The pMD Blog

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pMD Blog...

where we cover interesting and relevant news, insights, events, and more related to the health care industry and pMD. Most importantly, this blog is a fun, engaging way to learn about developments in an ever-changing field that is heavily influenced by technology.


These days the promise of what “the cloud” can offer is ubiquitous across technology organizations: faster service, always-on systems, ready to support 100 customers or 100,000 in an instant! Who isn’t interested in those promises? Often for established companies like pMD though, with 20+ years under its belt, it can be tricky to decide where to begin using this magical tech.


Planning for the Cloud & The COVID Curveball


The cloud comes with its own set of challenges out of the gate, challenges that pMD had been considering and planning for long before 2020 arrived. Appropriate research and design work is essential to ensure the responsible use of cloud technology. There are cloud vendors to vet and agreements to sign to ensure data confidentiality and HIPAA-compliance. And once all the initial legwork is done, there’s the technical feat of migrating our well-established traditional processes and computer systems to a new cloud-friendly approach - all while ensuring we don’t create any hiccups for our customers along the way.


But 2020 had different plans for us all, and after doing all the necessary prep work to begin using Amazon’s cloud, we found ourselves needing to cash in on some of those cloud promises - speed, scalability, and reliability - much earlier than expected. It was clear we needed to adjust our strategy to keep pace with the rapidly growing needs of telehealth capabilities across the country and to continue supporting providers who needed solid systems they could rely on. So we did what any good customer-obsessed company would do: we tossed our cloud roadmap and redrew it based on immediate customer needs.


The Proving Ground: Getting Big Benefits from Amazon’s “S3”


Along with a boom in telehealth demand came the need for more boundary-pushing remote communications. Seemingly overnight there were more people using pMD video and voice chat for virtual visits with physicians. There were more patients contacting practices and communicating with health care providers directly over secure messaging. And there were more important pictures and documents being uploaded, downloaded, and sent between providers, patients, and families than ever before - an activity that produces large amounts of data traffic behind the scenes. By monitoring that data flowing on our systems, it became evident we could serve our customers better by moving the piece of pMD responsible for attachments and files to Amazon’s cloud.


With some careful planning and a little elbow grease, we were able to successfully migrate this small piece of pMD to Amazon’s S3 service, the same technology that helps power companies like Siemens, GE Healthcare, and 3M. Almost immediately we saw a huge benefit to everyone using pMD. Patients and providers were able to access their pictures and documents in secure chat and patient profiles faster. Files could now be accessed more reliably and consistently with fewer annoying glitches, and we were able to offer stronger-than-ever protection against accidental data loss. Thanks to our HIPAA-compliance agreement with Amazon and industry-standard encryption, it was no hassle to continue keeping sensitive data secure, just as we always have.


A Partly Cloudy Forecast


While we’ve only just begun to leverage the promises of what the cloud can offer, we have continued to let data inform where we need “cloud-scale” next in pMD’s evolution. This way we can ensure an ever-growing, more reliable product for our providers, health care teams, and their patients. Best of all, Amazon’s world-class security and HIPAA-compliance means we easily maintain our high standards when it comes to data protection, auditing, and compliance, allowing us to focus on speed, security, service availability, and continuing to deliver what matters most to our customers and their patients: a partner they can rely on in health care.


To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.



Here's The Latest in Health Care:


As the COVID-19 pandemic isolates patients, virtual care has proven to be a lifeline for patients who need behavioral health services. In fact, at the Department of Veterans Affairs, providers have conducted 1.1 million virtual mental health visits with more than 350,000 veterans this year. The continued use of virtual services could help open up access to behavioral health treatment for millions of patients, leading to a potential breakthrough in overall outcomes and medical spending.  Read More

CMS will begin recouping accelerated Medicare loans it sent as COVID-19 relief as early as Monday, which could exacerbate the financial stress on hospitals and doctor's offices as the pandemic worsens. Despite pleading for loan forgiveness or relaxed repayment terms, providers that received loans won't receive Medicare reimbursement from their claims until the amount of the loan they received is reduced to zero.  Read More

The coronavirus pandemic has significantly increased demand for home-based medical care. Particularly for patients who are older and frail, this model of care has provided a viable alternative to urgent care centers and emergency rooms to reduce the risk of infection. Like telemedicine, the shift to more home-based medical care has been accelerated due to COVID-19 and is anticipated to continue to grow long after the pandemic.  Read More

COVID-19 has placed unprecedented stress upon the health care system, but we may not see the most significant impacts for a couple of years. Analyses predict a gap in Medicare revenues during the next three years of close to $150 billion. Also, expected reductions in state tax revenue will make sustaining current Medicaid program funding increasingly tricky. The pandemic has created a perfect storm to alter our system for financing health care long-term.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, secure messaging, clinical communication, and care navigation software.

We can all agree that 2020 has been a unique year for all of us. As things change and shift, many things do still remain the same, including MIPS reporting! We’ve made it to the halfway point of the year, trying to figure out the new normal and what business-as-usual looks like, which may leave you with a fuzzy memory that quality reporting may still need to be completed this year.  

As a qualified MIPS registry, pMD has been keeping an eye on the changes and requirements for reporting in 2020. We continue to offer our customers the tools to submit their 2020 MIPS data to CMS and navigate some of these changes using our robust dashboard and excellent account management.

The Elephant in the Room


Do you have to submit MIPS this year in the midst of a pandemic? Maybe.

Other quality programs have previously released amendments to decrease the amount of data submitted to ease the reporting burden during the first and second quarter of this year. However, for MIPS 2020, eligible providers submitting any of the categories (Quality, Improvement Activities, Promoting Interoperability, and Cost) still have the full year’s worth of reporting on the table and there are no changes to the measure requirements. 

The QPP did include a new Improvement Activity to give credit to organizations that participate in COVID-19 clinical trials and offered a complete solution to that performance category:

“Clinicians could also pair the new COVID-19 clinical trials activity with the existing Participation in a 60-day or greater effort to support domestic or international humanitarian needs (IA_ERP_2) activity for full credit for the Improvement Activities performance category.”

For practices affected by the pandemic, you can apply for an exemption to re-weight Quality, Cost, Improvement Activities, and/or Promoting Interoperability performance categories to 0%. You can find the application and additional information here. CMS will provide the determination of your application via email to the email address you list on your application. 

Changes to Scoring


MIPS Year 4 is turning up the heat for additional data and higher scores.  We are met with increased data reporting requirements in two categories and a 50% increase in final score to avoid a negative payment adjustment.

1) Quality measures must meet 70% of data completeness this year. 
2) Improvement Activities must apply to 50% or more physicians within a group to attest.
3) The performance threshold has been raised to 45 points to avoid a penalty and 85 points to get an exceptional performance bonus.  

Changes to Payment Adjustments


Speaking of payment adjustments, the maximum penalties have been increased again this year.  Clinicians who fail to sufficiently report MIPS are subject to a penalty of up to -9% payment adjustment on Medicare Part B FFS payments. Since the MIPS and MACRA programs have budget neutrality requirements, the rates for positive payment adjustments depend on national submission performance and will be scaled and distributed appropriately. Essentially, the money CMS can pay out to Medicare Part B FFS claim bonuses depends on the number of clinicians who do not submit or perform poorly.


A full list of changes to the Year 4 Final Rule and the most up-to-date information can be found on the QPP website

We are accepting new practices to report MIPS with us in 2021, feel free to take a look at what we offer for MIPS reporting here or give us a call at 800-587-4989 x2. We’d love to hear from you!

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.

If you were to get engaged, you can imagine you would want to call your closest friends and family first, right? Would you also want to tell one of the accounts you manage? I did! That might seem crazy, but I like to think that this is what makes pMD unique. Our entire team prioritizes partnering with our customers and developing strong business relationships. If you are lucky, sometimes, these business relationships also become friendships. 

The importance of account management


At pMD, each employee is an account manager. That means, we equally share the responsibility, on top of our departmental focuses, of working closely with our customers. Why do we do this? We do this to learn how to improve our product, stay ahead of the curve, make our customers happy, and change health care. We are in contact with our groups constantly, and not to sell them products and services, but to stay on top of what's changing in their world and in ours. We hope to connect with our users and create a relationship. When practices think of pMD, they do not just think of the purple app on their iPhone; they remember the pMD employees who ask, “how can we help?” Like many professional relationships, the closer you are, the better equipped you are to come up with creative solutions and strategies for success. 

One of my favorite memories at pMD was a pizza party financed by a customer of ours who wanted to say thank you for our assistance with satisfying his MIPS (Merit-based Incentive Payment System) annual requirement. MIPS can oftentimes cause a lot of extra strain for smaller practices; he shared that we alleviated these stresses, and in return, he wanted to treat us to a pizza party. During this lunch, our team ate together and shared stories about various customer relationships, and what they have each taught us over the years. 

A little goes a long way


In addition to my account manager responsibilities, my current title is Sr. Account Executive. I work with practices in a consultative way to evaluate our product and implement a new process that will improve their workflow and ultimately create ROI. Something unique about our pricing model is that our pricing is transparent and standardized across the country. In my four years here, we have not increased our price for our charge capture product. Why is this important? It means that, even with enhancements and new features, our customers can implement these free-of-charge. When you sign up for pMD, we are agreeing to be your partner today and moving forward. That's why it’s important for us to connect with our current customer base in order to understand their needs. 

In the current climate, we know our customers are facing some of the biggest challenges yet.  I've seen practices implement new processes in 1-2 days, where previously changes like this would take anywhere from 6-12 months. Our customers are pivoting quickly and need a partner who is dedicated to making sure those needs are met promptly. I feel proud to work at pMD where all of the employees value our customer relationships. It is very rewarding to help solve workflow kinks, provide 24/7 customer support, or simply be an ear to customers who need a partner (or friend) in a time where they are under an immense amount of pressure. 

We want to hear from you! What can we do to support your patients and practice?

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.

Source: Getty Images

Here's The Latest in Health Care:


While physicians are utilizing telehealth to treat their patients during this unprecedented COVID-19 pandemic, many still have outstanding questions about how to accurately code and document those visits. Health care business consultant Elizabeth W. Woodcock, MBA, FACMPE, an expert on coding and documentation, breaks down the answers.  Read More

As coronavirus numbers in the United States are exponentially increasing, health care leaders are extremely concerned about how this will play out in the coming months. With potential problems in the PPE supply chain, the upcoming flu-season, and a viable vaccine yet to be finalized, health care systems and providers are bracing for a tough battle ahead.  Read More

HHS will be sending an additional $4 billion in funding to hospitals affected by the COVID-19 pandemic. While the bulk of the funds will go to safety-net hospitals, HHS is expanding the criterion for payment for the next disbursement. In addition, more than $1 billion of the new funds will go to rural hospitals and other health care providers in small metropolitan areas.  Read More

An operating room isn't exactly the easiest place to follow social distancing guidelines in the age of COVID-19. Using 5G network technology, doctors in Italy recently demonstrated that telesurgery could now be a valuable and reliable tool in allowing surgeons to do just that. Surgeons performed surgery on a cadaver's vocal cords from nearly 10 miles away over a wireless 5G network.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, secure messaging, clinical communication, and care navigation software.

The year 2020 has had no shortage of culture-impacting events—that is for certain.  We’ve had heartbreaking celebrity deaths, devastating natural disasters, polarizing political happenings, monumental social justice movements, and of course—COVID-19.  So impactful the events of the first half of 2020 have been, that one could say that we have entered a whole new era, and in many ways, we definitely have.

The Impact of the COVID-19 Era


The impact of this new era is readily visible in our health care system.  In addition to dealing with the strain of caring for an influx of COVID-19 diagnosed patients, care must be provided for patients battling a plethora of other diagnoses but under severely restrictive safety protocols and operations. More than just adequately treating patients, it’s also ensuring safety for health professionals and also supporting the emotional needs of the patient families. All in all, perhaps more than anything, this era we’ve entered into has challenged the human connections and relationships that are essential to treating patients and saving lives.

When Telehealth Becomes a Necessity


Another impact of the COVID-19 era is that some conveniences became essential necessities.  Take telehealth, for example.  Over the past several years, organizations had been incorporating telehealth to some extent at an increasing but by no means blazing rate. In 2020, telehealth has become an absolute necessity—in some scenarios being the only way to continue seeing patients.  And given the volatility of this pandemic, telehealth will play a significant role in the foreseeable future.  The CMS regulations are changing, insurance reimbursements are adapting, and health care organizations are creating new workflows to provide care in this new era.  But a question worth keeping in mind through it all is how does a telehealth platform impact the human connections and relationships between health care teams, patients, and their loved ones.

Prioritizing the Human Connection


As part of my work here at pMD, almost daily I assist patients in getting oriented on our platform for their telehealth encounters on pMD. Most patients don’t need any assistance and never reach out to us, but often it’s the patients most in need of care who are the least tech-savvy, or who are very apprehensive about having their first video visit.  I have had personal phone calls with hundreds of elderly patients who have never downloaded an app before and just need a patient-caring presence to walk them through the process. I have had more calls than I can remember where I’ve conducted test video sessions with family members who ultimately were just really anxious about their loved one being set up properly to have their scheduled doctor visit.  The joy and appreciation that these people express when their concerns and anxieties about their telehealth software have been put at ease are very rewarding.  It’s also been quite entertaining at times, especially that moment when the video connects and we “celebrate” our success and put faces to our voices.

These moments I’ve shared with patients are because pMD’s commitment to providing the best customer support is not just for the health care organizations we partner with, it also extends to their patients.  The fact is, some people just need more technical support than others, and in this COVID era where telehealth is sometimes the only option, we continue to give our best toward helping every patient have a delightful telehealth experience with their health care providers.

Partnering with pMD


We here at pMD understand that adopting a patient-facing technology, such as a telehealth platform, inherently incorporates supporting those patients who need more technical support than others.  More importantly, we understand that a health organization implementing technology to facilitate patient care does not magically acquire the in-house capability to provide the premium technical support that some of the most in-need patients require. And in many cases, I’ve noticed that patients don’t seem to distinguish their experience with me from their experience with their doctor’s office as a whole. So accordingly, I value the interaction and treat it as such.  The takeaway being that choosing a technology platform is sometimes more than just choosing product features—it is engaging in a partnership that impacts the overall experience of all those involved. This is why we not only provide round-the-clock personal customer support, we continue to evolve our products and release new features with the delight of both providers and patients at the forefront.  

A telehealth platform that offers round-the-clock personal customer support, video/voice/text communication, availability on iOS/Android/Web, and many other features, does indeed check a lot of the boxes on a typical product requirements list.  But in my experience, it’s how all of the parts come together to create the greater whole of fostering human connections, and the partnership between health care organization and technology vendor, that is most invaluable in defining a telehealth platform.  And in an era where telehealth adoption has become an essential necessity, and quality human connections in health care are needed more than ever, I’m proud to be part of a team that prioritizes real partnership and continues to create offerings that put people first.

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.


Here's The Latest in Health Care:


The volume of telehealth claim lines increased more than 8,335 percent in April 2020 compared to last year as the pandemic continues to drive utilization, according to a recent analysis of insurance trends. Mental health diagnoses continue to drive the visits, followed by joint and soft tissue conditions and hypertension, suggesting more privately insured patients turned to telehealth to manage chronic conditions during the pandemic.  Read More

As COVID-19 cases continue to rise in parts of the U.S., many primary care practices are not ready to address the current surge or a second wave predicted to come in the fall. At the same time, practices are reopening to in-person visits because of uncertainty about the duration and severity of the COVID-19 pandemic and the impact on their practice financially.  Read More

Earlier this week CMS released details about the second-year performance results of the Quality Payment Program's Merit-based Incentive Payment System (MIPS), which determined payment adjustments for clinicians in 2020. Overall, the results are very positive with 98 percent of clinicians avoiding a negative payment adjustment, while 84 percent earned an "exceptional performance" designation, resulting in positive payment adjustments.  Read More

While overall, people are moving less throughout the day since the onset of the pandemic, FitBit reported that the amount of purposeful activity is actually going up, leading to statistically significant decreases in things like resting heart rate. The billions of data points that wearables like Fitbit and Apple Watch collect can do a lot more than simply tell us how we're spending our time during the pandemic, and could perhaps even help detect COVID-19 earlier.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, secure messaging, clinical communication, and care navigation software.

Accessible health care has been a challenge for individuals living in rural and underserved communities for decades -- barriers like transportation, social determinants of health, and the lack of insurance coverage have been major roadblocks in providing rural communities with the access to health care that they need to live longer, healthier lives. While these underserved communities often fly under the radar, it’s important to recognize just how many individuals are at risk because of their lack of available health care resources. In fact, individuals in rural areas have a 23 percent higher mortality rate than urban residents and a much higher rate of readmissions to both inpatient facilities and emergency room visits. The lack of access to specialty care also accounts for a dramatic percentage in what could be preventable hospital visits.

So, how does telehealth play a part in improving patient outcomes for rural populations? In the wake of COVID-19, telehealth has stepped up to the plate, stood its ground, and proven its worth to providers and patients across the country. While COVID-19 continues to be one large hurdle to overcome, it also presents rural communities with a silver lining: surges in telehealth deployment. As efforts and funding for the implementation of telehealth grow in rural areas, it’s presenting health care providers with the opportunity to bring specialized services and accessible health care to these areas in a more affordable manner and that is something we can all get on board with. 

Who Can Telehealth Help?


The Navajo reservations throughout the southwest region of the United States, an area that frequently goes unnoticed, is a notoriously underserved population. Home to roughly 20 percent of the nation’s Native American population, the Navajo population consistently scores poorly in overall health. In fact, Tribal communities are amongst the poorest and most vulnerable in the United States. On some reservations, life expectancy is lower than in some third world countries because of the lack of resources to access health care.

Not only is the life expectancy of Native Americans much shorter than other Americans, but they are also known to have a significantly higher mortality rate. This alarming statistic also includes higher rates of death from chronic illness, such as diabetes, chronic liver disease, depression, and more. And just to bring to light how bad the general health throughout these communities truly is: Indigenous peoples are likely to die of heart disease at a rate 1.3 times higher than all other races, and diabetes at a rate of 3.2 times higher.

What do these have in common? Both illnesses are reliant on constant monitoring and upkeep, but without access to affordable resources, many of these issues go unseen and untreated. Can telehealth alleviate some of these pains? Does telehealth truly have the opportunity to improve the outcomes for the patients by making health care more accessible?

Barriers to Entry


Now that telehealth is becoming more prominent in rural areas, providers will have the ability to tailor their telemedicine programs to best fit the needs of their patients, while eliminating many of the barriers that make it difficult for these individuals to receive care in the first place. 

Though the availability of telehealth services continues to grow, it is not without a few speed bumps along the way. Broadband access has been a constant concern for telehealth implementation. However, 63 percent of rural areas now have access to high-speed internet, and we can anticipate that number to continue to rise. Now more than ever is the time to consider a value proposition for these communities and how telehealth can serve these patients and ultimately lead to longer, healthier lives. 

pMD Solutions


pMD is constantly striving to improve the lives of both patients and providers to make an everlasting impact on health care. Now that telehealth deployments are surging, pMD’s clinical communication and care navigation platforms are creating an environment that allows providers to track the progress of their at-risk patients within these rural communities while ensuring that the communication between themselves and the patient will be seamless.

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.

Source: Getty Images

Here's The Latest in Health Care:


Rural health care providers have been hit hard by the COVID-19 pandemic due to the loss in revenue from canceled or deferred elective procedures and the additional expense of personal protective equipment. In response, the Federal Communications Commission (FCC) is adding almost $200 million to a rural health care program to help providers invest in telehealth services.  Read More

The transition of care is a critical time for patient intervention to prevent readmissions and emergency room visits. Patients do not oftentimes understand their medication instructions at the time of discharge, so having a solid transition of care protocol is essential to reducing liability, avoiding readmissions, preventing costs, and having greater overall patient satisfaction.  Read More

Nearly half of primary care clinicians reported that their burnout is at an all-time high, largely due to financial pressures caused by the COVID-19 pandemic, a new survey found. Plus, more than 60 percent of respondents said they've had "severe" or "near severe" stress levels in the last four weeks.  Read More

Providers participating in the Merit-based Incentive Payment System (MIPS) in 2020 didn’t exactly plan on providing care during a global pandemic. Fortunately, CMS has bent the rules a bit for 2020, providing assistance in the wake of COVID-19. CMS announced it will not use data collected during the first six months of 2020 when calculating Medicare quality reporting and value-based purchasing programs.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, secure messaging, clinical communication, and care navigation software.

"Love without conversation is impossible." This quote by American philosopher, Mortimer Adler, embodies a fundamental pillar of pMD design - something we'll call "love injection." Ever since the beginning, building software that is as intuitive as it is useful has been a core component of pMD product development. My previous post highlights empathy as the first and most important step of our design process and this post will focus on the upsides of a love injection and how it plays a part in our empathic design process. Love injection is our design team's internal call-to-action whenever our users encounter a scenario that leaves them feeling lost and unloved. Learning how we used it to overcome our missteps in product design will hopefully encourage your health care design team to leverage even more conversations with customers in the future.

The Backstory


Back in the early days of pMD telehealth we had far fewer patients on the platform. Then COVID-19 spread, and everyone was sent home, told to stay there, and attend medical appointments remotely. In the span of a couple of weeks, we suddenly had over 36,000 new patients using pMD for video calls. The deluge of new patient users - many of whom had never used telehealth services before - increased the customer support volume to unexpected levels. Questions we may have previously seen a few times over the course of a week resurfaced several times an hour: "What do I need enabled on my phone to have a video call?", "When will the doctor call me?", "What do I do now?", "I have a question for my practice...", etc. 

Immediate steps were taken by our customer success team to create more patient-facing documentation, so our new patient users could feel comfortable using pMD. These updates drastically improved our team’s response to patients, but we knew more had to be done to reduce the reliance on documentation alone while maintaining scalability. This became the catalyst for a new round of updates from the design team to make the user experience as intuitive as possible. Prior to COVID-19, we had been focused on telehealth through the health care provider lens and now it was time to revisit telehealth strictly from the patient's perspective. 

A Solution


To design effectively for patients, we revisited our design thinking process and focused again on empathy and designing with love. I'm referring to the three "laws of love”:

1. Love starts with what you know - build familiarity into the design.
2. Love makes complicated choices simple - one choice means no wrong choice.
3. Love is spontaneous! - Make it fun; make it rewarding!

Instead of a traditional user research study, I embraced Adler's quote and joined the support team in fielding phone calls from patients. Effectively, I became tech support for several hours every day. Assisting the customer support team opened my eyes to critical areas for improvement, namely around the onboarding experience for patients. One missing link was to ensure patients enabled all the proper app permissions whilst reassuring those that had properly enabled permissions, that they didn't have to do anything else until the doctor called at the scheduled time. 

As I answered patient questions and took notes, I thought about what I would like one of my own family members to see when setting up pMD. From start to finish, the pMD design team ultimately came up with an onboarding experience that we would feel comfortable having our grandparents use - that’s when we knew we had succeeded in injecting more love into the product experience. A week after the new onboarding update was released, the number of support inquiries related to app setup and onboarding before they started their first appointment decreased significantly despite a steady increase in new patient users!

Improving communication amongst the medical care team has long been a focus for pMD. This experience has shown us that we can never pause for a moment from speaking directly with our customers (both providers and patients alike) and showing them some love! I encourage you to open up more conversations with your customers - even temporarily hop in the trenches with your customer support team - and learn how you can give your product a proper “love injection.”

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.