HOME
SUBSCRIBE
ADVERTISE
ARCHIVES
CONTACT US
 
   OUR PUBLICATIONS
> Healthcare Technology
> Technology for Doctors
> Research Reports
> e-Newsletter
 
 


INSIDE THE OCTOBER 2005 ISSUE:

Wireless in Chilliwack
"We have been a clinic that embraced computerized scheduling and billing,” says Lila Bentley, clinic manager with Mary Street Medical Associates, in Chilliwack, BC. But about eighteen months ago, the clinic took a huge step forward with a complete electronic medical records (EMR) system. The transition has brought both challenges and rewards. Realizing what a major project it was undertaking, the Mary Street clinic minimized its risk by going with the largest EMR technology provider, Clinicare.  READ MORE

Physicians make VR work
How three Canadian doctors benefit from voice recognition software in their practices. READ MORE

EMR – a tale of two MDs
Dr. Eric Fishman of Florida and Dr. Karim Keshavjee of Ontario contribute to the EMR revolution in different ways. READ MORE

Departments
Editor's note: Lessons from disasters, and a sign in a men’s room.
News: Coquitlam, BC community clinic adopts DR technology; Smallest, lightest tablet PC launched.
Tech:
Toshiba Libretto; Roboform’s Pass2Go; Apricorn ultra-portable drive; Lexmark T640 series.
Chatroom: Christine Struthers: Dialing up healthcare. By Paul Lima

 

 

 

Wireless in Chilliwack

Clinic implements EMR with Clinicare, Tablet PCs and a wireless infrastructure.

By Frank Lenk

W e have been a clinic that embraced computerized scheduling and billing,” says Lila Bentley, clinic manager with Mary Street Medical Associates, in Chilliwack, BC. But about eighteen months ago, the clinic took a huge step forward with a complete electronic medical records (EMR) system. The transition has brought both challenges and rewards.

The New System: Realizing what a major project it was undertaking, the Mary Street clinic minimized its risk by going with the largest EMR technology provider, Clinicare. According to marketing manager Brent Mitchell, it now has about 200 clinics across North America running its systems.

Upgrading Mary Street needed both new software and lots of new hardware. Mitchell notes that Clinicare isn’t always involved in the total hardware package. “The only thing we insist on supplying is that IBM server,” he says. However, in the case of Mary Street, Clinicare supplied 100% of the hardware.

This meant replacing units that were running the old character-based billing and scheduling system. (Mitchell notes that there may still be a couple of text terminals lurking in a back room. Old systems, like old habits, die hard.)

The package included about ten desktop computers for use by support staff and new Tablet PCs for each of the clinic’s seven doctors. The Tablets have a wireless connection to one powerful IBM Unix-based server, while all other systems connect to another server.

This setup has proved very reliable. There have been no disasters, no lost data. And, despite the sophistication of the technology, Bentley reports that the clinic is able to maintain the system without an IT department. She adds that while Clinicare is able to remotely manage the clinic’s servers, this hasn’t been necessary so far.

Moreover, Bentley says that the Mary Street Clinic has enough spare capacity that it could conceivably host applications for other doctors. “We haven’t been able to get any other doctors to jump into the fray,” says Bentley. But she adds that this isn’t something the clinic is actively pursuing, just a possibility for down the road.

The doctors’ Tablet PCs have also worked out well. Mitchell notes that they replace separate desktop systems for each examining room and/or their private office. “The physicians just carry them from room to room throughout the day.”

“We take our Tablets with us everywhere,” confirms Dr. Martin Dodds, one of the doctors working at Mary Street. He adds that there’s an extra benefit. Since doctors always have the computers with them, security is improved.

Making the Switch: While there are obvious benefits of a major computer upgrade, the real focus of the Mary Street project was converting to EMR. That was not a trivial undertaking.

“Mary Street went through a learning curve,” says Mitchell. He notes that there’s an inevitable performance hit, but that it quickly pays off. “You tend to lose twenty percent of your productivity the first month, ten percent in the second month, then break even in the third month. You then become very efficient.”

Dodds agrees that it took some effort to make the transition. “Different people within our clinic did it differently,” he notes.

“I’m one of the technophiles,” says Dodds. In particular, he types moderately well. So his own approach was to computerize everything he could. “I would go through the entire chart and try to archive it,” he recalls.

But even so, it was far from a trivial process. “How do you go from a paper chart to electronic records?” asks Dodds. Especially when that ‘chart’ may be a folder a half-inch thick... and you may have filing cabinets full of ones just like it? “It’s the single biggest issue with going electronic,” says Dodds. “You don’t just scan it all. You have to pick out what’s relevant.”

“We did a dual system for quite a while,” Dodds continues. Thus, the clinic opted to digitize old information as-needed, while keying new information directly into the new EMR system. The result was that after about four visits, most patients’ relevant information would end up in the EMR system.

Anything missing at that point can still be retrieved from the old paper folder and scanned in, as required. Fortunately, the scanning process is fairly efficient. “Scanning and OCRing [optical character recognition] are extremely fast and very accurate,” says Dodds.

At this point, the clinic is over the worst of the transition. “I get maybe one chart a week that we haven’t finished archiving,” he reports. Still, even now, when a patient is being sent to a surgeon, the full history needs to be dug out.

On the other hand, even in such cases, the new system is showing its strengths. For example, when referring patients to a specialist, the clinic can now put together a specially-tailored background package. “Initially, we got feedback that it was too much information,” laughs Dodds. “Then they realized they were getting a better consult.”

While the change in operating procedures was managed smoothly, there were also a few surprises. For example, while Mary Street was a relatively small installation for Clinicare, Mitchell notes that it was one of the company’s earliest wireless installations. Wireless reception became an unexpected issue.

“Because of the nature of our building, we have a lot of concrete,” says Dodds. Doctors’ portable computers tended to lose the signal momentarily, whereupon the system’s security (quite rightly) wouldn’t easily allow them back in.

Fortunately, the solution was simple enough. Extra wireless access points were installed, ensuring strong reception throughout the building.

Reaping the Benefits: Though it may take some effort to get the information into an EMR system, benefits accrue when it comes time to get it back out.

“It’s so difficult to extract information from a paper chart,” observes Dodds. With EMR, he says, you can quickly find the information you need. In fact, the entire chart is instantly available, instead of having to be laboriously retrieved by support staff.

Dodds notes that when a patient calls in for a prescription renewal, the record is retrieved by the doctor in an instant. Before, staff would retrieve the records folder, send it to the doctor, who would have to check it, make appropriate annotations, and send it back.

Communications within the clinic are similarly streamlined. The new system lets Dodds easily send text messages to staff and doctors. If a call comes in while he’s busy with a patient, the front desk can send a text message that will quietly show up on his computer without creating a disruption.

Now that Mary Street has largely completed its own shift to EMR, further advantages can come in communication with outside agencies. For example, WCB forms are filed electronically instead of being faxed. Clinicare created a form for this purpose last year. “It’s a real benefit to the patient, because reports are being filed in a timely manner,” says Bentley.

Getting lab results electronically is probably an even higher priority. While scanning is quick and efficient for most paper records, it’s not accurate enough for number-laden lab reports. “The numbers are too critical,” says Dodds. “We have to manually enter them.” To be on the safe side, the clinic first acts on the original paper documents, then keys them in.

Electronic delivery of lab results is starting to happen, though work remains to be done. About 80% of Mary Street’s lab work is done by BC Biomedical Laboratories in Surrey. Clinicare has set up a direct connection, via BC’s PathNET system.

“It’s just another interface,” says Mitchell. He explains that Clinicare now works with about thirty such ‘interfaces’ across Canada. A group within the company is devoted specifically to creating these data connections.

However, Mary Street still does not have the ability to get lab results electronically from the local hospital. Bentley notes that this will probably have to wait for action by BC health authorities, who are still formulating connectivity strategy.

Ultimately, as EMR technology is more widely adopted, it will facilitate longer-term evaluations, easily showing if a particular condition is getting better or worse. EMR should have a huge impact on the overall approach to treatment of chronic conditions, allowing governments to find out which treatments are truly most effective in the long run.

“It’s part of primary-care reform,” says Mitchell. “The health care system is not going to be able to hospitalize us all.” By using the available patient data more effectively, long-term treatment strategies can be refined.

What’s important now is compiling all the available stats. “You need to have enough data in the computer,” notes Dodds.

Mitchell notes that Clinicare was one of the first systems to interface to the central database, uploading data to the governmental Web sites. Information is exported in standard XML format from the EMR system, automatically populating a government “toolkit” designed for each chronic disease.

Sharing basic patient information among physicians is also an important goal. “You can go around the world and get money out of an ATM, in local currency,” Mitchell points out. “But you can’t walk across the street to another physician and have him know anything about you.”

The Future of EMR: Mitchell estimates that only about 10% of Canada’s physicians are using some form of EMR at present. In the US, the percentage may be a few points higher.

“It’s coming, but it’s moving at glacial speed,” says Mitchell. “Any year now, it’s just going to break wide open.” Maybe even this year. “I think 2005 will be a pivotal year for adoption of electronic medical records,” predicts Mitchell.

Mitchell notes that doctors are by nature very cost-conscious, and by training very conservative. However, he estimates that EMR systems should pay for themselves within about twelve to eighteen months. “Our system saves physicians about 45 minutes a day,” says Mitchell. “They can improve the quality of their life, or increase their throughput.”

Bentley sees EMR as a necessity, for other reasons. Given the ongoing shortage of doctors, those looking at the clinic as a potential base will be very interested in the level of technology. “A lot of the younger doctors are well versed in electronic medical records, and they do ask about that,” she says.

The Mary Street clinic is still exploring all the possibilities, “We’ve only been in this nineteen months,” notes Dodds.

It’s fairly clear that a lot more can be done. “The system can do a lot more than we ask of it,” says Bentley. But everyone seems relieved that the transition to EMR is out of the way, and optimistic about the results. “The first part of the computerization is just to get around in it,” Bentley observes.  •

BACK TO THE CONTENTS LISTING

 


Physicians make VR work

How three Canadian doctors benefit from voice recognition software in their practices.
.
By Saul Chernos

Thanks to voice recognition technology, Ottawa neurologist Dr. Lucian Sitwell is able to provide detailed printed reports about patient encounters just minutes after the appointments have ended.

Doctors have traditionally dictated letters, reports and other notes, leaving office staff or outsourced services with the time-consuming task of typing handwritten notes or transcribing audio tapes. With recent improvements to voice recognition software, doctors can now talk to their computers and obtain print-outs in minutes.

Voice recognition harkens back to the early 1990s, when users had to articulate words one-by-one, pausing in between because the software only recognized discrete speech. The software has improved over the years and computers have grown much more powerful. Voice recognition software now recognizes normal ‘continuous’ speech and handles accents too.

Dr. Sitwell uses a specialized version of NaturallySpeaking for medical practitioners developed by Burlington, Mass.-based ScanSoft, and says the technology has helped to cut costs and improve efficiency. “It’s streamlined my office quite amazingly,” he explains. “Previously, even though I had excellent secretaries, when things really got busy, the typing got put on the back burner. Now, as soon as I dictate, it’s ready to send to the printer at the front of the office. The referring physician gets the report much faster, and a copy is filed right away. I have actually sent patients to their next appointment with my letter in hand.”

When Dr. Sitwell dictates letters into Microsoft Word, NaturallySpeaking Medical automatically fetches his letterhead and searches his Outlook Express database for the recipient’s name and address and enters these on the proper side of the page. This automation ensures that confidential information such as a patient’s date of birth cannot be seen until the letter is opened.

As with many kinds of software, there are tricks that enhance operation. Users can tailor their own voice macros, in the form of brief instructional phrases, to initiate commands and to input lengthy but routine pieces of text. One macro Dr. Sitwell created inserts the results of a standard ‘normal’ neurological exam. “It helps avoid repetition,” he explains. “I used to dictate a certain two paragraphs. Now, I just say ‘insert normal neurological exam’ and it shoots the whole paragraph in automatically.”

Dr. Sitwell has also developed voice-based templates for specific kinds of letters he sends to referring physicians, government ministries or patients. “NaturallySpeaking brings these up automatically. If I’m in a place where I don’t have my (OHIP) card reader, I have a macro that will push the patient data from a letter, including their name, date of birth, and date seen, right into my billing program.”

Ottawa respirologist Dr. Steven Bencze also uses NaturallySpeaking Medical and says he, too, sometimes hands patients detailed, printed instructions after a visit. “That’s one of the benefits – the notes are typed and printed right away. There are no lost or misplaced memos, and all my notes are legible because they are typed and printed immediately.”

Dr. Bencze recommends dictating notes during the visit to increase accuracy. “Your recall is not as good if you do it an hour or two later, or even right after the person has left the room.” Typically, he dictates into his computer, proofreads the material on-screen, and forwards it to the front desk for printing, filing and any other necessary action.

Dr. Bencze, who has used voice recognition software for more than a decade, says this process has freed his secretary for other tasks, saved on transcription costs, and helped boost overall efficiency. “It definitely improves the workflow and cuts down on expenses,” he says, attributing an increase in the number of patients he is able to see on a daily basis in part to improved procedures of this sort.

Another benefit is mobility. NaturallySpeaking allows users to dictate from multiple locations that are connected to a server-based computer network. Dr. Bencze says he appreciates the convenience of being able to dictate notes from wherever he happens to be working. “I have a hospital-based clinic and an office-based clinic, and I also have clinics outside Ottawa. I dictate to my computer as I go.”

Dr. Bencze uses a notebook with a 1.4 GHz Pentium, 1 gigabyte of RAM, an 80 gigabyte hard drive, running Microsoft Windows XP Pro. He also uses a Palm Treo 650 handheld that make digital voice recordings with a program called Audacity. When he returns to his office, he syncs his PDA to his computer and NaturallySpeaking transcribes the audio automatically. “The Palm is useful when I’m seeing patients in the hospital and I don’t have my notebook with me,” he says.

Current technology, such as Dr. Bencze uses, is recommended for optimum performance of voice recognition software. Charles Marriott, vice-president of Talk 2 Me Technology, a Canadian distributor for ScanSoft, says NaturallySpeaking requires a minimum 512 megabytes of RAM. Dragon NaturallySpeaking 8.0, the current release, works under Windows 2000 and XP operating systems. The software will usually work with Windows 98 but Marriott says neither ScanSoft nor Microsoft supports this older platform.

Available in English, French and other common languages, NaturallySpeaking Medical is compatible with Microsoft and Corel office suite programs and most electronic medical record applications, and it has specialist vocabularies for radiology, cardiology, surgery, general medical, family practice, obstetrics-gynecology, neurology, pathology, orthopedic, emergency, mental health, oncology, pediatrics and gastroenterology.

NaturallySpeaking is easy to install from CD but the real work begins after installation. While NaturallySpeaking Medical is enhanced by its specialist dictionaries, the key to the program is that it gets downright personal with users, establishing a ‘profile’ that grows increasingly intimate as it grasps an individual’s manner of speaking. Users launch this process by reading a five-minute text, penned by ScanSoft. NaturallySpeaking knows the words and, by hearing them spoken, learns to recognize nuances such as accents and speech patterns.

When a doctor speaks into a microphone, dictation is immediately transcribed directly into the desired program. Doctors can also dictate into digital recorders or PDAs equipped with compatible audio software, and Talk 2 Me Technology is currently introducing tablet computers bundled with NaturallySpeaking.

Dr. Jay Mercer, who oversees technology issues for the Canadian Medical Association as medical director of its Global Medic subsidiary, says some physicians have used voice recognition successfully but he doesn’t consider the technology ready for prime time. “People need to understand the ground rules. You have to buy top-end hardware, good software and a really good microphone. You have to work in an environment where there isn’t a lot of extraneous noise, and you have to be really patient. If you’re willing to do all these things ... then, yes, it’s going to work.”

However, Dr. Mercer says problems can sometimes crop up, creating sentences with unintended words. Charles Marriott, the distributor, says authors must always proofread their own documents regardless of how they’re created. “Secretaries aren’t perfect, either. If I have someone type something, it’s still my responsibility to proof it.”

According to Marriott, “NaturallySpeaking isn’t perfect, but it’s pretty good.”

Marriott says physicians need to be familiar with computers before they use voice recognition software, and they must be willing to spend time training the software to recognize their voice and manner of speaking. “You have to spend time customizing it,” Marriott says, comparing this process to housebreaking a pet. “You need to train a new puppy to do specific things, otherwise it does what it wants. Well, NaturallySpeaking does what it wants until you tell it that it’s wrong.”

Marriott adds that users need to recognize occasions when voice recognition makes sense and when it doesn’t. The software can be used to enter data on a chart, for instance, but there are times when it might be faster to use a keyboard and mouse.

Dr. John Tracey, a Brampton, Ontario general practitioner, says he is moving to an electronic medical record system and is testing voice-recognition to see how it performs that particular task. “One of the biggest barriers to going into an EMR system is the fact that a lot of doctors don’t type very quickly, or are not prepared to type all of their records into it,” Dr. Tracey says. “Voice recognition allows you to be free-flowing and dictate what you want.”

While Dr. Tracey has used several software-based voice recognition systems, he has settled on an application that Stratford, Connecticut-based Dictaphone hosts over the Internet. He connects to it via a VPN from wherever he happens to be. All communications with the application are encrypted for security purposes. “It turns my computer (an Acer TravelMate 8000 laptop) into a thin-client, so you don’t need a computer with tremendous computing power.”

Dr. Tracey pays a $300 monthly subscription fee but adds that he doesn’t use voice recognition to save money. Where I justify it is in terms of my ability to produce a better record. Records are clearer and fuller. I can say a lot more in three or four minutes than I can write. My notes are also legible. If one of my partners or colleagues is faced with one of my patients if I’m away, they can read those notes better than my handwriting.” •

BACK TO THE CONTENTS LISTING

 


EMR – a tale of two MDs

Dr. Eric Fishman of Florida and Dr. Karim Keshavjee of Ontario contribute to the EMR revolution in different ways.
.
By Issie Rabinovitch

Dr. Eric Fishman of Florida and Dr. Karim Keshavjee of Ontario don’t know each other but they have much in common: both are practicing physicians who spend a large part of their working hours encouraging and expediting the adoption of EMR (electronic medical records).

Dr. Fishman spends 20 hours a week practicing as an orthopedic surgeon in West Palm Beach. He spends the rest of his time as president of 1450, a Florida corporation that has been a major distributor of voice recognition software products and accessories in the United States and Canada since 1998. It is currently the largest distributor of ScanSoft Dragon NaturallySpeaking in the medical industry.

A division of 1450, emrconsultant.com, offers a valuable free service to physicians trying to computerize their clinics. It helps them choose the EMR software/solution that best suits their needs. It does that with a combination of automation and human inteaction.

The web site offers a tremendous amount of useful information. There’s a news and public policy section with many valuable links. In the EMR Data section there is a database of over 200 vendors who have satisfied various criteria (more on this later), a section entitled “Why an EMR?”, detailing 19 possible benefits, an extensive glossary of terms that is of interest to beginners and experts alike, Resources (over 20 links to discussion forums and documents), and links to seven key articles in the “Learn More about EMRs” section.

Valuable though these sections are, the major contribution of the www.emrconsultant.com site is its online questionnaire. In order to take the questionnaire, which is available only to physicians (in the U.S., Canada, and other countries), contact and practice information is entered in a secure fashion. The questionnaire is the product of considerable research and experience. It is linked to a sophisticated algorithm, developed by emrconsultant.com, which generates three to five suggestions for the physician. The process isn’t entirely automated. The suggestions produced by the algorithm are checked against the data by real people, including medical doctors, before they are sent off via e-mail. Within a week there is also personal contact via telephone.

If there is no charge to doctors using this service, how does 1450 pay for the considerable expenses it incurs? It has 15 employees, including a software developer, a webmaster, and other IT people. The answer is simple but interesting. The company has made arrangements with EMR vendors to receive a fee if they sell an EMR product to a person or organization referred to them by emrconsultant.com

In my discussion with Dr. Fishman, I naturally wanted to probe this arrangement. He made two points. If an EMR product satisfies demanding criteria, it is included in their database regardless of whether the vendor agrees to the fee arrangement or not.

Evaluation criteria of EMRs include financial stability and likely staying power – since it isn’t pleasant to have to switch providers due to bankruptcy.

Several major EMR developers have not entered into an agreement with EMRConsutant.com but that hasn’t affected the recommendations of the algorithm or the physicians at emrconsultant.com who check the results and possibly add to the recommendations.

“Once an EMR product meets our minimum standards for viability, we put the product into our system. EMRConsultant.com then utilizes a unique and proprietary software system that matches a healthcare provider’s practice profile and specifications with the top EMR products that best fulfill those criteria.”

Dr. Fishman added, “Furthermore, each developer with whom we have a business arrangement has confirmed that our clients will not be charged additionally because of our referral.”

Dr. Fishman mentioned that work was proceeding on Version 2 of the service, which will include an improved questionnaire and algorithm. At this time, the questionnaire is the same for all specialties. Although emrconsultant.com has served Canadian physicians, there will be better support for Canada in Version 2.

“We are committed to providing the most objective information possible to our clients, and while we may be compensated in some instances, many of the recommendations we make are to companies with whom we have no formal arrangements.

“We are committed to matching the healthcare professional and organization with the EMR best suited for them and will do so in every instance, with or without compensation. In either instance our services are free to you.”

The system works by matching a practice profile against the database of EMR vendors to determine which ones are the most appropriate for a thorough evaluation. Spending 10 minutes filling out the online Profile-Builder can save 10 or more hours of searching.

InfoClin, vendor of implementation methodology: Once EMR software is chosen, by whatever means, there’s the considerable problem of managing an effective implementation. I met with Dr. Karim Keshavjee at his walk-in clinic in Mississauga, Ontario to discuss this issue. Like Dr. Fishman, he is a practicing physician who spends more than half of the work week on the frontlines of the EMR revolution.

From 1995 to 2001 Dr. Keshavjee was with COMPETE and McMaster University. He worked on the project to develop and streamline methodology to computerize doctors’ offices. When he left McMaster University, he negotiated an exclusive worldwide license to market the EMR implementation methodology, which is the basis of Infoclin (www.infoclin.biz), the business with offices in Toronto that occupies his time when he isn’t in his Mississauga clinic.

Although it isn’t the focus of his work, he had some interesting observations about choosing an EMR. His comments that “your perception of the software depends on the demonstrator and not the software” and “don’t underestimate software that doesn’t look great” are worth remembering.

According to Dr. Keshavjee, “There is a 70 percent failure rate in EMR implementations. That’s serious, because the physician can have up-front costs of $40,000, and the benefits flow later.” If an EMR implementation fails, the up-front costs can’t be recovered and the benefits are never realized. That may explain why there’s a fairly low percentage of computerized offices and clinics.

InfoClin doesn’t deal directly with physicians. Its mission is to serve EMR vendors and practice management consultants so that they can improve the success rate of EMR implementation in clinics of 1-6 physicians. Dr. Keshavjee claims a 90 percent success rate when the COMPETE methodology is used.

His most prominent client in Canada is Nightingale, but he is in negotiations with other high-profile EMR vendors in this country.

He knows from experience the kinds of vendors to approach concerning his product. It’s not the big developers that target hospitals and big clinics. “Large vendors have their own in-house methodology.” In any event, the COMPETE methodology is aimed at 1-6 doctor clinics. There are three categories of vendors that service this market: Those that don’t understand the need, those that don’t see why they should buy someone else’s method, and finally, those that realize they need something better than they currently have in order to grow. Dr. Keshavjee tries to spend his time marketing his methodology to the third group.

The first step of the implementation is to do a site assessment to identify potential pitfalls. It can’t be business as normal during an implementation. Rather than closing down for days at a time, doctors are told to expect just 80% patient volume in the first month.

Among the tools that have been developed, there is a practice monitoring template – “like taking a temperature,” says Dr. Keshavjee.

A lot of the work can be done remotely, including checking the monitoring template to see which sites need support. It is possible to identify the laggards without an intrusive site visit.

In addition to the methodology, Dr. Keshavjee offers training and support for vendors.

When asked who else is providing similar technology and services, he replied “I have no direct competitors.”

When asked what he felt were the major benefits of EMR, he replied “There are a lot of small benefits that add up.” Pressed for a few bigger benefits, he mentioned, “Increased administrative and physician efficiencies, information is always available (no more running out to refer to the CPS), quick access to charts for looking up lab or medication info, charts are not lost and there’s remote access to records.”

He continued, saying, “The patient benefits include greater safety, prescriptions are legible, drug-drug interactions are detected by the physician rather than the pharmacist, patients can see what is in their chart and make corrections, better quality data, and a feeling that their doctor is modern and up on the latest.”

Although the advantages of computerizing a practice may vary from case to case, there is no doubt, according to Dr. Keshavjee that the benefits accrue to governmental healthcare systems and patients – not to doctors. “Nonetheless, in most provinces, it is the doctors who must foot the large up-front cost”. •

BACK TO THE CONTENTS LISTING

 


HOME - SUBSCRIBE - ADVERTISE - ARCHIVES - CONTACT US