Thursday, December 29, 2011

Ted’s Top Ten from 2011

Here are a few of my most popular and favorite articles fromthe past year. Thanks for reading and sharing this blog!

JANUARY 12, 2011 – This article offered the firsthead-to-head comparison of the first two trial presentation apps for iPad, andquickly found itself at the top position for all-time most popular articles,where it remains today. There are now others, including ExhibitA and ExhibitView for iPad, which I will be reviewing very soon.

JANUARY 24, 2011 – What is it about those iPad app reviews?Readership on this blog increased exponentially in 2011, largely attributed to themany iPad app reviews I’ve written. This article explores several apps for juryselection and monitoring, and is comfortably in the second position forall-time most popular articles.

MAY 3, 2011 – Often, litigators make certain assumptionsabout the Judge and jury, which are not always on the mark. One such assumptionis that Judges don’t care for the use of technology in court. Here are a fewnoteworthy quotes for the doubters.

MAY 18, 2011 – I’ve never really used a device just becauseit’s the cool thing to do. I do love my iPad, but I don’t believe it is a truelaptop replacement – regardless of what others might say. Same goes for myphone. I did my homework, and found that the Google phone would be a bettertool than the iPhone, and on a better network (Sprint) that still features anunlimited data plan. This particular article was also very popular in thenon-legal tech channels.

JULY 5, 2011 – It’s hard to believe this happen this pastyear – it already seems so long ago. Our justice system was put to the test, aswas our perception of trial coverage by the media. Whether you agree or not,the verdict stands.  This article wasvery popular in both the legal and non-legal audience.

SEPTEMBER 6, 2011 – Written for CAOC Forum Magazine, thisarticle was mentioned as one of the most-read posts on LinkedIn. While thebasics of trial preparation are similar, you’d better have everything ready togo in an abbreviated trial.

SEPTEMBER 21, 2011 – This was perhaps the saddest article I’veever written. Regardless of your position on capital punishment, we must notallow our judicial system to be manipulated in the interest of convenience orto satisfy public rage.

NOVEMBER 7, 2011 – Due diligence should go beyond thestorefront. Make sure the person who will actually be working with you isqualified. Don’t just accept the sales pitch.

NOVEMBER 20, 2011 – Hmm, looks like I was on a roll here. Ifyou are considering bringing in an outside vendor to assist with your nexttrial, this article offers another check-list of qualifications you should belooking for.

DECEMBER 4, 2011 – You can’t accuse me of tooting my ownhorn with this one. In fact, I’ve listed several of my favorite sources oflegal and technology information. In less than a month, it has found a home onmy all-time most popular articles, at number 3. Readers have added several oftheir own suggestions. Feel free to add yours.

Saturday, December 24, 2011

The F Words of Health Care

Vassily Kandinsky, 1923
Fragmentation, Fee-for-service and Futile care are the trifecta of what is supposedly ailing our health care system, or non-system, as it is fashionably described nowadays. Modern health care has reached its crisis point not due to hordes of people keeling over and dying in the streets, as they did during historical health care crises brought on by plagues and famine, but due to exploding costs of delivering decent care to all people. Since the issue now is mostly financial, health care as a discipline is attracting the interests of those who practice the dismal science of Economics. Over the last two centuries, economists have successfully addressed the F words in other industries with spectacular results in developed countries, so why not apply lessons learned to health care? 

The obvious reason to treat economists with suspicion in health care is the quintessential argument that people are not widgets, but there is another problem. Most tried-and-true solutions for increasing availability and quality while lowering costs of products are not accounting for the other explosion occurring as we speak – the Internet.  How can this assertion be true when we are in the midst of a government sponsored spending spree to computerize medical records and adopt Health Information Technology (HIT)? Apparently, even those who lead and define the HIT revolution are reluctant (or unable) to grasp its full implication, thus they are consistently underestimating the power of the Internet to serve the individual, and as a result are hedging their bets on technology with classic industrial models from days gone by.

In a 2008 Health Affairs article, Dr. Donald Berwick has defined what has become the official goal of policy making for the Secretary of Health and Human Services. Better known as the Triple Aim, the goals are to create better health, provide better care and lower costs of care. If you look at health care as just another industry, the Triple Aim translates into a better product with a better process at a lower cost. Well, when put this way, the solution is pretty obvious and it has been obvious for over two centuries. We must address the F words: eliminate Fragmentation by aggregating independent artisans in one physical location, stop paying Fee-for-service (piecework) and pay salaries instead, and most important, eliminate Futile work by standardizing the process. In short, apply the industrial revolution to health care and realize the economies of scale that brought prosperity and happiness to the developed world. Except that for some strange reason, this solution doesn’t quite work in health care.

Case in point: Federally Qualified Health Centers (FQHC). FQHCs started out in the early 1960s as community run clinics to provide medical care to the poor. By the mid-nineties, and with the best of intentions, the Federal government and the Centers for Medicare & Medicaid Services (CMS), created funding grants and reimbursement methods to support these clinics. Today there are thousands of FQHCs of different types, operating in health care shortage areas and providing team-based comprehensive care including preventative care, basic primary care, behavioral care, dental care, lab and pharmacy services, mostly to Medicaid beneficiaries and the uninsured, but also to small numbers of Medicare and privately insured patients. FQHCs must use mid-levels to provide and coordinate care and must report on quality measures. In return, FQHCs receive millions of dollars in grants for building and improvements, have access to cost effective workforce, can obtain free malpractice protection, are tax exempt and are paid more than double what a private practice is paid for Medicaid services. By all accounts, FQHC are addressing the triple Fs of health care rather well, but how are they doing against the Triple Aim objectives?

Studies are mixed regarding quality of care provided by FQHCs, and patients cared for by FQHC are largely sicker than those seen in private practice. Interestingly enough, neither Medicare, nor privately insured patients are flocking to FQHCs, in spite of the financial advantages offered, particularly to Medicare patients, and in spite of the spiffy state of the art facilities. This may, or may not be, an indicator for perceived quality of care. How about lowering costs? Do FQHCs provide care at a lower cost than, say, an independent solo private practice?  Adding direct reimbursement rates, grants, tax breaks and other benefits, FQHCs visits cost more than twice the amount paid by Medicaid to private practices, which cannot compete with FQHCs and all but disappeared from areas where FQHCs operate. What would have been the results if twenty years ago CMS would have decided to increase Medicaid fees and pay for uninsured visits to independent practices, instead of exclusively backing the creation and operations of a separate but equal clinic system for the poor? We may never know for sure.

FQHCs are only a small example* of why economies of scale are not easily achieved in health care. Large hospital organizations and even fully integrated health systems, which may be providing better care (or not) seem equally incapable of reducing costs in spite of attacking all three Fs, or seeming to do so, and there are two reasons for this failure: a) larger health care facilities have disproportionately larger overhead costs and b) large systems are better equipped to charge more for services, which renders their efficiency efforts less urgent. And this is not a matter of opinion. CMS acknowledges this built-in inefficiency as evident in the physician fee schedule which pays an additional “facility fee” for services provided in hospital owned outpatient clinics, presumably to cover the extra overhead. Surprisingly, CMS is consistently creating incentives and regulations to accelerate provider consolidation into these big inefficient and expensive systems. The only possible explanation would be that CMS is betting that elimination of the last two Fs (Fee-for-service and Futile care) will be easier in a consolidated environment and the gains will ultimately exceed the losses from doing away with independent practice (Fragmentation). What about information technology? Well, it is supposed to help with process standardization, data collection and performance measurements, similar to what computers do in every other industry.

We have all seen the infomercials for high-tech hospitals, where a bunch of doctors are seated around a conference room table, each holding a laptop or tablet, presumably discussing patients in a team environment. There is something very wrong with these pictures. First, it costs us a fortune to have all these physicians in one room. Second, there is almost no added utility for them to be using computers instead of passing around a piece of paper, and computers are expensive. Third, there is no patient in the room. Now let’s imagine a different picture: a primary care physician sitting in his office, with a patient next to him, both interacting with a computer on which a Skype conference is taking place with an oncologist sitting in his own office thirty miles away, a surgeon in a hospital lounge in the city and perhaps a radiologist half a continent away. Everybody on the call has access to the same electronic medical record, appointments can be made in real time, literature can be consulted and shared, prescriptions can be changed and a common care plan agreed upon by all and understood by all can be created and by using intelligent predictive analytics tools various options can be explored. Perhaps a family member in a different country is conferenced in and perhaps the patient is at home or in a break room at work. Perhaps there’s an electronic sign-up sheet for the oncologist, if the patient wants to ask something else later and have a physician friend in New Zealand listen in. And with one click on a PayPal button all doctors are paid for their time.

In this Internet age, manufacturing style physical consolidation is not only unnecessary, it is cost prohibitive. Modern lifestyles and modern medicine have created a need for doctors and patients to collaborate and the Internet is providing the means to accomplish such collaboration without having to physically gather everybody under one expensive roof. There is no need to obliterate the operational efficiencies of private practice and replace it with the bloated bureaucracy of large institutions, and there is no need to dispense with long lasting doctor-patient relationships in favor of computerized care coordination, and there is absolutely no need to substitute a bunch of numbers in a computer for a real patient. The Internet is decentralizing and individualizing everything from politics to manufacturing. Health care is, and always has been, decentralized, individualized and based on the local patient-doctor dyad. The resemblance is striking. We either embrace the fully aligned collaborative nature of the Internet to achieve better health, better care at lower costs, or engage in a doomed effort to impose an unnatural centralized command and control structure in health care just because it worked well for nineteen century steel manufacturing and because policy makers don’t truly understand the magnitude of the connectivity revolution.

* According to the Kaiser Family Foundation FQHCs had about $12.7 Billion in revenues in 2010, 75% of which came from Federal and State agencies. They served almost 19.5 million patients with over 77 million encounters. Simple math yields a cost of approximately $165 per encounter.

Friday, December 23, 2011

Three New Computer Labs Open Thanks to Timothy Smith Network Donation

Thanks to a generous donation by the Timothy Smith Network, the Hale, Trotter and Blackstone schools have all opened brand new computer labs this year.  The Timothy Smith Network donated $25,000 to each of the schools to purchase the new computer equipment.  The Nathan Hale school installed a new lab that features a SMARTBoard with integrated projector and 17 new iMac desktop computers.  The Blackstone School purchased thin-client multi-seat computers to completely renew two computer labs.  They were also able to establish a "mini-lab" of six computers in their Parent Center, which allows parents access to technology for Parent University and Parent ESOL classes that are held at the school.  Director of Accelerated Improvement at the Blackstone, Lisa Lineweaver, said "We are very appreciative of this generous donation from the Timothy Smith Foundation and excited about the boost to learning and student engagement that is sparking at the Blackstone."

The Trotter Elementary school used the donation to purchase 25 brand new PC's for their computer lab.  They are very excited to use the new machines for research, developing podcasts, presentations and utilizing intervention programs such as First in Math and Reading Counts.  They are also confident that the new lab will help to increase participation in their Technology Goes Home program which is a city-wide program that provides families with 15 hours of technology skills training.  At the end of the training graduates can purchase a netbook at an incredibly low price as well as qualify for discounted internet access.  The computers that were in the Trotter lab before the donation were older had become unreliable, costing the students valuable learning time.

A fourth school, the Higginson-Lewis school, also received a Timothy Smith Grant.  They purchased a number of different interactive technologies for their classrooms, including Mobi mobile interactive whiteboards, document cameras and iPads.

The Boston Public Schools would like to thank the Timothy Smith Network and their executive director, Susan O'Connor, for their continued support of our students, families and schools.

Wednesday, December 14, 2011

Rudolph the Red Nosed Reindeer

We are in the home stretch.........only a few more days! 
Here are some super fun reindeer sites to use with your 
kiddos during these last few days before the holiday break! 

This is one of the cutest sites out there to use during the Christmas season!
The Rain Deer Orchestra is a site where students touch the nose (or type the number on their shirt) of a reindeer to play different musical notes. There are three song choices to choose from- Jingle Bells, We Wish You a Merry Christmas, and Deck the Halls- or you can free play and play and make up your own song.
This is a fabulous site to use with students on your Smart Board-with a different student in charge of a different number or one student in charge of the entire orchestra. Students could also do this at individual student computers-which would be a fabulous way to practice number recognition and mouse skills.

Oh no! It's Christmas Eve and Rudolph the Red Nosed Reindeer is missing!
Rudolph is Missing! is an online story that asks inference questions as the story goes along. 
It's up to you to find out where Rudolph has gone!

Where's Rudolph? and Christmas will be ruined if he isn't found! 
Click on the picture to find the hidden reindeer.  Rudolph hides in a different place in every new game! 

Here's a fun online reindeer coloring page! 

There are many online sites where students can listen to Christmas stories. 
This is one of my favorites because it gives visitors the option to read the story themselves or have it read to you.

The Reindeer Barn is a part of the NorthPole.com site.  Raymond is a reindeer that lives in the reindeer barn with all the other reindeer and hopes to be the newest member of Santa’s reindeer team. Students find the places in the barn that take them to Raymond’s stories about his adventures.

Sparklebox has some great reindeer printables including these





Monday, December 12, 2011

Sharing, Collaborating, and Working with Colleagues - 21st Century Leadership Cadres



Teams ofteachers and administrators in 15 schools and 2 central Academic Departmentscame together this week to share best practices related to learning withtechnology via the 21st CenturyLeadership Cadres Professional Development. Highlights of the day includeduse of QR codes for workflow in the classroom and “above the line” teachingpractices related to 21st Century Learning. The goal of our leadership cadre isbuild a core group of educational technology leaders in each school. Thisyear’s program pilots the use of iPads for instruction. It also provides timeto “share, collaborate, and work with colleagues” which are key needs that teachers shared atthe Superintendent’s Teach + Sharethis week.

The 21st Century Leadership Cadres isa yearlong professional development opportunity sponsored by the Office ofInstructional and Information Technology (OIIT) and Apple ProfessionalDevelopment, that aims to develop cadres of leaders and teachers embedding 21stCentury Skills into teaching and learning.  Eachcadre is made up of school teams that include one Principal/Headmaster and twoteachers who participate in face to face learning sessions and onlinecollaborations. This is the third year that the BPS has offered the 21st Century Leadership Cadres. 



Mobile Living: Life on the Road


No, I’m not talking about hitting the road in an RV. I’mtalking about the out-of-town trial, and a few things you might not otherwisethink about until you need them – which would then be too late. I’ll offer afew thoughts here, and feel free to add yours at the end of the article.

Internet Connection– Honestly, I can’t imagine being without a decent connection these days, whenonly a few years ago, it was a pure luxury. In most courthouses in majorcities, you can get a decent cell-phone signal. If you can do that, and if youhave a smart phone that doubles as a Wi-Fi Hotspot, you’re set for providingaccess to several laptops, iPads, or other devices. There are also servicessuch as Courtroom Connect in many courtrooms, in addition to a free publicservice in some (usually intended for jurors). All due cautions apply to each.

Printing, Scanning,Copying – These common, simple daily functions must not be overlooked, andideally, you will be able to do a decent job of each in both the war room andthe court room. While the war room should have equipment available to handlethe expected volume, you should also be able to scan or print something in thecourtroom, if necessary. There are a number of portable scanners and printerson the market, and mine fit into my carry-on bag which I take to court with meeach day. I’d rather not print 10 copies of 12 different exhibits in a bighurry, but I can handle the occasional (or frequent) emergency.
With that, you might also consider using 3-hole pre-drilledpaper if you’re putting everything into binders, so you don’t have to worryabout punching the pages. One more tip is to bring along a high-capacitystapler, since many exhibits are too thick for a standard staple (over about 20pages). You should also check out local resources for vendors.

Redundancy – You shouldalways have a current backup of your trial database available. When you’re athome, this may be simple, but when you’re on the road, although dealing with the“blue screen of death” is no longer a routine issue, problems still occur. Irecommend have a second laptop of the same make, model and configuration, inaddition to a full copy on an external hard drive, which may be used totransfer from one to the other (leaving a third copy on the drive itself). I’mnot a big fan of data sync software either, and I have seen it fail. There’snothing quite like the feeling you get when you realize something has gonewrong. At least if you’re handling it manually, you will know what you did, andlikely have a quick recovery available. Also, over-writing database files doesn’talways go as expected, so I will first delete the old set, and then copy over theupdated set. Thumb drives and cloud services such as Dropboxcan also be helpful.

Other Devices –iPads, Tablets and other devices can also help to make your life a bit morecomfortable. If you have one, you know what I mean. If you don’t, you probablywon’t understand until you get one. Although there are even apps for trialpresentation which I’ve reviewed here, such as TrialPad,ExhibitA, Evidence,and now ExhibitView (currently onsale for $29.99, which I’ll be reviewing soon), most of the cases I handle arefar too complex for the capabilities of the iPad. On smaller matters, however,using the iPad in trial could be fun. I have successfully used mine in severalCLE presentations.

Use Caution With RoomServices – If you’re looking for an easy way of upsetting an otherwisehappy client, go ahead and turn in your expense report with a long list of topmovies, fine dining, cocktails, and sending out all of your suits you’ve beenmeaning to get dry-cleaned. Just because you’re living in a hotel doesn’t meanyou’re on vacation. Although your extravagant indulgences may be strategically distributedthroughout the duration of your stay, think of how it’s going to look on paper –one right after another.

Okay, off to court. Have a great day!


Tuesday, December 6, 2011

Senior staff members from the Department of Homeland Security visit students from John D. O’Bryant School of Mathematics and Science


Students from Mr. Henry’s AP Computer Science class and member of O’Bryant’sNavy ROTC gathered in the Science Auditorium on Thursday, November 17, 2011,for a presentation from senior staffers from the Department of HomelandSecurity.  Paul Mesterhazy, DeputyDirector of the National Cyber Security Division, and Kristina Dorville,Director of Cybersecurity Awareness Programs were invited to the school as partof Cybersecurity week in Boston (Nov 14 – 18).  Paul and Kristina discussed topics relevant to nationalcybersecurity and informed students that there are many jobs in the field ofcybersecurity that require talented students with math, science and programmingskills.  Paul and Kristinaresponded to thoughtful questions posed by O’Bryant students.  Paul and Kristina also met with BPS CIOMelissa Dodd and TechBoston director Felicia Vargas who shared informationabout the BPS Cyber Safety Campaign. Our guests were impressed with the Internet safety materials developedby BPS students and took samples of the materials to share with otherDepartment of Homeland Security administrators in Washington, DC.

Monday, December 5, 2011

The Pin Factory EHR

In 1776 Adam Smith explained to posterity how specialization increases productivity using the now famous example of a pin factory. While one master pin maker could turn out anywhere between 1 and 20 pins each day, going through all the steps involved in making pins all by himself, a specialized army of laborers, each fulfilling one step in the pin making process, could increase productivity more than two hundred fold and turn out almost 5000 pins per person per day. This would have the triple benefit of enriching the factory owner, creating jobs and making pins both affordable and widely available for consumers. What happened to the master pin maker, who used to make a very nice living when pins were expensive and hard to come by? He would most likely be employed in the factory to supervise the smooth flow and quality of the new pin mass production system. He would make sure that each laborer works at a speed appropriate for feeding the next laborer in line and he would probably sample a few pins here and there to make sure they are as sharp and sturdy as the ones he used to make in the olden days. When the master pin maker passes away a new supervisor would be hired, most likely one that has never made an entire pin before, but instead has a much better understanding of the production process. The profession of pin coordinator has been born.

Although Adam Smith put forward the notion of specialized labor, Henry Ford is customarily credited with the invention of the modern assembly line. Interestingly, Ford is attributing his invention to the observation of Chicago’s meat packing industry. It seems that while no two cows are identical, the butchering of animal life lends itself rather well to disassembly line methodology. Today, manufacturing assembly lines use human labor where it is cheap and in abundant supply, and are staffed with robotic machinery where human labor is expensive and/or scarce. In all cases the process is orchestrated and controlled by sophisticated computer software. This is why we are all able to purchase a car, chat on our cell phones and enjoy perpetually fresh slices of white bread in plastic bags, amongst many other wonderful things, which were once only available to the wealthy few.

Modern medical care is increasingly out of reach of most people. It is expensive, and adequate resources are scarce in many areas. Medical care also varies widely in quality, and the costs of production are anybody’s best guess, depending on geography, time of year and even workers vacation and education schedules. This is very much the same as making pins in the eighteen century. In all fairness, some specialization of labor has already occurred in medicine, but there is no coherent method of placing each worker in his/her station of the continuum of care, and there is no standard process by which workers hand off work from station to station. According to experts, this lack of orderly processing, along with the absence of quality control, is creating a terrible waste of resources and a flurry of defects in the finished products. If the advanced methodologies of modern day manufacturing are working so well for everything from cars to pins to cows, wouldn’t it make sense that we should at least try them in medicine?

Fortunately, we already have several pieces of the puzzle in the works. As mentioned above, we do have a certain degree of specialization in medical practice. We also have hospitals, which could function very much like factories, but as Clayton Christensen observes, most have no well-defined assembly lines. And then, of course, we still have the independent small shops that take piece-work home and operate without any standardized quality control. We also have the beginnings of computerized control systems in the form of Electronic Health Records (EHRs), which, according to John Halamka, are quickly moving from just bookkeeping software to dynamic coordination of processes, complete with encyclopedic knowledge of medicine and a good measure of artificial intelligence to devise and “enforce automated care plans”. 

The only thing left to do is to lay out proper assembly lines, and we don’t really need to think outside the box too much, because manufacturing has solutions for this dilemma as well. In modern industry, there are practically no factories that start out with raw materials and end up with a finished product. Instead, some factories concentrate on producing parts and others are built to receive parts and assemble them into useful products. Exact specifications for each part, to be followed by production lines and relied upon by assembly lines, make this geographically dispersed process possible. In health care, the primary care homes will serve as production centers, where people are constantly measured, tracked, tested and evaluated, so when they are finally shipped to a hospital for a procedure, the hospital knows immediately which assembly line to place them on and the omniscient EHR will control the most minute detail in the process, from medication dosing to incision size and implantable device brand and model, thus reducing both errors and costs. Once the hospital’s work is done, patients are released back to evaluation and management in production centers, and here is where the cyclical nature of health care differs from a typical manufacturing process, and this is why it is extremely important that EHRs be interconnected and preferably Cloud based to achieve a high degree of omnipresence.

Yes, there are many more details to be worked out, like emergencies, accidents and the exact specifications that an EHR should contain on each type of person. We will have to establish quality feedback loops between hospitals and primary care centers to continuously refine processes for both entity types, so basically the EHR will need to be able to adapt to, and learn from, new information, in a manner similar to IBM’s Watson software. Since people are not pins or even cars, the tolerance levels (allowed deviation from specs) will be high initially, so line workers will need to be highly skilled as well. In all likelihood physicians will be working those lines for the foreseeable future. As the learning control system improves, portions of work would be offloaded to less skilled resources and eventually to machines, and more significantly, entire tasks could be packaged into deterministic protocols and pushed out from expensive hospitals to the less skilled primary care production centers, which will further push the most trivial tasks to consumer owned devices.

Obviously, EHRs will prove to be the heart, brain and circulatory system, of the health care industry. As we speak, EHRs are increasingly being tasked with care coordination activities (not to be confused with continuity of care, or longitudinal care), which are the precursor to the industrial line controller. Folks wondering why they should use EHRs that are not ready for prime time, should understand that we have to have an EHR in every practice, so that the system can have visibility into current processes to learn, adapt, grow and devise new methods of providing care. After all, you cannot control that which you cannot see. 

If you think this is all farfetched and disastrous, please find a senior citizen that lived through the Great Depression and ask her what she thinks about dinner being prepared moths in advance in computer controlled industrial vats, thousands of miles away from home, pumped full of preserving chemicals, freeze dried, shrink wrapped and delivered by airplane to a football field size department store, with minimal human intervention, ending up in a small irradiation chamber in your home before it hits your dining table (or couch). Yet we all buy the stuff and feed it to our kids with no apologies, because it is cheaper, faster and more convenient than tenderly preparing beef stroganoff and baking pot pie at home, after work, every day. And neither grandma nor you can even fathom the handcrafting of pins by master artisans. Is health care really that much different?

Sunday, December 4, 2011

12 Top Legal Sites You Should Check Out


Many of us have our own short-list of web sites we checkfrequently to keep current on topics of interest. Whether you found your way tothis site through a web search, clicked on a Twitter, Facebook or LinkedIn link,I appreciate that you’re reading the Court Technology and TrialPresentation Blawg. Of course, I also greatly appreciate those who sharethis site with others. Web traffic and readership are pure motivation tobloggers, as are comments and compliments.

I am going to share a few of my favorite blogs which I enjoyreading regularly. I hope you’ll enjoy my list, which will focus on legaltechnology, jury selection, graphics and trial presentation. Feel free to addsome of your favorites in the comments area.

1.    Law Technology News-- The mother of all legal technology sites, this site is a Law.com publication,headed up by Monica Bay, a household name in legal technology. Articles areoriginal, fresh and timely, and they also have a print publication available. Authorsinclude a staff of excellent writers, and LTN features many familiar names inthe profession.

2.     The RedWell -- This site features a directory and preview links to currentarticles provided by a select group of bloggers. Topics include Jury Selection,Litigation Graphics, Trial Presentation, and Communication for Lawyers.

3.      The JuryExpert -- This site is not actually a blog, but rather a veryhighly-regarded monthly collection of articles, provided by members of theAmerican Society of Trial Consultants. Authors vary monthly.

4.     LinkedInTrial Technology -- With nearly 2000 members, this is the largest online groupfocusing on the intersection of law, technology, and visual communication.

5.      LawyerTech Review -- This site features a bi-lingual (English and Spanish) collectionof articles covering all the latest tech-toys a lawyer could want. A favoriteis the App Friday series, where legal luminaries are asked about the apps theyuse. Attorney Geri Dreiling is the Editor, with Enrique Serrano providing theSpanish version of the site.

6.      BowTie Law -- Attorney Josh Gilland explores legal technology and itsapplication in case law, and covers e-discovery frequently.

7.    Deliberations -- The “official”blog of the American Society of Trial Consultants features articles by JuryConsultant Matt McCusker.

8.    CogentLegal Blog -- Morgan Smith and company offer a great deal of insight on howto communicate visually, using graphics and animations. Smith, an attorney, isthe primary author, with contributions from others.

9.    TheLitigation Consulting Report -- Ken Lopez features helpful topics focusingon using graphics to speak to jurors. Some great ideas.

10.  igetlit.comInformation Graphics & Litigation -- Jason Barnes offers great insight on visualcommunication techniques based on his years of experience in the profession.

11. LitigationPostScript -- Dr. Ken Broda-Bahm provides perspectives of a Jury Consultant.Lots of great “how-to” info on jury selection and analysis.

12.  Litigation SupportTechnology & News -- Joseph Bartolo and Frank Canterino scour the netfor you to offer a collection of summaries of current articles found on manypopular blogs.

I’dgladly recommend any or all of these sites to those who are interested in themodern practice of law. Of course, there are many more, and feel free to addyour own in the comments section, and use the Twitter, Facebook, Google+ andother social media buttons to share this collection. As a disclaimer, I willmention that I have contributed to numbers 1, 2, 3, 4, 5 and 12 listed above.


Thursday, December 1, 2011

2011 EHR Adoption Rates

On Wednesday, November 30, the Centers for Disease Control and Prevention (CDC) released the results of its yearly survey on Electronic Health Records (EHR) adoption for office-based physicians. No surprises. Generally speaking, the majority of physicians in ambulatory practice are now using an EHR, and over half of surveyed doctors say that they intend to seek Meaningful Use incentives. The report is also presenting results broken down by State, so you can learn what folks are doing in your immediate vicinity. The more instructive exercise is to compare last year’s survey results [Fig. 1] to this year’s estimated EHR adoption numbers [Fig. 2].

Figure 1: Percentage of office-based based physicians with EHR - 2010
Figure 2: Percentage of office-based physicians with EHR - 2011

The most immediate observation is that 6.2% of physicians have adopted an EHR in 2011, thus returning to EHR growth rates preceding the 2009 -2010 slowdown, which was largely due to the confusion created by Meaningful Use regulations. The next observation is that the percentage of docs that have at least a basic EHR has gone up by 8.9% in 2011. A basic EHR is one that has “patient history and demographics, patient problem list, physician clinical notes, comprehensive list of patient's medications and allergies, computerized orders for prescriptions, and ability to view laboratory and imaging results electronically”. Although the survey instrument in 2011 did ask about more advanced functionality, and is practically identical to the 2010 instrument, the CDC did not publish a separate number for those with fully functional systems in 2011. Although I cannot be certain, I would assume that most of the growth in 2011 was fueled by Certified EHRs, which by definition should be fully functional. So if I had to guess, and I hope CDC will release the numbers so I don’t have to, I would estimate that in 2011 we have at least 20% of physicians using fully functional systems, which is roughly double what we had in 2010.

Another interesting trend that has been holding since around 2007 is that about a quarter of office-based doctors have some type of bare bones software in their office and they are not upgrading to even a basic EHR. Considering that over half of those surveyed intend to apply for Meaningful Use incentives, this trend is bound to change in 2012.  Some of these folks may have purchased a fully featured EHR, but chose to either not turn features on or chose not to keep up with upgrades to newer versions. For ambulatory EHR vendors these numbers translate into a market opportunity ranging from 50% of the market to a full 80% of ambulatory physicians.

It would be very beneficial if CDC released the complete data set from this survey (anonymised, of course), so we could gain a better understanding of EHR adoption patterns by practice type, size and location. Although it is widely acknowledged that larger practices and employed physicians are further along the curve, the rich details provided by the survey instrument should help both vendors and various organizations engaged in efforts to spur technology adoption, better target their work, and it could also illuminate any disparities which may affect quality of care for vulnerable populations and physicians who serve them.

In summary, the new CDC survey is showing a stable growth in technology use by office-based physicians, modestly improved by government initiatives over the last two years, and well positioned to further improve in 2012 and beyond.