17% Of Residential Care Facilities Used EHRs In 2010 (OPEN MINDS Weekly News Wire Book 2013)

But it actually should be very easy to deploy word processing templates that would fill in the dates based on the date the test is done and allow you to give the patient a printout for each test ordered. But for some more specific action items, the Singh group comes to the rescue again!

They discuss the key elements put together over several years in their VA system for communicating abnormal results. The first recommendation is to clearly define terms in your policy such as what are the specific test abnormalities that require either immediate notification or urgent notification they provide good examples in the article.

Secondly, the policy needs to clearly spell out the responsibilities of each provider remember their key lesson learned previously that ambiguous responsibilities, as seen when dual notification takes place, actually increases the likelihood that no action will be taken. Thirdly, they call for fail-safe methods for communication of abnormal results.

While that could be a verbal communication, they also allow for a computer notification that includes a mandatory response i. They do have contingencies for alerting other responsible parties eg. Particularly good are their recommendations about documentation of the communication that takes place, including verbal read-back, and an algorithm with escalation to supervisory level for after-hours situations.

Fourthly, policies should define reporting procedures for both critical and significantly abnormal test values. For any potentially life-threatening abnormal result, a verbal communication should take place. For the significantly abnormal but not immediately critical results they do allow a variety of electronic communications. Note that they also discuss that such notifications may not be always necessary on subsequent tests once the initial abnormality has been communicated. The fifth recommendation is specifying the timelines for notification of the results.

The sixth deals with timelines for patient notification and discusses the various means of patient communication that should be specified in your policy. The seventh recommendation is that your policy should incorporate feedback from key stakeholders in your organization. For instance, they found that reporting abnormal but not critical results to the on-call resident after hours may be counterproductive. And, lastly, the policy should include responsibilities for monitoring the compliance with and effectiveness of the communications.

The recommendations are excellent and you can learn a lot from this article. They should work especially well in an integrated system. However, some barriers still exist. We still have to deal with fragmentation of care and poor communication between disparate providers. In real life, it is still common for patients to seek their cancer care at tertiary cancer centers.

So if you are the radiologist at the small community hospital who noted the suspicious lesion on chest films, you may be unable to confirm that anyone actually took action because you and, all too often, the primary care physician may lack access to those records from the tertiary care cancer center. In fact, HIPAA might even preclude you from seeking that followup once your relationship with that patient has ended.

So you may have to be satisfied with verbally notifying the ordering physician of your findings and hoping that the patient ultimately gets the appropriate management. Wrong patient phone numbers trip up ER docs. Fake or inaccurate contacts raise risk when sick patients can't be found.

Singh H; Vij MS. Eight recommendations for policies for communicating abnormal test results. Print Delayed Diagnosis of Cancer. Real-Time Random Safety Audits. All too many of our patient safety activities are after-the-fact. Much of what we monitor is time-consuming, labor-intensive and costly and often reactive in nature. Because it is after-the-fact, staff often feel that it is punitive rather than constructive. We are big fans of those patient safety activities that are more proactive and can help capture vulnerabilities before they give rise to adverse patient outcomes.

A somewhat lesser known proactive patient safety activity is the real-time random safety audit RSA.

An excellent article appears in the March Clinics in Perinatology Ursprung by authors who have pioneered this technique in neonatal intensive care unit NICU settings. Weve previously talked about the line operations safety audits LOSA audits in aviation where an independent observer sits in the cockpit and monitors and assesses multiple operations and procedures, then critiques the crew. But the LOSA is resource-intense, requires a well-trained auditor, and behavior may be quite different when a known audit is being undertaken.

So many industries have adopted the simple real-time random safety audit. Ursprung and colleagues used trained research nurses to do the audits in their study but now use frontline staff for day-to-day RSAs. The concept is simple. Each day you randomly choose from a list of patient safety items your organization has deemed to be important some process or condition or piece of equipment for auditing.

Your list should be developed by a broad interdisciplinary team to reach consensus on prioritizing areas of importance for the unit in question. You then do your audit and provide immediate feedback to frontline staff. The person performing the audit could be a nurse, pharmacist, physician, respiratory therapist, or other appropriate individual. The important concept is to involve as many different disciplines as are relevant to that unit.

That is very helpful in fostering a culture of patient safety on the unit. One of the keys is keeping the number of questions and items to a manageable level, at least at the start. Ursprung and colleagues suggest questions to start with. They also recommend making a deck of printed cards, each containing a single question.

There are multiple copies of each question in the deck. You shuffle the deck so that you get the questions in a randomized fashion. For items considered to be of higher priority, you can include more cards with that particular item so that you are more likely to address it during the random process. Each day one card is selected and then all relevant patients or equipment, etc.

For example, you might look at procedures done on patients and have several cards with questions like If a procedure was done on this patient in the past 48 hours remember one question per card:. A real value of the RSA is the ability to give timely feedback to frontline staff. That is why the RSA is a good method for improving compliance with things like your dangerous abbreviations list.

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All too often we audit our dangerous abbreviations retrospectively, then give providers several weeks later notice of the times they used those abbreviations. They often feel offended and we hear comments like So shoot me.. Instead, when you look at dangerous abbreviations during an RSA you can give immediate feedback and are often in a better position to point out how use of that abbreviation might be confusing to nursing or pharmacy. Other considerations for the RSA are communication issues, in-house transport issues, timeliness of reports or consultations, delays in care, medication reconciliation, hand hygiene, use of catheters and other indwelling objects, care bundle compliance, alarms, device settings, pain management, oxygen use, and many others.

Of course, you also need to aggregate your results and report back on a regular basis at staff meetings, QI committee meetings, etc. But make sure that your use of audit findings is applied in a constructive fashion and avoid any semblance of punition or you may destroy the positive changes in safety culture. The study Ursprung identified numerous problems related to patient identification bands as well as problems related to delays in care, equipment issues, and others.

Not only did their audit result in some immediate feedback to correct problems, but their project also resulted in a change in the patient identification process and revision of guidelines for pulse oximetry alarms. Their original study was done using a research nurse and they asked questions per patient, which proved to be quite time-consuming. Therefore, the audit changed to the currently recommended format of one question per patient.

However, most of them are easily adaptable to other settings. You should also keep in mind that things in many healthcare settings differ by day of the week or time of day. So consider doing your RSA on evenings and weekends as well. That also helps foster involvement of all frontline staff in the patient safety process. The authors also suggest adding a little levity to the process. For example, include a trivia question on the back of some cards. We really like the concept of the real-time random safety audit. Though we might by chance pick up some of the issues during patient safety walk rounds, the RSA is a method that is more focused and much more likely to encourage staff buy-in and foster development of a culture of safety.

Look for more use of the RSA in the future. Ursprung R, Gray J. Clinics in Perinatology ; 37 1: Real time patient safety audits: Qual Saf Health Care ; Propofol, of course, recently hit the headlines for its likely role in the death of pop star Michael Jackson in But it has also been generating controversy off the front pages of standard media. Propofol has several characteristics that make it attractive as a sedating agent for procedures. It has a rapid onset of action and short duration of action so patients wake up sooner and can resume normal activities faster compared to most other sedating agents.

It also reduces the need for adjunctive opioids. And the ability to control the level of sedation also makes it attractive for use in procedures. But numerous safety issuees have surrounded propofol use. They include multiple examples of patients developing respiratory arrest or hypotension during propofol sedation for procedures. A sense of complacency or lack of fear because we use it all the time in the ICU may be factors predisposing to dangerous practices.

But they also noted the sometime unpredictable and profound effects of propofol noting that a patient can go from breathing normally to full respiratory arrest in seconds, even at low doses. Importantly, there is no reversal agent available like there is for other sedating agents or opioids. Yet propofol has quietly become the procedural sedating agent of choice in many venues, particularly when dealing with pediatric patients. In fact, at the recent Pediatric Academic Societies meeting research was presented on over 25, cases using propofol sedation in areas outside the OR by emergency physicians.

The vast majority of these 22, were performed in radiology. Controversy really erupted when CMS issued new interpretive guidelines regarding anesthesia services, which must be followed by hospitals who accept Medicare or Medicaid patients.

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The revised CMS guidelines point out that propofol is only indicated for general anesthesia, MAC monitored anesthesia care and for the sedation of the mechanically-ventilated patient. The guidelines essentially mean that propofol can only be administered by those with credentials to provide deep sedation or general anesthesia and many or most emergency physicians only possess privileges for moderate sedation Klauer The CMS guidelines do not preclude emergency physicians from administering propofol. Rather they clearly specify that the Department of Anesthesiology has responsibility to oversee performance of anesthesia or deep sedation throughout the hospital or healthcare organization.

They would be responsible for ensuring that all clinicians administering propofol are appropriately trained and credentialed and oversee the quality improvement monitoring of such use. A key point of contention is the issue of having one physician vs. In most cases where an anesthesiologist is involved, the is one person the anesthesiologist or CRNA overseeing the anesthesia or deep sedation and the second who is performing the procedure. In the ER or other venue where the emergency physician is involved , there might be only one physician who is attempting to do both.

As youd expect, specialty societies representing ER personnel have been active in opposing the new CMS guidelines. There are numerous position papers on use of sedating agents by emergency physicians as well see Mace and Goodwin The abstract presented by Mallory et al documented airway and respiratory adverse events in 3. Cases included two aspirations and one cardiac arrest but there were no deaths. They performed regression analysis and found the following variables to be independently associated with complications: Another recent study Larsen looked at the safety of propofol administration by pediatric intensivists for pediatric outpatient procedures in a single institution over a 6-year period.

In over cases, major complications occurred in only 0. Frequencies of complications in adults undergoing procedures with propofol sedation are a bit harder to come by because of varying types of procedure, varying personnel administering and monitoring the sedation, varying depth of sedation, and varying concomitant use of opioids or other sedating agents. For routine endoscopic procedures colonoscopies and upper endoscopies , the safety of nurse-administered propofol sedation has generally been accepted and position papers from most endoscopy-oriented specialty societies support nurse-administered propofol procedural sedation.

However, studies from more advanced endoscopic procedures, where deep sedation or anesthesia are often produced, provide some insight into the risks of propofol sedation.

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A recent study Cote et al looked at propofol sedation administered by CRNAs under the supervision of an anesthesiologist for patients undergoing advanced endoscopic procedures such as ERCP. Of the patients, hypoxemia developed in Airway modifications had to be performed in Independent predictors of the need for airway modifications were male sex, ASA class 3 or higher, and high BMI Mallampati score of 4 or higher was also more frequently associated with need for airway modifications but the small number precluded reaching statistical significance.

Though the authors conclude that propofol can be used safely for advanced endoscopic procedures, they stress that this was done under the supervision of very well qualified professionals. The accompanying editorial Vargo stresses the importance that the sedation team maintain constant vigilance during the procedure. Vargo also makes the case for using capnography as a key component of such vigilance, at least in that setting. Alarm Fatigue we discussed an article Deitch et al which looked at use of capnography during procedural sedation in the emergency department. Monitoring end-tidal CO2 during procedures in which IV sedation or IV opioids are used is theoretically very attractive since it is a better indicator of respiratory depression in such cases and should identify patients at risk before they develop oxygen desaturation.

Their randomized controlled trial in adults undergoing propofol sedation showed significantly fewer patients with hypoxia in the group monitored by capnography. That delay meant the physicians usually had adequate time to intervene. We have previously pointed out that it is extremely difficult to identify respiratory depression just by watching a patient. We have had medical students, residents, and attendings all observe patients on whom we had arterial blood gases and they did little better than chance at picking out which patients had respiratory depression.

So the ability to identify patients with respiratory depression before they become hypoxic is a major potential advantage. The editorial notes that capnography clearly identifies respiratory failure before it is apparent by either clinical examination or pulse oximetry. And it acknowledges the significant contribution of the Deitch study, though it points out that some methodological issues eg.

And many episodes of hypoxia are self-limited and resolve without any intervention. Recent court cases have also involved propofol. A suit in one case alleges that a patient with sleep apnea died during routine colonoscopy when the CRNA was unable to intubate the patient when he deteriorated after a reduced dose of propofol was administered. In another court case a jury found that the makers of propofol products failed to adequately warn not to reuse 50 ml vials of propofol on multiple patients. Use of such vials was found in an outbreak of hepatitis C linked to 2 Las Vegas endoscopy centers.

Tip of the Week Archive Apr-Jun 2010

Apparently such use of vials for multiple patients has occurred because of the nationwide shortage of propofol. The FDA has been cautioning against such usage and addresses a variety of issues related to the propofol shortage on its website.

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And propofol is one of those drugs that often goes unlabeled in syringes in ORs or other sites because staff think it is the only cloudy or milky drug likely to be in the field. So there remain many unanswered questions about the safety of propofol for procedural sedation and the best ways to minimize risk of adverse events if it is used. Until we have more complete answers we recommend:. Note that todays article does not address use of propofol sedation in the intubated, mechanically ventilated patient in the ICU setting. Every attempt should be made to assess the continued need for such sedation.

Daily sedation vacations are a key component of the IHI VAP Bundle and other bundles designed to prevent ventilator-associated pneumonia. Minimizing sedation also helps reduce the incidence of delirium in the intubated, mechanically-ventilated patient.

But the article by Strem found that patients who received no sedation had significantly fewer days on ventilators, shorter ICU stays, and shorter total hospital LOS. There was no difference in accidental extubations or VAP, though more patients in the no sedation group had agitated delirium. Those results are actually quite encouraging and the practice of eliminating sedation all together may become more widely accepted if these results can be replicated in other settings.

Propofol can be a very useful drug in a variety of settings. But it may have a small margin for error and there are safety issues lurking whenever it is used. Treat it with respect. Pediatric Academic Societies meeting May 1, HealthLeaders Media, April 13, Emergency Physicians Monthly March 24, Ann Emerg Med ; 51 4: Procedural Sedation and Analgesia. Procedural Sedation and Analgesia in the Emergency Department. American College of Emergency Physicians. May 5, http: Clin Pediatr Phila ; Of Mountains and Molehills.

A Randomized, Controlled Trial. Annals of Emergency Medicine ; 55 3: Green SM, Pershad J. A protocol of no sedation for critically ill patients receiving mechanical ventilation: The Lancet ; A surgeon gets a newly autoclaved instrument that is too hot to use. He sets it down on the surgical drapes. Yes, you know the answers they all resulted in iatrogenic burns to patients. Could they occur in your hospital? We bet they could. Thats because with few exceptions, such as MRI suites and neonatal units, most patient care units lack protocols and systematic assessments to determine who might be at risk for burns.

When you look at the examples above examples you realize there are really 3 key conditions that predispose patients to burns. There may be some additional predisposing factors, too, like impaired ability for the vasculature to help dissipate heat from the skin.

And, of course, you need a heat source. Patients who are obtunded or comatose or who are under anesthesia may not perceive heat or pain or be able to respond even if they could feel it. Patients who cannot communicate infants, patients with aphasia, patients isolated in MRI suites, etc. The patient with the diabetic foot ulcer who suffered a burn due to a warm compress was obviously predisposed by a diabetic peripheral neuropathy a key factor in development of diabetic foot ulcers. But even patients with normal sensation may get burns under certain circumstances.

Has the following ever occurred to you? You test the water temperature before you step into the shower and it feels too hot. You turn the hot water knob down or turn the cold water knob up and the water temperature is comfortable enough for you to begin showering. After a few minutes you increase the water temperature. The increased warmth may, in fact, feel good. But when you finish your shower you notice your skin is much redder than you usually experience.

This was adaptation to heat adaptation probably occurs at both the peripheral receptor level and a central level. You were no longer bothered by water at the same temperature that frightened you at the start. Yet that hot water was capable of burning your skin. The same sort of adaptation takes place to cold ever dive in a 65 degree lake?

You shout out Its freezing but after about a minute it becomes more tolerable. So the point is this: The potential damage to skin or other organs is a function of both temperature and duration. The burn in the patient with the warm compress is interesting from another perspective. One of the first questions we always ask in a root cause analysis RCA after any adverse event is was the procedure indicated in the first place?.

They point out that, though there is some basic science research suggesting that heat should improve wound healing, there is really a dearth of clinical evidence that heat therapy is efficacious for wounds. They also point out that wet heat scalding is more likely to cause a burn that dry heat. Microwaved objects are particularly dangerous. Heating with microwaves is not uniform ever sample safely the periphery of some food only to burn your tongue when you taste the middle?!

In addition, some of the warmth remedies for microwaving contain gels, or beans, or rice that retain heat for longer periods than the surface material. Burns in the OR may occur when heat is applied over an area where drapes over or under the patients skin had been soaked with alcohol or any one of a number of other solutions used in the OR this is also obviously a risk factor for surgical fires see our December 7, Patient Safety Tip of the Week on Surgical Fires ,.

In fact, some may develop chemical burns from these liquids. Anesthesia , whether local or regional or general, may predispose patients to burns. Even under general anesthesia, where a patient cannot respond, we wonder if there are subtle signs such as changes in heart rate, perhaps mediated reflexly at lower levels, that could alert the surgical team to a potential burn. There are special considerations in the neonatal period Mhrenschlager and Mhrenschlager The neonate has a reduced thickness of the stratum corneum, thus less protection against thermal injuries.

Thermal injuries in neonates have resulted from exposure to 1 transilluminating devides 2 infrared lamps placed too closely 3 other lights 4 tap water 5 warming bottles 6 even overheated plastic surfaces of disposable diapers. Burns may be an issue during MRI scanning. They stress that even with electrodes that have been approved for use with MRI, a serious burn can develop if the electrodes arent in complete contact with the skin surface for example, if excess hair hasnt been removed or if there is an air gap between the electrode and the skin.

Cables that are looped or coiled are especially likely to overheat during MRI so every attempt should be made to avoid looping or coiling and they should be kept off the patients skin by placing a blanket under them. Our focus in this weeks Tip of the Week is primarily on burns to the skin. However, dont lose sight of the fact that thermal injuries can also occur internally during surgery. Such are well known to structures such as bowel and ureters.

Tip of the Week Archive Jul-Sep 2010

Such injuries are often not recognized and result in tissue necrosis and delayed manifestations of symptoms. Lastly, burns may result from inadvertent radiation overdoses. Iatrogenic thermal injuries in the neonatal period BMJ ; bmj. Report of Two Cases and Review of the Literature. Journal of Burn Care and Research ; Surgical Safety Checklist for Cataract Surgery. Cataract surgery has a special place in our patient safety journey.

Our initial interest in surgical timeouts and checklists stemmed from a root cause analysis on an ophthalmology incident. One hand after another shot up! Probably a third of attendees had experienced this at their hospital. Implantation of the wrong intraocular lens was the most common occurrence in both databases. Errors in both the preoperative period and operative period were found to lead to the incorrect implantation.

In the preoperative period, contributory causes identified included faulty calibration of the A-scan equipment, transposition of records from the ophthalmologists office, transcription errors, switched patient identification stickers, and transposition of IOL power calculations while faxing records on two patients at the same time.

Intraoperative errors in almost all cases involved failure to identify the lens specifications properly before implantation. Multiple contributory factors were indentified, including changes in the OR schedule, changed staff assignments, staff changes during the procedure, poor lighting, multitasking and other distractions, and misreading the label on the implant box.

In one case the surgeon had dropped multiple patient charts and they were out of order when reassembled. Note in our June 5, Patient Safety Tip of the Week Patient Safety in Ambulatoy Surgery we discourage the practice of allowing the medical records of multiple patients to be in the operating room since it is too easy to mistakenly pick up the chart of the wrong patient during a procedure.

The new Surgical Safety Checklist: The sign in phase done before any anesthetic is administered includes identification of the patient and the procedure to be performed and the consent for that procedure. It also includes whether site marking has been performed and a precheck of any anesthesiology equipment and whether VTE prophylaxis is indicated. It includes some questions important for anesthesiology allergies, airway accessibility, special needs for draping or positioning.

It then asks some questions important to the ophthalmologist: Is the Patient on warfarin? Is the patient on tamsulosin or other alpha blocker? The first question obviously raises the question of bleeding risk and the latter the risk of the intraoperative floppy iris syndrome IFIS and other complications Bell et al During the timeout phase, the team introduces itself and confirms the patient identification, the procedure to be performed, the correct eye, the intended refractive outcome, the power and model of the lens to be implanted, and whether that lens implant is physically present.

Then any anticipated variations or critical events are discussed. For instance, the surgeon may discuss and planned variations in the surgery, need for special equipment, alternative lenses, etc. The anesthesiologist notes the ASA class, status of monitoring equipment, and any patient-specific problems. The scrub nurse notes whether sterility of the instruments has been confirmed and notes any other equipment issues. The sign out phase included documentation of the name and side of the procedure, status and count of all instruments, swabs and other materials, identification of any equipment issues, and instructions for post-procedural care of the patient.

One factor is that a surgeon in ambulatory surgery will often be performing many cases of the same or similar procedures. Interestingly, very experienced surgeons may be more likely to be involved in wrong-site cases, perhaps because their experience allows them to schedule so many cases in one day.

The quality of the medical records is often not as good in ambulatory settings. Often critical information is in the physician office record and never appears in the facility medical record. It is therefore incumbent upon the facility and entire team to ensure the adequacy of the medical record and all documentation prior to the procedure. And there are certain production pressures unique to the ambulatory setting. When a surgeon is booked for many cases in one day, there is a higher likelihood of last-minute changes in the schedule. Also, weve seen cases in the ambulatory setting where one patient may demand a procedure earlier in the day, leading to last-minute alterations in the order on the schedule.

And the pressure to get cases done promptly and stay on schedule are everpresent. Lastly, dont allow the medical records of multiple patients to be in the operating room at the same time since it is too easy to mistakenly pick up the chart of the wrong patient during a procedure. The recommendations of the American Academy of Ophthalmology Wrong-Site Task Force are also quite valuable and include special attention to intraocular lens implants and a checklist to help.

One good recommendation there is that the circulating nurse writes on the white board the patients name, operative eye, IOL style, and IOL power. WHO Safe Surgery Saves Lives website includes also an implementation manual and videos on how to use the checklist and how not to use it. American Academy of Ophthalmology. Dysphagia in the Stroke Patient: Our June 26, Patient Safety Tip of the Week Pneumonia in the Stroke Patient focused on the evaluation of stroke patients for dysphagia prior to feeding them.

Much of the morbidity and mortality in patients with acute stroke is related not just directly to the neurological deficit but rather to the complications such as pneumonia. The incidence of pneumonia in the acute stroke population varies considerably in the literature, largely because of stroke populations of varying severity and differences in definitions used. The human and financial impact of pneumonia in the acute stroke patient are substantial.

Use of a formal dysphagia screening tool has been shown to reduce the risk of pneumonia in stroke patients by as much as half Hinchey and there are reports showing that hospitals can increase their compliance with swallowing assessment by using preprinted order sets and by using written care protocols Hinchey , Book We were very disappointed when NQF waffled in on including swallowing assessment in stroke patients as one of its quality measures NQF presumably was concerned because the evidence base was not robust enough.

There has not been a significant change in the evidence base for assessment and management of dysphagia in the stroke patient since then. However, this month the Scottish Intercollegiate Guidelines Network released its guideline Management of patients with stroke: A national clinical guideline. This is the most comprehensive such guideline weve seen. It reviews the evidence base and makes recommendations not only for the assessment of dysphagia in the stroke patient but provides great recommendations about interventions in the dysphagic patient, nutritional status of the stroke patient, issues related to tube feedings, medication issues in the dysphagic patient, oral hygiene in the stroke patient, and training of both professional staff and lay caregivers in important issues.

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It also provides good advice about implementing and auditing the guideline and has a variety of useful tools in its appendix section. There is also a good quick reference guide with appropriate algorithms. Hence, assessing patients for dysphagia and aspiration risk is crucial. Note that seeing a patient cough on attempted swallowing is a good indicator of aspiration but the lack of coughing does not indicate safe swallowing. Factors associated with risk of aspiration are a wet, hoarse voice, a weak voluntary cough, any indication of reduced laryngeal function, and impaired level of consciousness.

Factors that have not proven to be accurate predictors of aspiration are pharyngeal sensation and status of the gag reflex. The gag reflex is commonly reduced in the acute phase after stroke. However, some patients with bilateral lesions develop pseudobulbar palsy and may have a normal or even increased gag reflex when their swallowing is impaired.

The water swallow test is typically used as a first line tool to screen for aspiration risk. This screening test is administered by a healthcare professional trained in the procedure, usually a nurse. After ten years in adult religious education positions, he moved to the computer and network hardware and software industry in the fledgling personal computer era, eventually landing back in adult education for a technical training firm. It was there that Tim was introduced to home healthcare through one of his training clients, who lured him aboard as their first CIO.

Tim lives in Colorado with his wife and two dogs and spends his free time hiking through the Rockies. She manages advertising sales and develops marketing strategies for Home Care Technology Report and all RCAI enterprises in addition to running her own marketing consulting business. She lives in Phoenix with her family. She has specialized in researching home telehealth technology applications since when she designed the Home Telemedicine segment of the National Library of Medicine website.

She continues that research and writing work through her company, Information for Tomorrow informationfortomorrow. A writer with a wide range of interests, she has also produced a children's book, Dingle: CMS announced on Center for Medicare and Medicaid Services, Also see Physician Stress and Burnout. Federal Executive Branch B. Federal Legislative Branch C. Federal Judicial Branch D.

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Area Health Profiles A. International Health Profiles B. National Health Profiles C. Regional Health Profiles D. State Health Profiles E. County Health Profiles F.