order Sets

    Documentation Templates

    20


    Health edecision use case 1 pilot partnerships
    Health and Reporting: eDecision - Use Case 1: Pilot Partnerships

    21

    RCKMS: Reportable Condition Knowledge Management System


    Rckms long term scope
    RCKMS Long term Scope and Reporting:

    Reportable Condition

    Knowledge Management System (RCKMS)

    Public Health State, Local, Territorial Agencies

    PH

    Reports

    Authoring Framework

    PH Reporters (Clinicians)

    Query/View

    Hospital Labs

    Database

    Who, What, When, Where, How

    Subscription Management

    Including Notifications

    LIMS

    Web Service

    EHR

    Other Web Services

    Ambulatory Care

    Structured Output

    Generator

    (3) Open CDS

    Local

    National, Clinical & Public Health Laboratories

    LIMS

    EHR

    DSS Web Service

    (2) Open CDS

    HeD

    HeD Compliant format

    - Triggering Criteria

    - Reporting Actions

    - Links

    (1) Health eDecision (Hed)

    • Output file Options

    • HeD file download

    • OpenCDS in Cloud

    • OpenCDS Locally Deployed

    22



    Data access framework examples
    Data Access and Reporting: Framework- examples


    Improving population and public health stage 3 priorities
    Improving population and public and Reporting: health: Stage 3 Priorities

    Target Outcome Goals

    MU Outcome Goals

    Stage 3 Functionality Goals

    MU Outcome Goals

    Stage 1 + 2 Functional Objectives

    • Efficient and timely completion of case reports

    • Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement

    • Shared information with public health agencies or specialty societies

    • Bidirectional public health data exchange

    • Providers know the health status of their patient population

    • Public health officials know the health status of their jurisdiction

    • Providers and specialty societies can track and manage domain specific events related to practice and devices

    • Providers and public health officials share information to improve individual and population health

    • Patient lists

    • Sharing immunization data

    • Cancer and specialty registry

    • Electronic lab reporting

    • Submission of electronic syndromic surveillance data

    25


    Improving population and public health case reports
    Improving population and public and Reporting: health: Case Reports

    Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • Efficient and timely completion of case reports

    • Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement

    • Shared information with public health agencies or specialty societies

    • Bidirectional public health data exchange

    • CEHRT uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit.

      • Recommended as certification criteria only

    26


    Improving population and public health registries
    Improving population and public and Reporting: health: Registries

    Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • Efficient and timely completion of case reports

    • Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement

    • Shared information with public health agencies or specialty societies

    • Bidirectional public health data exchange

    • EPs/EHs use CEHRT to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources)

    • EP/EH Registries examples: cancer, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community. EHs Only: health-care associated infections

    27


    Improving population and public health immunization history
    Improving population and public and Reporting: health: Immunization history

    Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • Eligible Professionals, Hospitals, and CAHs receive a patient’s immunization history supplied by an immunization registry or immunization information system, allowing healthcare professionals to use structured historical immunization information in the clinical workflow

    • Recommended CEHRT Functionality

      • Ability to receive and present a standard set of structured, externally-generated immunization history and capture the act and date of review within the EP/EH practice

    • Efficient and timely completion of case reports

    • Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement

    • Shared information with public health agencies or specialty societies

    • Bidirectional public health data exchange

    28


    Improving population and public health electronic lab reporting
    Improving population and public and Reporting: health: Electronic lab reporting

    Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • Efficient and timely completion of case reports

    • Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement

    • Shared information with public health agencies or specialty societies

    • Bidirectional public health data exchange

    No Change from Stage 2

    EH Objective: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practiceMeasure: Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period.

    29


    Improving population and public health syndromic surveillance
    Improving population and public and Reporting: health: Syndromic Surveillance

    Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • Efficient and timely completion of case reports

    • Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement

    • Shared information with public health agencies or specialty societies

    • Bidirectional public health data exchange

    No Change from Stage 2

    EP MENU Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practiceEH Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice EP/EH Measure: Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period

    30


    Former objective details proposed merged registry objective 404 405 407 eh objective
    Former Objective Details and Reporting: Proposed Merged Registry Objective(404, 405, 407 - EH objective)

    EH Objective:   Capability to electronically submit standardized (i.e., data elements, structure and transport

    mechanisms), commonly formatted reports to two registries (e.g., local/state health departments,

    professional or other aggregating resources) from the Certified EHR Technology, except where prohibited,

    and in accordance with applicable law and practice. This objective is in addition to and does not replace

    prior requirements for submission to an immunization registry.

    Measure: Documentation (or registry acknowledgement) of ongoing successful electronic transmission of

    standardized reports from the CEHRT to two registries (either mandated or voluntary)).  Attestation of

    submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR

    reporting period as authorized, and in accordance with applicable State law and practice.

    Registries include: cancer, health-care associated infections, children with special needs, and/or early

    hearing detection and intervention or external entities that maintain the registry (e.g., hypertension,

    diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include

    accountable care organization, public health agency, professional society, or specialty community)

    should maintain the registry

    Certification criteria: EHR is able to build and then send a standardized report (e.g., standard message

    format) to an external mandated or voluntary registry, maintain an audit of those reports, and track total

    number of reports sent.


    Former objective details case reports 402b
    Former Objective Details and Reporting: Case reports – 402B

    Certification ONLY


    Affordable care stage 3 priorities
    Affordable and Reporting: care:Stage 3 Priorities

    MU Outcome Goals

    Stage 3 Functionality Goals

    MU Outcome Goals

    Stage 1 + 2 Functional Objectives

    • CDS support to avoid duplicative care

    • CDS support to avoid unnecessary or inappropriate care

    • Eliminate duplicative testing

    • Use cost-effective diagnostic testing and treatment

    • Minimize inappropriate care (overuse, underuse, and misuse)

    • Formulary checks

    • Generics

    33


    Affordable care clinical decision support
    Affordable care: and Reporting: Clinical Decision Support

    Examples of Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • Demonstrate use of multiple CDS interventions that apply to quality measures in each of the six NQS domains. Recommended interventions include:

      • Preventive care

      • Chronic disease management (e.g., diabetes, coronary artery disease)

      • Appropriateness of lab and radiology orders

      • Advanced medication-related decision support (e.g., renal drug dosing)

      • Improving the accuracy/completeness of the problem list

      • Drug-drug and drug-allergy interaction checks

    • CEHRT should provide tools that enable the ability to provide these interventions

    • Related work that can inform: S&I HealtheDecisions, HITSC Clinical Quality WG

    • CDS support to avoid duplicative care

    • CDS support to avoid unnecessary or inappropriate care

    34


    Reducing health d isparities stage 3 priorities
    Reducing health and Reporting: disparities:Stage 3 Priorities

    MU Outcome Goals

    Stage 3 Functionality Goals

    MU Outcome Goals

    Stage 1 + 2 Functional Objectives

    • Patient conditions are treated appropriately (e.g. age, race, education, LGBT)

    • Eliminate gaps in quality of health and health care across race, ethnicity, and sexual orientation

    • Language

    • Gender

    • Race

    • Ethnicity

    35


    Reducing health disparities additional patient information
    Reducing health disparities: and Reporting: Additional Patient Information

    Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • CEHRT provides the ability to capture

      • Patient preferred method of communication*

      • occupation and industry codes

      • Sexual orientation, gender identity (optional fields)

      • Disability status

        • Differentiate between patient reported & medically determined

  • Communication preferences will be applied to the clinical summary, reminders, and patient education objectives

    • Providers should have the ability to select options that are technically feasible for them, these could include: Email, text, patient portal, telephone, regular mail

  • Recommended as certification criteria only

    • Patient conditions are treated appropriately (e.g. age, race, education, LGBT)

    36


    Reduction of disparities previous deeming recommendations
    Reduction of Disparities – previous deeming recommendations

    • Reduction of disparities in gap area

    • Identify areas where attesters should be required to demonstrate they have reduced health care disparities in high-risk populations


    Follow up items

    Follow-up Items recommendations

    Feedback from HITSC

    Imaging Sharing and PGHD


    Improving quality of care and safety imaging
    Improving quality of care and recommendationssafety:Imaging

    Functionality Needed to Achieve Goals

    Stage 3 Functionality Goals

    • For both Eligible Professionals and Hospitals imaging results should be assessable through CEHRT. Results consisting of the image itself and any explanation or other accompanying information

    • Recommended as a Menu Item for EPs and Core for EHs

    • All relevant data accessible through EHR

    • CDS supports timely, effective, safe, efficient care and prevention

    • CDS helps avoid inappropriate care

    39


    Hitsc clinical operations wg charge
    HITSC Clinical Operations WG Charge recommendations

    • How full image sets or designated key images are shared between different facilities and specialists: the high level architecture e.g. role PACS, Archives, and EMRs

    • How this is deployed with central and distributed reading facilities

    • What methods and technical standards are used to push, pull, or view images in one place that originated or were interpreted in another place

    • Issues encountered sharing reports and interpretations, or auditing, with or alongside the images themselves

    • Inclusion of time series data in scope in addition to radiological images



    Abbreviations terminology
    Abbreviations/Terminology recommendations

    • Metadata: in this context, patient identifiers, dates, acquisition technique

    • KIN: IHE Key Image Note

    • KOS:DICOM Key Object Selection

    • DIMSE: DICOM Message Service Element (traditional DICOM PS 3.7)

    • ULP: Upper Layer Protocol (traditional DICOM PS 3.8 TCP/IP protocol)

    • MLLP: HL7 V2 Minimal Lower Layer Protocol (used by all IHE HL7 V2 stuff)

    • IID: IHE Invoke Image Display

    • STOW: DICOM Store Over the Web by RESTful Services (STOW-RS)


    Discussion from hitsc
    Discussion from HITSC recommendations

    • Very difficult to set certification criteria with so much optionality in recommended standards

    • Need  guidance on specific purposes and use case scenarios for certification

    • “Our challenge was to provide a parsimonious collection of constrained standards for consumer and professional applications in tightly coupled (modality to PACS), and loosely coupled (web-based, cloud hosted image exchange) architectures.   We all agreed that we need to be very careful when writing certification criteria to avoid optionality such that vendors will be forced to implement many different standards (the "OR" of meaningful use becomes the "AND" of certification)” http://geekdoctor.blogspot.com/2013_12_01_archive.html

    Office of the National Coordinator for Health Information Technology


    Engaging patients and families in their care patient generated health data
    Engaging patients and families in their care: recommendationsPatient Generated Health Data

    Stage 3 Functionality Goals

    Functionality Needed to Achieve Goals

    • Enabling active participation by patients and families to improve health and care

    • Provide ability to contribute information in the record, including patient reported outcomes (PRO)

    • Patient preferences recorded and used

    • Eligible Providers and Hospitals provide the capability for patients to electronically submit patient-generated health information through structured or semi-structured questionnaires (e.g., screening questionnaires, intake forms, risk assessment, functional status), secure messaging or provider-selected devices using CEHRT. (Provider-selected devices pending consideration by HITSC)

    • Recommended as a Menu item

    • Low threshold

    44


    Standards recommendations
    Standards Recommendations recommendations

    • ONC should consider the Direct transport standard for secure messaging and data from devices

    • ONC should consider the HL7 Care Team Roster standard

    • ONC should consider the HL7-CCDA for structured and unstructured questionnaires

    • ONC should consider the Continua standard for data from devices

    • We encourage standards that support mobile access to patient data and PGHD given the proliferation of mobile devices. However, we do not recommend mandating a specific standard at this time given that might stifle innovation.


    Recommendations for development of consumer standards
    Recommendations for Development of Consumer Standards recommendations

    • ONC should consider an S&I Initiative to create needed collaborative care document structure to address versioning, expanded provenance, reconciliation, data governance and curation.

    • ONC should consider creating a process to align consumer product and provider standards

    • ONC should consider using BlueButton+ API approach to accommodate PGHD

    • Trust Framework expanded for consumer/patient adoption in emerging technologies (BB+)

    • ONC should ask the HITSC to prioritize consumer vocabularies to support wider consumer, patient and family engagement


    Hitsc discussion
    HITSC Discussion recommendations

    • The key discussion was an evaluation of the standards maturity and the level of adoption of the standards suggested for patient generated data.  Recommendations included Direct for data transport, CCDA for content capture, LOINC/SNOMED for vocabulary capture, and Continua implementation guides for devices.  

    • As a followup the Consumer Technology Workgroup will list examples of CCDA templates that can be used to support patient generated data use cases.  

    • Continua will provide us a list of the named standards so that we can validate the maturity and adoption of Continua's recommendation.  

    • We will also ensure that the CCDA templates include the appropriate vocabularies that will  enable incorporation of patient generated data into EHRs.

    • http://geekdoctor.blogspot.com/2013_12_01_archive.html

    Office of the National Coordinator for Health Information Technology


    ad