May God continue to bless America

This is America

There is a reason why we love this country, although at times it is difficult to put it into words.  We watch the news, and no matter the channel, the mission of the news is to tell us what is wrong with our country.  Shame on them.

My story is no different from most of yours.  I grew up in Maryland.  I grew up when Pong was the most amazing thing on the planet.  Like you, my world was put on hold to watch the landing on the moon—spectacular in black and white on a television that was so heavy it required the strength of two men to move it.

Maryland, Iowa, Oregon.  I have had the good fortune to have been to forty-seven states.  I am missing Alaska, Idaho, and Maine, and I would move to them sight unseen in a minute.  What makes my state special is the same as what makes yours special—I spent my youth there.

Cut grass in Maryland has a certain smell to it, as I’m sure yours does.  There is a certain mystique to the Maryland’s fireflies, its humidity, and its sport teams.  I knew the stats for every player on the Orioles and the Colts.  I was a devoted member of the Junior Orioles.  I collected soda bottle caps showing the names of the players of the Baltimore Colts.  Collectively, we gathered around a radio to listen to games of our teams.  At night I listened to the O’s on a transistor AM radio with an attached ear plug.

The most Maryland thing about Maryland is something most of you have never tasted—steamed crabs.  Not Dungeoness, not King, nor Snow…not Stone.  Blue crabs.  Caught in the Chesapeake Bay and its tributaries.  Caught by kids hanging chicken necks from a row boat.  Caught by men and women setting crab pots from rickety wooden boats.

Maryland was a summer’s day eating steamed crabs.  We would buy the live crabs and steam them in beer and vinegar.  The crabs were seasoned with a combination of Old Bay and the purveyor’s secret mix of spices.  Our senior class party was a crab feast.  Crabs were the de rigueur offering at cookouts, and after a game of softball.  Part of the attraction of eating steamed crabs was the informality of the feast.  You could not buy them in a “fancy” restaurant.  The etiquette of eating crabs required a picnic table covered in butcher paper or newspapers, a wooden mallet, a role of paper towels, and pitchers of beer or unsweetened iced tea.

Some would waste time with the accoutrements; corn, coleslaw, and hush puppies.  Fillers.  Eating steamed crabs required the discipline of a prize fighter—stay the course.  Set aside several hours.  Pace yourself.  Your fingers will endure cuts from the claws.  The seasoning will enter the cuts and sting—that is part of the ritual.  The meal was akin to a dance marathon.  The weaker players eventually fade away; the stalwarts press forth, maintaining a rhythm until there are no more crabs.

My wife and children are in Miami for the month.  As compensation, I bought a half bushel of crabs.  Eating crabs requires a bit of a religious fervor, a devotion to the task.  The coffee table in the family room is prepared for the event—covered with a large black trash bag, a roll of paper towels, a knife and a wooden mallet.  I lick the seasoning from each shell, remove the legs, find the hidden meat, and then vivisect the body.  I place the empty shells in a large pot, along with a mirepoix of vegetables to make a crab stock.

This is Maryland, my Maryland.  In some respect, this is a tiny portion of America, an exercise repeated thousands of times across the country.  Different states, different fares.  Slow cooked pork ribs, burgers and dogs, sweet corn, watermelon.  To an outsider, our sense of Americaness may not make much sense.  To Americans, these singular rituals—our traditions, handed down from generation to generation—are part of the fabric that unites us.

So, on this Fourth of July, enjoy what you are doing.  Plan on enjoying it again next year and the year after.  Remember those who came before you, for it was their traditions that you now commemorate.  Few countries celebrate the right of the individual—your right to be you.  That is what is special about this place.  Independence Day  is a celebration of your right to be you.

The EHR Certification Myth

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial–like Kojak without the warmth.

Why is this a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Why is EHR not the right answer?

The reason I chose to share this story is my belief that it is de rigueur among practitioners.  I have been spending some of my time working on behalf of a small clinic.  Four doctors, two offices, small lab, x-rays, some surgeries.

Great people, great mission.  Every physician spends several weeks each year doing unpaid missionary work in Africa and South America.  Their focus is caring, not dollars.  It is not my job to change their focus.  They do not turn away anyone who cannot pay.  Staff at the front desk help patients pay for their meds.  The four physicians routinely offer services and perform procedures for which they know they will not be paid.  I feel a real sense of pride helping them, and have slashed my rates to make sure they get the help they need without taking money unnecessarily from their coffers.  Their patients love them, and they add about a hundred new patients a month.

The business side of their practice could have been designed by Rube Goldberg.  As I interview the doctors, the nurses, the lab, and the front desk about the practice, I try to do so with a straight face, try not to betray the part of me that wants to say, “You’re kidding, right?”

They meet with about fourteen-hundred pharmaceutical reps each year.  I tried to pin down why they do it, but could not come up with an answer to support a business reason.  Since the pharma reps can no longer offer trinkets equivalent to those needed to purchase Manhattan, they give away lunch.  Enough lunches to ensure that everyone in the practice should weigh eight-hundred pounds.

They use the F-word a lot—faxes.  Two fax machines running often enough that without proper cooling they would melt through the floor.  The average fax is handled eight times before it is placed in the patient’s chart.

There is no email, no web site.  There is no triage—docs and nurses do not screen patient phone calls to determine who needs to be seen.  Seventy-five patients a day, two and a half people are full time on billing.  Three people man—actually, it should be “woman”, the front desk.  (Is that an intransitive verb, or simply poor writing on my part?)  The staff wants more staff.

I have been hired to help them with the selection and implementation of their EHR.  I can solve the EHR problem in five minutes, but I won’t.  Having an EHR will solve none of their problems, at least not until they turn what they do into a business.

Realigning their business processes will do more for their mission than any EHR.  Processes are inefficient and ineffective.  I cannot figure out how they collect money or pay bills.

I am willing to bet they are not alone in having these issues.  I’d bet that these problems can be extrapolated to hospitals.  Is Practice Management more important to physicians than EHR?  My guess is that the right answer is yes.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Why EHR would not have worked in the 1960’s

EHR, where’s my hammer?

Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools.  Let me tell you about my first house, a two-story stucco building in Denver, built in 1902.  My favorite part of the home was the brick wall.  That is had a brick wall was not apparent when I purchased it.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick.  I had to decide what to do.  I knew nothing about lathing—I know that’s not really a word—or plastering.  What to do.  My only tool was a hammer, so I began to hammer.  For those who haven’t done this, hundred year old plaster being pounded with a hammer makes a lot of dust.  This process proved to be very slow.

What did I do?  I bought a bigger hammer—such a guy approach to a problem, isn’t it?  It took three hammers to get down to just bare brick.  What would you have done?  When your only tool is a hammer every problem looks like a nail.

As you go through the EHR planning process in your war room—you do have a war room, don’t you?  (Try Sam’s Club, after all, they sell EHRs.)  Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you?  (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface.  One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators.  It’s not a panacea.  It won’t reach its potential unless you also integrate it with those systems that unlock its potential.  Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail.  What other tools are you using?  Please share your ideas about what works well.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What if GM were involved in EHR?

Goodness knows, the whole car thing did not work our too well for them

Do you ever think about the origination of some of your ideas?  For me, the good and the bad just seem to materialize.  Like the time a friend and I were hiking a peak in the Sangre de Cristo range in Colorado.  It had taken the better part of six hours of circuitous climbing to reach the summit.  It was late in the fall, and the temperatures were around freezing.  Roiling storm clouds were racing towards us from the west.

If we returned by the same route we knew we’d be caught up in a storm that we were neither prepared nor dressed to handle.  I spotted our car about six thousand feet below us.  If we headed straight to it, I thought we could cut our descent time by about an hour.  To do this though required that we make our own trail via a hunt and peck route of whatever the terrain permitted.  We dropped the first fifteen hundred feet in a matter of twenty minutes using a glissade.  This technique allows you to moonwalk and slide down a scree field, using your ice ax as a break.

After an hour we reached a point about two thousand feet above our car.  It was sleeting, and the wind was whipping around the face of the mountain.  There in the middle of nowhere stood a sign from the sheriff that read, “Devil’s Gulch, turn back.”  Our choice was to reclimb the mountain or to ignore the sign and press on.  I hate do-overs.  How tough can this be, I goaded him?  Be smart, kick it into high gear, and we’ll be done.

We pressed forward.  Fifteen minutes later, we reached a four hundred foot limestone cliff.  Between us and the next semi-reasonable terrain was a rather deadly looking wall of rock and scrub pine.  My pack made me feel like it was forcing me forward, so I removed it and tossed it over, thinking I’d retrieve it later.  Watching my pack bound from rock to rock for what seemed like more than a minute did nothing for putting me at ease.

We spent more time discussing each step than we spent taking it.  Those four hundred feet took us two hours.  Not my best idea, but it didn’t kill us.

So, during my run today, I had another idea.  This one is about OnStar, the GM tracking system.  I typed in to Google, “How does OnStar Work?”  Lots of hits.  The more I read, the more I began to feel like if one ignored the technology and focused on the concept a real argument could be made for pairing the idea, and a few others, and seeing what type of EHR network might be possible using a similar set of tools.

The OnStar concept is termed telematics, a combination of telecommunications and informatics.  Telematics is the integration of computing, wireless communications, and GPS.  It provides information to a mobile service like a phone, PDA, or laptop.  It is used for sending, receiving, and storing information over very large networks.  So, why is nobody having the conversation that says what if we image a similar network with added security that works from a healthcare provider’s office rather than a car.

OnStar doesn’t need Rhios.  OnStar has a single set of standards.  Now, instead of arguing why something like this can’t work in healthcare, isn’t there argument is seeing if it can?

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

When nurses end their shift

Here’s a piece I submitted to a writing contest at NPR.  It has nothing to do with healthcare save for the first sentence which NPR supplied.  In case you are wondering, my 12-step program is progressing nicely.

The nurse left work at five o’clock.  A twelve-hour shift—only lost one, better than some nights, worse than others.  Two hours before sunup, the icy wind gnawed at her ankles.  With her caffeine gauge on empty, she ducked into Starbucks, glancing waywardly at the plethora of coffees posted overhead on the menu board.

“Do you guys actually pay someone to think up all this stuff?”  She asked rhetorically.  The still groggy looking twenty-something guy behind the counter ignored her, not a bright move on his part.  His hair looked like it was cut with an ax; an errant flap of it skittered over his right eye with each movement of his head.  His right ear lobe was pierced in three places, although he only wore one earring.  The nurse noticed a barbed-wire tattoo around his left bicep.

Intent on continuing the conversation, even if it was to remain one-sided, the nurse inquired, “I suppose you guys have a marketing think-tank to invent the product names.  That word “Grande,” that’s Italian, right?”

Twenty-Something occupied himself by steaming a pot of skim milk.

“So, help me think this through,” she implored.  “Since Grande is the one in the middle, it must be Italian for medium.  And, “Venti,” that must mean large.  Right?  So, here’s where I’m confused.  The one labeled, “Tall.”  Something tells me that doesn’t translate to small in any language.  If you take a small cup of coffee, and make people order it as a tall cup of coffee, maybe they will actually think it’s larger than it really is.  QED.  Quod erat demonstrandum.  That’s Latin for cut the crap.”

The nurse knew she was jousting in soliloquies with an idiot.  Nonplussed, Twenty-Something merely rolled his eyes and asked her what she wanted.

The nurse was usually not a half-caff, double mocha, skimmed latte kind of person.  In fact, it troubled her that some people were—troubled her a lot.  The person she had hogtied and left in the trunk of her car was one of them; he hadn’t known when to shut up, so she had done it for him.  By the time she had checked on him during her break, he’d frozen solid.

“Any ideas?”  The Twenty-Something foolishly pressed the nurse.

“What do you recommend for somebody who just wants a cup of coffee?”

“Do you want regular or decaf?”

“What’s the strongest you have?”

“Ethiopian.”

“Give me your largest.”

“Shall I leave room for cream?” asked Twenty-Something.

She looked at the prices.  Two dollars for a cup of coffee.  Why would anyone pay that much and then hide the taste of the coffee with cream, she wondered?  “No cream.  Instead, give me a latte grande with skim milk.”

“One grande latte,” Twenty-Something replied, correcting her syntax.  “Is that all?”

“Better give me a large orange juice.  That’s what’s it’s called, isn’t it, or is that also a grande?”

Her wit was lost on Twenty-Something.  “Large,” she murmured through her teeth.  “And a bagel, plain.”

“Toasted?  Cream cheese?”  She knew he was toying with her.

She’s had enough, grabbed the coffee, and headed for the door.

He hollered for her to pay, but the look she gave him told him to let it go.

Too bad the trunk couldn’t hold two.  She’d come back tomorrow to visit the boy.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The EHR Certification Myth

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

Ramblings of an itinerant mind

This post has nothing to do with anything heady, nothing to do with healthcare.  I’ll pause for a minute while those of you who have better things to do with your time click the ‘X’ in the upper right corner.

Is there a time when regressing in your private life seems awfully attractive? Play along with me for a minute.  My wife and children are headed to Miami for a month; thirty days, 720 hours—I’ll defer to you to figure out the minutes.

While I am not looking forward to having them gone, I am looking forward to my Ponce de León hours of rebirth; finding my archived inner-self.  I may start by watching every Clint Eastwood movie—in order—smoking the Parodi beef-jerky cigars Clint favored in his B-movie westerns.  Lots of ill-advised scratching.  Socks skewed asunder in a forensic CSI Hansel and Gretel manner from one room to the next—follow the yellow brick road.  An ADHD month where I am able to accomplish everything that never made it to my to-do list.

What if via a time machine you were metaphorically single for a month?  I watch the Science Channel enough to know that a time machine requires one to travel faster than the speed of light which according to the laws of physics is mathematically impossible.  But suppose.

My first initiative—the Celine Dion CDs will be placed on the coffee table as coasters or tossed off the deck as though they were ninja shurikens (stars).  I then block “Dancing with the Stars” from the cable box.  People Magazine is used as fireplace tinder even though the temperature outside exceeds 90.  I get a thirty-day reprieve from the ‘just shoot me now’ question, “Should I do this or that,” knowing if I select column A she will select column B.

Pulse and BP both drop.  The lawn begins to grow.  Prior to the return of my family, I will be able to hide a giraffe in the grasses of my suburban savanna.  The anticipation of next thirty days reminds me of the book, The Cat in the hat Comes Back, knowing full well I will have to dedicate a few days removing all of the pink spots which have accumulated.  Paraphrasing…

“Then their mother came in and asked what did you do,

Did you have any fun; tell me what did you do?

Should I tell her about it?
Now, what SHOULD I do?
Well…
What would YOU do
If their mother asked YOU?”

That is how it appears to my inner Braveheart character.  The real me cowers knowing I do not have what Madeline Albright so inappropriately referred to as the cajones to pull this off—I am pretty certain she was also two spheres short of having the cajones of acting with the dignity required of her position—forgive me for being impolitic.

I am well trained.  The lawn will be mowed, the cover will be placed on the grill when it is not in use, the hose will be coiled neatly, the dishes will be aligned anally in the dishwasher, utensils upright and not spooning with one another.  The dust balls will surrender to the vacuum, and the plants will be watered.

Life goes on and so shall I.  The dream was good while it lasted.  I do not know if it is fear or cowardice which takes precedence.

If you call me during July, and I do not answer the phone, I may be vacuuming or dusting.  Please leave a message and I will get back to you after I run out of Pledge.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR: What bugs you about it?

This is the time of year in the east when cinerescent caterpillar nests hang thickly from the trees, peppered tufts of cotton candy.  During these long, flavorless August days, the sky is a similar achromatic color.  My nine-year-old is concerned because I told her we are having caterpillar soup for dinner tonight—watch out for the crunchy bits.  Once again, it seems I’ve gotten off message.

I wonder how much of the difficulty surrounding EHR has to do with getting off message, much like we seem to have done with the reform discussion.  What difficulties?  Got time?  You can name more of them than can I.

What is off message?  It’s that the day-to-day tactics of implementing EHR office by office, and hospital by hospital have overshadowed the strategy, have displaced the business driver behind the mandate.  The focus became internal, not national.  Bits and bytes have overshadowed charts.

I doubt few, if any, can articulate a believable explanation of how a few years from now your medical records will accurately and expeditiously be delivered from where you live to the lone clinic on Main Street, Small Town, USA, to the nurse practitioner who at midnight is giving you an EKG.

It’s that fact, that we are not able to define how we get from A to B, let alone do so with multitudes of A’s and B’s, that to me suggests we are building something of which we have little comfort will do what we set out for it do.

Clearly, there are hundreds if not thousands of very talented and dedicated professionals focused on finding a solution.  However, it seems their efforts remain handcuffed by hundreds of competing products, no well-defined overriding set of requirements that would enable anyone to say with certainty, “Yes, that is it.  That captures what we need to do.  When we have done that, we are done.”

Until that time, I think we all need to be concerned about the crunchy bits.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com