0
Connecting Rural Health
Communities in Wisconsin
Louis Wenzlow
Director of Health Information Technology
Rural Wisconsin H...
Presentation Overview
• RWHC Background
• RWHC IT Services
• Sampling of Membership
• AHRQ Planning Effort
• Shared Hospit...
RWHC Background
• Founded in 1979
• Owned and operated by 29 rural hospitals
• Integrated network of freestanding entities...
RWHC IT Services
• Secure Data Network (USF funds keep
costs low)
• Internet, VPN, and E-mail Services
• Perimeter Securit...
RWHC IT Services
RWHC IT Services
Goals:
• Leverage existing infrastructure
• Apply the shared service model to health
information technolo...
Sampling of Membership
Facility A (Low IT Penetration/Low Cost)
Facility
Management
Patient BillingPatient Billing
McKesso...
Sampling of Membership
Facility B (High IT Penetration/High Flexibility/High Cost)
Facility
Management
Patient BillingPati...
Sampling of Membership
Facility C (High IT Penetration/Low Flexibility/Managed Cost)
Facility
Management
Patient BillingPa...
Sampling of Membership
Other systems used by RWHC members:
• Dairyland
• Meditech
• EMS
Systems used by large urban provid...
AHRQ Planning Effort
Rural/Urban Collaboration
• 12 RWHC members
• 3 Madison hospital representatives
• Madison Patient Sa...
AHRQ Planning Effort
Initial Objectives
• Determine the “readiness” of the hospital partners to expand and
enhance their E...
AHRQ Planning EffortFacility
Manage
ment
PatientPatient
BillingBilling
McKesso
n
GL & APGL & AP
McKesso
n
HR &HR &
Payrol&...
AHRQ Planning Effort
Activities
• Consensus building through monthly meetings and discussions
• Detailed assessment survey...
AHRQ Planning Effort
Early Lessons
• Data exchange is expensive
– Santa Barbara ($10 million in seed money)
– NHIN ($156 b...
AHRQ Planning Effort
• Benefits of data exchange infrastructure accrue to larger
communities
– Santa Barbara Data Exchange...
AHRQ Planning EffortFacility
Manage
ment
PatientPatient
BillingBilling
McKesso
n
GL & APGL & AP
McKesso
n
HR &HR &
Payrol&...
AHRQ Planning Effort
• Markle Foundation: Achieving Electronic Connectivity in
Healthcare (2004)
– “Our recommendation is ...
Shared EHR Initiative
Shared hospital information system/EHR
defined: A complete hospital information
system (with tightly...
Shared EHR InitiativeFacility
Manage
ment
PatientPatient
BillingBilling
McKesso
n
GL & APGL & AP
McKesso
n
HR &HR &
Payrol...
Shared EHR Initiative
Benefits of a Shared EHR
• Contained implementation costs with common
established procedures.
• Cont...
Shared EHR Initiative
Challenges of Shared EHR
• Concern about loss of existing investments, and timing
of opportunities.
...
Shared EHR Initiative
Success Factors of a Shared EHR
• Commitment of organizational resources to IT.
• Commitment of orga...
Shared EHR Initiative
What Next?
• Meet with as many organizations as possible to provide details and
establish levels of ...
AHRQ Planning Effort
Revised Goals
1. Develop consensus and support among relevant
communities and stakeholders for collab...
AHRQ Planning Effort
4. Educate and recruit healthcare practitioners
from the community to participate in
collaborative ap...
AHRQ Planning Effort
7. Demonstrate the benefits of collaborative application
development and electronic connectivity thro...
Data
Source/
Recipient
Message
Transfer Other
Data
Sources/
Recipients
(Physicians)
Data
Source/
Recipient
Data
Recipient
...
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Connecting Rural Health Communities in Wisconsin

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Transcript of "Connecting Rural Health Communities in Wisconsin"

  1. 1. Connecting Rural Health Communities in Wisconsin Louis Wenzlow Director of Health Information Technology Rural Wisconsin Health Cooperative
  2. 2. Presentation Overview • RWHC Background • RWHC IT Services • Sampling of Membership • AHRQ Planning Effort • Shared Hospital Information System/EHR Initiative
  3. 3. RWHC Background • Founded in 1979 • Owned and operated by 29 rural hospitals • Integrated network of freestanding entities • Goal is to meet community healthcare network needs through advocacy and high value services
  4. 4. RWHC IT Services • Secure Data Network (USF funds keep costs low) • Internet, VPN, and E-mail Services • Perimeter Security and Web Filtering • Zix Encrypted E-mail for EPHI • Unitrends Remote Backup Vault for Off- site Data Storage
  5. 5. RWHC IT Services
  6. 6. RWHC IT Services Goals: • Leverage existing infrastructure • Apply the shared service model to health information technology and electronic health record (EHR) applications • Help build member hospital HIT capacity
  7. 7. Sampling of Membership Facility A (Low IT Penetration/Low Cost) Facility Management Patient BillingPatient Billing McKesson GL & APGL & AP McKesson HR & PayrollHR & Payroll None Time & AttendanceTime & Attendance None Supply ChainSupply Chain None MPIMPI McKesson Interface EngineInterface Engine NoneNone HIM DictationDictation Dictaphone TranscriptionTranscription Dictaphone E-signE-sign None Document ImagingDocument Imaging None Clinical Documentation AssessmentsAssessments None Vitals/I&OVitals/I&O None Patient EducationPatient Education None Physician Systems Practice ManagementPractice Management None Practice EMRPractice EMR None Hospital CPOEHospital CPOE None Physician PortalsPhysician Portals None Pharmacy E-MARE-MAR None DispensingDispensing None Med BarcodingMed Barcoding None Decision SupportDecision Support None Radiology RISRIS None PACSPACS None Tele-RadiologyTele-Radiology Amicus Departments LabLab None SurgerySurgery None ERER None
  8. 8. Sampling of Membership Facility B (High IT Penetration/High Flexibility/High Cost) Facility Management Patient BillingPatient Billing McKesson GL & APGL & AP McKesson HR & PayrollHR & Payroll Lawson Time & AttendanceTime & Attendance Kronos Supply ChainSupply Chain Medeclick MPIMPI Epic Identity Interface EngineInterface Engine Cloverleaf HIM DictationDictation Dictaphone TranscriptionTranscription Dictaphone E-signE-sign Dictaphone Document ImagingDocument Imaging Epic CDR Clinical Documentation AssessmentsAssessments Planned Vitals/I&OVitals/I&O Planned Patient EducationPatient Education Micromedex Physician Systems Practice ManagementPractice Management Epic Practice EMRPractice EMR Epic Hospital CPOEHospital CPOE Planned Physician PortalsPhysician Portals Epicare Pharmacy E-MARE-MAR Cerner DispensingDispensing Pyxis Med BarcodingMed Barcoding Planned Decision SupportDecision Support Cerner & Epic Radiology RISRIS Epic PACSPACS Planned Tele-RadiologyTele-Radiology Amicus Departments LabLab SCC SurgerySurgery McKesson ERER Logicare Discharge
  9. 9. Sampling of Membership Facility C (High IT Penetration/Low Flexibility/Managed Cost) Facility Management Patient BillingPatient Billing CPSI GL & APGL & AP CPSI HR & PayrollHR & Payroll CPSI Time & AttendanceTime & Attendance CPSI Supply ChainSupply Chain CPSI MPIMPI CPSI Interface EngineInterface Engine None HIM DictationDictation Lanier TranscriptionTranscription CPSI E-signE-sign CPSI Document ImagingDocument Imaging CPSI planned Clinical Documentation AssessmentsAssessments CPSI Vitals/I&OVitals/I&O CPSI Patient EducationPatient Education CPSI/Micromedex Physician Systems Practice ManagementPractice Management None Practice EMRPractice EMR None Hospital CPOEHospital CPOE CPSI Physician PortalsPhysician Portals CPSI Pharmacy E-MARE-MAR CPSI DispensingDispensing Pyxis Med BarcodingMed Barcoding CPSI Decision SupportDecision Support CPSI Radiology RISRIS CPSI PACSPACS Planned Tele-RadiologyTele-Radiology Amicus Departments LabLab CPSI SurgerySurgery CPSI planned ERER Logicare discharge CPSI forms planned
  10. 10. Sampling of Membership Other systems used by RWHC members: • Dairyland • Meditech • EMS Systems used by large urban providers: • Epic • Siemens
  11. 11. AHRQ Planning Effort Rural/Urban Collaboration • 12 RWHC members • 3 Madison hospital representatives • Madison Patient Safety Collaborative
  12. 12. AHRQ Planning Effort Initial Objectives • Determine the “readiness” of the hospital partners to expand and enhance their EHR capacities so they can be integrated with one another • Develop a workable model/plan for standards-based data-sharing that would allow multiple providers using disparate information systems to access patient information via a common platform • Create a quality measurement and enhancement tool that would allow project partners to measure improvements in quality and patient care that are directly related to EHR implementation
  13. 13. AHRQ Planning EffortFacility Manage ment PatientPatient BillingBilling McKesso n GL & APGL & AP McKesso n HR &HR & Payrol&Payrol& HIM DictatioDictatio nn Dictaph one TranscrTranscr iptioniption Dictaph one E-signE-sign None DocumDocum entent ImagingImaging None Clinical Docume ntation AssessmAssessm entsents None Vitals/I&Vitals/I& OO None PatientPatient EducatioEducatio nn None Physician Systems PracticePractice ManagemeManageme ntnt None PracticePractice EMREMR None HospitalHospital CPOECPOE None PhysicianPhysician PortalsPortals None Pharm acy E-MARE-MAR None DispenDispen singsing None MedMed BarcodiBarcodi ngng None DecisioDecisio nn SupportSupport None Radiolo gy RISRIS None PACSPACS None Tele-Tele- RadiologRadiolog yy Amicus Departmen ts LabLab None SurgerySurgery None ERER None None SupplySupply ChainChain None MPIMPI McKesson InterfaceInterface EngineEngine NoneNone HIM DictationDictation Dictapho ne TranscriTranscri ptionption Dictapho ne E-signE-sign None DocumeDocume ntnt ImagingImaging None Clinical Documen tation AssessmeAssessme ntsnts None Vitals/I&OVitals/I&O None PatientPatient EducationEducation None Physician Systems PracticePractice ManagementManagement None PracticePractice EMREMR None HospitalHospital CPOECPOE None PhysicianPhysician PortalsPortals None Pharma cy E-MARE-MAR Radiolog y RISRIS None Amicus Department s LabLab None None AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab Data Source/ Recipient Message Transfer Other Data Sources/ Recipients, (Physicians) Data Source/ Recipient Data Source/ Recipient Data Source/ Recipient Patient Record Locator AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab
  14. 14. AHRQ Planning Effort Activities • Consensus building through monthly meetings and discussions • Detailed assessment survey to establish group readiness to implement EHR applications and data exchange • Discussions about institutional strategic needs • Education sessions related to EHR implementation and data exchange • Research of existing vendor-independent data exchange efforts (Santa Barbara, Massachusetts, Taconic) • Site visits to existing shared EHR cooperatives (INHS, SISU) • Education of RWHC Board Members (CEOs of RWHC hospitals)
  15. 15. AHRQ Planning Effort Early Lessons • Data exchange is expensive – Santa Barbara ($10 million in seed money) – NHIN ($156 billion, and $48 billion annually to operate) • Data exchange and interoperability are two different things – Waiting on data exchange standards • Rural and urban hospitals have distinctive strategic interests – Urban hospitals have a strategic interest in data exchange – Rural hospital have a strategic interest in developing their internal EHR systems in preparation for data exchange.
  16. 16. AHRQ Planning Effort • Benefits of data exchange infrastructure accrue to larger communities – Santa Barbara Data Exchange: Moving Toward Electronic Health Information Exchange: Interim Report (2003) “The analysis shows that there are positive returns to health information exchange in all except small communities (e.g., one hospital and less than 100 physicians)…” • Benefits not aligned with those who shoulder the cost – According to the Advisory Board NIHIT Briefing, “hospitals and providers foot 97% of the ongoing costs, yet receive just 56% of the potential benefits. The remaining benefits are dispersed among payers and other stakeholders.
  17. 17. AHRQ Planning EffortFacility Manage ment PatientPatient BillingBilling McKesso n GL & APGL & AP McKesso n HR &HR & Payrol&Payrol& HIM DictatioDictatio nn Dictaph one TranscrTranscr iptioniption Dictaph one E-signE-sign None DocumDocum entent ImagingImaging None Clinical Docume ntation AssessmAssessm entsents None Vitals/I&Vitals/I& OO None PatientPatient EducatioEducatio nn None Physician Systems PracticePractice ManagemeManageme ntnt None PracticePractice EMREMR None HospitalHospital CPOECPOE None PhysicianPhysician PortalsPortals None Pharm acy E-MARE-MAR None DispenDispen singsing None MedMed BarcodiBarcodi ngng None DecisioDecisio nn SupportSupport None Radiolo gy RISRIS None PACSPACS None Tele-Tele- RadiologRadiolog yy Amicus Departmen ts LabLab None SurgerySurgery None ERER None None SupplySupply ChainChain None MPIMPI McKesson InterfaceInterface EngineEngine NoneNone HIM DictationDictation Dictapho ne TranscriTranscri ptionption Dictapho ne E-signE-sign None DocumeDocume ntnt ImagingImaging None Clinical Documen tation AssessmeAssessme ntsnts None Vitals/I&OVitals/I&O None PatientPatient EducationEducation None Physician Systems PracticePractice ManagementManagement None PracticePractice EMREMR None HospitalHospital CPOECPOE None PhysicianPhysician PortalsPortals None Pharma cy E-MARE-MAR Radiolog y RISRIS None Amicus Department s LabLab None None AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab Data Source/ Recipient Message Transfer Other Data Sources/ Recipients (Physicians) Data Source/ Recipient Data Source/ Recipient Data Source/ Recipient Patient Record Locator AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab
  18. 18. AHRQ Planning Effort • Markle Foundation: Achieving Electronic Connectivity in Healthcare (2004) – “Our recommendation is that both applications and (health information exchange) infrastructure should be developed and adopted simultaneously, in incremental steps that always bring us closer to the ultimate goal, and that deliver positive value for adopters at every stage.” – Positive value to ensure sustainability Consensus Position • Implement collaborative EHR applications that are in the participating hospitals’ strategic interests. Make sure the implementations are consistent with an eventual data exchange infrastructure. Plan for a common framework.
  19. 19. Shared EHR Initiative Shared hospital information system/EHR defined: A complete hospital information system (with tightly integrated financial, ancillary, and clinical modules) that is used by more than one facility and has inter-facility data exchange functionality.
  20. 20. Shared EHR InitiativeFacility Manage ment PatientPatient BillingBilling McKesso n GL & APGL & AP McKesso n HR &HR & Payrol&Payrol& HIM DictatioDictatio nn Dictaph one TranscrTranscr iptioniption Dictaph one E-signE-sign None DocumDocum entent ImagingImaging None Clinical Docume ntation AssessmAssessm entsents None Vitals/I&Vitals/I& OO None PatientPatient EducatioEducatio nn None Physician Systems PracticePractice ManagemeManageme ntnt None PracticePractice EMREMR None HospitalHospital CPOECPOE None PhysicianPhysician PortalsPortals None Pharm acy E-MARE-MAR None DispenDispen singsing None MedMed BarcodiBarcodi ngng None DecisioDecisio nn SupportSupport None Radiolo gy RISRIS None PACSPACS None Tele-Tele- RadiologRadiolog yy Amicus Departmen ts LabLab None SurgerySurgery None ERER None None SupplySupply ChainChain None MPIMPI McKesson InterfaceInterface EngineEngine NoneNone HIM DictationDictation Dictapho ne TranscriTranscri ptionption Dictapho ne E-signE-sign None DocumeDocume ntnt ImagingImaging None Clinical Documen tation AssessmeAssessme ntsnts None Vitals/I&OVitals/I&O None PatientPatient EducationEducation None Physician Systems PracticePractice ManagementManagement None PracticePractice EMREMR None HospitalHospital CPOECPOE None PhysicianPhysician PortalsPortals None Pharma cy E-MARE-MAR Radiolog y RISRIS None Amicus Department s LabLab None None AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab Data Source/ Recipient Other Data Sources/ Recipients Data Source/ Recipient Data Source/ Recipient Data Source/ Recipient Shared Datacenter with Integrated EHR AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab
  21. 21. Shared EHR Initiative Benefits of a Shared EHR • Contained implementation costs with common established procedures. • Contained capital costs with a shared data center and server model • Contained operating costs with shared system administration, help desk, etc. • On-going purchasing and negotiating power • Availability of patient safety tools • Data exchange capabilities between participating providers
  22. 22. Shared EHR Initiative Challenges of Shared EHR • Concern about loss of existing investments, and timing of opportunities. • Even with cost containment benefits of shared model, top-tier EHRs will require significant commitment, both capital & operating, of organizational resources to IT. • Integration means standardizing for the benefit of the organization. This can be threatening to departmental stakeholders, especially if they are accustomed to best of breed departmental systems. • EHR implementation is an inherently disruptive activity, which requires steadfast leadership through an extended period of great change.
  23. 23. Shared EHR Initiative Success Factors of a Shared EHR • Commitment of organizational resources to IT. • Commitment of organizational over departmental causes. • Commitment to stay the course. • Commitment to collaboration, since the more organizations do collaboratively, the more value is derived. (Organizations will ideally exhaust collaborative options before investing in their own HIT solution).
  24. 24. Shared EHR Initiative What Next? • Meet with as many organizations as possible to provide details and establish levels of interest. • Establish taskforce comprised of tentatively interested organizations, including as many stakeholders as is practical. • Develop a process that will take us through the establishment of taskforce decision-making procedures and vendor selection, and lead to financial numbers upon which organizations can make final decisions as to whether or not they want to participate. • If we have enough interested participants, establish a 501c3 organization, iron out governance issues, and create a detailed implementation plan and budget
  25. 25. AHRQ Planning Effort Revised Goals 1. Develop consensus and support among relevant communities and stakeholders for collaboration on application sharing and heath care data connectivity projects 2. Construct an effective organizational model with management oversight to support the development of collaborative healthcare application projects and regional health care connectivity 3. Identify and address any common barriers to health care cooperative applications and data information exchange
  26. 26. AHRQ Planning Effort 4. Educate and recruit healthcare practitioners from the community to participate in collaborative applications and data exchange 5. Build baseline capacity toward achievable information exchange among member institutions and stakeholders 6. On a stepwise basis, implement cooperative applications and data sharing initiatives among participating organizations and individuals
  27. 27. AHRQ Planning Effort 7. Demonstrate the benefits of collaborative application development and electronic connectivity through improvements in: the quality of patient care and service; provider-patient relationships, continuity of care, patient safety, improved delivery system efficiency 8. Communicate to key stakeholders and external constituents project status, barriers and accomplishments 9. As the need for health information exchange warrants, and after standards and other enabling mechanisms have been developed and tested, join with other organizations and consortia to participate in the establishment of a RHIO
  28. 28. Data Source/ Recipient Message Transfer Other Data Sources/ Recipients (Physicians) Data Source/ Recipient Data Recipient Data Source/ Recipient Patient Record Locator Data Source/ Recipient Other Data Sources/ Recipients Data Source/ Recipient Data Source/ Recipient Data Source/ Recipient Shared Datacenter with Integrated EHR AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab AttendAttend anceance None SupplySupply ChainChain None MPIMPI HIM DictatDictat ionion Dicta phon e TransTrans criptiocriptio nn Dicta phon e E-E- signsign Clinic al Docu menta tion AssesAsses smentsment ss None Vitals/IVitals/I &O&O None ntnt Physicia n System s PracticePractice ManageManage mentment None PracticePractice EMREMR None HospitalHospital CPOECPOE None Phar macy E-RE-R Radiol ogy RISRIS Departm ents LabLab
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