Today I want to be less pedantic than I have been recently and have some fun. I've already written about John Kotter in my blog “A Sense of Urgency”. Now I have gone ahead and read his fable about change, Our Iceberg is Melting. It is about a penguin colony in Antarctica. A group of penguins live as they have for many years. Then one curious bird discovers a potentially devastating problem threatening their home. Initially hardly anyone listens. The fable tells about resistance to change and how dramatic change was successfully brought about. The characters are familiar in our own lives and work. You can even decide which character in the drama describes you best.

 

Kotter believes in the power of stories to communicate important ideas with emotional impact. Read this story. Share it with others on your team. Talk about his Eight Steps and how to accomplish them in your electronic health record implementation. There is even a website with more tips and, of course, materials for sale.

The eHealth Initiative recently released its Fifth Annual Survey of Health Information Exchanges at the State and Local levels.   In this survey we are starting to see the clinical benefit of interoperable clinical systems.    More than 130 HIE initiatives are in progress with 42 of them reporting to be operational. 

The biggest reported reasons for implementing an HIE are improving quality (97%) and patient safety (90%) with the biggest challenge being developing a sustainable business model. 

The big news in this survey is the positive clinical and financial benefits being reported by the users of the system.  69% of the fully operational exchanges reported a reduction in health care costs.  The savings were attributable to reduced staff time, reduced redundant tests and decreased cost of care for chronic patients.  More than half of the exchanges reported positive impact on the delivery of health care.   Major benefits were increased access to lab results, improved compliance with chronic care and prevention guidelines, reduced prescribing errors and more rapid identification of disease outbreaks – something critical to our public health clients. 

The bottom line was that 69% of the operational exchanges reported a positive ROI.  This is the first survey in which a majority of the participants reported a positive ROI.

I have to admit...I somewhat expected this to happen...Medicare has extended the date on the banning of computer-generated faxed prescriptions for several years. While I know it's a relief for many prescribers, I have to say, I was somewhat looking forward to it. I thought it would be a great way for many prescribers to "take the plunge" and begin sending more prescriptions electronically. Of course, I'm a huge fan of e-prescribging.

So what is Medicare doing? CMS has extended its deadline for banning faxed prescriptions by three years, moving the Jan. 1, 2009, deadline to Jan. 1, 2012. The deadline change is included in the 2009 Medicare Physician Fee Schedule final rule announced by CMS on Oct. 30. According to a CMS press release, the agency reversed its position "in the interest of patient care and safety and to encourage prescribers and dispensers to adopt e-prescribing."

It's not surprising that several health organizations supported changing the deadline. For example, Steven Waldren, MD, director of AAFPs Center for Health Information Technology stated, “The Academy’s position was that the 2009 deadline would force some physicians to move backwards in their efforts to accomplish e-prescribing.” He stated that many EHRs have e-prescribing systems that fax prescriptions instead of sending them electronically.  Dr. Waldren went on to state, “…those physicians would have reverted back to paper-based prescriptions” if the deadline remained the beginning of next year.

The Pharmacy Health Information Exchange, operated by SureScripts-RxHub, maintains that sending prescriptions electronically versus fax is a much safer and more efficient way of sending prescriptions. E-prescribing offers proven benefits to physicians, including reductions in medication errors, reduced calls from pharmacies, electronic access to formulary information and external medication histories. In an effort to get prescribers to send prescriptions electronically, Medicare is offering its prescribers a 2% financial incentive beginning in 2009. If, however, by 2012, prescribers are not using e-prescribing, they will face a 2% pay decrease.

The entire 2009 Medicare Physician Fee Schedule final rule will appear in the Nov. 19 Federal Register.

When designing the content of your electronic health record, you have lots to think about. I've just written about data format decisions with some examples.  Databases also permit you to place rule-based controls around Clinician use of options and fields in the EMR. These tools protect data integrity by preventing unauthorized input and protecting content from modification. They help ensure that Clinicians are capturing the same sorts of information and that you are getting the information your organization must have. An effective controls strategy enforces desired content while minimizing the inclusion of inappropriate and unnecessary data. The type and extent of controls also implement your organization's goals and policies.

 

In other words, they are a very useful set of functions in your design toolkit. Now, what do I mean by Controls?  Here is a list of some with examples:

·    Define access to options and fields as for input or "read only"– Denying input access to finalized forms protects the integrity of the content and of accountability. Denying access to (disabling) a time field that auto-fills with the current time prevents fudging the time vital signs were recorded.

·    Make fields required or optional for filing. Required fields ensure completeness and consistency. Optional fields invite the addition of relevant information in consistent formats.

·   Use event logic e.g., "If this response is selected, then this will happen." If the required item “Pain Present Y/N” is clicked “No,” then the initially disabled fields for Intensity and Location remain disabled, preventing extraneous data. If  “Yes” is selected, then the Intensity and Location fields become enabled and required, ensuring compliance with organizational policies about assessing pain in all patients.

 

Hopefully I am giving you the idea. This document shows more examples of Controls with Avatar screen shots.

 

But a caution is in order. Controls must be deployed judiciously. As in so many situations, the path lies in establishing a balance, this time between control and flexibility. All organizations have legitimate data needs. Explaining these needs to Clinicians should be part of the implementation process. At the same time, if content is too tightly controlled e.g. all or most fields are required, Clinicians will feel overly constrained with little room for expression of their professional expertise. They will resent the software for turning them into robots. Nobody wants that.

Now that I have just advocated for EMR content customization, let’s return to content design. This is my favorite part of EMR implementation. I wrote earlier on educating the clinician members of your design team about databases. Next they need to understand the different data types available for capturing information and the implications of data type decisions. 

The most important distinction is between free text and dictionary-based data types. Everyone is already familiar with the notion of typing ongoing text. Similarly, most people have encountered check boxes on forms, e.g. medical histories attached to clipboards in doctor waiting rooms. Clinicians are comfortable with creating narratives as part of clinical histories and other documentation. Indeed I have seen several behavioral health EHR’s that consist entirely of textboxes for entering the organizations’ usual narrative content. Such EMR’s are essentially electronic paper, but what a waste! Among the advantages of an EMR are efficiency, standardization and aggregated reporting.  None of these is achieved using narrative textboxes.

 

But deeper issues lie beneath the type or click choice. Clinicians think of the clinical history as the patient’s story. I heartily agree with this. Effective treatment is grounded in understanding the story of the person’s problems and suffering. At the same time, the story includes numerous individual pieces of information, for example, past substance abuse, the presence of a firearm in the house, sexual abuse by a family member rather than a stranger and a parent who committed suicide. Such salient features of client stories, alone or in combination, can serve to trigger alerts about individual risk. They can help supervisors and administrators identify and monitor the care of clients with a defined set of problems. Aggregated, they can guide managers to unmet service needs.

 

Likewise, a case summary can be a text formulation and/or lists and measurement scales. The former presses the clinician to integrate an explanatory narrative that justifies an approach to treatment. The latter asks the clinician to abstract specific problems and strengths, to assign a diagnosis and to quantify patient attributes in various domains. The narrative facilitates reflection and understanding. The lists and scales sharpen focus and enable accountability. Aggregated lists and scales can help address important questions including about outcomes, efficacy and best use of resources.

 

Likewise with progress notes and so on. Now what of the original question – to type or to click? The answer is to do both in artful, disciplined combinations. In my next blog, I’ll give some examples of such combinations, which I hope will be artful and disciplined or at least useful. 

 

I realize that I jumped right in writing about EMR design. Without thinking, I just assumed that you would choose to develop content for your EMR that was customized by and for your organization. Obviously, you can opt for using an Off the Shelf solution. Let’s back-up a step and look at the pros and cons of content customization.

 

First the cons: these boil down to time and money. As I wrote earlier, content design is a team effort. It takes many meetings of a diverse staff group to develop a good design. (At UBHC the design workgroup had 29 members who met for a 1/2 day per week for three months.) The staff time costs money. There is no way around that. Also the time involved may extend your implementation schedule. Though this extension is not inevitable if you start the design task early. You can begin even before you select the Electronic Health Record application.

 

The pros boil down to facilitating staff buy-in and getting a better EHR, one that really reflects the information needs, workflows, clinical culture and policies of your organization. These issues are especially relevant to behavioral health organizations where humanistic values are high and industry standardization is low relative to physical health.

 

In my experience, leaders of EMR implementations define their greatest concern to be staff buy-in; so why pass-up the primary opportunity to engage clinical staff. I also have seen that those organizations, which began with an Off the Shelf approach, were invariably dissatisfied down the road. They turned to customization and then had to face the more difficult task of retrofitting their new information flows to accommodate what they already had in place. At UBHC the initial design remains sound eight years after the implementation.

 

So, is customization worth the effort? Clearly, I think it is.

As I wrote last time, when you are designing the content of an EMR you have to consider the dimensions of clinical culture, information flow, specific data capture and the use of controls. Good design also means finding solutions to meet the often competing needs of clinicians, management and, yes, the software.  It’s a complex process. I don’t claim to have all the answers, but over the past eight years as EMR implementation manager and then consultant for Netsmart Technologies, I have struggled extensively with the issues. 

First and most importantly, as the project manager for the implementation at UBHC, I did not struggle alone. We cast a wide net to recruit a workgroup of 30 members. The members were supervisors and line clinicians from all disciplines and levels of care as well as the leaders of all stakeholder departments. Here is a list of the participants if you want more details. Our charge was to design the structure and content of our electronic health record. We met for half a day a week for three months. The learning curve was steep. (more on workgroup education next time) The process was intense. The turf issues and, shall I call it, specialty narcissism were very much present. Together they created the major threat of “Content Creep.” This is a situation in which Staff want the details of their specific domains included and in their customary formats. The back-and-forth process eventually made it clear that to accommodate this range of domains would result in content that was too lengthy and complex. The phrase: “That item means 100,000 clicks per year…Is it worth it?” became a regular refrain.

By the time we were done, the participants had had the opportunity to understand the needs and concerns of wide range of functional areas and all LOC.  They were then able to make recommendations based on detailed knowledge of the information needs in balance with the realities of staff time and the software. The focused group process was powerful in setting the stage for the necessary compromises. Patience and determination were essential to discovering the solutions.

 So get your clinical leaders and line clinician “best minds” together and jump in. You don’t have to wait until vendor selection is complete. You can begin the content analysis and struggle now. They are generic.

When planning an EMR implementation, don’t be afraid to set brisk timelines and be sure that deadlines are known to be firm.

Peter F. Drucker, the greatest (in my opinion) of business management gurus, wrote that to do their best work people must have an optimum amount of challenge. There should be enough challenge so they must push themselves and can then feel pleased with their accomplishment, but not so much as to overwhelm and demoralize them.

In my experience of a very challenging EHR implementation timeline without any wiggle room, the pressure of the deadlines focused the efforts of all involved.  In the large, inclusive workgroups there was no time for old rivalries and territoriality. Compromises had to be made, so decisions could be reached and the process could keep moving. Tight deadlines permitted the building of momentum and of enthusiasm for the tasks.  In the context of group process under the watchful eye of top management, no one wanted to be identified as an obstructionist. At the same time the process itself must be open and creative as well as disciplined. There are always legitimate competing interests and needs. The issues must be wrestled with until good enough solutions are found.  Keep in mind that an EMR is not a final masterpiece. If anything it is a living entity in that it will be made to grow and change building on the experience of the uses. 

By the way, we met our deadline to the day, and I still feel proud of it years later.

The short answer to the title question is: everywhere. One definition of corporate culture is "How we do things around here.” It is the collective behavior of people using common corporate vision, goals, shared values, beliefs, habits, working language, systems, and symbols. It is interwoven with processes, technologies, and learning. A successful EMR implementation necessarily impacts all these domains.

In the late 90’s my home organization, UBHC, was being transformed from a community mental health center to a managed care oriented corporation. This meant a dramatic change in corporate culture. An electronic health record was at the heart of this transformation. Here are some examples. Professional identity would be challenged as appointment schedules became centralized and electronic. Clinical information would become more standardized and monitored. Communication would move away from face-to-face, often group settings to electronic methods. There was new attention given to productivity and efficiency. The financial needs of the organization were now a necessary and valid priority, which required all staff’s participation.  Fiscal staff needed to respect the work of the clinician as the source of revenues and clinical staff needed to contribute in the effort to successfully bill services.

The EHR implementation itself became the main vehicle of this cultural change.  Leadership and inclusive process were the key elements. These will be the focus of future blogs.

Also among the clinicians an apt, tongue-in-cheek phrase emerged: “Psychotherapy begins at home.” By this they meant that the frequent psychotherapy themes of recognizing and adapting to change had now become their own challenge. It told a truth that was clarifying, but uncomfortable. 

An effective electronic health record implementation requires oodles of collaboration among every slice and silo of the organization. Ideally such collaboration would be a given. But all staff members are human beings who tend to develop identities and loyalties based in shared relationships and experiences. In other words, locally. Enter turf as a perennial resistance to the change that comes with the move to an EHR.

At the time of our EMR implementation, my home organization had been in operation for more than 25 years. Many of the staff had been there for > 10 years. Place and people already had a long history together.

Factional divisions were plentiful; blaming the other was usual.  Many staff groups believed that their function was the crucial operation and that other functions existed to service their operation's needs.  There were adversarial relationships between programs.  For example, Inpatient staff thought a hospitalization was central to the treatment and that they could more properly diagnose and treat a patient based on their 24/7 observation. Outpatient staff, meanwhile, believed a hospitalization was a disruption in care and that they better understood the patient because of long-term contact in the natural setting.  Then there were fiscal staff who thought clinicians were too lazy to do correct documentation for billing, while clinical staff saw fiscal staff as lacking compassion. … and on and on. I’m sure there are 100’s of choice examples out there.

So what to do?  My condensed answer is to get them in a room together, give them a task and a strict timeline and tell them they must be successful.  Details to follow.

A recent article in the New England Journal of Medicine surveyed 3000 outpatient medical practices on their use of an electronic health record.  Among the many results was the finding that nearly 400 of the practices had already purchased an EHR system, but had not yet implemented it. There are many possible explanations for this. I want to use the finding to segue to talk about motivation and the implementation leadership. (The leadership may be one or several people.  Both configurations can work, and these thoughts pertain to both situations.)

There are many, many elements necessary for a successful EHR implementation (or I wouldn’t have material for an ongoing blog), but the implementers’ determination and energy are the primary forces driving an implementation through to its completion.

The organization’s implementers have to face the resistance of staff, the scope of the task and the personal effort level involved. They will probably develop feelings, such as anxiety, anger, frustration and their own resistance, which may look like procrastination, over planning, even letting themselves be persuaded that an EMR just cannot work in their setting.

The implementation leaders need to discern a personally important mission in the EHR project to support the deep and steadfast commitment that is necessary. As I wrote here in an early blog, for me the mission was to make the electronic health record serve the clinical work. The passion for this mission still energizes me.  

I’d like to hear other people’s thoughts, feelings and ideas about the mission for EMR implementers.

E-prescribing is gaining more momentum than ever! I’m happy to report that the DEA has published a set of proposed rules for electronic prescribing.

 

On June 27, 2008 the DEA released its proposed rules for electronically prescribing controlled substances. Specifically, the document is titled “21 CFR Parts 1300, 1304, et al. Electronic Prescribing for Controlled Substances; Proposed Rule.” (http://edocket.access.gpo.gov/2008/pdf/E8-14405.pdf) This rule affects prescribers, e-prescribing systems, intermediaries, and pharmacies. When you look at the rule, you will see it is rather long and complex. However, a nice summary is found on page 36751 and the actual proposed rule starts around page 36769.

 

The DEA has established a comment period that ends on 9/25/08. I encourage everyone to take a look at the rule and participate in commenting. This is a rule that is going to affect us individually and collectively and we want to make sure our voices are heard.

A recent article reports findings that uncertainty about Return on Investment (ROI) is a significant barrier to the adoption of Electronic Health Records. In my last blog, I introduced a monograph, “Measuring the Business Value of IT Investment,” by Craig Symons. He believes that financial measures are not enough when making decisions about IT investment.  In that blog, I presented his view about the lack of precision inherent in the financial measures.

Symons further describes that IT investments often provide intangible benefits which are hard to measure and so are left out of financial measures. Let’s think from the clinician’s perspective: No more trips to the record room; no more searching through pages of lab results for the crucial information or struggling to read months even years of hand-written progress notes to get the big picture of what is going on with a patient. (FYI I worked mostly with schizophrenic people who had long often-complex histories.) Confider that such delving into a difficult case would likely not occur at all with a paper chart because the process is so cumbersome and time-consuming. A well-designed EHR also provides decision support tools and links to the universe of knowledge on the Internet.

Symons also notes that IT investments produce not only immediate benefits but also provide opportunities for future benefits.  Consider the benefits to quality and cost of care in the potential for communicating with other providers. There is also the exciting opportunity to bring web-based interactivity to the patient-provider relationship.

Seems that the intangible and potential benefits truly deserve a place when thinking about an EHR implementation. 

Yet another look at the article on Electronic Health Record implementation from the New England Journal of Medicine. It presents a survey of nearly 3000 physicians in outpatient medical practices nationwide. The results showed that just 4% had extensive electronic records systems in their practices, and 13% had basic systems. The survey asked respondents to identify the barriers to moving from paper to an electronic health record. The second most frequent response after cost was uncertainty about return on investment (ROI).

ROI is a commonly used formula-based numeric measure, but it is not as straightforward as one might think. Sure maybe you can project a definite positive ROI before the fact. The EHR implementation I managed at UBHC was in the black after the first two years thanks to bringing all billing in-house and discontinuing all transcription services. But such initial cost-saving opportunities may not be available to your organization. Your situation may be unclear. Time to pause and think about the place of ROI in IT decision-making.

Using ROI as a factor in decisions about an EHR is problematic. As Craig Symons states in his monograph “Measuring the Business Value of IT Investment,” purely financial measures such as ROI imply a precision that does not exist. He describes that the calculations used in the measures are based on estimates of benefit, which in turn are based on assumptions. So the accuracy of the calculated ROI is only a good as the underlying assumptions. He presents other shortcomings of purely financial measures, which I’ll touch on soon.

Symons presents several alternative approaches to evaluating IT projects. Have a look.

Have you heard?! On Wednesday (July 9, 2008) the Senate approved a Medicare bill that, among other things, will provide financial incentives for physicians to use electronic prescribing. The bill is called the Medicare Improvements for Patients and Providers Act of 2008 (HR 6331). According to the bill, physicians who use electronic prescribing for their Medicare patients will be eligible for incentive payments of 2% in 2009 and 2010, 1% in 2011 and 2012, and 0.5% in 2013. Doctors who do not use electronic prescribing by 2012 will see a pay cut of 2%.

 

Another part of the bill halts a scheduled 10.6% Medicare physician pay cut. Although the President has threatened to veto the bill, it was passed with enough votes to override a veto, paving the way for it to become law.

 

For the electronic prescribing community, I think this is the best thing since sliced bread. I think it’s great the government is providing incentives for using technology rather than punishment for not.

 

For those still not convinced of the return on investment of using an e-prescribing system, these incentives certainly should help.

Let’s look again at the article on EHR implementation in the July 3rd issue of the New England Journal of Medicine. It presents a survey done in late 2007 and early 2008 of nearly 3000 physicians in outpatient medical practices nationwide. I discussed in my last blog the results showing that just 4% had extensive electronic records systems in their practices, and 13% had basic systems.

The survey asked respondents to identify the barriers to their moving from paper to an electronic health record. Unsurprisingly, the most frequently mentioned barriers were financial, namely the amount of capital needed and uncertainly about return on investment. The size of the capital investment is a straight up problem. Governmental policy makers, insurers and vendors are all exploring solutions in various brews of requirements and inducements as fit their areas of authority and self-interests. For example,legislation was recently proposed calling for a national inter-operable electronic health record (EHR) system. Some sources consider the proposed legislation could be used as a back door approach to force doctors and hospitals to implement EHRs.

Since you are looking at this blog, I assume you or your organization are at least thinking about implementing an EHR. If funding is currently an insurmountable barrier, you can still begin preparing. Learn more about the benefits others have gotten from EHRs. Think about the areas of greatest inefficiency or communication failures in your organization and how the problems could be addressed by improved processes assisted by an EHR infrastructure. Think about the impact on the organization and the barriers and resistances.

It's not too early. A successful EHR implementation begins in the minds of the leaders.

As to Return on Investment, I'm going to write some thoughts on that one in the next blog.

While there has been much discussion in healthcare policy and political circles as well as media buzz about Electronic Health Records, the actual implementation of EHR’s in the U.S. remains low.  An article in the June 18 New England Journal of Medicine cites a survey done in late 2007 and early 2008 of nearly 3000 physicians in outpatient offices nationwide. The results show that just 4% had extensive electronic records systems in their practices, and 13% had basic systems.

There are lots of details in the article. Here are some highlights regarding usage. There were higher levels of EHR use by younger physicians and those who worked in primary care or large group settings. Interestingly,  providers serving higher proportions of minority, uninsured or Medicaid patients were not significantly different in their EHR adoption than other physicians. Also adoption was higher in the Western section of the country.

Happily, a large majority of the physician users were satisfied with their systems – 93% for fully functional system users and 88% for basic system users.

Among the 83% of respondents who did not have electronic health records, 16% reported that their practice had purchased but not yet implemented such a system at the time of the survey. An additional 26% of respondents said that their practice intended to purchase an electronic record system within the next 2 years. So, many practitioners are on the path to implementing an EHR. It is not too late to be a leader in your field and in your community by joining this group.

Supporting NCCBH in Washington

Last week I attended the NCCBH Hill day in Washington, D.C. to lobby on Capitol Hill for legislation that supports the mental health community.  We addressed many issues effecting the industry (a list of the agenda we addressed can be found at the National Council for Community Mental Health website), but I particularly focused on one that effects the users of our Electronic Medical Record systems:  The Support the Community Mental Health Services Act (H.R 5176/S. 2182).  

This act addresses the need to provide funding to co-locate primary care/chronic care services at CMHCs; to integrate treatment for co-occuring mental heath and substance abuse disorders; to provide funding for workforce recritment and retention; to enhance behavioral health eduction and training; to provide funding for telepsychiatry and patient education; and finally one that directly impact users of electronic health records, psychiatric software, and medication management systems.  This final measure would require the Secretary of HHS to collaborate with the Office of the national coordinator to develop a plan to ensure that components of the National Health Information Infrastructure address the needs of behavioral and substance abuse providers.  

I met with Senator Hilary Clinton, Senator Charles Schumer and Congressman Steve Israel and got very good response from all offices.  We requested that they co-sponsor the legislation and endorse it.  I recommend that each of you communicate with your local legislators and request the same.  It is easier than you think.   

When/Will Consumer Directed Healthcare Impact Behavioral Health?

At Netsmart Connections we spent time talking about the trend toward consumer centric care and involving the consumer in the care process.  We discusssed consumer portals that provide consumers with access to their electronic health record and medication histories.   

As part of that discussion we looked at how the cost of healthcare is impacting the US economy and several changes to the system that are being proposed to address the problem.  Yesterday I had a conversation with Ryan Daniels from William Blair, Netsmart's investment banker.  I have attached two of Ryan's market analyses (his 2007 and 2008 updates on the CDHC impacts to the healthcare provider markets) in which he looks at how Consumer Directed Healthcare (CDHC) is or will be affecting the primary care marketplace.  Although these reports look at primary care primarily, he does speak about how some behavioral healthcare providers are well positioned going forward because they are less dependent on government funding.  This does not apply directly to many of you, but is a trend worth following as we often see funding approaches that are first tried on the primay care market work thier way into the behavioral health markets.

The question to be discussed is if and/or when this trend will impact behavioral health and public health.  I have had several discussions down in Washington as to how these trends will impact the medicaid and indigent populations and I have gotten several different answers:  1) it wont; 2) they will be treated differently; 3) thier HSAs will be managed by someone for them.   It is not clear where this is going, but it is a trend very much worth watching. 

If anyone has any input please contribute to the group.

External Connected Care

In my last blog entry I discussed Internal connected care.  To truly have connected care, internal connected care is the enabling technology to facilitate external connected care.  External connected care is the ability to share clinical data between disparate providers.  It allows a discharge summary to arrive at another provider before the consumer arrives to give the agency the consumer's diagnosis, active medications, reason for referral, demographic data and much more.  We call this new product CareConnect, and are using the evolving national standard called a Continuity of Care Document (CCD) transfer information between Avatar, MIS and Insight systems.  

Many behavioral health and public health agencies do not have the resources to Develop and maintain interfaces to various RHIOs and other providers.  The Netsmart CareConnect system will allow them to make a single connection to CareConnect and have Netsmart manage the interfaces to other providers and RHIOs.  Connecting care in this fashion will provide better service to the consumer by reducting potential medication errors and by reducing inpatient admissions by emergency rooms by providing the clinicians with the information they need when they need it.

We are continuing to define and extend the CCD to add behavioral and public health extensions.  At Connections a few weeks ago we had some discussions about these extensions.  Some preliminary ideas were to add components of a substance abuse assessment, a risk assessment and a suicide assessment.  What are your thoughts?