Digitized Medicine

Mandating Masks at Schools When the Infectivity Rate Goes Up: A Responsible Action

I am a 61 year-old ER physician who has worked at a pediatric ER in Dallas-Fort Worth for 30 years.  At my job I take calls from other ERs across North Texas who have critically ill or injured children that need admission to a pediatric ICU.  For 30 years I have always accepted those transfers.  But multiple times I’ve recently had to turn them down because our ICU is “full” (no more beds).  We then help send those critically ill children to West Texas, Arkansas, New Mexico, Oklahoma or wherever a pediatric ICU bed can be found.  

How would  you like to be the parent of one of those children sent hundreds of miles from home? 

And if you are a school superintendent or school board member, how does this real-life story from the frontline make you feel about supporting school policies that allow unvaccinated, mask-less people around the children you are responsible to care for?

Bed shortages this severe did not happen before Covid-19.  The pandemic is real (come visit the ER to see for yourself), vaccines work (nearly all hospitalized are unvaccinated) and masks have been proven to reduce the risk of infection for over 100 years (since the 1917 pandemic).  They work, and that's why you expect your surgeon to wear a mask during surgery to prevent the germs in their mouth and nose from getting into your surgically-exposed body.    

Mandating masks makes sense when the infectivity rate goes up.   

Are you and your school districts going to be part of the solution, or part of the problem?  

 

Vaccine Mandates, Hyperbole and Hypothesis

Today my hospital’s leadership mandated Covid-19 vaccination.  Get vaccinated, or get terminated.  I get it, and I love it!

It is an ethical decision for us to get vaccinated-- to protect the children we serve, and also to do our part to give the virus fewer victims to infect (because as more people get infected, higher goes the risk for the virus to mutate into a more dangerous or even resistant variant).

For your friends and acquaintances who are hesitant about vaccine safety, there’s a lot of clear information in the message my hospital delivered today: Cook Children's Health Care System Mandates Covid-19 vaccination

Regarding the potential for long term side effects from Covid-19 mRNA vaccines, I like this article from another children's hospital, Children's Hospital of Philadelphia:   Covid-19 vaccine safety

 

My two-cents worth regarding the speed with which these Covid-19 vaccines were developed and approved for use:

The pandemic gave research scientists an unprecedented number of people around the world who eagerly volunteered to be trial patients to test the vaccine; the worldwide prevalence of the infection also created an environment where a large percentage of these trial patients quickly got exposed to Covid-19.  Within a remarkably short period of time, a significant number of trial patients who got the placebo instead of the vaccine got infected.  These conditions greatly shortened the time it took for research studies around the world to reach the statistical degree of confidence needed to affirm vaccine efficacy and safety--the same level of confidence as previous vaccine studies that took a decade or more to develop and test!  Its not hard to imagine vaccine trials taking longer to draw statistical conclusions for diseases that are much less prevalent than Covid-19.  In addition, the mRNA technology allows new vaccines to be developed and scaled up in an exponentially shorter time than the previous methods of vaccine development.  Prior to Covid-19, this technology had fortunately already been used for more than a decade in the development and testing of other vaccines, so it did not have to be built from scratch when the novel coronavirus sprang loose.

And, please, can people just stop being so gullible to all those bizarre vaccine myths?  When seeking the truth about the vaccines I personally have high confidence in the conclusions of research scientists who are paid to make hypotheses and then design studies to prove or disprove those hypotheses.  If they do so in an unethical manner, they lose their jobs.  Plus, I can look at the data myself if I want further proof.  I have actually looked at some Covid-19 research data, and IMO it is solid.  On the other hand, I am always highly skeptical of any information provided by TV and social media pundits who are paid to get high ratings.  Rather than designing studies to prove hypotheses, they design rhetoric to create hyperbole.  Hyperbole is exciting.  But hyperbole is opaque and dangerous.   Proving hypotheses is boring.  But the conclusions are transparent and tangible. 

Getting the COVID-19 shot is A-OK!

Getting your Covid-19 vaccine shot is “A-OK”—an Act Of Kindness.  And it is a broad, intentional act of kindness rather than a  narrow, random  one! 

I am an ER physician.  Here I am today being kind to my wife, my 96 year-old mother and anyone else who would be vulnerable to COVID-19 if I unintentionally infected them:

I  hope others share my feelings of excitement and confidence in the vaccine’s safety and effectiveness.  My own confidence stems from “insider” information from my son's fiancé, a biostatistician working on COVID-19 research studies, and my own observations as  I followed vaccine research progress this year.  I saw no shortcuts taken--just brilliant  scientific research within an environment of reduced bureaucratic red tape-- and a little bit of educated luck sprinkled in.  A truly astounding achievement!.

#A-OK  #WeAreCookChildrens

Because of the pandemic, because of the election, I pray

The 2020 presidential election was held only three days ago.    Since then:

• The number of daily new cases of COVID-19 in the United States has been exponentially increasing, now nearing 120,000 new cases each day
  • because of the pandemic 
• The number of people dying each day from COVID-19 is increasing 
  • because of the pandemic 
• The presidential race remains extremely close
•  An unprecedented number of people mailed their ballots rather than risking exposure to COVID-19 by going to a polling place
  • because of the pandemic 
• So most of the votes currently being counted are the mailed ballots
  • because of the pandemic
•  Local elections officials have a shortage of poll workers
  • because of the pandemic 
• So it is taking a really long time to tally the votes  
  • because of the pandemic 
• And election results in 5 closely contested states remain too close to call
  • because of the pandemic 
• After Trump began fanning conspiracy theories about voter fraud this past summer by denouncing mailed-in ballots and asking his followers to vote in person, he is now proclaiming victory and declaring voter fraud with no evidence of broad-based or systemic fraud
• After Biden encouraged voters to vote early or mail ballots to reduce risk of exposure to COVID-19, he is now winning the majority of mailed-in votes still being counted and is gaining on Trump in all the contested states
• Biden has asked Americans to be patient while legally casted votes get counted
• In the past 12 hours Biden took the lead in 4 of the 5 closely contested states after the lead apparently flipped in 2 of them 
•  Americans in general, and the news media in particular, have understandably been mesmerized by the presidential election and lost focus on COVID-19 even as new cases are reaching critical levels 

So this is what today, November 6th, 2020, is like:

• A chaotic election, the result of which will have a profound impact on how America addresses the pandemic
• A pandemic with exponentially rising rates of new daily infections which will have a profound negative impact on the economy for decades to come

How well we respond to the pandemic has direct correlation to how negatively the economy is affected.  For decades.  

 

I pray for America and our elected leaders.

WEAR a MASK and Don't Pee on Me!

When one is exposed to coronavirus floating around in the air while wearing a mask, naturally there will be fewer germs that get through the mask to one's nose and mouth than if one is not wearing one.   This is critically important, because emerging data suggests that being inoculated by a fewer number of germs at the onset of infection results in milder disease and more asymptomatic disease.  This is good news.  It may turn out that wearing masks to decrease the initial inoculum of germs is a more effective way to manage this pandemic than by locking down society.  

But this works only if we can effectively change people's attitude and behavior to always wear masks in public, and to NOT bow down to uninformed political statements or "patriotic" feelings about personal freedom.  Otherwise we end up risking more government-enforced shutdowns.

Stop at red lights,

don't take a loaded gun on a plane,

don't pee on someone sleeping on a public park bench

and WEAR a MASK!!!   

It's just what American citizens have to do during this pandemic.  It is not within your right to put my life at risk by running a red light, shooting a gun on a plane or infecting me with coronavirus.   And don't pee on me either.  That's gross.  You have NO right to threaten me or wetten me like that!

#LetsKeepOtherSfeAndDry

Dear Parent Who Refuses to Immunize Your Children: Are Going to Refuse the COVID-19 Vaccine?

Dear parent who refuses to immunize your children:

None of us are immune to the COVID-19 virus, so it is rapidly spreading through our communities causing unimaginable changes to our lives.  This infectious disease is directly impacting your family.  Neither you nor your children nor their grandparents are immune.  Although your children are not in the age group considered at higher risk for severe illness, their grandma and grandpa are.  So if your children get a fever or cough this week, be sure to keep them away from your parents.  Also, since you are not immune, you can catch COVID-19 from your kids.  When you get infected, you may not feel any symptoms for 2-14 days, but during that time you are infectious and can spread it to other people, like your parents.  So if your children have a fever and cough, you should stay away from your parents for at least 14 days AFTER your children get well.  Your parents at much higher risk of death from COVID-19 as compared to the flu, so please protect them.  And take care to protect yourself, as your risk of dying from COVID-19 death is higher than for your children.  And even though your children have a very low risk of dying from COVID-19, it is not a zero chance.

You can clearly see how devastating this infectious disease is impacting your family and our society. When is it going to stop?

When a child or parent recovers from COVID-19, they will likely have at least temporary immunity to it.  Once 50-80% of us have been infected and gain that immunity, the virus will have difficulty finding a human host to infect.  This is called “herd immunity”.  Herd immunity will result in the death of the COVID-19 epidemic.  It is possible that it will re-emerge later if herd immunity drops down too far.  At this time we don’t know for how long we will individually remain immune to COVID-19 after recovering from it.

But when a vaccine becomes available, we will be able to artificially induce immunity in our children, ourselves and our parents. And if boosters are needed to prevent herd immunity from dropping, we will be able to get booster shots.

One thing for sure is that you don’t ever want to live like this ever again.

But the truth is that this is actually NOT unimaginable. This was once polio. This was once measles. This was once whooping cough. This was once rubella. Haemophilus meningitis. Meningococcal meningitis. Diphtheria. Tetanus. Pneumococcus.

Currently our society is protected against these infectious diseases because we can artificially induce immunity through childhood vaccines. But your children are not protected against them.  And if enough parents refuse to immunize their children, the herd immunity in our society will fall below the level needed to prevent the next infectious disease epidemic.  The next epidemic could be polio, measles or pertussis.  Children and adults can die from diseases we can prevent through vaccinations, in some cases with higher death rates than COVID-19.

So when a COVID-19 vaccine becomes available, are you going to refuse to immunize your children?  And are you going to continue to refuse to immunize your children against the other infectious diseases that used to cause epidemics and kill people?  If so, just know that your fears are placing your parents and other children at risk of dying from a preventable disease.

Autonomic Angst Conjured By The Word-Which-Must-Not-Be-Spoken to Physicians

If while speaking to a group of physicians you use the word “provider” before you come to your important point, you will never get your point across.  In fact, you may not even get another sentence in, such is the autonomic angst conjured by the word-which-must-not-be-spoken. 

Most physicians resent being called the word-which-must-not-be-spoken, and some are instantly enraged by it.  Protect your valuables should you let it slip out of your mouth.  It is felt by physicians to be demeaning and disrespectful.  There are many reasons given for this, but I think the root cause is that the word-which-must-not-be-spoken is intertwined with bureaucratic red tape that has increasingly constrained the practice of medicine, especially over the past decade.  For example, the CMS Meaningful Use, PQRS and MIPS payment programs are all written for “eligible providers”.   Literally thousands of pages of rules, regulations and policies that impact the day-to-day activities of those who are said to be a word-which-must-not-be-spoken.   

Who wouldn’t resent such a word?

This happened because the word-which-must-not-be-spoken was adopted by policy writers for the rules and regulations associated with Medicare and Medicaid, as well for private insurance payors, to lump together all of the clinicians they pay for providing health care services to their clients.  To make it easier to write such regulations and policies, a single word was chosen to describe all the people that this word intentionally lumps together--physicians (M.D.s and D.O.s), nurse practitioners, physician assistants, podiatrists, chiropractors, dentists, anesthesiology assistants, audiologists, certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists, clinical social workers, occupational/physical therapists, psychologists, registered dieticians and speech language pathologists to name a few. 

It sounds reasonable to lump all those people in with one word when writing policy rather than writing the whole list every time, doesn’t it?  But the word-which-must-not-be-spoken has unfortunately spilled out of regulatory-speak into common vernacular.  Personally, I can verify that after reading a 400-page CMS rule where the word-which-must-not-be-spoken is used over a thousand times,  it gets imprinted on the brain and difficult to avoid using for several weeks afterward.  So now PCPs are not primary care physicians anymore, but instead are called primary care words-which-must-not-be-spoken. 

So, one may ask, why did the policy writers not call us clinicians instead?  That would be more palatable. 

Well, the issue is that CMS and private payors also pay “entities” such as acute care hospitals, long-term health care facilities, physician practices and other clinical facilities and practices.  All of these entities are also considered to be “providers”, but they are not clinicians. 

Since entities do not have independent thoughts or feelings, they are not offended by the word-which-must-not-be-spoken, so you can call them providers without fear for your valuables.  In my opinion, it would have been better for policy writers to differentiate clinicians (people providers) from entities (facility providers), but that boat left the dock more than a decade ago.

I admit to being rankled for many years by the word-which-must-not-be-spoken, but I've gotten over it.  If one ignores the connotation of the word due to its overuse in bureaucratic red tape, it is really not such a bad word.   In fact, look it up in the dictionary, and you will see it is actually a word one should be proud to be called. 

Although I understand the autonomic angst conjured by the word-which-must-not-to-be-spoken, as it has been thoroughly butchered by government policy writers, at the end of the day call me a "provider of quality healthcare" and I'll go home happy.

Or just call me "Matt".

Matt Murray, M.D.

Provider of Quality Healthcare

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Does use of a Scribe in the Emergency Department Increase Productivity and Improve Patient Flow... Yes, But...

Does use of a scribe to document in an electronic health record (EHR) increase an ER physician’s productivity?  Do scribes improve ED physician’s satisfaction with their profession?  Do scribes help improve ED patient flow? Well, overall yes, scribes improve productivity, but not necessarily for all ED physicians.

I am a pediatric ER physician and my pediatric emergency department (ED) has a scribe program.  Use of scribes was "free" until 3 years ago when our organization decided to stop paying for scribes.  A compromise was made, though, with ED physicians--we could individually decide to continue using scribes, but would have to pay half the cost.  All but 2 of 28 ER physicians decided to continue using scribes.  The cost is essentially covered by seeing a couple additional patients each shift.  Clearly the majority of us feel scribes improve wRVU production by more than that.  And since ED physician productivity is one of the main factors within the ED patient flow diagram, increased productivity correlates with fewer bottlenecks and overall improved ED patient flow. One colleague told me he sees a 20% decrease in productivity when he does not use a scribe, but the degree of impact varies from physician to physician in our group.  Part of the increased productivity has to do with tasks a scribe can do other than EHR scribing, like fetching this or that.  And in some cases, it looks like scribes help physicians cherry-pick lucrative patient cases---don't get me started on that one (I finally figured out why I never got to see the known appy patients that got transferred in).

All of our most highly productive ER physicians use scribes.  In addition to being naturally gifted "fast" physicians, they spend less time on documentation during their shift.  Most of their notes are in draft form at the end of the day.  Some will spend 45-60+ minutes editing and signing notes after their last patient, but most will go home and complete the notes 1-2 days later.  I think scribes are particularly valuable to those faster-types of physicians, both for productivity and for physician satisfaction.  Scribes allow them to maintain a fast pace with less work to do after their shift to complete charts.  

I am one of the two exceptions who chose not to pay for a scribe.  Both of us take a methodical approach to seeing patients, hence neither of us are in the high productivity range, but neither of us saw our productivity drop.  In fact, I eventually found that I could see more patients without a scribe.  Most of my notes are completed and signed when the patient is discharged, and typically the rest of my notes are completed within 30 minutes after seeing my last patient.   My method of working requires me to spend a lot more time documenting during my shift as compared to "fast" physicians, unless its crazy busy when documentation simply has to go out the window for the sake of getting patients seen and properly cared for. 

Why would some physicians like myself be faster without a scribe?  This would be a great subject to study.  In my individual case I feel it has to do with how my mind processes information and my method of working.    

First, I am 59 years-old, and the framework for my thought processing in previous decades was built around formulating a plan as I wrote out my ED note on paper.  When EHR and scribes came along, I found it difficult to process information and formulate a plan while verbalizing information to a scribe, so I ended up using a small notepad to write brief notes to help me "think" as I spoke to the scribe. I apparently need to see the words to help me plan. With voice recognition I can see my words going onto the screen, similar to when I saw them going on paper, and I thus find myself better able to process information and formulate a plan simultaneously.  Second, although I'm older and not as efficient using a keyboard as my younger colleagues, I'm tech savvy.  After eliminating use of scribes I found ways to leverage voice recognition and certain personalization tools in our Epic EHR.  Using our voice-recognition tool I created HPIs, MDMs, critical care templates and discharge instructions with built-in [macros].  I also created voice commands to dictate frequently used smartphrases that can be built in Epic.  Whenever I found my hands leaving the mouse and dictation device to reach for the keyboard, I would make note of that and later on think about ways to eliminate the need for a keyboard in that particular situation using voice recognition or personalization tools within the Epic EHR.  For frequent point-and-click actions (i.e. Save, Enter, Order, Open My Note....) I programmed buttons on the dictation device which significantly reduced mouse clicks.  Thus, I now spend most of my day with one hand on the dictation device and the other on the mouse, and happily see more patients without a scribe.

So in our group nearly all of the ED physicians subjectively feel scribes improve their productivity and, as a result, improve ED patient flow.  Even when the organization reduced reimbursement for the scribe service to 50%, nearly all chose to pay for their scribe service.  At least one ED physician sees a 20% decrease in productivity without a scribe, but the degree of impact varies from physician to physician..  And finally, the two ED physicians who decided not to pay for a scribe were able to maintain, or even increase, their productivity.    

Prayers and Praise from an ER Physician for the Spiritual Marrow of Hurricane Harvey Victims

I am more than 400 miles from the Texas Gulf Coast, and I am a different person today.

 

I rarely write about my professional experiences as a pediatric emergency physician in Digitized Medicine.  After all, this blog "belongs" to my other passion which is to promote the maturation and use of health IT to improve the quality of healthcare.  But I had an extraordinary experience in the emergency room yesterday that connected the dots between personal face-to-face care and use of health IT to improve care.  It was extraordinary in how it led me on a personal journey to seek a better understanding, or perhaps acceptance, of human suffering under God's benevolent watch. 

 

In the ER I cared for a young boy whose family from Port Arthur, Texas, currently "resides" in a Fort Worth public shelter as a Hurricane Harvey flood victim.   In order to get medical record information on this displaced patient, I called the Greater Houston HealthConnect (GHH) which is a regional health information exchange (HIE) that remotely stores electronic health information for over 4 million patients from the Houston/Beaumont region in southeast Texas.  For patients in the Corpus Christi area the HASA HIE similarly stores patient information.   The HIE help desk representative took my name/phone number and told me I would receive a call-back in a few minutes from an HIE representative who was physically working at a Houston flood shelter.  Less than 5 minutes later I received that call.  It was as noisy in her background as it was in my ER.  The HIE rep asked me for the patient's demographic information, then found him in their database within one minute.  There was information from several hospital visits recorded that we together browsed through for a couple of minutes.  She would describe the types of online information available while I provided direction on what to skip and what to drill down into.  Although available data on this patient was sparse, our findings gave evidence to my initial diagnostic impression and reduced the risk of chasing unlikely etiologies of the patient's condition.  Considering the circumstances, I found the experience efficient and valuable.  

 

So if you are a physician seeing a displaced Hurricane Harvey victim, you may find HIE services useful for accessing additional medical record information:

 

• For patients from the Houston/Beaumont/Port Arthur region, call 832-564-2599 (GHH)
• For patients from the Corpus Christi area, call 210-918-1361 (HASA)
• More information is available on the Texas Medical Association website

 

Those are the facts of the story along with some practical advice.  But on a personal level I am a different person today.  

Before entering the room I reviewed nursing notes which informed me that this young boy and his mother had been sent from Fort Worth's emergency shelter.   I took a moment to mentally prepare myself and entered the room.  Since nature had physically displaced this mother from her home, family and friends, I felt sure I would see and feel the emotional strain that such isolation must yield.  Despite this preparation my heart pierced and spine shivered as soon as I looked into mother's eyes.  They were deep and disturbingly languid.   But I was honestly not prepared for a different feeling--one that was difficult and seemed to come from within my own being--that slugged me in the gut as we sat face-to-face.  I did not understand in that moment exactly what I was feeling.   I had a job to do and just got busy serving this family to the best of my ability.

 

I understand through training and experience that physicians should remain aware of the potential transference of emotions from patient to physician.  So after my ER shift I took some time at home to quietly discern what it was that struck me so harshly.  I recognized that I had indeed felt the transference of emotional fear from homelessness and loneliness due to isolation.  But I gradually came to realize the most disturbing emotion--the one that sucker-punched me--actually originated from within myself.  It was my own personal thoughts and feelings about this mother's worldly disempowerment that pierced my heart and shook my spine as we sat and spoke.     

 

However, while in the room I also sensed something else in the fabric of this young mother's framework that served as a basis of survival, even if just by a thread.  Afterall, she had made it to an unfamiliar hospital with her ill son from a flooded home more than 430 miles away.  I was sure she must have some physical and mental attributes that served as sources of some strength, but I felt something much deeper.  As I later reflected on this, I came to firmly believe that this young mother's core framework of strength must be built around her spiritual marrow.   A marrow encased in bone that nature cannot break.  A marrow with everlasting spiritual empowerment.  A marrow undisturbed, and even strengthened, by worldly strife.  

 

With these thoughts in mind I turned to the book of Psalms.  I found a chapter that spoke to me about the spiritual marrow of righteous people who nevertheless are afflicted with suffering:   

 

Psalm 34:19-21

The LORD is close to the brokenhearted, saves those whose spirit is crushed.  Many are the troubles of the righteous, but the LORD delivers him from them all.  He watches over all his bones; not one of them shall be broken.

I give praise to God's gift of spiritual marrow.   I pray for all victims of natural disaster.   Love and blessings to each of them.  

 

 

mm

 

 

 

Although the behavior of one EHR vendor was wrong, more serious problems are inflicted by government-run EHR certification criteria

This week eClinicalWorks resolved a lawsuit by agreeing to pay $155 million for falsely claiming it met Meaningful Use (MU) EHR certification criteria.   Although the alleged behavior of eClinicalWorks was wrong, we have much more serious problems inflicted by the government-run EHR certification criteria.  

The business of EHR vendors is to gain clients and earn profits.  Developing innovative tools that help physicians care for patients should be the primary focus of their business.  Instead, vendors are held hostage to government-run certification criteria that are constantly changing and sometimes ambiguous.  While I do not condone the apparent behavior of eClinicalWorks, I am much more concerned about the  certification processes that led to this situation.   

The certification process evolved out of the 2009 HITECH Act that promoted the use of EHR technologies by offering incentive payments to hospitals and physicians who successfully adopted and used EHRs.   This resulted in an unprecedented rush of business for EHR vendors.  While EHR vendors began ramping up resources to meet the demands of the sales cycle and EHR implementations, they were also hit with government-imposed EHR certification criteria--criteria that are still changing frequently and sometimes are ambiguous.  This exponential increase in EHR client demands along with rapidly changing certification criteria crushed EHR vendor resource availability.  This constraint on resources forced them to focus on developing and testing EHR products to meet the specific certification criteria required by the government.  In my opinion, the unintended consequence of overwhelmed EHR vendors is that they then did not have available resources to focus more on:

1. Improving usability
2. Identifying and managing patient safety risks inherent to EHR use
3. Developing innovative tools and functions that actually improve how physicians care for patients 

As a result, EHRs were developed to meet MU EHR certification criteria, but failed to improve poor usability.  EHR products could meet certification criteria, yet fail to adequately address patient safety risks associated with implementation and use.  And the constraint on EHR vendor resource availability remains an impediment to the development of innovative tools and functionalities that EHR vendors really should be focusing on today.

Physicians do benefit from EHR certification by reducing risk during the EHR selection process.  That is why the Certification Commission for Health Information Technology (CCHIT) was created in 2006 as an independent, not-for-profit group.  CCHIT certification was based on a consensus of stakeholders who determined core functionalities that a basic EHR should provide.  I participated in that effort, albeit in a brief, very small way (providing some input on pediatric core criteria).  I recall we were careful to avoid requirements that could hinder EHR product innovation.  CCHIT ceased operations in 2014 after the government created the MU EHR Certification program.  

CCHIT certification was much less prescriptive than what the government imposes today.  Less prescriptive EHR certification was, in retrospect, the right approach to take.  And we did it without government involvement.  Government works at its own hindered pace, and that pace is much slower than what an unencumbered EHR market could accomplish.  I think the government needs to get out of the EHR certification business.   But whether government remains involved or not, the EHR certification process needs to learn from CCHIT and rely more heavily on building consensus of physician stakeholders.  We will do what is best for our patients.    

So, this week one vendor was called out by the government for false claims regarding EHR certification.  But that one vendor is really not the problem.  The real problem is that the development of all EHR products has been, and still is, impeded by the government's EHR certification program.  

Matt Murray, MD

cook children's health care system..