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POSTS BY TAG | Secure Messaging



Chat with Patients: A Case for Secure Patient Text Messaging


Chat with Patients? A Case for Secure Patient Text Messaging

Recently, I was talking with a physician who is a new pMD customer. We were having a great conversation as she sought to satisfy her curiosity with how to get the most from the pMD software. Then I mentioned our new Chat with Patients feature, and she turned away from me, her previous openness instantly gone. She made a half turn away and laughed dryly, “Oh God. No.”

This was not surprising. The idea of patients having unfettered access to a doctor’s phone can seem like the loss of a last vestige of privacy, unfiltered patient needs adding to the cacophony of the many already trying to reach them.

So I shared a different story, one not filled with an endless interruption and immediate need. This type of communication can be better for both the medical provider and the patient receiving care. Surgery offers one compelling example.

Patient Text Messaging Before & After Surgery

Surgery represents a great opportunity to connect with patients via secure text for the following reasons: there is a clear episode of care, which includes a scheduled procedure, preceded by an instruction-filled pre-operative visit and followed by a post-operative period where concerns over pain, discomfort, new medications, and other follow up issues often emerge.

There are problems with other types of communication. Phone calls can offer endless rounds of telephone tag and voicemails, and email messages often are lost, misunderstood, or don’t have immediacy. Further, for patients who work, calls to workplaces and messages left can create privacy concerns. So, having a way to securely text and communicate in an asynchronous and timely way - texts don’t pile up the way emails do - can offer both better clinical outcomes and higher patient satisfaction.

Using Chat with Patients App Feature: The Process & Results

Below is the process for how a current pMD user is using the new Chat tools for text messaging with patients:

The scheduling coordinator invites patients who have a capable smartphone as part of their pre-operative process. She lets the patients know that pMD is a tool for them to have a direct contact as they go through their procedure.

She has found that younger patients have no issues with loading and using pMD and neither, to her surprise, did older patients. As long as they have a supported iPhone or Android, they have been able to easily download the app and get started.

Patient Text Messaging Helps Avoid Surgery Rescheduling

Prior to their procedure, patients commonly reach out to her with questions about the timing of the surgery, medications, and location of the facility where the procedure will take place. So far, at least one patient was saved from missing their surgery as they asked about a medication which, had they taken it, would have caused their surgery to be rescheduled.

Chatting with Patients After Surgery

The types of messages the coordinator receives after surgery often include those of the “what is normal?” variety, as well as questions about pain, medications, and the timing and location of follow up appointments. Having an easy way for patients to ask these questions helps avoid readmissions and missed appointments and allows the practice to stay on top of patient outcomes!

Secure Patient Messaging with pMD a “Real Life Saver”
The scheduling coordinator reports the following on using pMD as a tool to connect with patients:

"This has made such a huge difference in my contact with patients. They work, and texting them is so much simpler and more convenient than calling or email. I also love that it's not invasive. They don’t get my private info. This has been a real life-saver for me."

I also had the opportunity to connect with a patient using the platform, who reported more satisfaction with the care they received and a closer bond to the practice providing the care:

“Using the pMD app was a real anxiety reducer. If you have a question and something’s not right, you can get an answer through the pMD app. It’s immediate. You feel closer to the doctor and staff. It’s more personal. The app was very easy to download and use. I would recommend this to everyone! Doctor’s offices could really cut down on the number of phone calls. I would prefer practices that use this type of technology!”

I shared this story with the physician, and her demeanor quickly changed. Her practice is in the process of hiring a nurse to contact all their procedural patients, and pMD’s Chat with Patients would be a more effective way of connecting. With the right plan, secure patient text messaging offers unique and compelling benefits. Contact us and we will help you put a winning plan together!

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.


Design Thinking: An Empathetic Approach to Innovation article


Design Thinking: An Empathetic Approach to Innovation

The original Apple computer mouse. A children’s toothbrush with a fat, grippy handle. pMD’s secure chat with patients. What do they have in common? They are all prime examples of products born from a thorough design thinking process.

What is Design Thinking?

At its core, design thinking can be defined as a human-centered approach to problem-solving. The process of design thinking is often simplified into five steps: empathize, define, ideate, prototype, and test.

Design Thinking Model

(source: Stanford d.school)

In my discussion, I’ll take a deeper dive into the first two steps (and arguably most important): empathizing with the human and defining the problem.

Empathy and Definition in Design Thinking

What do empathy and problem definition look like in practice?

In 1966, designers were approached to reimagine a children's toothbrush. At the time, all children’s toothbrushes were fairly similar: shorter versions of adult brushes, which were skinny sticks with a brush head. The designers spent a large amount of time simply watching children and adults brush their teeth. What they discovered was revolutionary -- children, unlike adults, gripped the brush with a clenched fist. In contrast, adults displayed increased dexterity and balanced the brush between their fingers. To tackle this difference, the design team created a new toothbrush featuring a thicker handle lined with squishy gel. An adult might not care for the design, but to a child, the thick handle and colorful, grippy gel made all the difference. That model quickly became the best-selling toothbrush worldwide...for the next 18 months. Needless to say, the rest of the market caught on, and now all children’s toothbrushes still feature the same original design elements: a fat handle with grippy gel.

The reason for the success of the children’s toothbrush is that the design team first empathized with the human (“Why is brushing my teeth no fun?!”) before defining the problem they were actually solving (“Why is my toothbrush difficult to use and hold?”). Connecting with the customer is arguably the most important part of design thinking, because without the human connection, designs often miss the mark for real-life use cases.

Design Thinking at pMD: Empathy is #1

Empathy forms the basis of all pMD interactions with customers. In meetings and on support calls, before diving right into what might be wrong or how customers might need our help, we first make sure to check in and ask how their day is going or what exciting plans they have made for the weekend. Talking with customers about their daily life not only shows that we see them as real people with real lives, but these seemingly trivial conversations can also yield intriguing insights into how we can improve our products. For example, when talking with some of our users, we found their day was less than ideal due to an increased amount of time spent playing phone tag with patients. This led to an internal discussion about improving provider communication with patients and ultimately resulted in a new Chat with Patients feature available soon for all users of pMD. Through constant refinement and testing, we eventually created a solution that both providers and patients love. This positive response stems from a deeply-rooted passion for the most important steps of design thinking: empathizing with people and hearing their real problems. At pMD, we wear many hats, but the one that we wear first and most proudly is the hat of empathy. When empathy and design connect, wonderful solutions abound:

Customer Reviews of pMD Chat with Patients

I urge you to challenge convention and speak to your customers on a more personal level. Instead of viewing customers as numbers on a spreadsheet, see them as people that you can help in ways you haven’t yet discovered.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.


Healthcare communication


Coordinating a patient’s care is complex. Professionals from a variety of disciplines deliver care to a single patient at various times throughout the day. Specialists may be traveling from several different locations from across a city to where this one patient is receiving care. And all of this complexity limits the chance for care teams to reliably connect with each other regarding the current plan for a patient’s care.  This is when inefficiencies and medical errors arise.

Ineffective Healthcare Communication Causes Medical Errors

The growing body of research on medical error prevention reveals that ineffective or insufficient healthcare communication among care team members is a significant contributing factor to adverse events. Ineffective communication is at the root of nearly three of every four medical errors. Industry studies have classified communication errors that led to inefficiencies and medical error into a few buckets:

1) Communication that was simply too late to be helpful for the patient.
2) Failure to include the whole care team in communication about a patient.
3) Communications that proposed an action where that action was not completed.

Thus, access to a common healthcare communication platform that can link up multiple providers and support clarity in communication during the critical seconds of need must be implemented to help stop avoidable medical errors.

Reduce Medical Errors with pMD’s Healthcare Communication Platform

At pMD, we’re passionate about reducing those avoidable medical errors and saving lives. pMD’s HIPAA-compliant clinical communication and free secure messaging platforms are one key way we’re doing just that.

1) We know that texting is a quick, easy method to connect a team and convey information that can save lives. So, we’re proud to provide a proven, secure communication platform to support healthcare teams - for free.  

2) Sending images securely, including labs, diagnostic images, skin conditions, or wounds post-surgery, can link internists to specialists, residents to attendings, and patients directly to triage nurses.

3) We know that with text alone, a message can lose the inflection, emotion, or intensity intended by the sender.  So, we’ll be adding the ability to send and receive voice memos, giving messages back the volume, pitch, rhythm, and speed that can help convey a clear message.

4) And we know that verbal and non-verbal aspects of communication can be vital in ensuring clarity. Therefore, we’ll also be adding HIPAA-compliant video communication capabilities, even to our free secure messaging platform, to execute care team huddles from anywhere, to facilitate the integration of specialists, and to even host telemedicine encounters directly with patients or medical decision-makers.

At pMD, we know a text, picture, voice memo, or video encounter can vastly improve the clarity of communication. By utilizing a common secure healthcare communication platform which includes the right individuals at the right time, we can reduce medical errors and save thousands of lives.  For more information, or to easily sign up for free pMD® Secure Messaging™, please visit us here!

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.



Secure video chat


Last year we were excited to announce the launch of our free Secure Messaging product, which is now enabling thousands of health care providers across the United States to communicate in a way that’s convenient and secure. As that offering has gained adoption, we’ve been actively soliciting feedback from our user base in order to understand how we can continue to make the product better for them. One of our biggest takeaways has been that, while secure text messaging has indeed addressed a major pain point, there are additional scenarios where a richer form of communication would be helpful.

That’s why we’re excited to announce the upcoming release of secure video chat capability.  This new feature will enable providers to utilize pMD to quickly get a second opinion from another clinician, connect with a nurse at a remote clinic, or even chat directly with a patient who may not be able to leave his or her home. Best of all, video chat will be built into our free Secure Messaging product.

Secure Video Chat Added to Free App for Bigger Impact on Health Care


We know that often, vendors dangle new features behind a paywall, or an upgrade requirement, rather than shipping them directly to their customers. However, our philosophy at pMD has always been, first and foremost, to help clinicians provide better patient care.  The cutting edge design agency, Chagency, sums up this approach well in a recent blog post, suggesting, “Help [your users] grow so you can grow together.” To accomplish this, we push down as much value into our free offering as we possibly can, knowing that the more people who benefit from pMD, the bigger the impact we’re able to have on health care in this country.

pMD Product Suite Growing to Improve Health Care Communication


We’re extremely excited about this upcoming enhancement to pMD’s product suite. We look forward to continuing to gather feedback from our customers as they leverage this new tool to improve their care delivery. Most importantly, we’re not done innovating. In fact, we’re just at the beginning of a compelling roadmap of new features to empower richer communications in health care.

 
App with secure video chat capability

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.






250,000. That is the number of deaths from medical error calculated in a study by patient safety researchers at Johns Hopkins. That would make medical error the third leading cause of death in the United States, outnumbered only by heart disease and cancer. Medical error is a problem that can affect anyone. Unfortunately, this doesn’t get the same amount of attention as other issues facing health care. Comparing medical error to the current drug epidemic in the United States, the Johns Hopkins report would put the death toll from medical error at 3.5 times the number of individuals killed by drug overdoses in 2016. However, thanks to great work being done by groups like IHI and AHRQ, as well as patient safety researchers, there are steps the health care industry can take to reduce medical error.

It is worth saying that Johns Hopkins’ estimate of 250,000 isn’t without criticism. Health care systems in the United States differ dramatically by location and finding a reliable estimate of the number of patients severely affected by medical error is no easy task. This difficulty is compounded by the fact that the Centers for Disease Control and Prevention (CDC) does not register medical errors as a formal cause of death and that the causes of medical error are hard to solve. Studies have found that common causes of medical error include fatigue, inadequate supervision, inadequate experience, and faulty communication. These causes are often institutional failures and can't be addressed by simply flipping a switch. So, what can be done in the face of a problem with such a broad scope and no single solution? And what can an individual practice do to start addressing medical errors in their own backyard?

One example of something hospitals could do to begin addressing this issue is to implement common sense systems to catch errors before they affect a patient. For example, medication errors, a common source for medical error, can be dramatically reduced by implementing systems like Barcode Medication Administration (BCMA), where a doctor or nurse scans the medication before giving it to the patient. This simple step gives the computer a chance to check the provider’s work. But, it isn’t necessary to implement new systems that can cost a practice thousands of dollars a year. For smaller clinics, simply applying “Do not Disturb” rules whereby those administering medication are able to work in a quiet place, free from interruption, was shown to reduce the error rate of those administering medication by roughly the same amount. Another key focus of patient safety research is patient handoff. Because of the complexity and variety of patients’ conditions, patient handoffs must adjust to fit the patient's situation and do have the potential to be a large source of communication errors. However, one study looking at patient handoffs found that implementing a mnemonic device, called I-PASS, to guide physicians through patient handoffs reduced adverse events by almost a third. Simple changes like using the I-PASS method are inexpensive and are designed to ensure that all critical patient information is communicated effectively and in a timely manner. Implementing these changes doesn’t have to come at the cost of reducing the quality of patient care. The same study found that there was no increase in time spent conducting patient handoffs and there was no decrease in time spent with patients.

Humans are prone to making mistakes, and doctors are no exception. One report says that rather than blaming individuals for mistakes, institutions can create a culture of safety in the workplace and design their systems to protect patients, making patients safer while unburdening doctors with the stress of being one simple mistake away from being on the bad end of a tragic statistic. pMD is proud to work with health care teams to promote communication in the hopes of preventing medical error and improving patient care.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.









At pMD, our goal is to always push the envelope to help make providers’ lives easier and ultimately improve the quality of patient care. We are constantly updating our application to be as robust as possible and releasing new features that increase provider productivity. Recently, the pMD engineering team has been focusing on polishing our secure messaging features and among those items is encrypted push notifications. While “encrypted push notifications” may sound a bit boring, it is actually a very exciting feature that will greatly improve our users’ experience while using pMD® Secure Messaging™. But before talking about that, I want to briefly discuss the term ‘encryption’.

Simply put, encryption is a way to convert information into gobbledygook in order to prevent unauthorized access to that information. Encryption works by using an encryption algorithm, or set of rules, along with an encryption key. When text is processed by an encryption algorithm, it is unreadable until it is translated back to readable text using the same algorithm and the encryption key.

To illustrate this we can observe the Caeser Cipher, one of the oldest encryption methods in the world. The Caeser Cipher works by replacing each letter in a text and shifting the letter over by a certain number of positions in the alphabet. For example, with a shift of 2 the letter ‘A’ becomes the letter ‘C’, the letter ‘D’ becomes the letter ‘F’ and so on. So if we use “hello” as our text and our key (the number of times we move a letter) is 2, “hello” will become “jgnnq”. To convert our text back we simply do the reverse of our algorithm with our key of 2 and voila! The text turns back to “hello”! Now that you know the basics of encryption, let’s return to our topic of encrypted message notifications.

Messaging applications have become so commonplace that certain features are expected to be included in every messaging application. One of these staple features is being able to read the message body from a notification on your device’s locked screen. Though it may sound straightforward, this wasn’t actually possible to do when pMD originally released our secure messaging service, simply because we had no way of encrypting our notification! No encryption, no HIPAA-compliance! It wasn’t until Apple released some code that our developers were able to process an incoming pMD notification before displaying its contents. This means that we can encrypt the notification when sending it to a user’s device and decrypt the contents upon arrival to the user’s device.

What does this mean for the our users? The biggest win for our users is being able to read the pMD message directly from their locked screen! At pMD, we all use pMD® Secure Messaging™ to communicate with each other and understand that sometimes, it’s inconvenient to unlock your phone, tap on pMD, tap on the messages tab, and finally tap on the conversation to read the received message. With this feature, we bring a positive contribution to the overall experience of using pMD.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.









pMD’s culture promotes the importance of customer feedback, which we’ve discussed in previous blog posts. Through conferences, implementations, and support, we’re always looking for the best way to enhance our product so that our customers can focus on improving patients’ lives. So, it’s no surprise that since its launch in 2014, pMD’s secure messaging product has been molded by the feedback and input of our customers.

Recently, the pMD team has consistently heard that providers would like to utilize pMD® Secure Messaging™ to communicate with their patients using the same platform they already use for internal communication. As emails go unanswered and phone calls are forwarded to voicemail, messaging becomes the most effective and efficient choice when deciding how to communicate with patients.

With the number of Americans that own smartphones continuing to rise to 77% in 2018 (Pew Research Center), more patients than ever before can connect with their health care providers, so we asked ourselves: how can we make the process of communicating from both sides - patient and provider - as seamless as possible?

When engineering pMD’s system for messaging with patients, we started with everything that makes pMD’s current secure messaging system an optimal solution for health care providers: an easy-to-use interface similar to your favorite text messaging app, an architecture built around security compliance, and a system of robust and reliable notifications to ensure that time sensitive information is delivered when it matters most. We spent time improving our sign up process to remove clunky steps and make sure that new patients can be on-boarded and start messaging in seconds.

On the provider side, we added clear delineations between internal and external messages, so providers, office staff, and administrators will always be reminded when their communication is being sent outside the organization. We know how important it is for providers to maintain control of the conversation threads, so we designed a system that allows caregivers to open and close conversations, while still allowing patients to initiate conversations. Providers’ personal information is hidden from patients’ view, and messages with patients can be shared among all members of the care team so that providers can collaborate and patients receive the highest quality care. pMD® Clinical Communication™ is already helping organizations deliver better care, and this additional feature set will allow those groups to reach their community on a whole new level.

pMD is currently working with innovative health care organizations to transform the way they interact with their patients. If you’re interested in learning how we can help improve your patient care through custom workflows and communication tools, contact us!

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, care navigation, and clinically integrated network software and services, please contact pMD.









Here’s a fun fact about me: before I started my career in health care technology sales, I was changing lives in other ways - I was a teacher. I hear a lot of shock when I talk about my career path, and how I could have made such a drastic shift. I mean, clearly the roles of sales and teaching are night and day, right? Well, not really, actually. I have found that the very characteristics that made me a great teacher - empathy, compassion, and being a good listener - really correlate strongly to my day-to-day sales role. There is one such trait that I have found to be even more critical in both my teaching role and my role at pMD: agility.

What does it mean to be agile? Quite literally, it means having the ability to move quickly and easily. As a pMD employee, especially on the sales team, it is imperative we are able to be agile. We must be able to shift our focus quickly, become product experts at the drop of a dime, relate what we know back to a practice’s current obstacles, and give our developers the ability to innovate while feeling confident the sales team will be able to show value in the new products they are building. Here’s an example of agility in action:

When I first started at pMD a little over 2 years ago, we really had 2 core products: pMD® Charge Capture™ and pMD® Secure Messaging™. It took me a while to understand and articulate the intricacies and value of those two products, but I eventually got into a groove. I was in my comfort zone. Suddenly there was talk of expanding our product line. Our customers needed more from us and we needed to rise to the occasion. Thus, we also became a MIPS Registry.

Now, if you aren’t sure what MIPS is, let me tell you that becoming knowledgeable enough to sell a MIPS registry product is no small feat. Many MIPS registries are exactly just that. They do not have other product lines they are selling simultaneously. At pMD, we were expected to know how MIPS reporting differed for an infectious disease practice versus a hospitalist group and so on, all while continuing to sell our existing product suite. Did the sales team complain and throw our hands up in defeat? Hardly! We were agile, quickly moving to learn all we could about MIPS, and providing our customers and prospective customers with the insight they needed to make an informed decision.

This agility has helped us to “go with the flow” as we continue to expand our product offering. A couple of months ago we added additional products to our product suite, such as pMD® Clinical Communication™, pMD® Care Navigation™, and pMD® Clinically Integrated Network™, to serve the needs of today’s health care market. We as a sales team have been at the forefront of explaining these products to our prospective practices and helping to communicate feedback to our developers. This allows us to grow as members of the pMD team, learn from industry best practices, and reshape pMD’s business priorities by listening to the market. While being agile can at times be challenging, it is also what keeps our day-to-day exciting because who is satisfied with the status quo?

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, care navigation, and clinically integrated network software and services, please contact pMD.









pMD’s products put the patient at the center of everything we do. When we pair innovative products with the creative, consultative approach we take for every customer inquiry and then in turn see the value to our patients, it is truly a remarkable feeling. One example below may best illustrate the impact that a pMD solution can have when care teams have a common platform to collaborate around patient care.  

A group of surgical residents caring for patients across various clinical teams needed a way to capture shared rounding notes on patients. In addition, they wanted to be able to communicate between teams using a secure messaging solution to share patient details, update care plans, and send pre- and post-operative photos.

Few technology solutions are available today to support patient care for residents. Many organizations currently use paper rounding notes that can be lost in the rush of the day, shared spreadsheets where only one resident can access the data at a time, or non-secure file-sharing programs. None of these options truly meet the residents’ needs. Since clunky workflows that are currently in place still get the job done, these old methods have continued into 2018.  

Resident groups tell us that better communication can improve patient outcomes. Residents using pMD Clinical Communication™ can send messages about patients and update each other on care plans. They have the ability to securely send images to a chief or attending physician for a second opinion. Additionally, patient data can be recorded at bedside right from their mobile phone and can include updating medications, allergies, code status, and care plans. These are all kept up-to-date, in real-time, and stored on a shared patient list visible to the whole group.

HIPAA-compliant, health care messaging that’s easy to use paired with pMD’s customizable platform for mobile data capture is exactly what these residents and administrators were looking for to bring their workflow into the twenty-first century.  

We know that each practice or group faces a unique set of challenges. That’s why we approach every opportunity as unique, invest time upfront to understand workflows that support patient care, and build solutions that account for those challenges. This is also why we here at pMD work closely with existing customers to implement new products and product features as those challenges evolve.

At pMD, we are customizing solutions to help teams deliver better patient care. To explore these solutions for your group or for more information on how pMD can support your unique practice or patient population, don’t hesitate to contact us.




 If you'd like to find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, care navigation, and clinically integrated network software and services, please contact pMD.



Imagine, if you can, a world where medical information crosses boundaries - safely, reliably, timely, as effortlessly as water. What is required to create such permeable boundaries? Sure, there are the base technical requirements. System B must be able to read, understand, and digest System A’s output. As convoluted as medical information standards can be, there are reliable pieces there. Reliable yet limited.

So, to achieve something more dynamic, deeper, and more useful, what is required?  I think trust plays an outsized role. I am not talking about the trust inherent in the security profiles of each system, though that is important. I'm talking about the trust of the people involved. The human element.  You need to know who you are working with, what they are about, and establish if they are on the same page.

At pMD, we actively seek out partners with whom we can achieve richer technical connections as well as dynamic personal collaborations.  A recent example is the links we are building with a regional EMR company called iMed.  iMed reached out to us last year as they were assessing partners to perform the MIPS registry role for their customers.  Their dream was to create a new module in their software allowing their customers to collect quality data as they entered clinical data into iMed. This made a lot of sense. Capturing quality data in real time would help their customers achieve their MIPS reporting goals and set them up for ongoing success as the medical market continues to reach towards measurements beyond the raw financial value of services.

We met their team, shared what pMD does and what they needed and found a compelling fit.  As they developed this new module we worked closely with their team to share what registry reporting requires so they could consider those requirements in their software.  Finally, we attended their user group meeting, spoke with their customers alongside their team to better link their customers, the module, and pMD’s MIPS registry services together.

We are currently rolling out version one of our collaboration, which allows for regular data uploads from our now mutual customers into pMD, sharing that data back with the reporting providers, and targeting gaps and opportunities for improvement.  The goal is to fully automate this process this year.

It has been a rewarding and productive collaborative effort to create real interoperability between iMed and pMD, for the benefit of those providers using both systems. This type of work is part of fulfilling our mission to make doctors happy and we hope for many years working with our friends at iMed and others who want to create more vital, dynamic, and trusting health care data ecosystems.

 If you'd like to find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, and care coordination software and services, please contact pMD.