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Connected Health for Providers: Information Technologies to Improve Health Care Delivery

Posted: 21 Oct, 2013   Recommendations: 4   Replies: 46

Dear All,

What are the hallmarks of effective Health IT for medical providers? What are the barriers and facilitators for using these technologies to enable patient-centered care and better coordination of care? What of the meaningful use standards for electronic health records: will they be drivers of innovation or not? And how can we organize the slew of electronic messaging happening between clinicians on patient cases so vital data doesn't get lost?

These are some of the questions and topics we invite you to discuss in our new Expert Panel, organized with Partners HealthCare Center for Connected Health as a complement to the 2013 Connected Health Symposium. If you were not able to attend this year’s symposium, or attended, but wish to discuss these important topics further, now is your opportunity to connect with some of the speakers, and hear from additional experts in the field. This virtual expert panel is free and open to all.

We’re delighted to welcome the following panelists for our discussion:

- Eleanor Chye, PhD, Asst Vice President For Health, AT&T Advanced Business Solutions, will dive into the issue of the "para-EHR", - all the electronic communications that go on between providers on patients' cases , which is rarely captured in current systems, and what AT&T is doing about it.

- Kamal Jethwani, MD, MPH, Manager of Research and Innovation at Partners HealthCare Center for Connected Health, will share some insights and reflections from this year’s symposium.

- Adam Landman, MD, Chief Medical Information Officer for Health Information Innovation and Integration, Brigham and Women’s Hospital, will share a research prototype making electronic medication administration reconciliation system (e-MAR) more efficient using mobile devices and Near Field Communication.

- Karla Thornton, MD, MPH, is a Professor in the Division of Infectious Diseases at the University of New Mexico School of Medicine in Albuquerque, New Mexico and the serves as the Associate Director of Project ECHO (Extension for Community Healthcare Outcomes), a project that develops the capacity to safely and effectively treat chronic, common, and complex diseases in rural and underserved areas in the U.S. using video-conferencing technology and case-based learning.

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve health care delivery in underserved populations in the US. We will share evidence and key points from relevant AHRQ resources to support this discussion, and encourage you to review these materials and ask questions, share complementary resources, and describe your experiences implementing these best practices.

How to Participate:

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Once the panel has concluded, we will invite everyone to answer a similar, short follow-up survey.

We look forward to this discussion, so join the conversation and share your thoughts!

Sincerely, Sophie



Sophie Beauvais Replied at 5:03 PM, 21 Oct 2013

Dear All,

We look forward to this expert panel discussion on health information technology for and by providers. First of all we're delighted to announce a new panelist joining our discussion:

Karla Thornton, MD, MPH, is a Professor in the Division of Infectious Diseases at the University of New Mexico School of Medicine in Albuquerque, New Mexico and the serves as the Associate Director of Project ECHO (Extension for Community Healthcare Outcomes), a project that develops the capacity to safely and effectively treat chronic, common, and complex diseases in rural and underserved areas in the U.S. using video-conferencing technology and case-based learning.

Please also note that as we get ready for this panel next week, I will share some highlights on this topic as found in publications by the Agency for Healthcare Research and Quality (AHRQ) throughout this week. I invite you to review these materials and share your thoughts on applicability and relevancy to your work.

Many thanks, Sophie

1. Enabling Patient-Centered Care Through Health Information Technology Report
Executive Summary:
Evidence Reports/Technology Assessments, No. 206. Investigators: Joseph Finkelstein, MD, PhD, Amy Knight, MD, Spyridon Marinopoulos, MD, MBA, M Christopher Gibbons, MD, MPH, Zackary Berger, MD, PhD, Hanan Aboumatar, MD, Renee F Wilson, MS, Brandyn D Lau, MPH, Ritu Sharma, BS, and Eric B Bass, MD, MPH.The Johns Hopkins University Evidence-based Practice Center. Rockville (MD): Agency for Healthcare Research and Quality (US); June 2012. Report No.: 12-E005-EF

The main objective of this report is to review the evidence on the impact of health information technology (IT) that supports patient-centered care (PCC) on: health care processes; clinical outcomes; intermediate outcomes (patient or provider satisfaction, health knowledge and behavior, and cost); responsiveness to needs and preferences of patients; shared decision making and patient–clinician communication; and access to information. Additional objectives were to identify barriers and facilitators for using health IT to deliver PCC, and to identify gaps in evidence and information needed by patients, providers, payers, and policymakers.


The barriers identified in AHRQ’s review includes: poor interface usability and problems with access to the health IT application due to older age, low income, education, cognitive impairments, and other factors. The studies also mentioned low computer literacy in patients and clinicians, and insufficient basic formal training in use of the health IT application as barriers to effective use. Studies also identified physicians’ concerns about potential new work, problems with workflow, and problems related to new system implementation, including the lack of adequate funding. Both patients and physicians worried about confidentiality of patient information. Other studies cited depersonalization, incompatibility with current health care systems, concerns over privacy, the need for standardization of health IT applications, and problems with reimbursement as potential barriers.

Important deficits were found regarding the information needed to support estimates of the cost, benefit, impact, sustainability, and net value of using health IT to enable PCC. Most of the existing evidence focuses on process outcomes, clinical outcomes, and intermediate outcomes, with a paucity of research on the effects of health IT on responsiveness to the needs, preferences, and values of individual patients or on shared decision making with patients, their families, and providers. Also, very few studies addressed the cost or sustainability of using health IT to promote PCC.


Facilitators for the utilization of health IT included ease of use, perceived usefulness, efficiency of use, availability of support, comfort in use, and site location. Particularly several tudies suggested that a high rate of satisfaction with an application’s ease of use, perceived usefulness, and efficiency of use can drive utilization of health IT in patients and physicians. Other studies mentioned availability of support, comfort in use, and site location as facilitators of health IT implementation and use.

Other questions include:

Are health IT applications that address one or more components of PCC effective in improving health care process outcomes?

> Each type of health IT application that AHRQ studied, from decision support to telemedicine to tools for patient self-management, has resulted in positive, and often significant, improvements in process outcomes. The evidence is insufficient to determine whether any particular type is more effective than the others, but telehealth applications and care management tools were the health IT types most frequently cited as having a positive impact on at least one health care process outcome.

Are health IT applications that address one or more components of PCC effective in improving clinical outcomes for patients?

> The components of PCC addressed most frequently were related to coordination and integration of care, and an enhanced clinician–patient relationship. Overall, AHRQ found that various health IT applications implemented to enhance PCC generally improved clinical outcomes for patients with diabetes, heart disease, cancer, and other health conditions, and several of these interventions showed a statistically significant favorable impact.

Are health IT applications that address one or more components of PCC effective in improving intermediate outcomes for patients?

> The studies most frequently cited telehealth applications as having an effect on intermediate outcomes, but less than half of the telehealth applications had a statistically significant positive effect on at least one intermediate outcome. In contrast, for three of the health IT types that had fewer studies of intermediate outcomes (care management tools, personal health records/patient portals, and electronic messaging), the majority of studies reported a statistically significant positive effect on at least one intermediate outcome. This observation makes it difficult to formulate any strong conclusion about how the impact on intermediate outcomes varies by type of health IT application.

Telemedicine and other interventions that focused on integration of care and information exchange generally had positive effects on patient–provider communications and satisfaction among patients and providers. Tailored health IT interventions aimed at increasing patient engagement during the clinical encounter yielded positive results on patients’ question-asking behaviors and patient and provider satisfaction.

To meet the needs of different types of stakeholders, the AHRQ reviews encourages investigators to engage consumers, their families, clinicians, and developers in the design of studies and the selection of the most important outcomes to assess.

Attached resource:

Sandeep Saluja Replied at 1:58 AM, 22 Oct 2013

Very interesting and pertinent!

A/Prof. Terry HANNAN Replied at 2:07 AM, 22 Oct 2013

All, the attached 2 slide Powerpoint slide set has been provided to me by the creators acknowledged on the slides. They demonstrate how the technology can and must be adapted to the end users.
When Eleanor turned on her computer (2nd slide) the postal truck went across her screen to her letter box. See the number of emails she sent in the next 12 months.
To myself this means the technology must work for us as Steve Jobs did with iPhone.I hope this is seen as positive contribution. Terry

Attached resource:

Sophie Beauvais Replied at 9:37 AM, 28 Oct 2013

Hi Everyone,

Welcome to this week’s virtual expert panel discussion “Connected Health for Providers: Information Technologies to Improve Health Care Delivery.” Thank you to you and to our panelists joining us this week: Eleanor Chye, PhD, Asst Vice President For Health, AT&T Advanced Business Solutions; Kamal Jethwani, MD, MPH, Manager of Research and Innovation at Partners HealthCare Center for Connected Health; Adam Landman, MD, Chief Medical Information Officer for Health Information Innovation and Integration, Brigham and Women’s Hospital; and Karla Thornton, MD, MPH, Professor in the Division of Infectious Diseases at the University of New Mexico School of Medicine in Albuquerque, New Mexico, and Associate Director of Project ECHO (Extension for Community Healthcare Outcomes). We look forward to a great discussion!

Right away, I’d like to invite our panelists and everyone to share their work and reflect on the following questions: What are the hallmarks of effective Health IT for medical providers? What are the barriers and facilitators for using these technologies to enable patient-centered care and better coordination of care? What of the meaningful use standards for electronic health records: will they be drivers of innovation or not? And how can we organize the slew of electronic messaging happening between clinicians on patient cases so vital data doesn't get lost?

We’re also delighted to organize this panel as a follow-up to the Connected Health symposium. Here are some tidbits and reflections from the conference. Would be great to read everyone’s thoughts on these as well.

Many thanks, Sophie


"Innovations is not features. People often look too much at software and not enough at service."

"Telehealth has to be a win for doctors. Givre us more time. Make my job easier." Ron Dixon, MD. Dixon also reflected on the difficulty to get paid for telehealth and the barriers between states.

"Para-EHR is the new normal."
There was a good amount of discussion on the "para-EHR" - all the communication, text, email messages and images, that take place between clinicians outside of the EHR - and that never make it in - but are very key to the care of patients. Some proposed to focus on the "team care" approach where not just one doctor or clinician receives a communication about a patient but the whole team managing that person. This could include copying/integrating the EHR. Many noted that technology solutions exist to do this but are either not rolled out or properly integrated. Integration of communications systems is needed but the patient needs to be at the center of it. A speaker cited Australia as having only one EHR.

Many seemed to think that patient engagement was the last mile for EHRs. Others said that the real issue was the need for legislation around these communications... considering that the FDA just said it would not regulate on health apps that did not address diagnosis... how likely is this to happen and is this really a solution?

Karla Thornton Panelist Replied at 10:38 AM, 28 Oct 2013

Good morning, my name is Karla Thornton. I am an Infectious Diseases Physician in the Department of Internal Medicine at the University of New Mexico Health Sciences Center in Albuquerque, New Mexico. I currently serve as the Associate Director of Project ECHO (Extension for Community Healthcare Outcomes). Project ECHO is a health care delivery model which uses telehealth technology to support primary care clinicians in the treatment of complex diseases. Project ECHO was started in 2004 by Sanjeev Arora, a gastroenterologist and Hepatitis C specialist, to increase access to Hepatitis C treatment in the primary care setting. For a good, relatively short introduction and explanation of the project please consider watching this TEDx talk which Sanjeev recently gave:

We feel like Project ECHO is one of the tools that can be used to address some of the questions posed to this panel, particularly better coordination of care and patient-centered care. The goal is to provide high-quality, multidisciplinary care within the primary care setting without having to send patients to multiple specialists where their care becomes disjointed. Project ECHO uses technology (videoconferencing and the internet) to leverage scarce healthcare resources (specialists’ time and knowledge). We want to de-monopolize knowledge and make specialty care available in a cost-effective way to underserved populations.

I look forward to the discussion this week.

Sandeep Saluja Replied at 10:52 AM, 28 Oct 2013

We must all welcome this very relevant discussion.In fact,if the delivery of medical care to the remotest corner is to meaningfully take place,this is the way forward.
While it is good to have programmes focussed on specific disease states,it is much more important to be able to use these tools for holistic care cutting across all specialities

chris macrae Replied at 12:34 PM, 28 Oct 2013

Has anyone come across the Health evillages program of the Robert Kennedy Foundation and Partners
I chose this sample bookmark
There is quite a lot of information at their website but what isn't quickly clear is whether they edit their content in an open source way. More generally does anyone in mhealth for the developing world keep a wiki of open content or some such?

sanjeeb samal Replied at 2:43 PM, 28 Oct 2013

Great working model to replicate elsewhere in the world. It would be enlightening to know as to how this works financially? Who funds such a project? Is it a challenge to convince the primary clinicians to join this project?
Country like India can hugely benefit from similar project. But, such a project will face lack of infrastructure and funding for impementation here. My article on what I perceive of  telemedicine in Indian context

Kamal Jethwani Replied at 4:45 PM, 28 Oct 2013

Thank you for setting up this virtual panel, Sophie! We are excited by this opportunity to extend the discussions that started at our symposium this year. We had over 1200 attendees and the discussions were just so enriching and exciting.

One particular panel that deserves some discussion was one that Elanor participated in, on Para-EHR. These are basically systems or networks where patient-generated data lives, outside of the EHR. This includes texts, emails, images etc. The discussion focused on whether these should ever make it into the EHR or PHR, how they should be incorporated, and whether they're of any importance at all. The conclusion from my perspective, pointed to the fact that these are all important inputs, and while they may not be immediately ready for incorporation, they're important data points in understanding more about the patient and would be rich inputs into any decision support that we want to employ for better population management.

Has anyone seen good use of Para-EHR data for clinical decision support or population management?

Eleanor Chye Panelist Replied at 5:34 PM, 28 Oct 2013

What an exciting thread so far from posters to this thread - I think a common theme I am hearing here is that there are two pre-requisites for connected health to take off:
1. Easy to use by the patient (per Terry Hannan's earlier post that even so-called simple technologies such as email, to an older patient, will be bewildering)
2. Extremely low-cost - otherwise the connected care solution would work in developed economies but stumble in emerging economies

For both, I turn to how mobile devices, not just smartphones but "dumb" ones, can have an impact on connected care outcomes at an affordable cost. The important thing is not to add more bells and whistles on the technology front, but focus on the customer user-interface and user-experience. I was struck at the Connected Care symposium by what Andrew Watson of UPMC shared - that globally we have 6B active cell phones. And by 2014, we can expect more cellphone connections, than we have a global population

And while we are all enamored by smartphone apps, let's not forget at the impact that low-cost (albeit very targeted texting) can have on changing individual behaviors and providing bite-sized education/ coaching/ reminders for improved outcomes.

Karla Thornton Panelist Replied at 11:44 PM, 28 Oct 2013

I wanted to respond to sanjeeb samal's questions regarding implementation of Project ECHO. These are great questions and often asked when people learn about the project. Our project has been funded by some state legislative funding but mostly grants (RWJF, AHRQ and others). Our project does not align with the current fee for service medical care system in the United States. Despite this huge hurdle many others have stated ECHO projects outside of New Mexico and several outside of the United States and have found creative ways of maintaining funding. This model works best in a closed system like the VA where there is an incentive to contain cost and avoid unnecessary specialist visits, travel, etc...

We have never had difficulty getting primary care clinicians to join. They report they derive great satisfaction from learning new skills and interacting professionally with peers and mentors. It would not work to assign someone to do this. It is completely voluntary and only the interested clinicians get involved.

Thanks for the questions.

Bruce Struminger Replied at 12:46 PM, 29 Oct 2013

I would like to add to Karla's response about Project ECHO. I am a primary care internal medicine MD with the Indian Health Service working in a remote region of the Navajo Reservation. Our clinic serves a patient population of ~7500 and there are 6-7 primary care providers. After six years with the CDC overseas I returned to clinical medicine in September of 2012, and when I arrived at the health care center in Red Mesa, AZ, patients with HIV and HCV and complex rheumatologic disorders were not receiving care at the center, but were being referred to a larger facility one hour away or to the academic medical center (University of New Mexico) in Albuquerque 4.5 hours away. I wanted to provide care for patients with HIV, HCV, and complex rheumatologic conditions so that they would be able to receive their care locally and not be required to travel long distances, which creates a barrier to access to care. I became an active user of Project ECHO's HCV, HIV and rheumatology tele-health consultation clinics in November of 2012, so have now been participating in their programs for nearly a year.

Why do I participate?
-I wanted to be able to offer high quality, best-practice medical care for patients in my community with HIV, HCV, and complex rheumatologic conditions. By being able to participate in weekly or monthly Project ECHO sessions on HCV, HIV, and rheumatology (the tele-health clinics I have participated in most) I have been able to present my patients with these conditions and receive real time expert advice on their care and treatment. I have been able to get answers to my clinical questions within one week (all of these teleECHO sessions meet weekly) so that I could schedule follow up visits for my patients within 1-2 weeks of the visit that generated the question I wanted to answer for my patients and modify their care and treatment as appropriate based on the expert advice I have received. I have really enjoyed getting to know academic colleagues at UNM who are the faculty for this program and know them well enough that when I have questions requiring an immediate answer I can call them or email them and usually receive a response to my urgent question within minutes or hours. While I have learned a lot by presenting cases via teleECHO sessions, I have learned even more about HCV, HIV and rheumatology from discussions about clinical cases presented by my clinician colleagues spread across the Southwest of the US and across the US (for those who participate in the monthly IHS HCV ECHO). I have developed a number of strong relationships with these clinician colleagues practicing in similar contexts to me and call them regularly to share experience outside of the formal ECHO sessions. Also, I receive free CME credit for the time I am able to spend participating in the ECHO sessions, an added bonus that is particularly significant now that funding for CME support has been cut within the IHS for the past two years (we used to receive $1500 per year for CME; we no longer receive this and likely will not have this support reinstated for several years given the state of the federal government budget generally and the IHS budget specifically). The IHS is a single-payer system and I am on salary. By being able to provide clinical services for HCV, HIV and complex rheumatologic conditions, the IHS saves $$ that we would be spending on contract health services for referral consultation services and our patients receive the care they need in a timely manner. If a patient needs a higher level of care and direct access to a specialist at an academic medical center, the ECHO specialists are able to facilitate appointments for them so that the patient can be seen much more rapidly (within days or weeks rather than months).

How is this an effective means for improving access to specialty care services in rural and underserved locations?
-Patients with HCV, HIV and complex rheumatologic conditions were previously not receiving services for those conditions at our health facility. I would not have felt confident/comfortable evaluating patients with HCV and complex rheumatologic conditions without easy access to subject matter experts. I am able to participate in the ECHO learning sessions when I am able and for as long as I can [there are not attendance requirements; you tune in when and for as long as you are able]. Most of the sessions are an hour and take place during the lunch hour (from noon-1pm). Sometimes I tune in for only 15-20 minutes if my morning clinic is running late, but even 15-20 minutes is often worthwhile; I can ask a question if I have one and in 15-20 minutes I will can usually hear 2-3 cases presented.

Colleagues within the Indian Health Service decided we wanted to create a special IHS HCV teleECHO clinic and this was launched in March of this year and sessions are monthly, so we have had eight sessions so far. Multidisciplinary teams including MDs, PHNs, social workers, and pharmacists from across the country where the IHS operates (from Alaska, Oregon, Minnesota, South Dakota, Montana, Oklahoma, Arizona, New Mexico, etc) participate in the monthly sessions. We present several cases and discuss programmatic issues specifically relevant to the IHS context. This initiative has been so successful that we launched a Navajo Area IHS HIV ECHO two months ago and 6-8 clinical teams from across the Navajo Reservation (the size of West Virginia) participate each month, presenting cases and discussing programmatic issues; this is really helping strengthen the network of HIV providers across the Navajo Nation--I am confident this will help strengthen our communication and coordination and the quality of care for our HIV patients. We are considering expanding this Navajo Service Area initiative to a national IHS HIV ECHO, developing a learning network of HIV clinicians and their multidisciplinary teams across Indian Country from Alaska to Maine.

How has Project ECHO benefitted and improved the outcomes for my patients?
-I have evaluated >10 patients infected with chronic Hepatitis C and am preparing several for rx that will begin in the next few months, as soon as sofosbuvir is available in mid-December. I have presented 3-4 complex rheumatologic patients who needed immediate treatment for rheumatoid arthritis and ankylosing spondylitis; the wait for a consultation at our closest referral center one hour away was 4-5 months. While I feel competent to treat routine HIV infection, I had one patient who developed treatment resistance and was able to rapidly develop an alternate salvage ART regimen based on his GART and advice from the ECHO HIV team; within several months from detecting ART resistance this patient has an undetectable viral load again and is doing well.

What have been the greatest challenges to participation?
-Carving out time to participate is always the greatest challenge; often morning clinic will run over, so it can be difficult to join the teleECHO sessions right on time, but this is ok--there are no penalties or criticisms for joining a session late. My clinical director is supportive of my participation; she wants to see our clinic offering a greater breadth of services and wants them to be delivered at a high level of quality. Optimally one primary care provider would volunteer to participate in one ECHO specialty care session, so that several primary care providers would become local experts in different specialty areas and each of those providers would devote 1-2 hours per week or every few weeks to participating in this program so that they could become competent within 6 months within their chosen specialty area. At this point, after one year of regular participation, I feel competent to evaluate a patient with Chronic Hepatitis C, and recently began seeing HCV patients at the regional referral hospital which has a backlog of HCV patients waiting for evaluation, so have become a subject matter expert not only for my local community, but for the region which covers a patient population of 50,000.

The video technology has been a challenge for some participants, but once each participant figures out the technology--and the Project ECHO team has been super helpful about set up and trouble shooting--it usually works seamlessly. ECHO is shifting to a cloud based video conferencing support system that should be even easier to use with higher voice and image quality over limited or low bandwidth on any kind of device (desktop and laptop computers with cameras, mobile devices like smart phones and tablets, and internet based systems like Polycom).

Sophie Beauvais Replied at 1:25 PM, 29 Oct 2013

Dear All,

Great discussion so far; Keep the questions and comments coming!

– On Para-HER –

I wonder if these “off-the-record” communications should be treated more as a new way of doing medicine and bettering of services than trying to include these in the EHR. I mean the images all or most) come from exams taken who should be in the record… As a patient I do get the emails that I have to sign in on a secure portal to view and they are filed in my record and that’s really nice because that and the rest of my health info (as far as me seeing that practice) is all there. But if I cannot access it for some reason or need a communication fast I appreciate the flexibility that the office/clinician has to communicate directly – I’m guessing it might be the same between clinicians, and if these communications were all recorded would they change/still happen?

– On Project ECHO – fascinating info from Karla Thornton and Bruce Struminger! I have 2 questions:

Clearly project ECHO has increased access to specialty care for underserved populations. Do you think this has also generated a need/an interest for personal health applications (either from you the providing clinician or an ask from the patient) – even basics like medication text reminders – as a way to further support treatment management? Or is this somewhat irrelevant to this population because of language barrier or other?

You mention that the project is moving to cloud based video conferencing. What technology will you be using and why? I help run a private clinical consult exchange community where Partners In Health clinicians receive specialty consult from Boston-based colleagues and discuss patient management with their colleagues at various country sites (Haiti, Rwanda, etc.) so very interested in this model.

Last, some "food for thought" -- Susannah Fox at the Pew Center just shared some interesting numbers on the context for mobile health in the US. Would love to hear your thoughts on these:
- 39% of US adults are caregivers.
- Caregivers activities online: 46% go online for diagnosis; 52% participate in any online social activity related to health in the past year; 70% get info care and support from family and friends online; 72% gather health information online
- 45% of US adults live with chronic conditions - do you advise them to use apps?
- Top consumer apps: 38% exercise, fitness, pedometer or heart rate monitoring; 31% diet; 12% weight.
- To Eleanor Chye’s point about the need to focus not just on smartphones: about: 81% of cell phone activity is text messaging!

Best, Sophie

Attached resource:

David Grayson Replied at 3:51 PM, 29 Oct 2013

Hi I have a question for Karla Thornton re Project ECHO. We are being encouraged by our CEO to adopt this model here in NZ. Are you aware of any organizations in NZ or Australia who are currently part of Project ECHO? Thanks David Grayson

Erika Harding Replied at 4:38 PM, 29 Oct 2013

Hello David. My name is Erika Harding, and I am the Director of Replication for Project ECHO. We have 29 ECHO hubs or independent projects in the US, 32 worldwide. We currently do not have projects in Australia or NZ, but I believe I met your CEO just last week and discussed how the model may apply there. There are also a number of interested Academic Medical Centers in Australia beginning the exploration process. Of course, the model originates in NM, where we have much in common with Australia and NZ - geographic and socioeconomic barriers to care, large indigenous communities, high rates of DM and other chronic diseases. As a result we have adapted a model that not only can be used to train primary care physicians, but also is highly relevant to many other community clinicians and providers, including community health workers.

Should you or others be interested in learning more, we have monthly ECHO "Introductions," which are 1.5 hour videoconferences in which our founder and director Dr. Sanjeev Arora gives a 40-min. presentation and then takes questions. We also have monthly one-day ECHO "Orientation" events, which are held here in Albuquerque and give a deeper exposure to the model and how it can be adapted to meet community needs and resources. We also offer 2-3 day trainings (ECHO "Immersion") for committed replication partners. Please see our website for registration or additional information:

All of our outreach, education and technical assistance is offered without charge, with the hope that this model can create tremendous collective impact and improve health outcomes worldwide.

A/Prof. Terry HANNAN Replied at 4:50 PM, 29 Oct 2013

Sophie, can you give permission for me (&others) to use these slides for educational materials? Terry Hannan

Sophie Beauvais Replied at 4:57 PM, 29 Oct 2013

Hi Terry, The Pew Center slides? They're available open access on the web
at the link I shared so my guess is you can use these as long as you
credit. Best, Sophie

A/Prof. Terry HANNAN Replied at 5:07 PM, 29 Oct 2013

Thanks Sophie. Acknowledging is very important which is why I asked. Terry

Bruce Struminger Replied at 5:26 PM, 29 Oct 2013


Hopefully I am understanding your questions correctly. I am not sure my experience using Project ECHO has increased my interest in using other technologies like SMS messaging to improve patient adherence to medications like ARVs, I would say I do not see a direct link--Project ECHO strengthens connections between academic medical experts and primary care providers; SMS messaging technology strengthens connections between providers or health care teams and patients. But I think the technologies are complementary and I think implementing SMS messaging would be a terrific idea for helping improve patient medication adherence for my HIV patients in particular, but would probably benefit many of my patients who have chronic medical illnesses and who need to take medications daily.

In terms of the technology and the move to cloud based technology for hosting the video conferencing, the platform that Project ECHO will be using is Zoom. Karla may have more to add about this. I have used it once to connect to a Project ECHO session and the experience was super simple and the video and audio quality was excellent and the cost for hosting up to 25 participants is $9.95/mo. Link to their web site: They also have educational and business pricing plans:

A/Prof. Terry HANNAN Replied at 5:40 PM, 29 Oct 2013

Bruce, this is an excellent response. Your comments demonstrate the need for linked communications across health domains and specific links within domains. A great call for standardisation, interoperability and scalability. Terry

David Grayson Replied at 5:58 PM, 29 Oct 2013

Thanks for your reply Erika. Our CEO returns next week so we will no doubt be signing up soon. Will be good to connect with the Australian academic centers to develop a regional network of ECHO users as well as linking in with your US sites.

Adam Landman Panelist Replied at 7:39 PM, 29 Oct 2013

This is a great discussion. In addition to patient-provider access and communication, there is potential for cell phones and mobile devices to help improve provider workflow and efficiency.

We have developed mobile two applications that may be of interest to the group:
1) CliniCam – a mobile app that allows secure capture of clinical images and transfer to our EHR (see video We found that our providers were using their personal phones to take clinical images of patients, then email to themselves and copy and paste into the EHR. To solve the numerous security and privacy vulnerabilities, we developed this secure app and are currently using in our hospital.
2) NFC eMAR – nursing use of bar-code based medication administration is a best practice to improve medication safety (and a stage 2 meaningful use requirement). However, barcode reading of meds can be difficult and the equipment required is bulky and cumbersome. We developed a prototype next generation eMAR system using a tablet equipped with near field communication (NFC), see Using NFC, nurses can "tap" instead of scanning. Further, the tablet is the entire device, making it more portal. An initial pilot study in a simulation study showed this was well received by nurses and had similar efficiency to bar code scanning.

Is any one else using mobile solutions for health care providers? Do you have any app ideas or ways to apply NFC for health care?


Mika Wang Replied at 8:44 PM, 29 Oct 2013

"there is potential for cell phones and mobile devices to help improve provider workflow and efficiency"... definitely agree with Adam there.

We've developed and received FDA clearance for our iPad image viewer app, MobileCT. This app helps improve provider workflow in several ways:
- reduce time to access patient images
- review images remotely (outside 4 walls of hospital)
- share images with other providers to request second opinion or make a referral
- collaborate remotely with other providers using extensive cursor and annotation tools

We are currently building out a web-based version for access anywhere, anytime via

Applications in the developing world for remote consults, second opinions, etc. Anyone else here working on apps for cloud-based imaging? Please reach out!


Attached resources:

Ethan Bindelglas Replied at 2:37 AM, 30 Oct 2013

There is a free service provided by the Swinfen charitable trust in the UK which links remote undeserved regions of the world with consultants worldwide. The service is free and supported by Verizon. Their email is and the website is There is no reason why a provider on the Navajo resvation or elsewhere could not have a telemedicine link through them in addition to ECHO, is there? They have a triage service which links the primary care provider with the appropriate consultant. It is a very nice service.

Bruce Struminger Replied at 12:10 PM, 30 Oct 2013

One issue I did not emphasize in my long posting above is the role of standardized patient information collection and presentation. Project ECHO has developed standard patient presentation forms for each of the disease clinics including those for HCV, HIV, rheumatologic conditions, chronic pain, etc.; I download these forms and use them as a guide to collecting my history and physical info when I am interviewing a patient with the relevant disease condition and then complete and submit the completed form just prior to presenting the patient to an ECHO clinic. These forms help ensure that the pertinent clinical information is collected and that the subject matter experts have a comprehensive picture of the patient with all the key information they need to make a well informed clinical recommendation. This standardization of information collection and presentation also helps ensure a more efficient patient presentation by the provider to the ECHO community so that the presentation can be completed in 5-10 minutes; this helps ensure the clinic flows more smoothly and efficiently. The clinical information from the standard patient presentation forms (whether for an initial patient presentation or a follow up presentation--and there are different forms for each of these, the follow up forms generally shorter) is entered into a web-based data base to help manage the patient information (which is de-identified to keep things HIPPA compliant) both for the provider and the subject matter experts so that the clinical information can be organized over time as patients are often presented for follow up recommendations. This data base is not only useful for keeping track of the clinical info for individual patients, but can be assessed for cohort or population level analysis, which can be very useful for disease management program design and improvement for a local or regional community.

A/Prof. Terry HANNAN Replied at 4:38 PM, 30 Oct 2013

Bruce, are copies of these forms available? Terry Hannan

Joaquin Blaya, PhD Replied at 5:57 PM, 30 Oct 2013

Project ECHO sounds really great and something along the lines of the
experiences described in another GHDonline panel "Creating, working in, and
evaluating Telemedicine projects" (
On that panel was Dr. Richard Wootton who worked with the Swinfen
Charitable Trust that was mentioned previously.

Though far smaller than ECHO, we've created a system that tries to automate
a bit of the para-EHR data that has been mentioned, I say only a bit
because this system calls and text messages chronic disease patients and
registers their responses to questions, but doesn't include any data
between the patient and their family for example. Here's a 3 minute video
about it

Basically the idea is if chronic disease patients have to make sure they
take small actions every day for the rest of their lives, how about we have
something that as non-invasively as posible asks them how they are doing
with these actions and then alerts clinical staff if they need help showing
them the history of the patient's responses. This system only uses
automated phone calls and SMS to interact with patients because we
completely agree with Eleanor Chye's comment about using "dumb" phones.

Our experience here in Chile has been that even though we used technology
that the diabetic and hypertensive patients know how to use i.e. answer the
phone and press a number on their key pad, we still find that about 40%
need some assistance in not getting nervous when they answer the phone call
thinking that they might not answer the question right or in time. With the
SMS we send, it actually has been less problematic than we expected. About
the same amount of patients (40%) or so require some help in viewing their
text messages, but we thought it would be much higher.

The idea behind this is that if you can ask patient's how they are feeling
in a consistent fashion you can provide targeted assistance for their
specific problem in a timely way, and so far with the 1,300 patients here
in Chile we've found that after an initial effort of having chronic disease
patients get used to the system, it helps the patient's get their questions
answered and the clinicians in being able to respond to small, but
important questions and nip problems in the bud.

Gerente de Desarrollo, eHealth Systems <
Research Fellow, Escuela de Medicina de Harvard @@
Moderador, @@>

Bruce Struminger Replied at 6:35 PM, 30 Oct 2013

Terry, Attached are examples of some of the patient presentation forms for the HCV, HIV, and rheumatology clinics. I recommend writing Project ECHO for additional examples of their patient presentation forms. I am also including a copy of a modified form developed by the University of Washington for their ECHO program for the Pacific Northwest. Bruce

Attached resources:

Karla Thornton Panelist Replied at 12:36 AM, 31 Oct 2013

This has been a very interesting discussion. Thanks Bruce for all your insights. I, like Bruce, don't feel my experience with ECHO and the providers on our network has generated a particular interest in personal health applications. I don't have much experience in this area but find the discussion enlightening and hope to learn more.

sanjeeb samal Replied at 2:32 AM, 31 Oct 2013

Thanks to GDHonline for providing platform to discuss such brilliant project like Project-ECHO. 

It will be great to expand knowledge horizon with the participants sharing their experience on application of IT in operations management in healthcare setups ultimately improving healthcare delivery e.g. application of theories of six sigma, constraint management, lean management, bench-marking,usage of  statistical tools for assessing areas of improvement, reducing wastage, delays, errors.

Steven Wanyee Macharia Replied at 8:51 AM, 31 Oct 2013


I am also interested in forms that ECHO has developed and uses - can these
be shared? My interest is based on the fact that there inevitably exists
variability for a multiple of reasons in terms of essential data sets that
inform form design.

Bruce Struminger Replied at 11:15 AM, 31 Oct 2013

Joaquin, While I am not aware of much or any experimentation with SMS messaging to remind patients to take their medications or to get exercise or attend their clinic appointments, most Native Americans have cell phones and I think this is something that needs to be piloted and assessed. I think implementation of cellphone based reminder messages for a variety of patient application could be very helpful and effective. Hopefully there will be some pilot initiatives to test these ideas out in Indian Country.

Sophie Beauvais Replied at 12:53 PM, 31 Oct 2013

Dear All,

Many thanks for the great exchange so far. Today we'd like to ask our panelists and participants, clinicians as well as technology folks, to answer this question: What are the concerns (or barriers) and facilitators for the use of Health IT by medical providers to enable better coordination of care?

Here are a few, please complete this list and share some examples and thoughts:

- Added work (some physicians have to use 50+ IT applications on any given day for admin/reimbursement purposes mainly!)
- Incompatibility with current health care systems
- Not sure it’s useful

- Perceived usefulness
- Ease of use
- Available technical support

Attached resource:

A/Prof. Terry HANNAN Replied at 4:07 PM, 31 Oct 2013

Sophie, from the perspectives of "clinicians" as providers I had the following paper published last week. Terry Hannan
Hannan TJ, Celia C. Are doctors the structural weakness in the e-health building? Intern Med J. 2013;43(10):1155-64. Epub 2013/10/19.

chris macrae Replied at 5:11 PM, 31 Oct 2013

hi I tried to post this a couple of days ago but it doesn't seem to appear (apologies if you did get it before)

Here are some follow up links to my post number 7 asking whether Robert Kennedy Foundation Health evillages is part of the collaboration we are searching - most come from twitter analyzing my interest in

Today's conference at Mountain View recommended by Matthew Holt of Health Care Blog and Health 2.0

Neil Versel journalist at As a board member of Health evillages he occasionally posts on its progress eg

Open Mhealth which is also followed by Tedmed and mhealthsummit - and which recommends conference ny nov 14.15 and
::: the social business of health is one of 7 youth practice movements friends of Youth Capitalism and Open Society are trying to massively connect around a new 501 Foundation inspired by Muhammad Yunus and launching 22 Nov Atlanta with Opinion Leader support of eg Ted Turner and Jimmy Carter - would welcome ideas on who to collaboratively linkin ...

Adam Landman Panelist Replied at 5:22 PM, 31 Oct 2013

Earlier this week, Kamal Jethwani from Partners Center for Connected Health posed the question of whether anyone has seen Para-EHR data for clinical decision support or population management?

This may bring us back to the discussion of whether Para-EHR data should be part of the EHR. Ideally, clinically decision support would be able to use additional data about the patient (age, past medical history, medications) that are typically available in the EHR. So, unless the Para-EHR data is part of the EHR (or linked to EHR data), it may be difficult to do sophisticated clinical decision support or population management.

An area I am seeing interest in is patient reported outcomes (not sure if everyone considers this Para-EHR data). Several companies and researchers are creating mobile apps for patients to report on they are feeling, activity levels, etc. Through a web-based provider dashboard, providers can review the patient data. You can imagine decision support, that processes the patient outcomes in real-time and automatically notifies the provider under certain conditions, such as if the patients pain exceeds a certain threshold (or their activity levels decline). The providers could then proactively reach out to the patient before the condition worsens (and hopefully prevent ED and hospital visits). Alternatively, the app might make suggestions to the patient based on their reported outcomes.

This is just scratching the surface. Any one else using or have ideas for using Para-EHR data for clinical decision support/population management?


Sophie Beauvais Replied at 11:52 AM, 1 Nov 2013

Dear All,

For the last day of our panel discussion, we wanted to focus on discussing monitoring and evaluation. How do you measure the impact of health IT applications on health care provided and on health outcomes? What about longitudinal studies?

Clearly, clinicians and providers are overextended. The use of Health IT is, for many, a requirement. But many choose to adopt new technologies because they want to improve how they provide care, whether it’s their institution offering the tool or them taking it on like with Project ECHO or clinical decision support tools which are used in the vast majority of health practices in the US and that many access via mobile.

To go back to Adam’s point on patient reported outcomes, seems to me like it means more than just adopting an app but really changing how providers manage their patients, which I imagine could be of great value in the long run for people with chronic or complex diseases. I was surprised to find zero mention of the impact of the use of information technology in a Jan. 2013 AHRQ review on “Outpatient Case Management for Adults With Medical Illness and Complex Care Needs,” which they call out as a clear research need for CM.

Other innovative solutions are being developed and researched at the provider level to make key steps in the delivery of health care more effective, like Adam’s prototype making electronic medication administration reconciliation system (e-MAR) more efficient using mobile devices and Near Field Communication.

Last, you might be interested in this recap of reviews on impact from studies consumer health informatics (CHI) applications:

- In terms of the impact of CHI on intermediate health outcomes, significant positive impact was demonstrated in at least one intermediate health outcome of; all three identified breast cancer studies, 89 percent of 32 diet, exercise, physical activity, not obesity studies, all 7 alcohol abuse studies, 58 percent of 19 smoking cessation studies, 40 percent of 12 obesity studies, all 7 diabetes studies, 88 percent of 8 mental health studies, 25 percent of 4 asthma/COPD studies, and one of two menopause/HRT utilization studies. Thirteen additional single studies were identified and each found evidence of significant impact of a CHI application on one or more intermediate outcomes.

- Eight studies evaluated the effect of CHI on the doctor patient relationship. Five of these studies demonstrated significant positive impact of CHI on at least one aspect of the doctor patient relationship.

- In terms of the impact of CHI on clinical outcomes, significant positive impact was demonstrated in at least one clinical outcome of; one of three breast cancer studies, four of five diet, exercise, or physical activity studies, all seven mental health studies, all three identified diabetes studies. No studies included in this review found any evidence of consumer harm attributable to a CHI application.

- Evidence was insufficient to determine the economic impact of CHI applications.

Many thanks in advance, Sophie

Attached resources:

Joaquin Blaya, PhD Replied at 2:00 PM, 1 Nov 2013

This has been a really interesting panel and the perspectives have been
really intriguing and I think are a demonstration of how we in the US are
beginning to see that for the "modern" diseases we have to go beyond the
walls of the hospital (both in physical and in technological aspects)
because by the time the patient gets to the hospital it's too late for many

I would however like to focus my comment on what I think is a common theme
in health IT, which is to focus on the IT or the information rather than
the people (be it provider, patient, family...).

Specifically what I mean by that is the focus on, for example para-EHR
data, without the context of the patient (and I hope this is not seen as a
comment on any person). So for example, talking about para-EHR data or
applications to help teenagers with Type 1 Diabetes and older patient with
Type 2 Diabetes are completely different conversations. For teenagers,
paraEHR will mean facebook, mobile apps with heavy social context and
concentration of information, and having very quick and short interactions.
In older and also less educated patients, it's the complete inverse, slower
interactions with little concentration of information, probably little or
no internet (only 38% of 65+ people in the US have internet). Hence why
for the latter populations phone calls, automated or human, make sense
(hence why our system is based on that), whereas if you called the second
population they would probably hate it and stop using it.

The second point I'd like to make on this idea is to not forget the
human/psychological aspects of our interactions (even with IT). How will we
best take care of our patients (and how will they recuperate faster?)
Obviously with good medical treatment, but perhaps just as important is
with good and "caring" follow up and prevention. If I have an operation and
a nurse follows up with me when I'm at home about how I and the wound are
doing in a "caring" way (as opposed to a phone call where I can feel I'm a
burden to that person), I'm much more likely to A) be honest about how I'm
feeling and B) continue to take care of that wound and be proactive. This
is obviously very subjective, but I do believe there are studies showing
this sort of behavior (though I don't know of any specific ones off hand).
So, how is this relevant to the conversation? Because I think looking at
how we as health care providers or system use para-EHR data should focus on
how we do it in a way that resonates with the human side of the patient, as
opposed to the concrete, behavior changing, data side of the patient. I'm
probably not explaining it well, so perhaps an example. In attempts to
improve medication adherence there have been many devices most of which
have consisted of some type of device that you take home and interact with
to report how you are, be in a touch box, and iPad, a web page or others.
Most of these have not had a significant impact. Usually the enthusiastic
patients use if for a month or two and then just get bored (or get tired of
being called only when they do something wrong) and stop using it.

However, I do remember (though I wasn't able to find it on google) and
experiement at MIT where they placed the pill box within a furry teddy
bear-esque stuffed animal (no automation or electronics of any sort,
literally just a stuffed teddy bear with the pill box in it's stomach), and
they in a short-term study found that this improved adherence due to the
emotional attachment to that stuff animal. So not that this is the remedy,
but just showing how sometimes simple things, when they are in sync with
our human side, are very effective.

Gerente de Desarrollo, eHealth Systems <
Research Fellow, Escuela de Medicina de Harvard @@
Moderador, @@>

Keri Wachter Replied at 3:01 PM, 1 Nov 2013

Joaquin, powerful points, thanks. Your last comment reminds me of MIT's Huggable Robot to monitor the health of children recovering from medical treatment: It's meant to be both a therapeutic companion animal for the child as well as a data collection tool, as it has sensors that monitor the patient's health. Here's another link about it from a few years ago:

In response to Sophie's comments, I wanted to share with the group a teaching case study written by the Global Health Delivery Project entitled, "Electronic Medical Records at the ISS Clinic in Mbarara, Uganda." It shows the evolution of an EMR system at a low resource HIV/AIDS clinic in Uganda. It also digs deeps into what it takes to collect and systematize accurate health data for patient care and research. We'd love to hear your feedback and thoughts on the case if you have a chance to read or teach it.

Thanks to all for a stimulating conversation. It's been fascinating to follow along.

Attached resource:

YiDing Yu Replied at 4:10 PM, 1 Nov 2013

This is a truly free-roaming and fascinating discussion! One of the remarkable opportunities that health IT has enabled is to bridge communications that are fragmented in the current EHR system. I currently work with with my team on a mobile-to-web application called Twiage ( to facilitate timely communication of pre-hospital data collected by EMTs (or first responders) in the field to nurses and physicians in the ED. The goal is to use mobile phones to bridge a communication divide affordably and easily to improve patient outcomes in the U.S. and in resource-poor settings.

To answer Sophie's recent questions, as a primary care resident at BWH/HVMA, I care a great deal about population management. One of the pain points I think health IT should address is the constant fear that I "lose touch" of patients. For example, I make a plan with a patient to return to clinic in 4-6 weeks for drug monitoring and uptitration of their medication. Who follows up if this appointment is missed? What about a missed diabetes check? Should I enforce their next visit by dispensing only 4 weeks of medication? Should I make a personal reminder every time this happens (too inumerable to count)? The truth of the matter is that for most of these "misses", there is no significant adverse event. The drug monitoring is usually normal. A delay in 6 months to reach LDL or BP goals? The patient usually feels fine. Intensive population management programs for high-risk patients spend significant dollars to monitor and "touch" high-utilization, high-risk patients, but health IT could serve a crucial role in inexpensively monitoring and alerting me to improve care to low or moderate risk patients.

With relation to para-EHR, I see one of the main barriers to uptake as information overload. How should I interpret the daily steps, stairs climbed, data from products like Fitbit? Was this a voluntary change, evidence of stress, vacation, or depression, and should it be an alert for "at risk" health status in a patient with chronic illness? In the time crunch of a 15-20 minutes PCP visit, I don't need more raw data; I need to know how data should change my practice.

Given the amount of data literally at our patient's fingertips, can we mine it to give clinicians actionable alerts? I completely agree with Adam that this is an area of great potential. is a startup that is trying to get at this very question. They hope to mine patient data with algorithms that help predict if changes in phone use (decreased texting patterns, phone calls, movement) could predict relapse of depression and an opportunity to reach out to the patient. I think this is the next step for para-EHR data to truly take off and impact daily practice.

Sophie Beauvais Replied at 7:51 AM, 4 Nov 2013

Dear All,

Thank you to everyone who participated in this virtual Expert Panel. We will be sharing some lessons learned in a Discussion Brief to be published here in the coming weeks. Starting today until Monday, November 11 9AM EDT, we would like to invite you to take a short follow-up survey at this link:
Results from this survey will help us understand the impact of our Expert Panels and how we can improve.
Best, Sophie

Karla Thornton Panelist Replied at 8:10 AM, 4 Nov 2013

This has been a really interesting discussion and I appreciate the invitation to participate. I have been traveling and haven't been able to participate for the last few days. I wanted to mention that we have done some patient and provider outcomes in Project ECHO, particularly in the Hepatitis C arena.

Here is a link to the page with some of these publications:

We are planning some prospective studies currently to look at patient centered outcomes in the realms of Chronic Pain, Diabetes, Addiction and Hepatitis C. If you would like more information about Project ECHO or have questions for me you can e-mail directly at .


George Otto Replied at 5:45 PM, 4 Nov 2013

Hi All,

I'm sorry to have no input on this as I do not have much experience on
this topic. But it has been a real privilege for me to be on this
panel and to have to read through your discussions. I have been
intrigued by some of the low cost IT technologies available and
applicable in underserved areas. Where I come from some of this can be
definitely useful to us where health delivery systems are fragmented
and basically its a challenge delivering health services to the remote
communities and I believe some of these health IT system would really
help. I will now try to promote some this within our health system,
and may be ask for help in piloting one or two in my country.

many thanks

Eleanor Chye Panelist Replied at 6:30 PM, 4 Nov 2013

Wanted to echo (no pun intended, or perhaps I did :) all the great comments in this thread, truly been a terrific discussion. One final point to note on para-EHR - completely resonating with YiDing's comment that we have to make the EHR actionable. And I think this is in line with what we are seeing in the Meaningful Use requirements for Phase II and III - where there is increasing emphasis on actionable outcomes from the EHR (e.g. alerts to physicians on drug-drug-interactions) and overall more use of predictive analytics.

Sophie Beauvais Replied at 7:25 AM, 27 Jan 2014

Dear All,

Thank you again to everyone who participated in our virtual Expert Panel, "Connected Health for Providers: Information Technologies to Improve Health Care Delivery", late October/early November 2013. Starting today until Monday, February 3 at 9AM EDT, we invite you to take a final short 5-question follow-up survey at this link:

Results from this survey will help us understand the impact of our Expert Panels 3 months later and how we can improve.

Best, Sophie

Isabelle Celentano Replied at 2:30 PM, 31 Jan 2014

Thank you once again to all of our colleagues here in the community for taking the time to share such important insights and expertise during this Expert Panel discussion.

We have summarized some of the common themes and key points shared here in a new Discussion Brief, which can be accessed on the GHDonline website by visiting:

We encourage everyone to continue the conversation by chiming in with experiences you might have with health IT either as a provider or a patient, or with ideas on how the impact of these innovations in technology can be measured.

Also, one final reminder about our 3-month follow-up survey, which closes on Monday morning.

The survey is 5 questions long, but should only take 2 - 3 minutes to complete (really!) - your responses help us understand the impact of these Expert Panels and how we can improve these kinds of discussions in the future.

If you haven't taken the survey already, your feedback would be greatly appreciated:

Many thanks,

This Expert Panel is Archived.

This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.