3-D Printed Facial Prosthesis Offers New Hope for Eye Cancer Patients Following Surgery

Made to cover hollow eye sockets, flexible custom masks provide more affordable, fast- production alternative to traditional prosthetics

CHICAGO – Researchers have developed a fast and inexpensive way to make facial prostheses for eye cancer patients using facial scanning software and 3-D printing, according to findings released today at AAO 2014, the 118th annual meeting of the American Academy of Ophthalmology. Their novel process can create more affordable prosthetics for any patients who have hollow sockets resulting from eye surgery following cancer or congenital deformities.

In the United States, more than 2,700 new cases of eye cancer are diagnosed each year, according to the American Cancer Society, and the mortality rate is high for the disease. Some patients undergo a life-saving surgery known as exenteration that involves removing the contents of the eye socket and other tissue. The research team hopes to bring these patients relief by providing a more affordable facial prosthesis that will allow them to live their lives more fully and with less stigma.

Conventional facial prostheses can cost $10,000 to $15,000 and take weeks to produce. Each one is created by an ocularist, an artisan who makes a mold of the face, casts it using rubber and then adds the final touches such as skin color and individual eyelashes. Patients and their families often have to pay out-of-pocket for facial prostheses because health insurance oftentimes will not cover the cost.

University of Miami researchers developed a process to manufacture facial prostheses in a matter of hours at a fraction of the cost of a traditional prosthesis using topographical scanning and 3-D printing technology. Patients are scanned on the undamaged side of their face using a mobile scanner. The software then creates a mirror image. Along with a scan of the side of the face with the orbital defect, the program can mesh the two scans together to create a 3-D image of the face. The topographical information then goes to a 3-D printer, which translates the data into a mask formed out of injection-molded rubber suffused with colored pigments matching the patient’s skin tone.

The project started as the brainchild of David Tse, M.D., professor of ophthalmology at the Bascom Palmer Eye Institute in Florida and the Nasser Ibrahim Al-Rashid chair in ophthalmic plastic, orbital surgery and oncology. Dr. Tse was treating a child with eye cancer who had both eyelids removed and underwent exenteration. The family could not afford an ocularist, so Dr. Tse raised donations to help pay for her first prosthesis. Now a teenager, she has grown out of the prosthesis and must instead wear an eye patch.

“Hopefully, using this quick and less expensive 3-D printing process, we can make an affordable facial prosthesis for her and also help thousands of other people like her who lack the resources to obtain one through an ocularist,” said Dr. Tse.

Designed and developed in partnership with Dr. Tse and a team at the Composite Materials Lab at the University of Miami, the 3-D printed prosthesis possesses several advantages over the conventional type created by an ocularist. The material involves a proprietary mix of nanoparticles that provides extra reinforcement and makes it possible to match many shades of skin. Over time, conventional facial prostheses can discolor and fray at the edges, but nanoclay protects the material from breaking down and changing color when exposed to moisture and light. It also prevents dirt from depositing. If the prosthesis ever needs to be replaced, reproduction can happen with the press of a button.

“Once we have a patient scanned, we have the mold, so we can create a new prosthesis in no time,” said Landon Grace, Ph.D., director of the lab and an assistant professor of mechanical and aerospace engineering. “Our long-term goal is to help patients anywhere in the world. We could get a mobile scan, download the data in Miami, print out the prosthesis and ship it back to the patient the next day.”

Rapid and cost-effective orbital prosthesis fabrication via automated non-contact facial topography mapping and 3-D printing (PO467) was presented at AAO 2014, the 118th annual meeting of the American Academy of Ophthalmology in conjunction with the European Society of Ophthalmology, which is in session October 18-21 at McCormick Place in Chicago. More than 25,000 attendees and 620 companies from 123 countries gather each year to showcase the latest in ophthalmic education, research and technology. To learn more about the event Where All of Ophthalmology Meets, visit http://www.aao.org/2014.

More 3-D Printing Technology Research

Additional 3-D printing technology results will be presented at AAO 2014 by ophthalmologist David Myung, M.D., Ph.D., of the Byers Eye Institute at Stanford University. His work centers on a 3-D-printed lens adapter system that enables high quality images of the eye using smartphones, which may help increase access to more affordable eye care. The poster is titled “Design and Rapid Prototyping of a Novel 3-D Printed Smartphone Lens Adapter System” (PO328).

About the American Academy of Ophthalmology
The American Academy of Ophthalmology, headquartered in San Francisco, is the world’s largest association of eye physicians and surgeons, serving more than 32,000 members worldwide.  The Academy’s mission is to advance the lifelong learning and professional interests of ophthalmologists to ensure that the public can obtain the best possible eye care. For more information, visit www.aao.org.

The Academy is also a leading provider of eye care information to the public. The Academy’s EyeSmart® program educates the public about the importance of eye health and empowers them to preserve healthy vision. EyeSmart provides the most trusted and medically accurate information about eye diseases, conditions and injuries. OjosSanos™ is the Spanish-language version of the program. Visit www.geteyesmart.org or www.ojossanos.org to learn more.

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Video on Building Accountability and Consistency Into Your Workflow

What do you think of this video?

I found this video really interesting. Vishal Gandhi, CEO of ClinicSpectrum took his post Building Accountability and Consistency Into Your Healthcare Practice on EMR and HIPAA and turned it into video format. He did it quickly, so I think it could benefit from a little polish, but I love the idea. Video can capture people’s imagination in a way that text can not.

Going to the topic of the video, I’ve seen a lot of practices that can benefit from the idea of accountability in their practice. In many respects, Vishal is just describing how to implement some best business practices into your clinic. Many practices could benefit from these simple ideas.

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Fine Thinking Friday

I just posted a tweet summary of today’s #HITsm chat about meaningful use. It was full of amazing insights on what’s happening with EHR, meaningful use and healthcare IT. There were so many insights that it got really long, but go and read it anyway. It’s still just a bunch of easily digestible tweets.

Since the post was getting too long, I didn’t want to make it longer by including some of the off topic tweets that were sent during the #HITsm chat. I guess that’s where it’s an advantage to have a full network of EHR and Healthcare IT blogs. I decided that I’d share the really interesting off topic tweets from today’s Twitter chat here.

What a great discussion between Keith and Stephanie. I think we’d all like to see a “little less talk…a lot more action!” (sorry to get that song in your head, but I had to do it)

Gregg Masters response to this tweet was spot on: “Bingo! you nailed the problem. ‘complexity’.” It is super complex and Mandi’s right that no doctor is going to go through the trouble. Bernadette also replied to the tweet and said that “Experts like you are precious.” Very true!

This is the challenge that we’ll be dealing with for a while to come. The shift will not be easy.

I love when a Twitter chat goes off topic. These tweets are great examples of why I like it. Definitely worthy of a Fine Thinking Friday post!

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Hospitals and Ebola

It seems like you can’t turn your head anywhere without hearing something about Ebola these days. I heard one TV station in Dallas being called the Ebola news. It’s probably pretty accurate considering it’s been the epicenter of the news coverage. Although, the coverage has seemed to be a little all over the place. In fact, the coverage for Ebola has hit so many places, that I’ve basically avoided almost all of the coverage. I’ve only gotten a little bit of coverage from the sources that I ready regularly. I guess I’ve also seen a few headlines on social media.

With that said, I have dug a little deeper on what’s happened with the EHR and Ebola discussions. Although, that story seems to be even more convoluted and misunderstood than the larger Ebola story. If you want something really valuable (notice the sarcasm font), check out this just released joint statement from the AMA, AHA, and ANA that basically says “We’re working together on it.” If I were a member of any of these organizations, I’d have to consider quitting.

Here’s my short synopsis on what we should know about Ebola:

1. Be thoughtful in how you avoid any communicable disease (Ebola included). That doesn’t mean you have to lock yourself in your house and never go out.
2. We need to get Ebola under control in Africa. If we don’t, then we could have Ebola become a real issue in the US.
3. EHR software can help healthcare professionals identify and track Ebola if configured properly.

There are a number of groups and organizations trying to come together to spread the EHR best practices when it comes to Ebola. I’ll be interested to hear what they find.

Those are my general thoughts on what’s happening. As I said, I’m not an all encompassing expert on the topic. Let’s all share what we know and what we’re doing in the comments.

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Healthcare IT Leaders Embrace Federal Interoperability Plans

CHIME and HL7 see new interoperability roadmap as an important step towards realizing the promise of health IT; Organizations underscore need to incorporate critical standards under development for Stage 3 Meaningful Use

ANN ARBOR, MI October 17, 2014 – The federal government’s top health IT advisors on Wednesdaymade important recommendations on how public and private stakeholders should progress towards interoperability in healthcare. Leaders from the College of Healthcare Information Management Executives (CHIME) and Health Level Seven International (HL7) embraced the recommendations of the JASON Task Force, calling them a significant step forward in achieving the promise of information technology in healthcare. CHIME and HL7 also highlighted the need to incorporate critical enhancements to standards currently under development for Meaningful Use Stage 3.
During a joint meeting of the Health IT Standards and Health IT Policy Committees, federal officials discussed new details regarding a national interoperability roadmap and outlined concrete recommendations meant to improve the appropriate access and use of health data.  The JASON Task Force said that a solid foundation for interoperability should utilize public APIs, advance modern communications standards, such as HL7’s Fast Healthcare Interoperability Resources (FHIR®), and use Meaningful Use Stage 3 as a pivot point to initiate this transition.

FHIR is a simple-to-use format that can improve interoperability for a range of technologies, including EHRs, patient-centric solutions and mobile applications.  A next generation standards framework created by HL7, FHIR combines the best features of HL7’s Version 2, Version 3 and CDA® product lines while leveraging the latest web standards and applying a tight focus on implementability.

“Today’s discussion and the recommendations of the JASON Task Force represent an evolution in thinking,” said CHIME President and CEO Russell P. Branzell, FCHIME, CHCIO. “The updated roadmap and the recommendations put forth by the JASON Task Force incorporate a tremendous amount of stakeholder input and articulate the challenges facing our industry much more completely than previous efforts.”

“The prioritization of standards-based interoperability and a commitment to long-term policymaking will enable healthcare to benefit from information technology in very tangible ways,” said Charles Jaffe, MD, PhD CEO of HL7.

CHIME and HL7 believe important recommendations were accepted by the full Health IT Standards and Health IT Policy Committees. HL7 and CHIME also support allowing time to make Meaningful Use Stage 3 more impactful with the inclusion of key standards that are still under development.  “There remains a disconnect between artificial government timelines and the realities of standards and technology development,” Branzell said.  “This highlights a principle concern with how health IT policy is created, adopted and implemented at the federal level.”

CHIME and HL7 are committed to collaboration in the advancement of health IT initiatives such as FHIR and support government efforts on the interoperability roadmap.

The College of Healthcare Information Management Executives (CHIME) is an executive organization dedicated to serving chief information officers and other senior healthcare IT leaders. With more than 1,400 CIO members and over 140 healthcare IT vendors and professional services firms, CHIME provides a highly interactive, trusted environment enabling senior professional and industry leaders to collaborate; exchange best practices; address professional development needs; and advocate the effective use of information management to improve the health and healthcare in the communities they serve. For more information, please visit www.cio-chime.org.

About Health Level Seven International (HL7)

Founded in 1987, Health Level Seven International (www.HL7.org) is the global authority for healthcare information interoperability and standards with affiliates established in more than 30 countries. HL7 is a non-profit, ANSI accredited standards development organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services. HL7’s more than 2,000 members represent approximately 500 corporate members, which include more than 90 percent of the information systems vendors serving healthcare. HL7 collaborates with other standards developers and provider, payer, philanthropic and government agencies at the highest levels to ensure the development of comprehensive and reliable standards and successful interoperability efforts.

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DrFirst Launches Electronic Prior Authorization for Providers Nationwide with CoverMyMeds

DrFirst’s Patient Advisor ePA+ Service to deploy to 300 EMR Systems Beginning October 28th

Rockville, MD, October 17, 2014

DrFirst, a leading provider of healthcare IT solutions, announced today that its new electronic prior authorization (ePA) service, Patient Advisor ePA+SM, will begin rolling-out to providers on October 28th.  Using the service, prescribers and their staff will be able to initiate, submit and complete prior authorizations electronically, and will be able to respond to prior authorizations that are initiated from pharmacies after a claim rejection, from within their eRx/EMR workflow.  The release of Patient Advisor ePA+ marks the first live prior authorization solution that is fully integrated within the e-prescribing process.  The service will encompass multiple prior authorization sources, beginning with CoverMyMeds, the industry leader in automating prior authorization processes for prescription drugs.

Prior authorization (PA) is the formulary management process requiring insurance carrier pre-approval for certain prescribed medications. Traditional PA – including paper forms, faxes and phone calls – is exceptionally time-consuming for medical practices, amounting to more than 20 hours per week per physician of staff time to support PA requirements.

The Patient Advisor ePA+ service will deploy to 150 of DrFirst’s more than 300 EMR, EHR and HIS system partners, as well as to all users of DrFirst’s Rcopia® and RcopiaMUSM stand-alone e-prescribing platforms.  In December, DrFirst will continue deployment of Patient Advisor ePA+ to the balance of its partner EMR, EHR and HIS systems.  This deployment schedule is designed to enable the availability and adoption of ePA capabilities that are truly meaningful to doctors and medical staff nationwide, and with no cost to their practices.

CoverMyMeds functionality has been fully integrated within DrFirst’s Patient AdvisorSM medication adherence and clinical content platform.  As a result of functionality provided by CoverMyMeds, Patient Advisor ePA+ will also be the first and only fully integrated ePA solution supporting all plans and all medications.  Patient Advisor is standard functionality within DrFirst’s e-prescribing technology, but can also be integrated directly within the workflows of third-party EMRs.

“Our intent with Patient Advisor ePA+ is to provide a full-spectrum, multi-source, easily integrated ePA solution to all EMR, EHR and HIS vendors,” said G. Cameron Deemer, president of DrFirst.  “Our leadership in other medication management areas, such as controlled-substance e-prescribing (EPCS), serves as a model for our ability to bring high-value technology to EMR systems; in the case of ePA, and with an exceptional partner like CoverMyMeds as the cornerstone of our service, we will similarly and rapidly make this transformative functionality available to providers.”

“CoverMyMeds offers an all-drug, all-payer prior authorization solution,” said Matt Scantland, co-founder of CoverMyMeds. “Our existing integrations with more than 45,000 pharmacy locations and 72% of payers makes us the most connected PA provider in the industry and we anticipate providers using Patient Advisor ePA+ will be able to reduce the amount of time required to process prior authorizations by as much as 70%.”

DrFirst will additionally integrate other ePA services into Patient Advisor ePA+, including Surescripts CompletEPA as well as connections with individual payers, PBMs and other multi-payer connections, in order to provide the most comprehensive selection of ePA sources to EHR and HIS system vendors nationwide.

About DrFirst

DrFirst pioneers technology solutions that inform the doctor-patient point of encounter, optimizing provider access to patient information, enhancing the doctor’s clinical view of the patient, and improving care delivery and clinical outcomes. Our growth is driven by a commitment to innovation, security and reliability across a wide array of services, including Medication Management, Medication Adherence, and Secure Care Coordination and Collaboration. We are proud of our track record of service to more than 45,000 providers, 300 EMR/EHR/HIS system vendors, and 650 hospitals and other acute care facilities. For more information please visit www.drfirst.com.

Posted in e-prescribing, EHR, Electronic Health Record, Electronic Medical Record, EMR, Health IT Partnerships, Healthcare, Healthcare Interoperability, Healthcare IT | Tagged , , , , , | Comments Off

Healthsense Launches New Health Dashboard, Delivering Instant Insight for Proactive Care

Minneapolis, Minn. –October 16, 2014Healthsense, Inc., the fastest growing provider of technology-enabled care solutions for the senior care continuum, announced today the release of its eNeighbor® Dashboard™, a first-of-its-kind application which utilizes proprietary analytics to help providers make more informed care decisions.
The eNeighbor Dashboard arms care providers with the actionable information needed to address the rising costs and challenges of caring for a clinically complex, rapidly growing senior population. It provides caregivers with access to the right data at the right time so they can deliver high quality care and reduce unnecessary costs to the healthcare system.
Part of the Healthsense eNeighbor remote monitoring platform, the eNeighbor Dashboard is a web-based preventative monitoring application that quickly and easily identifies health concerns through a tiered analysis of data collected by sensors placed in an individual’s home. These sensors continuously gather data on activities of daily living (ADL), key wellness indicators such as sleep quality and activity, and other physiological information.
“By collecting comprehensive ADL information, we are able to visualize alterations in patterns that often reveal an oncoming change in a person’s level of wellness. Individualized summaries of activity changes and trending reports provide actionable information to care providers, allowing for proactive care and the avoidance of exacerbations of chronic or acute conditions,” said Julie Carr, Healthsense Director of Clinical Operations.
This information, collected throughout each 24-hour period, is compared against previously established individual benchmarks and rated by significance of change. An analysis is displayed for each category with trending information over time based on pre-established activity levels. This gives providers further insight into the health and wellbeing of their care population, making it easier to identify health changes that may need further analysis or intervention. The trending information also allows providers to ascertain whether those in their care are responding to treatment or changes in their environment.
“The eNeighbor Dashboard is the latest example of Healthsense’s commitment to provide innovative technology that delivers measurable value to caregivers and those in their care,” saidA.R. Weiler, Healthsense President and CEO. “By enabling proactive care management through more timely interventions, the eNeighbor Dashboard helps to lower total medical expenses while improving caregiver productivity. This results in enhanced top- and bottom-line financial performance through greater staff efficiencies, broader service offerings and a lower cost of care.”
Healthsense will debut the eNeighbor Dashboard at the National LeadingAge Conference, October 20-23, in Nashville (Booth #1324).

About Healthsense, Inc. 

Healthsense is the fastest growing provider of technology-enabled care solutions for the entire senior care continuum. With our full range of health and safety monitoring systems, providers are empowered to proactively deliver the highest quality care possible through critical health information. Caregivers reduce costs, increase independence and enhance senior experiences when armed with the right information at the right time.
Visit www.healthsense.com for more information.
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Creating mHealth Apps That Do Something for You

There was a great LinkedIn discussion happening around the Fitness Tracker Fallout post that I did previously. One of the comments by Dean Tucker, Founder & CEO at MyNightCare, LLC, provided some really interesting insights into the mHealth app market:

The focus of the current crop of devices and apps requires one to “do” something, engage in a social competition, analyze our own data, and follow advice from someone or something we don’t know or trust.

The secret to successful apps and their utilization will be revealed when the apps and tracking devices the apps rely upon provide the answer to the question, “what does this do for me”, rather than telling me, “here is what you need to do.” What I want is the ability is to have a life monitoring ecosystem, with the sensors and devices we already have in our lives, complemented by new passive sensors, and the active tracking devices we choose to use, when we want or need them. That is where Apple, Google, Samsung, and all of other aggregators, will play the lead role. The supporting specialty apps will be there for when I want to drill down, or focus on a particular activity or health related issue.

What a powerful concept to consider. Most apps could really benefit from thinking about what the mHealth app can do for the user as opposed to what the user needs to do for the app. That’s not to say that the user shouldn’t have any involvement in doing something with the app. However, it takes a very specific situation and motivation for a user to be willing to do the work before receiving the reward.

Dean is right that we’ll see an amazing shift in fitness tracking once the devices collect the data automatically with no intervention from the user. We’re heading that direction and those that master that kind of health tracking are going to be the big winners.

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New Affordable Care Act Initiative to Support Care Coordination Nationwide

The Centers for Medicare & Medicaid Services (CMS) today announced the availability of a new initiative for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. Made possible by the Affordable Care Act, ACOs encourage quality improvement and care coordination through the use of health information technology, helping to move our health care system to one that values quality over quantity and preventing illness over treating people after they get sick.

The new ACO Investment Model is designed to bring these efforts to better coordinate care to rural and underserved areas by providing up to $114 million in upfront investments to up to 75 ACOs across the country.

“The ACO Investment Model will give Medicare Accountable Care Organizations more flexibility in setting quality and financial goals, while giving them greater accountability for delivering quality care efficiently,” said CMS Administrator Marilyn Tavenner. “We are working with these organizations to make necessary investments that encourage doctors, hospitals and other health care providers to work together to better coordinate care and keep people healthy.”

Through the CMS Innovation Center, this initiative will provide up front investments in infrastructure and redesigned care process to help eligible ACOs continue to provide higher quality care. This will help increase the number of beneficiaries – regardless of geographic location – that can benefit from lower costs and improved health care through Medicare ACOs. CMS will recover these payments through an offset of an ACO’s earned shared savings.

Eligibility is targeted to ACOs who joined the Shared Savings Program in 2012, 2013, 2014, and to new ACOs joining the Shared Savings Program in 2016. The application deadline for organizations that started in the Shared Savings Program in 2012 or 2013 will be December 1, 2014.  Applications will be available in the Summer of 2015 for ACOs that started in the Shared Savings Program in 2014 or will start in 2016.

Recently, ACOs in the Pioneer ACO Model and the Medicare Shared Savings Program generated over $372 million in total program savings for Medicare ACOs while also improving the quality care delivered to Medicare beneficiaries.

ACOs are one part of the overall effort provided by the Affordable Care Act to help lower costs and improve care and quality. For example, the Affordable Care Act has helped reduce hospital readmissions in Medicare by nearly 10 percent between 2007 and 2013 – translating into 150,000 fewer readmissions – and quality improvements has resulted in saving 15,000 lives and $4 billion in health spending during 2011 and 2012.

For more information on the ACO Investment Model, please visit: http://innovation.cms.gov/initiatives/ACO-Investment-Model/

ACO Investment Model CMS Fact Sheet: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-15.html

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Computer Assisted Coding Applications Slated for Strong Growth Potential

HIMSS Analytics’ Autumn 2014 edition of the Essentials of US Hospital IT Market highlights the promising sales opportunities for IS Infrastructure and HIM applications

CHICAGO (October 15, 2014) – Computer Assisted Coding applications are poised for increased growth among hospitals, according to data from the latest HIMSS Analytics Essentials of the U.S. Hospital IT Market report (Autumn 2014 edition). Released today, the report evaluates the support service applications and medical devices used most by hospitals across the U.S.

Leveraging data from the HIMSS Analytics® Database, the report profiles 25 support service applications and medical devices being used in hospitals across the nation in terms of their market penetration (saturated, mature to maturing) against their projected sales volumes (decelerating, marginal to accelerating). Computer Assisted Coding was observed as having the highest growth potential. This is a significant finding for health Information Technology (IT) vendors as this accelerated projected sales volume is occurring in a maturing market.

“In preparation for the shift to ICD-10, it is no surprise that the sales potential for coding solutions is high,” said Lorren Pettit, Vice President of Market Research for HIMSS Analytics. “The findings suggest that market opportunities are ripe for vendors with Computer Assisted Coding solutions.”

The 25 applications observed are divided into the following categories:

  • Ambulatory
  • Clinical & Business Intelligence
  • Document/Forms Management
  • Health Information Exchange (HIE)
  • Health Information Management (HIM)
  • Home Health
  • IS Infrastructure
  • IS Security
  • Medical Devices

Nearly half of the applications (11 of the 25) profiled can be characterized as standard business tools due to their relatively high market penetration level. Five applications were marked for a healthy growth trajectory over the next five years, while 15 applications reflected a growth trajectory of less than 10 percent during the same period.

The report also covers the market utilization of each application in the marketplace at more than 5,400 U.S. hospitals tracked by HIMSS Analytics. The market utilization assessment for each application is determined by the number of hospitals in the market which have installed the application.

Please contact consulting@himssanalytics.org for more information on purchasing the HIMSS Analytics Essentials, Autumn 2014 Edition, and for a copy of the Executive Summary. Visit the HIMSS Analytics website for more information.

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About HIMSS Analytics

HIMSS Analytics collects, analyzes and distributes essential health IT data related to products, costs, metrics, trends and purchase decisions. It delivers quality data and analytical expertise to healthcare delivery organizations, IT companies, governmental entities, financial, pharmaceutical and consulting companies. Visit www.himssanalytics.org.

HIMSS Analytics is a part of HIMSS, a cause-based global enterprise that produces health IT thought leadership, education, events, market research and media services around the world. Founded in 1961, HIMSS encompasses more than 52,000 individuals, of which more than two-thirds work in healthcare provider, governmental and not-for-profit organizations across the globe, plus over 600 corporations and 250 not-for-profit partner organizations, that share the cause of transforming health and healthcare through the best use of IT. HIMSS, headquartered in Chicago, serves the global health IT community with additional offices in the United States, Europe and Asia.

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