Delivered by Craig Brammer at CITIH 2011. Focus on discussion of regional and national initiatives and opportunities for regional partners to leverage them for driving healthcare improvements, public health and research. This session will provide a broad perspective on the many initiatives related to HIT. Experts from the regional and national level will discuss data models, privacy concerns and adoption strategies from their different perspectives. Also addressed will be planning for NHIN direct adoption as a complimentary strategic to full HIEs.

1. Health IT and Health System Reform
The Ohio State University Center for IT Innovations in Healthcare
April 2011
Craig Brammer
Office of the National Coordinator for Health Information Technology
craig.brammer@hhs.gov

2. Agenda
g
1.
1 Uniting the Tribes of Health System Improvement
2. HITECH Status Report
3. Uniting the Tribes in 17 US Markets: The Beacon
Communities
4. Health IT as Infrastructure for Accountability
2

3. Agenda
g
1.
1 Uniting the Tribes of Health System Improvement
2. HITECH Status Report
3. Uniting the Tribes in 17 US Markets: The Beacon
Communities
4. Health IT as Infrastructure for Accountability
3

4. 4

5. The “Tribes” of Health System Improvement:
A Multiplicity of Approaches, Strategies and
A Multiplicity of Approaches Strategies and Tools
1. The Quality Improvement Crusaders
2. The Payment Reformers
3.
3 The Consumer Energizers
4. The Health IT Champions
McKethan AN, Brammer CB. Uniting the Tribes of Health
System Improvement. The American Journal of Managed
Care. 2010;16:SP13-SP18.
5

6. Tribe 1: The Quality Improvement Crusaders
y p
APPROACH: Scientific evaluation methods and management
techniques to achieve better patient outcomes
Data analysis and performance measurement
- Provider feedback processes evidence informed guidelines
Provider feedback processes, evidence‐informed guidelines
Management techniques
- L
Lean manufacturing, continuous quality improvement
f t i ti lit i t
Learning and “best practices”
- e.g., avoiding complications in the ICU, reducing hospital
d l h d h l
readmissions, improving care transitions, reducing infection and
surgical‐complication rates, etc.
6

7. Tribe 2: The Payment Reformers
y
APPROACH: Alternatives to volume‐based payments to support
systematic improvements in care and opportunities for slower spending
growth
Performance Incentives
- P4P, high‐performance networks, never events
Payments promoting provider alignment and care coordination
- ACOs, medical homes, bundled payments, readmission penalties
7

8. Tribe 3: The Consumer Energizers
g
APPROACH: Information and appropriate incentives to help consumers
improve their own health, save money, and achieve better outcomes
Value‐based insurance design
- Red ced copa s for effecti e treatments incenti es for seeking
Reduced copays for effective treatments, incentives for seeking
care from high‐performance providers/networks
Consumer directed health plans
- HSAs and high deductable health plans
Consumer information to support health decision making
C i f ti t t h lth d i i ki
- Shared decision making/informed patient choice, “motivational
technologies” to support behavior modification
Transparency of cost and quality information
8

9. Tribe 4: The Health IT Champions (aka, Wireheads)
p
APPROACH: Electronic infrastructure to support administrative
simplification, error avoidance, cost containment and improved outcomes
Electronic health record adoption and information exchange
- Standards and interoperabilit pri ac & sec rit MU incenti es
Standards and interoperability, privacy & security, MU incentives
Tools to support clinicians in delivering high value care
- Cli i l d i i
Clinical decision support, performance feedback, ePrescribing
f f db k P ibi
Tools to support consumers in receiving high value care
- Personal health records, mHealth applications, eVisits
Tools to support purchasers in rewarding high value care
- Data aggregation and performance measurement
9

10. Tribal Approaches to Health System Reform
pp y
Quality improvement activities are often unsustainable due to
volume‐based payment methods
volume based payment methods
Payment reforms are ineffective if unaccompanied by changes in
provider practices and consumer behavior
Uncoordinated care subjects even highly engaged and informed
p
patients to fragmented care
g
Higher spending on technology with uncertain benefits is
worrisome
Yet…tribal approaches to health system reform are ubiquitous
10

11. Segmentary Lineage and Health System Reform
g y g y
In his 1940 book about the Nuer people in
southern Sudan, British anthropologist E. E.
Evans‐Pritchard coined the term “segmentary
lineage” to describe how members of a society live
in a web of nested identities or tribes.
At any given time, individuals are members of
several groups in a hierarchy, from the local or
proximal (eg, my street, my neighborhood) to
proximal (eg my street my neighborhood) to
larger groups (eg, my region, my country).
The most meaningful group affiliation at any
given time depends on the scale and nature of
external threats or conflicts.
11

12. The Scale and Nature of External Threats to Health Care
*Insert obligatory slides on spending trends, regional variation, per
capita costs relative to other industrialized nations, etc.
capita costs relative to other industrialized nations etc
*Insert obligatory slides on McGlynn study, IOM reports, AHRQ
annual quality report, etc.
*Mention growing dissatisfaction with health care, for example…
Majority of Americans Give Quality of Health Care a C, D or F. US News
& World Report; April 14, 2011.
New Survey: 72 Percent in U.S. Think Health System Needs Major
New Survey: 72 Percent in U S Think Health System Needs Major
Overhaul. The Commonwealth Fund; April 15, 2011.
12

13. The Scale and Nature of External Threats to Health Care
13

14. Agenda
g
1.
1 Uniting the Tribes of Health System Improvement
2. HITECH Status Report
3. Uniting the Tribes in 17 US Markets: The Beacon
Communities
4. Health IT as Infrastructure for Accountability
14

15. The HITECH Framework: Meaningful Use at
its Core
it C
Regional Extension Centers
ADOPTION
Workforce Training Improved Individual
& Population Health
Outcomes
Medicare & Medicaid MEANINGFUL USE Increased
Incentives and Penalties Transparency
& Efficienc
Efficiency
State HIE Program Improved
Ability to Study &
y y
Standards & Certification
St d d & C tifi ti EXCHANGE
Improve Care Delivery
Privacy & Security
Health IT Practice Research
15

16. Conceptual Approach to Meaningful Use
p pp g
Improved
Outcomes
Advanced
care
processes
with decision
Capture /
p support
share data
16

17. Meaningful Use Survey Findings
g y g
Percent of Non‐Federal Acute Care Percent of Office‐Based Physician
Hospitals Planning to apply for CMS’ Practices Planning to apply for CMS’
EHR Incentive Programs
EHR I ti P EHR Incentive Programs
EHR I ti P
90 90
81%
80 80
70 70
60 60
50 50
41%
40 40
30 Planning in 30 Planning in
Subsequent Subsequent
20 Year
Y 20 Year
Y
Planning in Planning in
10 2011 or 2012 10 2011 or 2012
Application Application
0 0
US H
Hospitals
it l Physician Practices
Ph i i P ti
17
Source: American Hospital Association Information Technology Survey, 2010; National Center for Health Statistics, National
Ambulatory Medical Center Survey, 2010.
17

18. ONC Programs
g
Technical $693 million
Assistance
– 62 Regional Extension Centers
Workforce
$118 million
Training – 84 Community Colleges training new
health IT support personnel
State Health
Information
$564 million
Exchange – 56 grants to states and territories
HITECH laws and policy development
Interoperability
gy
Technology standards and certification
18
18

19. ONC Program Results to Date
g
Technical 57,716 providers enrolled with the
Assistance Regional Extension Centers
Workforce 3,600 graduating this spring
Training
State Health
Information
46 state plans approved
Exchange
449 certified EHR products on the market
Interoperability conforming to standards
19

20. State Health Information Exchange Program
g g
Goal: Ensure that every provider has at least one option for
meeting health information exchange requirements of
meaningful use
Four year program, 56 states and territories were awarded
$548 Million awarded in total funding for HIE planning and
implementation
States need an ONC approved State Plan before federal
St t d ONC d St t Pl b f f d l
funding can be used for implementation –46 have been
approved
Multiple approaches are being pursued, many oriented around
core services and gap‐filling
20

21. State Health Information Exchange Challenge Grants
g g
10 Awards ($16 million) for Breakthroughs in Key Areas
– Reducing preventable hospital admissions (NC)
p g g , , ,
– Improving long‐term care transitions (CO, MA, OK, MD)
– Consumer‐mediated exchange (IN, GA)
– Meta‐data approaches to granular data sharing (IN)
– Di ib d
Distributed query for population health (MA, MT)
f l i h l h (MA MT)
21

22. Health Information Exchange (The Verb)
g
22

23. Health Information Exchange (The Verb)
g
Document/Message Security and Trust
Directories and Certificates
Standards relationships
Vocabulary Standards Delivery Protocols
23

24. Capabilities for Nationwide Health Information Exchange
p g
– Secure transport
p
– Content standards
– Computable consent
– Patient matching
–R
Record locator service
d l t i
– De‐identification
– Distributed query
– Meta data
24

25. Emerging Direct Ecosystem
» 50+ vendors have committed to roll‐out Direct‐enabled functionality,
and ~20 states include Direct in their approved State HIE plans*
EHRs HIEs & HIOs States
4Medica Med3000 AAFP MedAllies Alabama
Aprima MEDgle Ability MedCommons California
Allscripts NextGen Akira Technologies MEDfx Florida
Care360 OpenEMR ApeniMed Medicity Illinois
Cerner Polaris Atlas Development MedPlus Iowa
eClinicalWorks RelayHealth Axolotl Mirth Kentucky
e‐MDs Sage Healthcare CareEvolution MobileMD Minnesota
Epic Siemens Covisint National Health Svcs Missouri
GE Healthcare Sunquest Garden State Health NetDirector Montana
Greenway WorldVistA Systems Inc. Orion Health New Hampshire
GSI Health ProviderDirect New Jersey
Harris RedwoodMedNet North Carolina
HINSTx
HINST Secure Exchange
S E h Ohio
Ohi
PHRs Ingenix Solutions Oregon
Inpriva Surescripts Rhode Island
Dossia IVANS Techsant Technologies South Carolina
Microsoft HealthVault Kryptiq Corporation
yp q p Thomson Reuters Texas
NoMoreClipboard.com Lifepoint Informatics Verizon Vermont
RelayHealth max.md Wellogic West Virginia
Wisconsin
* Source: http://directproject.org/content.php?key=getstarted&sub=vendorsupport (as of April 2, 2011) 25

26. Security & Interoperability Framework
y p y
Promote a sustainable ecosystem that drives increasing
interoperability and standards adoption
Create a collaborative, coordinated, incremental standards
process that is led by the industry in solving real world
problems
Leverage “government as a platform” – provide tools,
coordination, and harmonization that will support interested
parties as they develop solutions to interoperability and
standards adoption.
26

27. S&I Framework’s Transitions of Care Initiative
Challenge: Meaningful Use Stage 1 and foreseen Stage 2
requires information to be exchanged in Transition of Care.
requires information to be exchanged in Transition of Care
Implementers confused on how to use the specifications to exchange
required data
req ired data
Exchange of clinical summaries hampered by ambiguous common
definitions of what data elements must be exchanged, how they must be
encoded, and how those common semantic elements map to MU specified
formats. (C32/CCD and CCR)
Lack of a robust toolset to aid in development and validation of conformant
templated clinical documents is a major impediment to the widespread
adoption of standards.
27

28. Security & Interoperability Framework Stakeholders
y p y
Call for Participation: The overall success of the S&I
Framework is dependent upon volunteer experts from the
healthcare industry and we welcome any interested party to
get involved in S&I Framework Initiatives, participate in
discussions and provide comments and feedback by joining the
Wiki.
For more information on how to get started as a volunteer
please visit:
http://jira.siframework.org/wiki/display/SIF/Getting+Started+a
http://jira siframework org/wiki/display/SIF/Getting+Started+a
s+a+Volunteer
28

29. Agenda
g
1.
1 Uniting the Tribes of Health System Improvement
2. HITECH Status Report
3. Uniting the Tribes in 17 US Markets: The Beacon
Communities
4. Health IT as Infrastructure for Accountability
29

30. Beacon Communities
ONC allocated $265 million over 3 years to 17 communities,
including $15M for technical assistance and evaluation, to
including $15M for technical assistance and evaluation to
demonstrate the feasibility and the health care delivery benefits of
widespread HIT adoption and exchange of health information.
Core aims:
Build and strengthen health IT infrastructure as a foundation to
improve quality of care, health outcomes, and cost efficiencies;
i li f h l h d ffi i i
Demonstrate that health IT‐enabled interventions and
that health IT enabled interventions and
community collaborations achieve concrete cost/quality
performance improvements;
Test new innovations to improve health and health care
30

31. Beacon Community Programs
31
31

32. Beacon Communities
•Governance
•Subsequent
•IT & •First wave of
measurement interventions 2012 & waves of
2010 infrastructure
i f t t 2011 •Innovation
interventions
•Interventions networks 2013 •Dissemination of
lessons learned
logic models
In 2011, Beacon interventions will “engage” ~5,000 providers and “touch”
approximately 600K individuals around specific health improvement
aims:
• 9 Beacon Communities’ work includes improving care transitions (e.g.,
k l d
process improvements and information flow at hospital discharge).
• 10 Beacon Communities’ work focuses on the use of IT tools and process
improvements (e.g., CDS) to improve performance of physician practices.
improvements (e g CDS) to improve performance of physician practices
All Beacons submit cost/quality/health data on their performance quarterly.
Starting in May 2011, CMS will supply provider‐level reports from Medicare.
32

33. Examples from Beacon Communities
p
Central Indiana spreading admin/clinical measurement and P4P
model from 9 to 42 counties
Grand Junction Colorado redesiging primary care with strong HIE
and measurement
Tulsa spreading Doc‐t0‐Doc electronic specialty referral system and
deploying Archimedes provider and region‐level CDS/predictive
modelingg
33

34. Examples from Beacon Communities
p
North Carolina deploying Asthmapolis to support pediatric asthma
improvement
San Diego deploying mHealth linked to immunization registry to
alert parents of young children about immunizations
Bangor, Maine using remote monitoring to help manage frail elderly
Geisinger, Intermountain & Mayo spreading tools and technologies
beyond IDS to broader community
34

35. Beacon Community 90‐Day Launch Plan
Program Goals
Community Core cost, quality, and population health
Objectives
Obj ti CO CO
improvement aims
Measured MO MO MO MO
Outcomes Well‐defined measurable improvement goals
Defining risks and barriers and establishing plans to prevent or mitigate them
Outputs O O O O O O Operational & process results of core activities
Activities A A A A A A Tasks/interventions leading to outputs
Resources R R R R R R R R R R R R Resources needed to support activities and meet
stated outcome goals
Sustainability plan outlining provider reimbursement, program
revenue, and other strategies
35

36. Geisinger (“Keystone Beacon Program”)
Summary of 1 out of 10 Beacon/Geisinger Community
Program Goals
Objectives (Logic Models)
Community Improve quality and efficiency among targeted patients with Chronic
Objectives
j CO Obstructive Pulmonary Disease (COPD) and Heart Failure (HF)
Reductions in hospital admissions, avoidable 30‐day hospital readmissions,
Measured MO MO and ED visits among target patients; increased access to/utilization of
Outcomes p
primary care services among same patients
y g p
Specific plans to prevent or mitigate implementation risks and barriers
Outputs O O O O Medication reconciliation outputs, hospital discharge counseling,
targeted case management contact, web‐based portals, others
Comprehensive HIT‐enabled care model includes care process redesign and
Activities A A A A teaming; integration across all systems of care, care protocols; performance
feedback to patients and clinicians, and reminder systems
Specific funding allotments to core activities phased in over new areas and
Resources R R R R R R R R over time; dedicated administrative, IT, and clinical teams
Sustainability plan: integration of accountable care payment model aligned
S t i bilit l i t ti f t bl t d l li d
with health IT‐enabled performance improvement goals
36

37. Keystone Beacon Community
Lead Geisinger Clinic
Service Area Central Pennsylvania
Population Total patient population in catchment area: 256,203 Total # of target providers: 16 practices, 3 hospitals
Total target patient population: 51,000
Select •Improve the management and outcomes for patients with COPD and CHF
Performance
P f •Ex: 90% of t
E f target patients on ACEi or ARB, 100% with follow up <7 days post discharge
t ti t ARB ith f ll 7d t di h
Improvement •Increased patient engagement
Goals •Improve medication reconciliation
•Reduce all cause hospitalizations, 30-day readmissions, and preventable ED visits for patients with CHF,
COPD, and within 30 days of surgery
•Improve influenza vaccination rates to 100% for patients with CHF and COPD
Select Hospital-Based Care Managers
Interventions •Identify high-risk patients with CHF, COPD, and other chronic disease to facilitate smooth transfers to
either home or a long-term care facility using the Provenhealth Navigator System (4 CM to start)
Care Managers in Ambulatory Physician Practices
•Facilitate medication management and action plans for patients with COPD and CHF (3 CM to start)
•Teach self-management action plans including nutrition and daily weights;
•EHR-enabled exacerbation protocols for CHF and COPD management
Remote Care Managers
•Centralized call center for 3 CM who will provide telephonic management for 4 weeks post discharge.
Patient Portals, PHRs, and Patient Engagement
at e t o ta s, s, a d at e t gage e t
•Patient portals, secure messaging, and self management tools interoperable with the EHRs facilitate
patient engagement and patient-provider communication
Computerized Clinical Decisions Support Tools
•Alerts identify candidates for influenza vaccine, trigger guideline based care, and notify providers via
HIE connection of patient hospitalizations/ED visits
Other Notable The Beacon Community considers patient engagement, satisfaction, and perceived quality of life as important
Characteristics measures.
The Beacon Community has active engagement of long-term care facilities.

38. Five Domains of the Beacon “Learning System"
g y
Domain Focus Area
1 Establishing Beacon strategic direction; aligning Beacon
Leadership & Stewardship Community performance improvement goals with policy at the
local and national level. Communications and outreach.
2 Achieving meaningful use goals; collaborating on the testing and
HIT & Meaningful Use documentation of new technologies (e.g., clinical data repositories,
master patient indices, EHR interfaces to HIEs)
3 Learning from best practice care delivery innovations (e.g., care
g g
Clinical Transformation transitions programs, medication therapy management programs,
medical homes, remote monitoring)
4 Data & Performance Developing robust performance measurement and feedback
Measurement capabilities; testing new measures and measurement approaches
(e.g., patient‐reported outcomes measures)
5 Strategic planning and implementation activities focused on
Sustainability and
payment reforms to sustain performance improvements and
f i f i d
Payment Reform
support infrastructure developed under the Beacon Program
38

39. Greater Cincinnati Beacon Community
Lead HealthBridge
Service Area Greater Cincinnati Region
Population Total target pediatric population: 18,000 Total adult patient population in catchment: 1,530,337
Total target pediatric population in year 1: 4600 Total target adult population: 159,000
Total target providers in year 1: 123 Total target providers: 50
Select •Improve management for adult diabetes
p g
Performance •Ex: LDL < 100, BP < 130/80, A1C < 7, and aspirin use
Improvement •Reduce ED visits and 30-day readmissions for diabetes by at least 15%
Goals •Improve outcomes for pediatric asthma
•80% of population achieves symptom control, 60% for Medicaid
•Reduce pediatric asthma ED visits, school days missed, and hospitalizations by 60%
•Improve flu vaccination rates f hi h risk asthmatic patients t 80%
I fl i ti t for high i k th ti ti t to
•Improve smoking cessation among diabetic patients by at least 5% from baseline, goal 10% by 2013
Select Patient Centered Medical Home
Interventions •Model to be deployed in 20 practices, facilitate judicious and coordinated care, payment reform
Physician Data Reporting and Performance Feedback
•Diabetes Quality Institute to monitor data and enact rapid cycle change for diabetes management
Care Coordinators in Ambulatory Physician Practices
•Support asthma and diabetes management plans
•MDI coaching for asthma
•Self management coaching
Computerized Clinical Decision Support Tools
•Facilitate appropriate use of spirometry
•Alerts for ED admissions and hospitalizations for asthma exacerbation
•Screen for symptom control in asthma
•CDS in schools for referral to PCP based on symptoms
•Identify candidates for influenza vaccination (asthma, long-term care facilities)
Identify long term
Medication Therapy Management
•Medications in hand at time of hospital or ED discharge
Other Notable GE has committed to providing $1 million of in-kind resources, including equipment, software and funding to
Characteristics assist with performance measurement, public reporting and payment reform.

40. What are we learning?
g
It’s early but…
Clearly defined populations
Strong leadership & governance
Specific health care objectives
Performance measures and
feedback systems
Evidence‐based interventions
Strategies to learn from
interventions
40

41. Agenda
g
1.
1 Uniting the Tribes of Health System Improvement
2. HITECH Status Report
3. Uniting the Tribes in 17 US Markets: The Beacon
Communities
4. Health IT as Infrastructure for Accountability
41

42. The “Era of Accountability” is about lowering the cost of
improvement.
improvement
42

43. Past and Emerging Models of Accountability in Provider
Payments
Performance‐based payments
- “Peanuts for process”
Peanuts for process
Bundled payments
- Prospective payment system (PPS) (1980s)
- Participating Heart Bypass Center Demonstration (“CABG”)
- Bundled or “episode” payments in new health law
Shared savings
- Physician Group Practice Demonstration (“PGP” Demo)
- Healthcare Quality Demonstration (“646” Demo)
Healthcare Quality Demonstration ( 646 Demo)
- Accountable Care Organizations in new health law
43

44. ACA Provisions Catalyzing a Shift from Fragmented Care to Coordinated Care
SUMMARY IMPLICATIONS
Patient-Centered Medical Homes (Section 3502)
Community-based, interdisciplinary inter-professional teams that Will drive improved organization of outpatient care
support primary care practices
Government to provide grants or enter into contracts with eligible Will fund care coordination and a team-based approach
entities
Accountable Care O
A t bl C Organizations (S ti
i ti (Section 3022)
Shared-savings program that encompasses primary care, Requires vertical coordination
specialist practice, and hospitals
Care processes to be redesigned for the efficient delivery of Most of the savings are likely to come from hospitals
high quality
high-quality services
Bundled Payments (Section 3025)
Pilot program Will provide incentives for care-delivery systems to reduce costs
in order to increase margins
Applicable to eight conditions selected by the Secretary of health
and human services
An ‘episode’ of care defined as the period from 3 days before
admission through 30 days after discharge
Readmissions Reduction Program (Section 3025)
g ( )
Reduces payment for readmissions Will motivate hospitals to engage with care coordinators and
organize delivery systems better
Applicable to three conditions selected by the Secretary of HHS;
to be expanded in 2014
Secretary to determine definition of ‘readmissions’
Hospital-Acquired Conditions (Section 3008)
Payments for care for hospital-acquired conditions to be Will provide hospitals an incentive to standardize protocols and
reduced starting in 2015 procedures to reduce hospital acquired conditions

45. Synergies with Proposed ACO Rule
y g p
Meaningful use as core expectation
Fifty percent of the ACO PCPs need to be meaningful users by the second year
g
of the contract
Information must follow the patient
ACOs creating data lock‐in by limiting or blocking information flow risk
ACOs creating data “lock in” by limiting or blocking information flow risk
having their agreements terminated
Quality measure alignment
Large overlap between the clinical quality measures in the EHR Incentive
Program and in the proposed ACO rule
Focus on care coordination and seamless transitions
Builds on HIE and Beacon work
Patients as full partners
Access to both medical records and evidence‐based data
A b h di l d d id b d d
45

46. Key Roles for HIT in the Era of Accountability
y y
Putting accountability in accountable care organizations
Putting coordination into medical homes
Divvying up bundled payments among providers
y g p p y gp
Tracking health care acquired infections in real time
Facilitating enrollment in health information exchanges
Facilitating enrollment in health information e changes
Creating the efficiencies that will make expanded access affordable
Accelerating data collection and reporting for population health
Facilitating secure access to consumer health information
46

47. Key Roles for HIT in the Era of Accountability
y y
EHR: HIE: CDS:
Electronically Exchanging Improved care
capturing and
p g health decisions
processing information
information about
patients and
populations
l ti
47

48. Key Roles for HIT in the Era of Accountability
y y
In addition to EHR, HIE and CDS deployment…
Data Aggregation
CDWs, Linking payer and clinical data, Distributed data models, etc
Analytics
Predictive modeling, performance measurement, assessing cost across
episodes of care, etc
p ,
48

49. Going Forward
g
Better Better Transform
a so
Technology Information Health Care
Goal V: Achieve Rapid Learning and Technological
Federal Health IT Strategic Advancement
Ad t
Plan 2011‐2015
Goal IV: Empower Individuals with Health IT to
Improve their Health and the Health Care System
Goal III: Inspire Confidence and Trust in Health IT
Goal II: Improve Care, Improve Population Health,
and Reduce Health Care Costs through the Use of
Health IT
Goal I: Achieve Adoption and Information Exchange
through Meaningful Use of Health IT
49
49

50. The Good News About Technology Adoption
gy p
WILL THE STETHOSCOPE EVER COME INTO GENERAL USE IN
CLINICAL MEDICINE?
A STRONGLY NEGATIVE VIEW EXPRESSED IN 1821
50