Customer Relationship Management CRM in Modern Health

Customer Relationship Management CRM in Modern Health Care Delivery Group Presentation – IS 6800 Renee’ Ross Hung Winn M. D. , J. D 1

Agenda w w w w Definition of CRM Importance of CRM to General Managers Statistics Industry leaders Success stories Case Study – MU Healthcare System Best Practices Lessons Learned 2

CRM – What is it? w CRM – “Strategy used to learn more about customers’ needs and behaviors in order to develop stronger relationships with them” http: //guide. darwinmag. com/technology/enterprise/crm/index. html? ; last accessed September 27, 2004. w CRM – “Any application or initiative designed to help an organization optimize interactions with customers, suppliers, or prospects via one or more touch points – such as a call center, salesperson, distributor, store, branch office, Web, or e-mail – for the purpose of acquiring, retaining, or cross-selling customers. ” Goodhue, D. L. , Wixon B. H. , and Watson, H. J. , “Realizing Business Benefits Through CRM: Hitting the Right Target In The Right Way” MIS Quarterly Executive, Vol. 1, 2, 2002, pp. 79 -96. w CRM introduced in 1993 3

Importance of CRM to GM’s w CRM can…. n n n Increase customer service levels Improve efficiency of call centers Cross-sell products more effectively Help sales staff close deals quickly Simplify marketing processes Increase ROI http: //guide. darwinmag. com/technology/enterprise/crm/index. html? ; last accessed September 27, 2004 . 4

Importance of CRM to GM’s “Research has shown that companies that create satisfied, loyal customers have more repeat business, lower customeracquisition costs, and stronger brand value —all of which translates into better financial performance” http: //siebel. com; last accessed October 17, 2004. 5

CRM Spending w w 2001 - $8. 8 billion 2003 - $9. 4 billion 2005 projection - $30. 6 billion Gartner estimates that large businesses spend between $30 million and $90 million on CRM initiatives over a 3 -year period Mello, A. , “Watch out for CRM’s hidden costs” October 17, 2001; http: //techupdate. zdnet. com/techupdate/stories/main/0, 14179, 2818263, 00. html; last accessed on October 29, 2004. 6

CRM Spending w Budgeting for CRM – hidden costs n n Project management Software integration Data maintenance Training w Gartner revealed many businesses underestimate CRM costs by 40 -75% Mello, A. , “Watch out for CRM’s hidden costs” October 17, 2001; http: //techupdate. zdnet. com/techupdate/stories/main/0, 14179, 2818263, 00. html ; last accessed on October 29, 2004. 7

CRM Infrastructure Dyche, J. , The CRM Guide to Customer Relationship Management, Addison-Wesley, Boston, 2002 8

CRM Targets / Components w Applications w Infrastructure w Transformation All three are necessary, to some degree, for successful implementation of CRM initiatives Goodhue, D. L. , Wixon B. H. , and Watson, H. J. , “Realizing Business Benefits Through CRM: Hitting the Right Target In The Right Way” MIS Quarterly Executive, Vol. 1, 2, 2002, pp. 79 -96. 9

Retention vs. Acquisition w. Retention of customers gives greater benefit over acquisition of new customers • Builds trust and loyalty • Up-sell and cross sell opportunities w. Move customers through the lifecycle §Acquisition, Growth and Retention §Movement will maximize their value and increase profits Ref 21, 22 w. Studies indicate that increasing the number of customers a company retains each year by just 5% can increase contribution to shareholder value by 40% to 95% 10

Retention vs. Acquisition w Average U. S. companies lose 20% of customers every year – not knowing why w Costs 6 to 7 times more to attain a new customer than to retain current customers http: //www. crmtrends. com/crm. html; last accessed October 28, 2004. Bleicher, Paul. “An Imposing Change. ” Pharmaceutical Executive. Jun 2004. p. p. 26 -30. 11

CRM Success Stories w 80% of organizations report success with CRM programs w Examples n Union Pacific Railroad (Siebel) l n 4500 users / Replaced legacy system / Strategic part of overall business intelligence strategy Northwestern Memorial Hospital, Chicago (People. Soft) l 5800 employees / Replaced legacy system / “Automation means clinicians can focus more time on patient care. Having People. Soft as a support system will help us achieve our mission of patients first. ” Ref 7, 16, 20 12

CRM Failure w Failure rate of 15 -25% w 85% of CRM users cannot quantify benefits Krass, P. , “CRM: Once More, Without Reeling” March 17, 2003; http: //www. cfo. com/article/1, 5309, 8948/BS/12/4, 00. html; last accessed October 15, 2004. 13

CRM Industry Leaders 14

w Company Information n n w Headquarters in San Mateo, California Founded 1993 5000 employees 2. 8 million users at 4, 000+ organizations 2003 revenue - $1. 35 billion Strategy n w “CRM for Everyone” – CRM software solutions for any kind of organization, any type of user, and any budget Product Offerings n n Siebel Business Analytics Siebel On Demand Siebel Sales Siebel Professional http: //siebel. com; last accessed October 17, 2004. 15

w Company Information n n Headquarters in Pleasanton, California Founded 1987 12, 000 employees Serving 12, 200 organizations 2003 revenue - $2. 3 billion w Strategy n Flexible and adaptable business solutions w Product Offerings n n n 1. People. Soft Enterprise One People. Soft World http: //www. peoplesoft. com; last accessed October 17, 2004. 16

w Company Information n n Headquarters in Bellevue, Washington 900 customers in 50 industries w Strategy n Through three audience-specific portals, Onyx Employee Portal, Onyx Customer Portal and Onyx Partner Portal, Onyx Enterprise CRM provides proven technology ideal for business environments that need flexible, reliable and manageable CRM w Product Offerings n n n Onyx CRMExpress Onyx Portable CRM Onyx Analytics http: //www. onyx. com; last accessed October 17, 2004. 17

w Company Information n n Headquarters in Waldorf, Germany Founded 1972 30, 000 employees 2. 8 million users; 1, 500 partners w Mission n To provide collaborative business solutions for all types of industries and for every major market w Product Offerings n n n 1. my. SAP Business Suite my. SAP ERP SAP x. Apps http: //www. sap. com; last accessed October 17, 2004. 18

CRM and Electronic Medical Records (EMR) w “Initiative designed to help an organization (physician / hospital) optimize interactions with customers (patients) for the purpose of acquiring or retaining customers (patients). ” Goodhue, D. L. , Wixon B. H. , and Watson, H. J. , “Realizing Business Benefits Through CRM: Hitting the Right Target In The Right Way” MIS Quarterly Executive, Vol. 1, 2, 2002, pp. 79 -96 19

Need for EMR w Archaic information systems w According to the Journal of American Medical Association, “as many as 98, 000 patients die each year in U. S. hospitals from preventable medical errors w Lack of reliable health information. Swartz, Nikki, “A Prescription for Electronic Health Records” Information Management Journal, Vol 38, 4, 2004, p. 20 -22. 20

Market for EMR w The market for EMR for physicians excluding the hospitals is $500 M in 2004 and expects to grow to $ 5 B in 2008 J. Larson, The Arizona Republic 21

National Agenda for EMR w “ BY COMPUTERIZING HEALTH RECORDS, WE CAN AVOID DANGEROUS MEDICAL MISTAKES, REDUCE COSTS AND IMPROVE CARE” w In the US, every patient should have EMR or EHR within 10 years President Bush’s State of the Union address, 1/20/2004 22

Electronic Medical Records w In Massachusetts, Blue Cross & Blue Shield of Massachusetts plans to donate $50 millions to fund a pilot project that electronically links patients’ medical records between the hospitals and health care providers in 3 communities. w The goal is building a statewide EM system that connects hospitals and clinics. This mission has a widespread support among insurers, hospitals and doctors. L. Kowalczyk, Global Staff 23

Electronic Medical Records (EMR) w Transition from paper medical records (PMR) to EMR requires strong physician leadership and institution’s committeemen of human and capital resources 24

Case Study MU Healthcare System 25

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Case Study w MU HEALTH CARE SYSTEM MU Health Care system consists of 2 operational entities: l School of Medicine (SOM) w University Physicians (UP): medical practice l MU Health Care w University Hospital w Columbia Regional Hospital w Clinics 27

MU School of Medicine 28

MU School of Medicine (SOM) w DEAN n n n Associate Deans Chairpersons of Basic Science Departments Chairpersons of Clinical Departments (Medicine, General Surgery, Obstetrics and Gynecology, Pediatrics, Family Medicine…) l UNIVERSITY PHYSICIANS 29

University Physicians w Headcount: n n UP: 635 (370 physicians + 265 staff) IT: 22 or 3. 5% of total UP headcount w Budget: n UP ‘s revenue: 110 M IT services: 2. 7 M or 2. 5% of revenue Electronic medical records (EMR) n IDX system: scheduling and billing n n 30

MU Health Care w EXECUTIVE DIRECTOR n n CIO, CFO Hospital Directors UNIVERSITY HOSPITAL l COLUMBIA REGIONAL HOSPITAL l CLINICS l 31

University Hospital 32

University Hospital w Tertiary acute care hospital w All services except Women’s Health and Neonatal Intensive Care Unit (NICU) w Trauma Center w 260 Beds w Number of patients served: 11, 532 (2003) 33

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Columbia Regional Hospital w 262 -bed acute care hospital w Surgery: Orthopedic Surgery, Urology, General Surgery w Medicine w Women’s Health Services: Obstetrics, Gynecology and others w Neonatal Intensive Care Unit (NICU) w Number of patients served: 6, 477 (2003) 35

MU Health Care w Headcount: n n MU Health Care: 5700 employees ITS: 108 or 1. 9% of the total headcount w Budget: n n MU Health Care: 620 M ITS: l l l 13. 5 M or about 2. 2% of the total revenue 50% of budget for personnel 50% of budget for hardware, software and outside supporting services w Total beds: 522 w Total in-patients served: 18009 w Total out-patient visits: 544, 395 36

MU Health Care System w Customers: n n Health care providers: physicians Patients w Electronic clinical information is the organization’s effort to recruit and retain customers. n n Operational efficiency Improved quality of care 37

MU HEALTH CARE SYSTEM w Hospital Clinical Information System w Electronic medical records (EMR) 38

MILESTONE DEVELOPMENTS w Fall 2001, Vice Chancellor for MU Health Care System, committed to develop electronic medical records. w Dean and Executive Director strongly supported the project w A physician leader was appointed as a liaison between IT leadership and physicians. w Cerner was selected as a technical provider for the project. w Goal: Incremental implementation of system-wide electronic health information (EHI) 39

CERNER RELATIONSHIP w December 2001 n n Technology fees, traditionally referred to as “licensing and support” Consulting (implementation) fees – pay as you go w September 2003 n Outside consultants to renegotiate the contract 40

CERNER CORPORATION w Founded in 1979 w Headquartered in Kansas City w Leading supplier of healthcare information technology, with more than 5, 273 associates and 1, 500 clients worldwide. w In 2003, it had a revenue of $839. 6 million and net income of $42. 8 million. 41

CERNER CORPORATION w Offers centralized electronic medical record to seamlessly deliver health information such as laboratory results, images, medication and allergy data to health care teams that depend on complete, timely information. This increases measurable quality of care w Enables executives to manage resources, comply with regulations and recognize trends and best practices by combing clinical, operational and financial data from across the enterprise and the industry. 42

ELECTRONIC MEDICAL RECORDS w The cost of converting paper medical records to electronic medical records is $10, 000 – 30, 000 per physician. w The cost of electronic clinical information is between $50 M – $100 M for health care system of 2 - 3 hospitals L. Kowalczyk, Global Staff M. K Mc. Gee, Informationweek. com 43

EMR’s Progress w 2002 n The projects was launched but progress was impaired by concerns about MU Health Care System’s fiscal situation. w 9/2003 n The project was reactivated on an accelerated time frame. 44

Patients' Medical Information Clinics w Demographic information including insurance w History: allergy w Physical examination w Laboratory: blood tests, radiographic images w Diagnoses w Treatments 45

Patients’ Medical Information Hospitals w Demographic information including insurance w Physician’s initial evaluation n n History Physical examination Laboratory: blood tests, radiographic images Diagnoses Treatments 46

Patients’ Medical Information Hospitals w Subsequent visits: n Progress notes: medical students, residents and attending physicians w Physicians’ orders w Nursing notes: vital signs and assessment 47

Traditional Medical Information Drawbacks w Important clinical information is not timely available: n n outpatient information is not available when the patient is admitted to the hospital Consultations w Inefficiency: n n Duplication of effort Time consuming Illegible records Missing medical records 48

HCFA Compliance Consultants Transport Family Ethics Pharmacy Techs Attending PATIENT Residents Student Nurses Med record OR Clerks Xray Lab Insurance Student JCAHO Policies Computer 49

Hospital Clinical Information System UH CRH Medical records Cerner HBOC Orders Cerner HBOC Materials management Procure IMMS Clinical pathology ALG (UH only) ALG (CRH only) Anatomic pathology Co. Path M Western star Pharmacy Pharmakon HBOC Operating room Surgi. Serv ORSOS Radiology MARS HBOC Cardiac cath lab Whitt (UH only) Whitt (CRH only) 50

Accomplished Projects w Hospital clinical information system (UH) n n n Physicians’ orders Profile (medical records management) system at UH Document imaging – clinical and financial w EMR (UH and Clinics) n n n Clinical information is flowed into the Central Data Center and thus retrievable through Powerchart Documentation with Powerchart First. Net – Emergency Department’s tracking and triage w Cerner runs the Central Data Center off campus w Power Chart is an electronic format of standard consultation notes, progress notes and operative notes. 51

POWER CHART w Physicians’ electronic medical records w Structured documents: n n n Consultation notes Progress notes Operative notes w Secured electronic signatures 52

Current Projects 2004 w Pharmacy system – UH – complete w Operating Room Management system – UH w Replacing: n n Radiology system - UH/CRH Anatomic pathology system - UH/CRH Clinical pathology system - UH/CRH Blood bank system - UH/CRH w Physician and nursing documentation on-line for inpatent documentation w “Power Chart office” in the clinics 53

EMR Program’s Goals Patients: Improved quality of care Providers: Better working environment MU Health Care System: Enhanced financial performance 54

EMR’s BENEFITS w Patient care will improve n n Better health outcomes Higher satisfaction w Providers’ lives will be better n Easier, more time to provide good care from improved efficiency w The bottom line will be enhanced n Decreased costs, increased revenues 55

What are medical errors? w Adverse event (AE): injury or death of a patient w Near miss: an event or situation that could have resulted in AE but did not w Medical Error: n n failure in execution of plan and its details OR use of wrong plan 56

Complex Nature of Medical Care w ICU study n n n Average of 178 “activities” per patient per day 99% proficiency rate means 1. 7 errors per patient per day Even 99. 9% may not be safe enough 57

Latent Errors in System Design w Three Mile Island, Bhopal, Chernobyl, Challenger disaster w “Accidents waiting to happen” w Human error is proximate cause w Root cause(s) present in system - long time w The error is a symptom of the underlying systemic disorder 58

Perspective on medical errors w Physicians, nurses, pharmacists are highly trained, careful, and dedicated professionals w Lack of awareness of scale of problem w Most errors do no harm w Most errors are symptoms of the underlying systemic disorder. w EMR is one of the solutions to the systemic disorders of the health care delivery 59

The Work of Providers w What is the real work of health care providers, i. e. , those with direct patient contact? n n n Process information Apply technical skill Build relationships 60

Information Processing w Start with a baseline knowledge and experience w Acquire information from the patient w Supplement with examination and diagnostic testing – both past and present w Use baseline knowledge, occasionally supplemented information at time of care, to formulate a plan of care 61

Information processing w Communicate the plan n Orders/prescriptions – i. e. information transfer to other providers Information transfer to the patient Information to referring physician/PCP w Orders implemented w Charges applied to services rendered n Interfaced with IDX system for efficient billing and collection 62

Physicians and Information: Communication w With each other… n In. Box messaging w With our patients… n IQ Health w With our referring physicians n n Auto-fax Direct access w Employers 63

PHYSICIAN’S ORDERS HANDWRITTEN 0: 02 min Doctor writes order 0: 33 Average until unit secretary enters order 0: 11 Unit secretary enters order 0: 34 Average until nurse begins to verify order 0: 06 Nurse verifies order 1: 26 Pharmacy receives order ORDERS GENERATED ONLINE 0: 03 Doctor writes order/Pharmacy receives order Source: Modern Healthcare, 2001 64

EMR and Physicians’ orders w In hospitals, when physicians order medications for patients electronically, serious medical errors were reduced by 55%. D. Bates, M. D. , Brigham and Women’s Hospital. 65

Documentation w Documentation occupies a significant portion of physicians’ effort in providing medical care. w Good documentation improves medical care and a defense against medical lawsuits n More lawsuits are defended because of good record keeping than because of actual events. 66

Credibility of Medical Records w Delayed filing of lab results w Incomplete files w Illegible records w Altered records w Fabricated records w Loss and concealment of records 67

Physician Documentation w MUHC is in the forefront of implementing these capabilities n Over 100, 000 Power Notes have been completed – almost all inpatient w We have the skill and commitment of physicians necessary to continue progress in this area 68

Plan of Care w The most appropriate plan of care requires the presence of all needed information at the point of decision-making n In its simplest – this concept means everything now available on paper spread out across a system of care is available instantly in an organized, retrievable fashion at all locations of care via the EMR 69

Physicians and Information: Knowledge at the Point of Care w On-line resources w Structured documentation w Order sets w Alerts & reminders w Continuous Quality & Safety Improvement 70

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Health Insurance Portability and Accountability Act (HIPAA) w Secured access to the data: n n Password Electronic signature w Close monitoring access to EMR: n Employees are prohibited to view even their own medical records. 72

Benefits of EMR w Improves quality of care n n n Information available at time and place of care Reduces medical errors Improves coordination of care w Providers’ better professional lives n n n More efficient More effective Less professional liability Ref 3, 4, 5, 6 73

Benefits of EMR w Improves the institution’s financial performance: n n Improves billing and collections through timely and more accurately submitting the charges to insurers. Reduces healthcare costs resulting from inefficiency and incomplete information Reduces the cost of professional liability Increases volume by retaining and recruiting more patients and physicians Ref 3, 4, 5, 6 74

CRM Strategy w w w Balance the business in favor of the customer Maintain customer loyalty DATA, DATA Qualitative research to understand customers Develop specialty programs that meet customers’ interests w Know which markets and marketing strategies are the most profitable Ref. 26 75

CRM Best Practices 76

Best Practices w w w Vision / Strategy Know your Customer Differentiate Technology – data requirements Metrics Monitor Nelson, Scott, “Eight Building Blocks of CRM” Gartner Group, June 19, 2003; http: //www 2. cio. com/analyst/report 1483. html; last accessed October 25, 2004. 77

Vision / Strategy w Alignment of vision/strategy with: n n Business objectives Customer requirements w Organizational readiness, including capabilities, policies, incentives and practices Nelson, Scott, “Eight Building Blocks of CRM” Gartner Group, June 19, 2003; http: //www 2. cio. com/analyst/report 1483. html; last accessed October 25, 2004. 78

Customer Analysis w Identify -- know who your customer is w Segment -- high-value, high-potential, lowpotential w Profile -- know your customer’s habits, behaviors and profitability Nelson, Scott, “Eight Building Blocks of CRM” Gartner Group, June 19, 2003; http: //www 2. cio. com/analyst/report 1483. html; last accessed October 25, 2004. 79

Technology – data requirements w Define and map data requirements n n What customer data is necessary? What system will the data come from? Nelson, Scott, “Eight Building Blocks of CRM” Gartner Group, June 19, 2003; http: //www 2. cio. com/analyst/report 1483. html; last accessed October 25, 2004. 80

Metrics w Metrics & goals must be established up front Nelson, Scott, “Eight Building Blocks of CRM” Gartner Group, June 19, 2003; http: //www 2. cio. com/analyst/report 1483. html; last accessed October 25, 2004. 81

Monitor w Get feedback from customers w Audit customer experiences by periodically sampling customer touch points w Use this information to measure effectiveness and identify areas for improvement Nelson, Scott, “Eight Building Blocks of CRM” Gartner Group, June 19, 2003; http: //www 2. cio. com/analyst/report 1483. html; last accessed October 25, 2004. 82

Lessons Learned w Need to pay close attention to triangle: people, process, and technology w Get executive involvement – top down w Establish measurable business goals w Implement incrementally w Ensure CRM architecture will scale to future needs as you grow Spitz, Keith. “Lessons Learned by a CRM Veteran. ” Computerworld. Sep 20, 2004. Vol. 38, p. 26 83

The Future of CRM w Top 5 CRM Trends for 2005 n n n Optimizing past CRM investments Customer retention Data analysis Channel integration Partnerships 84

Questions ? ? ? ? ? ? 85

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Goodhue, D. L. , Wixon B. H. , and Watson, H. J. , “Realizing Business Benefits Through CRM: Hitting the Right Target In The Right Way” MIS Quarterly Executive, Vol. 1, 2, 2002, pp. 79 -96. Swift, Ronald S. , “Executive Response: CRM is Changing Our Eras, the Information we Require, and our Processes” MIS Quarterly Executive, Vol 1, 2, 2002, pp. 95 -96. Chin, Tyler, “Data Mining, ” American Medical News, Vol 46, p. 19. Swartz, Nikki, “Doctors, Hospitals Advised to Keep Records Electronically” Information Management Journal, Vol 38, 1, 2004, p. 9. Swartz, Nikki, “A Prescription for Electronic Health Records” Information Management Journal, Vol 38, 4, 2004, p. 20 -22. Finkelstein, Joel B. , “Health IT chief: Public-private partnership needed for EMRs” American Medical News, Vol 47, 28, pp. 5 -6. Pastore, Michael, “CRM Spending Increases Despite Myriad of Market Players, ” November 2, 2000; http: //www. clickz. com/stats/big_picture/hardware/article. php/5921_502171; last accessed on October 11, 2004. http: //www. crmtrends. com/crm. html; last accessed October 28, 2004. Mc. Govern, Todd and Panaro, Joseph. “The Human Side of Customer Relationship Management” Benefits Quarterly, Vol. 20, 3, 2004, pp. 26 -33. Powers, Thomas L. , and Bendall, Dawn. “The Influence of Time on Changes in Health Status and Patient Satisfaction”. Health Care Management Review. Jul-Sep 2004. Vol. 29, 3; pp. 240 -248. Vandermerwe, Sandra. “Achieving Deep Customer Focus, ” MIT Sloan Management Review. Spring 2004. Vol. 45, 3; pp. 26 -34. Mello, A. , “Watch out for CRM’s hidden costs” October 17, 2001; http: //techupdate. zdnet. com/techupdate/stories/main/0, 14179, 2818263, 00. html ; last accessed on October 29, 2004. 86

References 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Miller, Robert H. and Sim, Ida. “Physicians’ Use of Electronic Medical Records: Barriers and Solutions. ” Health Affairs: Mar/Apr 2004. Vol. 23, 2; p. p. 116 -126. Krass, P. , “CRM: Once More, Without Reeling” March 17, 2003; http: //www. cfo. com/article/1, 5309, 8948/BS/12/4, 00. html; last accessed October 15, 2004. . http: //www. peoplesoft. com; last accessed October 17, 2004. http: //www. sap. com; last accessed October 17, 2004. http: //www. onyx. com; last accessed October 17, 2004. http: //www. convergys. com/; last accessed October 17, 2004. http: //siebel. com; last accessed October 17, 2004. Spitz, Keith. “Lessons Learned by a CRM Veteran. ” Computerworld. Sep 20, 2004. Vol. 38, p. 26. Bleicher, Paul. “An Imposing Change. ” Pharmaceutical Executive. Jun 2004. p. p. 26 -30. Lipscomb, Darrin, “Making the Case for Customer Relationship Management ” CRM Guru, April 12, 2004; http: //www. crmguru. com/articles/2004/Making the Case for Customer Relationship Management ; last accessed October 15, 2004. “Making the most of CRM” http: //www. pharmafile. com/pharmafocus/Features/feature. asp? f. ID=357&m=7; last accessed October 12, 2004 http: //guide. darwinmag. com/technology/enterprise/crm/index. html? ; last accessed September 27, 2004. Nelson, Scott, “Eight Building Blocks of CRM” Gartner Group, June 19, 2003; http: //www 2. cio. com/analyst/report 1483. html; last accessed October 25, 2004. Nancarrow, Clive and Rees, Sharon and Stone, Merlin, “New Directions in Customer Research and the Issue of Ownership: A Marketing Research Viewpoint, ” Journal of Database Marketing, Vol. 11, 1, 2003, pg. 26. Dyche, J. , The CRM Guide to Customer Relationship Management, Addison-Wesley, Boston, 2002 87

References 29. 30. 31. 32. 33. 34. Larson, J. , The Arizona Republic President Bush’s State of the Union address, 1/20/2004 Kowalczyk, L. , Global Staff Mc. Gee, M. K. , Informationweek. com Modern Healthcare, 2001 Bates M. D. , J. Brigham and Women’s Hospital 88