Information provided by Health Train Express and Digital Health Space is informational only. We do not endorse specific solutions. Inclusions are provided as reference only. Readers should consult with their own consultants for further details.

Tuesday, July 31, 2012

PPACA is Coming Soon To Your Neighborhood


“No matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period.”

President Barack Obama,
Speech to the American Medical Association
Chicago, June 15, 2009

In truth, prospects are bleak that you will be able to keep your doctor and even bleaker that there will be enough doctors to meet demand under Obamacare.

Patients and physicians are about to be hit smack in the face by the increased demand for healthcare services that will occur as PPACA becomes effective.  Physicians will no longer to be able to bear the brunt of reductions or new methodology of physician reimbursement.

Studies show that the rate of early physician retirement, or a move to another professional career,  are and will be occurring over the next 15 years. There is also  no way to predict what the effect of PPACA will have on older practicing physicians. Many will chose to leave without their retirement portfolio fully funded.  Rather than risk future losses from their medical business with increased overhead, the burden of IT, malpractice risks, and increased patient volume….many will leave medicine and seek other opportunity.

An Investor’s Business Daily/TIPP survey conducted in September of 2009 found that 45 percent of doctors said they “would consider leaving their practice or taking an early retirement” if the health law stands.

More than 800,000 doctors were practicing in 2006, according to government data. Projecting the poll’s finding onto that population means that 360,000 doctors would consider quitting!

And even without a mass exodus, the Association of American Medical Colleges envisions a shortage of about 160,000 doctors by 2025.

The greatest tragedy of Obamacare may be losing prematurely a generation of the most highly-trained, skilled physicians in history to a health overhaul law that the American people did everything they could to stop.

Physicians say they simply won’t practice under Obamacare rules that strip away much of their autonomy, drown them in bureaucracy, and leave them even more exposed to lawsuits.

Doctors are quietly making their plans now to restructure their practices, retire early, get another job, or otherwise protect themselves from the coming regulatory avalanche and payment cuts. 

ref:  National Review Online 

Another significant change has been the lack of trust in the AMA as witnessed by their flip flop during the debate on PPACA.  At first the AMA was in favor of the measure and then at the last moment was opposed to it as they measure the grassroots reaction to  PPACA.  With 850,000 physicians, only about 150,00 physicians belong to the AMA. 

By their own admission “AMA estimates that 60 percent of membership dues are allocable to lobbying activities of the AMA, and therefore are not deductible for income tax purposes. i.e., they are lobbyists. The question is who are they lobbying for? Physicians, patients, or themselves? Their self-interest is in survival, selling books, marketing insurance products, publishing a journal, and other activities.

The AMA has  radically reduced it’s membership dues to attract new members. Many of the members are students, or resident physicians in training, who received a special rate for membership.

I am an ardent supporter of health care reform, but can’t support PPACA (Obamacare) in it’s present form.  Some are now pronouncing how much easier it would be “just to continue on the present path.

What do you think?

Monday, July 30, 2012

The Olympic Flame Out for the N.H.S.


Feeling the Heat ?


During the past year or I have been reading about the change being made to the NHS, and the privatization as well as de-constructing it’s bureaucracy to allow more local control and administration..

So what was this opening ceremony about how wonderful the NHS is?  Certainly it did honor the thousands of health care professionals,nurses, and physicians who work in the setting of the NHS.  It also shamefully ignored the international theme of past Olympics and inappropriate for the setting, although it was masterfully done.  I don’t want my humble opinion overshadowing the event itself.   The two most  notable events were James Bond and Queen Elizabeth sky diving to the opening ceremony.  Mr. Bean also added a symphonic note to the ceremonies.  No one can fault the Brits for their ‘dry humor’.  It eclipsed  G.W.H. Bush and his sky-diving antics for several  birthdays.

This may have been staged to honor the NHS workers, but it came across as a politically inspired, and government funded advertisement, for who? Was this a message to the United States for Donald Berwick’s acclaim for socialized medicine?

They have had this system for decades, it’s taken that long to analyze it’s worth, and that long to make a change.  It’s going to take some time to analyze the internal workings of NHS to find out how they use outcome studies, assess quality of care and other metrics. (do they have meaningful use for their electronic health record system?)

  Marilyn Tavenner, MHA, BSN, RN.

Does our current ‘acting head of CMS participate in social media to effect openness and transparency (a ‘buzzword’) for President Obama.  It would be far more effective and efficient to use social media rather than the hierarchy of titles, distant meetings by health consultants and the multiplicity of meetings, mostly held in the Washington, D.C. area at one end of our large country. 

Most physicians can ill afford the time lost to go to a distant meeting, that does not offer CME.  There is no reason whatsoever that HHS cannot schedule meaningful webinars and links to information about the processes.

Digital Health Space


Scrapbook photo 2       Photo

We have been working on a new entity for about 12 months on Google Plus. Digital Health Space.

Google plus is now a key feature for Google, which is tightly integrated with Gmail, Search, Google Docs,  and many other  features for Google.  Google has become much more than a search engine.  Vic Gundrota, Vice-President responsible for the new Google Plus and Google Hangouts likes to call Google a ‘destination site'”.

Google purchased YouTube a little more than a year ago, and has now tightly integrated it into their overall selection of application.  Many healthcare providers have produced videos of surgeries, educational materials and much more, hosted on YouTube,, and easily accessible from their social media stream on Google Plus.

Google Gmail has added a hangout feature on their email site. It is possible to open a hangout directly from Gmail.   It is also  possible to build several different business pages on Google Plus.  Among our pages are +Digital Health Space, +Health Care Social Media, + G+MD .

Digital Health Space is also developing a weekly Hangout on Air for health professionals.  Watch for further announcements here, on Google + and twitter as well as Facebook.

Sunday, July 29, 2012

Dr. Tom Ferguson, e-health Pioneer, Has Died


In April 2004 an important persona in health care social media passed on. I thought it a timely subject for a Sunday morning.

John M. Grohol, PsyD  Chief Editor and founder of PsychCentral  writes about Tom from a personal perspective, as opposed to those of us who read him via his internet blog and other activities.

Tom Ferguson


This face is familiar to early bloggers in the health field. Tom is an original visionary in what the internet meant to everyone in healthcare and all the other places we see on the world wide web.

He originated in the early 1990s around the time that web browsers came into being. Prior to that posting or reading on the world wide web was done with archaic commands (http)  (ftp) which are now integrated seemlessly into web browsers.

Back in the early 1990′s we were both thinking about how the Internet was changing the roles of doctor and patient.

Thriving online self-help support communities available (yes, this was before the Web became popular) where tens of thousands of people went online everyday and offered self-help support and care to one another.

Was this the seeding of what we now know as social media in medicine?

He thought it was amazing people were already harnessing the power of online technology connections to bring it to online human connections where the technology simply faded into the background. He was the first doctor I knew who ever spoke so plainly about the future of healthcare, where he envisioned empowered patients taking care far more into their own hands, and doctors acting more as professional guides to help along the way.

He authored a series of white papers about the new revolution in health, but which morphed into a book by the time they were completed. The white papers were entitled, “e-Patients: How They Can Help Us Heal Healthcare,” the white papers turned into a book that will eventually be published with ideas on how ordinary people can help fix healthcare in America.

He and others talked about the new breed of “e-patients,” and where ideas percolated such as each person having their own health “dashboard” would be invaluable to an individual living healthier, better lives. The vision was limitless.

He was one of the pioneers in e-health, but unfortunately most of his thinking was just too far ahead of what a business could actually market or sustain. Despite that his seed took root and eventually has bloomed. 


Besides, how can you build a business around an empowered consumer patient, when all of the power in the healthcare system in America was in the hands of the all-knowing doctors and the insurance companies? But that never stopped him from trying.

Today our patients are more empowered with social media, advocacy groups and the idea of “patient centric medicine”.

Finally, perhaps if physicians and others had come together with a unified face the outcome of health care for all would not be so adversarial.

After all, the physician and the patient have the same goal….good health.

In the 1990s as the business model for medicine was  beginning to change, only a few adapted, the majority were left behind.

Thursday, July 26, 2012

Have We Been Here Before?


This blog has been prepared by the author, Gary M. Levin MD as a preparatory narrative for forming an ACO and/or Medicare Shared Savings Group.

This information is reprinted from the regulations promulgated by:

Centers for Medicare & Medicaid Services

Not for the faint of heart.

Accountable Care Organizations, Guidelines for Medicare Shared Savings Programs

Today we start a …multi-part narrative on how ACOs are formed, the process and explanations of numerous templates to legally form an accountable care organization.

It's a brave new world. Some of the issues sound very much like the failed health maintenance organizations of the 1990s, although the process is much more defined and carefully regulated by CMS. The agreements solely pertain to Medicare and eligible Medi-caid participants. Nothing is said about private insurers or the remaining marketplace.

It may be assumed that CMS leads the way in a controlled marketplace, while the private market will operate under the free market system with price competition and guidelines taken from CMS in regard to outcomes and quality of care.

It is a giant leap of faith that this will work across the country. The expense of establishment of ACOs is not known. Most of the early ACOs are already well organized health systems which serve as the foundation for layering an ACO upon it. In markets that do not yet have ACOs the burden is upon the local stakeholders to begin the process. An unknown factor for these less privileged hospitals and providers is the cost of organizing and the overhead and cost factors to determine what their rates will be. It will not be a cookie-cutter process.

Chances are very likely that insurance companies will evaluate and dictate their payment structure taking into account the federal regulations that not more than 15% can be allocated to their own administrative costs. Hospitals and ACO providers will have to negotiate from a position of relative weakness given the market power of CMS and larger and larger health insurance companies. Wellpoint's acquisition of another company (Amerigroup) for $4.9 billion dollars bespeaks the profits insurance companies sit upon. It begs the question why health care is so expensive in the first place.

As usual CMS has a project deadline that is heavily loaded upfront requiring entities to organize and file applications on relatively short notice (much like HIT incentives and meaningful use) with enrolled providers signed into the ACO. Most of this on faith that it will work financially. In other words, sign on the dotted line, and then we will tell you how you and how much you will be paid.


An ACO participant is identified at the billing TIN level. An ACO provider/supplier is a practitioner billing through the ACO participant’s TIN.

We want to ensure that each applicant understands the definition of an ACO participant and ACO provider/supplier. According to the regulations at 42 CFR 425.20, an ACO participant means an individual or a group of ACO providers/suppliers that is identified by a Medicare enrolled TIN that alone or together with one or more other ACO participants comprises the ACO. For example, an ACO participant may be a solo practice, a group practice, a hospital, an FQHC, among others.

An ACO participant may be composed of one or many ACO providers/suppliers that use, or have reassigned their billings to, the ACO participant TIN. An ACO provider/supplier means a provider or supplier enrolled in Medicare that bills for items and services furnished to Medicare fee-for-service beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant. The key point is that an ACO participant is identified by its Medicare-enrolled TIN.

All ACO providers/suppliers billing through an ACO participant TIN are included in the ACO by virtue of their relationship to the ACO participant and the ACO participant’s relationship with the ACO.

The Medicare Shared Savings Program is a program designed for ACO participants, as described above, that come together to form an ACO. Many important program operations use claims and Center for Medicare Medicare Shared Savings Program

Page 2 of 4

other information submitted to CMS by the ACO participant through its billing TIN, including calculation of shared savings, assignment, and benchmarking. Therefore, an ACO cannot apply to participate in the Medicare Shared Savings Program unless the ACO participants have agreed to participate in the Medicare Shared Savings Program and to comply with the program regulations.

The ACO applicant also must ensure that all ACO providers/suppliers associated with each ACO participant TIN have agreed and will comply with the program regulations.

Consequently, an ACO may not include an entity as an ACO participant unless all providers and suppliers billing under that entity’s billing TIN have agreed to participate.

Agreements or contracts between or among the ACO, ACO participant, and ACO providers/suppliers related to participation in the Medicare Shared Savings Program must be executed before the ACO submits its application.

As part of the application process, we ask that you submit the list of ACO participants, who, along with all the ACO participants’ associated ACO providers/suppliers, have agreed to participate in the program. This means that the ACO participants you submitted or will submit, in addition to all their associated ACO providers/suppliers, signed agreements or contracts before the application was or is submitted.

It is important that agreements between and among the ACO, ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities comply with our regulations.

Content of agreements or contracts between the ACO and ACO participant.

As part of the application process, we ask that you submit a sample agreement you have with each of your ACO participants. This sample agreement and the associated executed agreements with ACO participants, at minimum, MUST contain the following:

1) An explicit requirement that the ACO participant agrees to participate in and comply with the requirements of the Medicare Shared Savings Program under 42 CFR part 425.

General references to compliance with Federal law are not sufficient. General references to compliance with Medicare regulations are not sufficient.

2) A description of the ACO participants’ rights and obligations in, and representation by, the ACO, including how the opportunity to share in savings or other financial arrangements will encourage ACO participants and ACO providers/suppliers to adhere to the quality assurance and improvement program and evidence-based clinical guidelines and should include language giving the ACO the authority to terminate an ACO participant for its non-compliance with the ACO’s participation agreement with us or any of the requirements of 42 CFR part 425.

Additionally, ACOs must not require that beneficiaries be referred to ACO participants or ACO providers/suppliers or to any other provider or supplier (42 CFR 425.304(c)(2)), except under the specific and limited circumstances expressly permitted by the regulations.Medicare Shared Savings Program

Page 3 of 4

The ACO may or may not need a separate legal entity, however the ACO governing body must have a specific fiduciary duty to the ACO.

“””We want to ensure each applicant understands the eligibility requirement related to the ACO’s governing body. According to the regulations at 42 CFR 425.106, the ACO must maintain an identifiable governing body with authority to execute the functions of the ACO.

The governing body must have responsibility for oversight and strategic direction, holding the ACO management accountable for the ACO’s activities. The governing body members must have a fiduciary duty to the ACO and must act consistent with that fiduciary duty.

• The governing body of the ACO must be separate and unique to the ACO in cases where the ACO comprises multiple, otherwise independent ACO participants.

The governing body members cannot meet this fiduciary duty requirement if the governing body is also responsible for governing the activities of individuals or entities that are not part of the ACO.

• If an already existing entity applies to the program as an ACO, the ACO governing body may be the same as the governing body of that existing entity, provided it satisfies the other requirements for a governing body, including the fiduciary duty requirement.

These regulations mean that if your ACO is comprised of two or more otherwise independent ACO participants, your ACO must have a legal entity and governing body that is distinct and separate from each of them (the governing body must be the governing body of the legal entity that is the ACO, and not the governing body of a parent or subsidiary entity).

For example, if several separate group practices decide to come together for purposes of participating in the Medicare Shared Savings Program (but will otherwise maintain separate practices), they must form a separate legal entity to be the ACO.

This legal entity must have a legal structure with a governing body that has a fiduciary responsibility to the ACO alone and not to any other individual or entity. If an existing entity, such as an IPA representing many group practices wants to apply as an ACO using its existing legal structure and governing body, each group practice represented by the IPA must agree to be an ACO participant and each provider and supplier within each group practice must agree to be ACO providers/suppliers as discussed above.

If only some of the represented group practices want to become ACO participants, the IPA cannot use its existing legal structure and governing body for the ACO, because it cannot meet the regulatory requirements, including the fiduciary duty requirement.

If only some of a group practice’s providers and suppliers agree to be ACO providers and suppliers, then that group practice may not become an ACO participant.

In summary, the ACO’s governing body decisions must be independent from influence of interests that may conflict with the ACO’s interests, including the interests of group practices that are not participating in the ACO but continue to be represented by the IPA for other purposes, such as commercial contracting.

Assess your application for the Medicare Shared Savings Program.

Please review this memo carefully and consider your current ACO organization, agreements, and application attestations in light of it. “””

List of Required Documents for ACO formation and Application to become an ACO for CMS approval process.

Medicare Shared Savings Program

Submit FormCMS-20037 Application for Access to CMS Computer Systems no later than July, 9 2012

See How to complete Form CMS-20037 [PDF, 427KB] for instructions on how to complete your CMS 20037.

Your application is pre-populated with the information you gave us on your Notice of Intent to apply (NOI).  If you find an error in any pre-populated information, send an email with the change request and correct information to  In the subject line, include your ACO ID and the words “Request to Change Pre-populated Information.”

How to Submit an Application if you are a Physician Group Practice Transition Demonstration Participant

This group has special privileges in regard to abbreviated applications.

How to Complete the Application

Use the MSSP Reference Table [PDF, 506KB as a guide as you complete your application in HPMS. See 2013 Medicare Shared Savings Program Application Form [PDF, 259KB] for a copy of the application questions. Be sure to use the required templates,

All the documents you submit must clearly identify you as the ACO applicant with the identification number (ACO ID) you got with your Notice of Intent to Apply (NOI) acknowledgement e-mail

Some questions require you to submit supporting documentation to us.  Using file compression software such as WinZip, compress each section’s files together.  Upload the compressed files in HPMS in their respective file upload locations.  Narratives and/or other supporting documentation are compressed and uploaded to the ‘Supporting Applications Materials’ location. This does not apply to your ACO Participant List. Use the ACO Module User Guide in HPMS for help uploading.

How to complete the ACO Participant List Template

Use the ACO Participant List Template [ZIP, 5KB] to give us your ACO Participant List. See How to complete Participant List Template [PDF, 424KB] for instructions on how to complete it. See also ACO Participant List Frequently Asked Questions.

How to Complete the Governing Body Template

Use the Governing Body Template [ZIP, 10KB] to tell us about your Governing Body. All fields relate to the members on the Governing Body. Do not leave any fields blank.

See How to complete Governing Body Template PDF, 255KB] for instructions on how to complete it. See also Governing Body Frequently Asked Questions.

How to Complete the ACO Participation Agreement Template

Use the ACO Participation Agreement Template [ZIP, 282KB] to tell us about your agreements with your ACO participants. For additional guidance, see Additional Guidance for Medicare Shared Savings Program Accountable Care Organization (ACO) Applications [PDF, 113KB]

See How to complete Participation Agreement Template [PDF, 249KB] for instructions on how to complete it.

How to Complete the Executed Agreements Template

Read the guidance we issued around applicants, participants and agreements.

Use the Executed Agreement Template [ZIP, 11KB] to list the ACO Participants you have executed ACO Participation agreements with.

See How to complete Executed Agreements Template [PDF, 176KB] for instructions on how to complete it.

Requests for Additional Information

In two words: “ON DEMAND”


We must get the requested information by the date specified on the CMS notice.  We consider the date of submission as the actual date we get the information, and not the postmarked date on the submission.

Patients and Providers: “We're from the Government and we're here to help you “

Applications posted on CMS Web site

Updated in July 2012

NOIs accepted  Nov. 1, 2011 - June 29, 2012

CMS User ID forms accepted Nov. 9, 2011 - July 9, 2012

Applications accepted

Aug. 1,2012 - Sept. 6, 2012 Application approval or denial decision

Fall 2012

Reconsideration review deadline* Dec. 11, 2012

Helpful Links and Additional Information

Final Rule Published in the Federal Register on November 2, 2011

Shared Savings Program Web site

Shared Savings Program Final Waiver


Shared Savings Program Frequently Asked Questions


Disclosures and Waivers:

None of the above information should be considered official and this document is NOT endorsed by CMS. The reader should not base decisions or deadline dates without first contacting CMS at the indicated email addresses listed herein.


Wednesday, July 25, 2012

The Whole Foods Alternative to Obama Care

This article was posted in the Wall Street Journal, August 11, 2009.


Mr. Mackey is co-founder and CEO of Whole Foods Market Inc..

"The problem with socialism is that eventually you run out
of other people's money."

—Margaret Thatcher



PPACA, The Patient Protection and Affordable Care Act is law and is in the early stages of adoption. Most observers do not see how the law will not increase deficit spending. The upside is that most citizens will have insurance.

With a projected $1.8 trillion deficit for 2009, several trillions more in deficits projected over the next decade, and with both Medicare and Social Security entitlement spending about to ratchet up several notches over the next 15 years as Baby Boomers become eligible for both, we are rapidly running out of other people's money. These deficits are simply not sustainable. They are either going to result in unprecedented new taxes and inflation, or they will bankrupt us.

Will there be a return on investment?

Most assuredly “Yes”. Although it will take some time to assess the gains,, there are categories of expenditures that will decrease.

1. Early intervention in acute and chronic conditions will decrease disability and costs associated with illness.

2. Coverage for immunization will decrease morbidity and mortality from infectious diseases

3. Treatment for HIV and AIDs will be readily available for all patients.

4. Encouragement and incentives to remain healthy using wellness programs, proper nutrition and exercise will fuel wellness industry growth. Patients in these programs may be entitled to premium reductions for participation.

While we clearly need health-care reform, the last thing our country needs is a massive new health-care entitlement that will create hundreds of billions of dollars of new unfunded deficits and move us much closer to a government takeover of our health-care system. Instead, we should be trying to achieve reforms by moving in the opposite direction—toward less government control and more individual empowerment. Here are eight reforms that would greatly lower the cost of health care for everyone:

Eight things we can do to improve health care without adding to the deficit.

• Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits.

• Repeal all state laws which prevent insurance companies from competing across state lines.

• Repeal government mandates regarding what insurance companies must cover. These mandates have increased the cost of health insurance by billions of dollars. What is insured and what is not insured should be determined by individual customer preferences and not through special-interest lobbying.

• Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year. These costs are passed back to us through much higher prices for health care.

• Make costs transparent so that consumers understand what health-care treatments cost. How many people know the total cost of their last doctor's visit and how that total breaks down? What other goods or services do we buy without knowing how much they will cost us?

• Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

• Revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren't covered by Medicare, Medicaid or the State Children's Health Insurance Program.

  • Allow a tax credit to physicians and for profit hospitals for a percentage of  ‘care to the uninsured’. This will incentivize both physicians and hospitals to provide ‘charity’ care.  The time and services to patients are a form of charitable donations in kind.

Enable Patient and Physician communications in Patient Centric Medicine by emphasizing health habits, exercise and education in nutrition.


How to Communicate well with a Patient while working on an EHR in Real Life


When physicians who are used to carrying paper charts start using tablets or desktop computers in the exam room, it’s going to be disruptive, said Larry Garber, MD, an internist and medical director of informatics at the Reliant Medical Group in Worcester, Mass. How a physician manages this disruption “can absolutely make or break the relationship between doctor and patient,” he said.

About five years ago I observed that most EMRs are not ethnologically designed resulting in  a less than optimal machine-human interface.  About three years ago tablet PCs came into being, and HER vendors ported their EMR to that interface and/or smartphones. While this improved the situation somewhat, some patient-physician interactions  remain.

Several medical schools have realized the impact bad communication can have on patient satisfaction and outcomes. They have built communication skill-building into their curricula to help prevent this unintended consequence from technology use. But even absent formal training, it’s not too late for practicing physicians to acquire these skills with a few small steps:”

There are many outstanding clinicians who falter when adapting to an EMR, some of which has to do with a new work stream, resulting in frustration and anger.


By preparing oneself going into an EMR and dealing with the most important issue..the patient-physician relationship-- stress can be reduced.  Learning how to use the EMR is only a portion of adopting HIT.

Exam room setup.

“Some practices have implemented a basic triangle design that puts the physician, patient and computer screen at each of the three corners, allowing the doctor to look at both patient and computer screen without shifting his or her body. It can make patients feel they are being looked at even when the physician is looking at the computer screen, Dr. Garber said.

Work-flow design.


“The computer terminal should never be the first place the physician goes when entering the room. The doctor should go to the patient first, greet him or her and establish an agenda for the visit. After that is done, the doctor should have some kind of transitional line explaining what he or she is about to do in the EHR, such as, “OK, let me jot down a few notes.”

Employ the LEVEL system

LEVEL stands for:

L: Let the patient look on. This goes back to the triangle setup that allows the physician to easily share things on the computer screen with patients.

E: Eye contact. Dr. Garber said there is no hard and fast rule of how eye contact should be measured, but he treats every patient encounter as he would a conversation with a friend or family member.

V: Value the computer. If the physician praises the benefits of the computer, the patient will appreciate its presence. Saying things such as, “With my EHR, I can look that up” or “I can send your prescription straight to the pharmacy,” will help patients think their care is more advanced because of the computer, Dr. Garber said. Sharing visuals on the screen, such as a chart mapping historical cholesterol levels, also will help patients appreciate the computer.

Physicians who struggle with their EHR sometimes vent their frustrations to patients. “That frames the computer in a negative way to the patient,” Dr. Stream said. “Positive framing is really important. Physicians have got to set it up that the computer and EHR [are] there for the patient’s benefit and not describe it as a nuisance or an irritation.”

E: Explain what you’re doing.  It’s important for doctors to be transparent about everything they do. Talking through each step — “I’m sending your prescription now” or “I’m looking up those test results” — will make patients more comfortable. It also will help alleviate the perception that the doctor is doing something else, like checking emails or sports scores.

L: Log off. A big fear patients have about technology is the security of their data. Logging off while they are still in the exam room makes them confident the next patient won’t walk in with their information still on the screen, Dr. Garber said.

EMRs are here to stay, be proactive in using it. One idea is to have a survey regarding the patient’s experience with your office and the EMR, in order to judge your effectiveness in communicating to your patient while you work. Admittedly, multi-tasking can be a challenge.

A suggested survey is available and can be downloaded here  


YouTube Demonstration:


History of Social Media and Bloggers on the Health Train Express


Publishing delayed by - Fate

Sunday morning for me is a time of reflection.  I dipped into my rich collection of bookmarks, archived blogs,  and favorites on a backup volume stored on a hidden away dusty external drive.  After a six year hiatus I plugged the drive in the light went on, and almost unexpectedly the drive directory appeared instantly. Hmm, sometimes this stuff actually works !  What was amazing is that I am now using Windows 8 pre- release and the backup was made on Windows XP.

A great deal has changed on the internet, many things have disappeared, blogging has matured into a much easier platform, and has additional social outlets in Facebook, Twitter, and now Google Plus. 

In 2005 I was privileged to participate in the founding of Trusted.MD by Dmitriy Kruglyak.


At that time I wrote a column about RHIOs (Regional Health Information Exchange), now known as Health Information Exchanges. The point being that we do much of the same tasks only using a different name to describe them, each hopefully a better iteration of our common goals. RHIO became HIE, HMO became PPO, became ACO, and more Unwritten confidentially rules became HIPAA law.

Normally in health care or health policy blogs we write about “late breaking events”, not about historical archives.  However I think it important to know from whence we came to realize how our social media activity adds to the ‘collective consciousness’ of our world not only in health care (which has become a central focus) for almost everyone in the U.S. as we ponder enormous standardization and seek better health for everyone.

I suggest we look at Trusted.MD  from 2005.  The most striking feature is the lack of graphics, photos, and imaging. The structure and content are basic text, tables, and formatted like MSDOS.  The content however is rich and worthwhile, creating interest in blogging. Trusted.MD can still be found and it’s curator, Dimitryi Kryglyak can be found there and in all my social media sites, links, twitters and places I have not gone to as yet.  Dimitryi Kruglyak is not properly credited as a pioneer in social media.  Let’s bring him some proper recognition.

The medium is both the message and it’s content. Our rapid progress often obscures the many groundbreaking seminal events.

   Google Plus Hangout

Today in mid 2012 having a social media presence is equally important as having your own website.  Many users have elevated their blog site into a form of website, or landing page with many embedded links.

Not only has HIT dragged MDs into the 21st Century, Social Media is in the process of doing the same.

Hopefully the government can keep it’s hands of social media.


Thursday, July 19, 2012

Crowdsourcing and Health Care Reformation


Two terms I have encountered recently are “collective consciousness “  and crowdsourcing.  Collective consciousness has been around for some time, and now with social media it takes on a new power magnified almost infinitely as social media platforms integrate and share data.

A new form of venture capital has emerged as a result of the internet and social media, called ‘kick starter funding”  and “crowdsourcing’.  Thus far little of this has been applied to HIT, or healthcare in general. It could be very valuable for developing health resources in underfunded projects, away from conventional rules.


Enthusiasm seems to be the main stimulant rather than a financial return on investment.  There are many crowdsourcing projects which are available.  

There are many sources of information on how to crowdsource.1,2,3    

How Mass Collaboration Changes Everything

Here Comes Everybody: The Power of Organizing Without Organizations
We Are Smarter Than Me: Crowdsourcing New Businesses
The Art of Community: Building the New Age of Participation (Theory in Practice)

The Complete Idiot's Guide to Crowdsourcing [Kindle Edition] This is readily available as a kindle sample and can be downloaded to the Kindle Cloud or smartphone or iPad reader for free.  This is also  true of some of the above titles.


Crowdsourcing is facilitated by the use of social media collaboration to collect a like minded group of people for a project.

In heath care it could be one of the following, as well as many additional ones

Cost effective mobile health applications to be developed by ‘indies’

Rural health development

Remote monitoring

Public Health Concerns

Health in the inner-city

Medical Device Funding

Crowdsourcing and/or Kickstarter funding is not necessarily a cash contribution, it can be things such as any ‘in kind’ legal services, accounting services, office space, utilities, office equipment, computers, printers, supplies, advertising, sponsoring speakers, educational materials, and whatever overhead is required.  The principals seeking funding detail what is needed, project management, and budgets, and also may contribute financially or with free services until such time as the business becomes self-sustaining.

This unusual form of starting an enterprise is popular in some circles, and may also find advantage in health care circles..

In some sense this mechanism is already in action for hospital foundation funding for new equipment, new hospital wings, education centers and more.  Even here social media, facebook pages, twitter, and Google plus could magnify those efforts.


Tuesday, July 17, 2012

After the Supreme Court: Moving Ahead to Implement the Affordable Care Act, Improve Health and Health Care and Lower Costs Tuesday, July 17, 2012, National Press Club, Washington, DC



Prominent Health Care Leaders spoke today at the National Press Club, a well known and respected venue for disseminating important news in many sphere of influence. 

Health Affairs  Conference:

 After the Supreme Court, Moving Ahead To Implement Affordable Care act Improve Health and Health Care and Lower Costs”

I am a well known skeptic regarding our present law designed to reform the U.S. Health Care System.  However health reform is what we need and the present law can and should be carefully read and amended. PPACA has been in existence for almost two years and has now been exposed to public scrutiny.

The Video of the Presentation

Most physicians will face a duality, a decline in reimbursements, and a concern is also, “How so I learn to do this?”


Monday, July 16, 2012

10 Things You didn't Know were in The Affordable Care Act


If you are curious what the details of the Patient Protection and Affordability Act that could make it 1000 pages in length.  Here are some of them. This should be required reading for high school students. It will affect the rest of their lives.

The Kaiser Foundation reports:

So you think the Suprneme Court upheld a law that requires most people to buy health insurance? That's only part of it. The measure's hundreds of pages touch on a variety of issues and initiatives that have, for the most part, remained under the public's radar. Here's a sampling:  

Postpartum Depression (Sec. 2952)
Urges the National Institute of Mental Health to conduct a multi-year study into the causes and effects of postpartum depression. It authorized $3 million in 2010 and such sums as necessary in 2011 and 2012 to provide services to women at risk of postpartum depression.

Abstinence Education (Sec. 2954)
Reauthorizes funding through 2014 for states to provide abstinence-only sex education programs that teach students abstinence is "the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems." Federal funding for these programs expired in 2003.

Power-Driven Wheelchairs (Sec. 3136)
Revises Medicare payment levels for power-driven wheelchairs and makes it so that only "complex" and "rehabilitative" wheelchairs can be purchased; all others must be rented.

Oral Health Care (Sec. 4102)
Instructs the Centers for Disease Control and Prevention to embark on a five-year national public education campaign to promote oral health care measures such as "community water fluoridation and dental sealants."

Privacy Breaks for Nursing Mothers (Sec. 4207)
Requires employers with 50 or more employees to provide a private location at their worksites where nursing mothers "can express breast milk." Employers must also provide employees with "a reasonable break time" to do this, though employers are not required to pay their employees during these nursing breaks.

Transparency on Drug Samples (Sec. 6004)
Requires pharmaceutical manufacturers that provide doctors or hospitals with samples of their drugs to submit to the Department of Health and Human Services the names and addresses of the providers that requested the samples, as well as the amount of drugs they received. 

Face-to-Face Encounters (Sec. 6407)
Changes eligibility for home health services and durable medical equipment, requiring Medicare beneficiaries to have a "face-to-face" encounter with their physician or a similarly qualified individual within six months of when the health professional writes the order for such services or equipment.

Diabetes & Death Certificates (Sec. 10407)
Directs the CDC and the HHS Secretary to encourage states to adopt new standards for issuing death certificates that include information about whether the deceased had diabetes.

Breast Cancer Awareness (Sec. 10413)
Instructs the CDC to conduct an education campaign to raise young women's awareness regarding "the occurrence of breast cancer and the general and specific risk factors in women who may be at high risk for breast cancer based on familial, racial, ethnic, and cultural backgrounds such as Ashkenazi Jewish populations."

Assisted Suicide (Sec. 1553)
Forbids the federal government or anyone receiving federal health funds from discriminating against any health care entity that won't provide an "item or service furnished for the purpose of causing … the death of any individual, such as by assisted suicide, euthanasia, or mercy killing."

Reprinted with permission from Kaiser Health News


Witchrunner:   There's lots not to like here. 1. Postpartum Depression: There's already been studies. Why waste more money? 2. Abstinence Education: Why is any money spent on this? Does it really cost money for a teacher to say "the only way to make sure you don't get pregnant, gets std's, and other sex related conditions is not to have sex?" 3. Power Driven Wheel-chairs: Rent 'em all? Talk about increasing costs! It might make sense if someone isn't expected to live long, but it's not easy to see that this could increase costs by 1,000 times. Just go to your rent-a-center and rent your furniture. After 6 months to a year you'd have owned it outright. 4. Oral Healthcare: Already done! 5. May or may not be feasible, depends on situation. 6. Ridiculous amount of paperwork required for this, and to what end? 7. Too broad and probably unnecessary in a lot of cases. If the physician sees the need for a 6 month check up then it is already being done. 8. Diabetes? A total waste of money! Five people die in a car wreck and all the bodies have to go to a coroner to determine whether they had diabetes? 9. Duplication of what is already being done. 10. Can't argue with this. May not be government's job, but since they have a ton of regulations, might as well have this one.

CM6969: Why cherry-pick a few problematic areas and pretend the whole thing needs to be discarded due to easily fixable problems? n this case, the problems were: Insurers denying expensive health care, causing suffering and death. Insurers putting annual or lifetime "caps" on coverage, again causing suffering and death. Medical costs not covered by insurers leading to financial hardship or bankruptcy. People with "pre-existing conditions" unable to obtain insurance, sometimes after loosing their job (and employer provided coverage) or after their old insurer dropped their policy. Children with birth defects being denied medical coverage due to "pre-existing conditions" (absurd, but it was happening) People without health insurance relying on expensive emergency room care, unable to pay, and the costs being transferred to paying or insured patients.

WhatHappened:   Health care should never be about proving a profit for an insurance company. It should be about providing health care services and treatments to people in need. And the only way you can do that is by putting the insurance companies in their proper place of providing supplemental services to the people who who have the need of their services.

We will never have a national health care program that works as long as the health insurance companies are calling the shots. They aren't in business to provide health care services or treatments, they are in business to make a profit.


Sunday, July 15, 2012

Telehealth or Telehell ?

It is touted that telehealth, video conferencing, telemedicine and mobile health applications will assist in reducing the cost of medical visits.  However, CMS has thus far not addressed reimbursed issues which is a major deterrent.  At first glance this may be true, however nothing is that simple and technology and regulations always alter the equation.

TeleMedicine encompasses many functions

Remote monitoring

Physician-patient video conferencing, email or chat

Physician-physician consultation ie,



Video documentation:

Hospital internal conferencing


Because of recent intense interest I did some research on this issue and found many states are outlining the requirements for telemedicine.

Health Providers have no difficulty proposing cost effective uses for tele medicine. The issues are that regulations and fear that privacy would be breached. Thus far I have not seen any rules regarding  patient and provider waiving HIPAA rights.  Does anyone know anything about waiving HIPAA? Leave a comment or tweet me @glevin1

California has issued guidelines for telemedicine on their California Board of Medicine online website.

Recently, the Medical Board received an inquiry regarding informed consent and whose obligation it was to obtain the necessary consent from the patient who would be undergoing the medical procedure.  Specifically, the question was whether physicians could delegate this task to another licensed health care provider or other personnel under their supervision.  While the Board could find no statutory or regulatory bar to this proposed process, the Board suggests that public policy is best served when the physician performing the procedure secures the consent from the pa tient.  In this manner, if the patient has questions or concerns, the physician is in the best position to address those matters.  The following is provided as a reminder of the legal requirements when practicing medicine via telehealth: Telehealth (previously called telemedicine) is seen as a tool in medical practice, not a separate form of medicine.  There are no legal prohibitions to using technology in the practice of medicine, as long as the practice is done by a California licensed physician.  Telehealth is not a telephone conversation, e-mail/ instant messaging conversation, or fax; it typically involves the application of videoconferencing or store- and-forward technology to provide or support health care delivery.

Business and Professions Code §2290.5 (b) states: “Prior to the delivery of health care via telehealth, the health care provider at the originating site shall verbally inform the patient that telehealth may be used and obtain verbal consent from the patient for this use.  The verbal consent shall be documented in the patient’s medical record.” This is important:  Please note that the standard of care is the same whether the pa- ent is seen in- person, through telehealth, or other methods of electronically enabled health care.  The Medical Practice Act, including informed consent laws, applies in every area of medicine and in every practice setting and circumstance.  California laws pertaining to the use of telehealth should not be construed to alter the scope of practice of any health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.  Physicians need not reside in California, as long as they have a valid, current California license.

Many individual States are preparing or already have issued guidelines and/or regulations regarding Telehealth and Telemedicine.

Provided here are sources of information for those considering adding telemedicine to your  practice.

New CMS Rule on Telemedicine Credentialing and Privileging

Federal Spotlight on VA's SCAN-ECHO

Some perils of telemedicine

New York Statement on Telemedicine

State Reimbursement Policy appears to be addressed in New York


HHS reports progress on telehealth regulations

Regulations for tele-medicine are developing very rapidly and are in a state of flux.  Those considering tele-health in their  practice are advised to review current law and regulations from their state licensing authority. Most articles are dated, and incomplete.


Friday, July 13, 2012

America, Land of the Free, Home of the Brave, and Home of the Unhealthy



“There are those who look at things the way they are, and ask why... I dream of things that never were, and ask why not?”
Robert Kennedy

This often quoted statement is very applicable to today’s conundrum of providing health care to all American’s

“Progress is a nice word. But change is its motivator. And change has its enemies.”

“I believe that, as long as there is plenty, poverty is evil.”
Robert Kennedy

These quotes from R.F.K. ring in the ears of those who knew the man in the 1960s.  It was true then as Americans traversed the world of civil rights and inequality.

Today we also have marked inequalities  in health care,  some due to inherent systemic flaws, some due to our present economic morass, and some due to an obsolete medical bureaucracy.

Healthcare is in a state of flux, not from medical advances, although rapid progress is continuing in genomics, proteomics, diagnostics and all the other ‘ics”. but in how we fund health and wellness, along with treating chronic illnesses. Some illness is acute and brief, some develops from acute illness followed by prolonged chronic illness, and/or disability.  Along with these economic demands and included in chronic illnesses is prevention of disability and ongoing rehabilitation.

Loss of employability contributes great dependency and further economic stress on our economy.   It frequently severs the ability to earn income.

Important items missing from PPACA are tort reform and re-organizing medico-legal adversity.

Republicans and Democrats need to step back and look at the goals for health care in America.  This is a non-partisan issue, however self-interest and fear of economic failure dominate the process, not just for individuals, but industry as well.




<a rel=”author” href “”>Gary Levin on Google+</a>

Thursday, July 12, 2012

Organ Donors Simplified



Infographic Printing Human Organs

A New Epidemic


Epidemic?  Most think of some serious or potentially fatal disease sweeping a country or around the world. This one is different, and perhaps beneficial.

You have “webitis”. No, its not a new medical malady inflicted by endless moussing, clicking, surfing, emailing or participating in social media.

Chances are however that you are among the millions who search the internet for information about what ails you.  Your last doctor visit went off well, but there were some issues you did not understand and your doctor ran off (since he only has about ten minutes to spend with you,(most of the time) without being sure you knew what ‘webitis’ really is.

You are among those who search for health care information on the internet. The phenomenon continues to grow rapidly.

Health Site Audience Grows 60 Percent Over Past Three Years
Over the past three years, U.S. Internet users have shown a steadily increasing trend in visitors to sites in the Health category, which range from general health content sites to branded pharmaceutical sites. The number of total unique visitors accessing these sites on a monthly basis has increased from 86.9 million in June 2008 to 139.1 million in June 2011, representing a 60-percent increase.

Trend in U.S. Unique Visitors (000) to Online Health Sites

Interestingly, the rate of growth in visitors to health properties over the past three years outpaces the growth of the total U.S. Internet audience by more than a factor of 4 (60 percent vs. 13 percent), showing the demand for health information continued to increase at a strong pace.

Even more telling is the growth in audience penetration of Health properties over the past few years. Three years ago, less than half of the total U.S. online population visited health sites. Currently, health sites now reach approximately 2 out of every 3 Americans going online monthly, an increase in penetration of nearly 20-percentage points since June 2008.

 Mobile Health Information Visitation

Mobile health is also experiencing a rise in those seeking health information, which parallels the growth of mobile apps overall. This may also indicate the importance of your web information being programmed for best visibility on tablet pcs or smartphones.  Patients look for information on the fly, perhaps even as they leave your clinic on the way home, or on the way to the pharmacy following a clinic visit.

At the end of the day, these trends we’re seeing from comScore data show the demand for online health information to be far from waning and the prospect for sustained health visitation to be strong. Consumers have never before had as much ability to find health information to inform their health care decisions as they do now, and with the proliferation of connected devices enabling greater access and constant connectivity, it is only likely that the use of online health sources to engage with health information will continue to grow.


comScore, Inc.


Wednesday, July 11, 2012

The Singularity of Health Reform


Medicine in the United States is approaching a singularity, the hypothetical future emergence of greater-than-human intelligence through technological means. The occurrence of a technological singularity is seen as an intellectual event horizon, beyond which events cannot be predicted or understood. Proponents of the singularity typically state that an "intelligence explosion"[2][3] is a key factor of the Singularity where super intelligences design successive generations of increasingly powerful minds. (Wikipedia)

Big Data and advancing algorithms are approaching a singularity as current ideas  studying outcomes, and analysis of practice standards merge together.

The effects of health reform as mandated by PPACA attempts to control the “butterfly” (chaos theory) with micro-management of reform.  Nevertheless an ‘event horizon’ quickly appears in the equation. Micro-management inevitably devolves into inefficiency when an entity is given free reign without an expiration date for it’s authority.

For the purpose of writing this article I shall incorrectly assign the title “Obama Care” to the PPACA. Like it’s non-decipherable eponym the contents of Obamacare are overwhelmingly written in government-ese.  The Law requires over 11oo pages, and 2.75bmb of data.  It already has been amended several times with numerous waivers and has faced one serious challenge before the Supreme Court..


House of Representatives Passes Amendments to Defund PPACA

The 2011 budget agreement just passed by U.S. Congress on April 14, 2011, contains provisions that repeal and de-fund certain provisions of the Patient Protection and Affordable Care Act (as amended by the Health Care and Education Reconciliation Act of 2010) (PPACA).

Complexity abounds: Health Care Reform for Cafeteria, HRA and Wrap plans

Some changes to PPACA original requirements already have been made both at the legislative and regulatory levels.  For example, the Republicans succeeded in repealing the infamous 1099 filing requirement earlier this spring -- albeit through a bipartisan vote

The Cooperative Health Insurance Program Repealed

Free Choice Voucher Program Takes a Hit

Medical Liability Reform has yet to be addressed, and does contribute significantly to cost containment, and defensive medicine.


Tuesday, July 10, 2012

Social Media Is No longer Just Social


Mission creep  is the descriptive term which explains how a previously focused goal becomes another things .

For those who use social media in healthcare regularly this apparent.. The internet began as a ‘sideshow’ and within five to ten years it became a necessity. If you are not using social media you would not be aware of the advantages and power of the social media sphere.


HOW TO Sell Social Media to Cynics, Skeptics & Luddites

For example: (personal uses)

1. Twitter , along with use of hashtags provides the opportunity to direct traffic to your web site, blog, and/or even Google Drive or Live drive.  GDrive provides sharing to anyone who has the link to that document (or folder).

2. Information source: Many physicians and others regularly tweet from meetings and symposia using a meeting hashtag.  Specific hashtags can be found on Symplur, a site devoted to medical hashtags with some specificity.  It’s not just for social contact at the meeting, (ie, “meet me at Starbuck’s afterward”). Tweets can be linked with photos and/or graphic using a smartphone or tablet with Flickr, yFrog, and other photo sharing sites. (most are free with limited storage capacity) Videos can be uploaded to YouTube and linked to Twitter announcements.  Imagination leads one to many other outbound messages. The 2012 Top Ten Photo Sharing Sites.

3. Search on twitter using hashtags is a primitive form of search, limited only by your knowledge of which hashtags are useful in the area you are interested in. Unfortunately at this time hashtags seem to appear by popular  acclaim and usage. There is as yet no nomenclature that is officially blessed by the twitter community.

4. Facebook and Google can be used as well, offering more than 140 characters. (I preface this with the fact that there are several url shorteners, as well as text abbreviation services which truncate tweets longer than 140 characters, providing a link within your tweet.  Linkedin is well known among professionals. It offers much to professionals. This sleeper network has become more popular and is now more integrated with other social media sites.  Although Linkedin recently prevented twitter feeds to their site, the reverse is not true, allowing a Linkedin  user to simultaneously tweet.

5. Many applications have been developed which offer simultaneous social media messages across multiple applications. Tweetdeck allows a single tweet to also be placed Facebook, and Linked in.  A  post on a Google stream can be shared on Twitter, or  Facebook. Google is closely linked with YouTube, and can be used for live video and Google on Air Hangouts. Buffer app creates the ability to send your tweets repeatedly during a 24 hour period (at times when most users are active). Inserting a hashtag improves the chance that your recipients get the message(s).

6. Analytics, BuddyMediaSocial Media ExaminerSocialBroSprout Social (free trial), Google AnalyticsTwitter Analytics are available to measure your impact, followers, networking, influence and the times your tweets are most read.  It is possible to schedule your tweets at those times. MentionMapp is one of the coolest maps of  the twitter universe. Type in your “twitter handle” and presto you have a map of your own twitter galaxy. For those of you proficient in spreadsheets and APIs there are a host of free Macros and apps.

7 Facebook uses “friends” or ‘likes’. Google Plus for Business as well as Personal Google Plus  uses “circles”. Twitter uses “followers” to organize your audience.  There are some nuances, which go beyond the limits of my blog.

8. Blogs and web sites provide insider information about health and facilities as well as providing meeting schedules, agendas, and speaker lists.

Steve Ballmer, the reaper of Windows 7  Microsoft has already said that Windows 8 tablets, irrespective of their x86 or ARM underpinnings, are PCs.

9. Web 2.0 and Health 2.0 may be ending to be replaced by Mobile    Studies and surveys indicate that mobile applications in health care will multiply exponentially in 2012.  They also reveal a relative decrease in laptop, and desktop computers as compared to sales of tablet pc and smartphones. Almost everyone will use their mobile device much like a pc, giving facebook, twitter and google plus an advantage with applications designed especially for mobile, and consumers carry them wherever they are, waiting for your message.   And yes all of this is coming to an EMR for your examining room. Just like your progress notes used to be.


After all isn’t this what separated the MDs from the RNs and others? (Illegibility) And this is probably why CPT codes and ICDs evolved.

If you are not using social media for some vague reason such  as stereotyping, you are cheating yourself out of an efficient and powerful medium. The caveat is ‘learn how to use it”

Mayo Clinic even offers a Residency in Health Care Social Media .

Social Media Toolkit from Doctors 2.0  2012 Meeting

Let’s talk about the Internet & Social Media in Healthcare – Kathi Apostolidis

“Come on, Dad, get with it”  (a favorite lecture from my kids).


Monday, July 9, 2012

Doctors 4 Patient Care on The Health Train Express



Tomorrow, July 10th Doctors 4 Patient Care will give testimony in Congress regarding the impact of the Patient Protection Affordability Care Act. Never before has a Law had such an oxymoron for a title. The law is not about patients, not about protection, not about care. It however is an  act….an imaginary folly created by who knows.

Included in today’s post is the link to testimony of the participants.  Erick Novak MD states the issues simply, and without useless rhetoric.   Most of what you read here is read by you the “choir”.  It’s meant for our patients and governmental officials to read.

Please forward this to all your contacts

I urge you to respond with a ‘ROAR’