A Surprising Statistic
A recent blog article on the Modern Healthcare web site states that 12.1% of the U.S. population has had their protected health information (PHI) compromised in data breaches. That amounts to approximately 1 in 8 Americans that have been affected.

With assurances of doctor-patient confidentiality, notice of HIPAA practices at the doctor’s office, and the need to sign a release form to get one’s own medical records, this is a staggering number, and it’s a tough pill to swallow.

More clinicians are using portable devices such as laptops, tablets, and even Google Glass in an effort to better coordinate care and increase provider productivity. As a result, patients’ medical information is no longer contained just within the medical records room but is transported in and out of the office and even maintained on the cloud. While there are many benefits to the implementation of these technologies, the opportunity for data to be misplaced or stolen is increased.

What is The Wall of Shame?
The Office for Civil Rights (OCR) within the Department of Health and Human Services (HHS) is the watchdog for compliance with the HIPAA Privacy and Security Rules. The OCR Secretary must publicly post any data breaches affecting more than 500 patients, and that data can be found in a searchable database on the OCR site.  Many in the industry refer to this as the Wall of Shame.

When the Health Information Technology for Economic and Clinical Health Act, or HITECH, went into effect in February 2010, it strengthened the existing Privacy and Security Rules under HIPAA.  One key change made was that business associates of covered entities are now equally responsible for complying with these rules and are subject to the same fines and penalties.  Medical transcription companies, healthcare documentation specialists working as independent contractors, or any vendor or third party working with protected health information are examples of business associates.

Data breaches may take many forms. Laptops containing PHI are stolen or accidentally left behind; electronic protected health information (ePHI) on an organization’s server becomes available on Internet search engines due to changes in server configuration; ePHI stored on a photocopier hard drive is not erased when the equipment is returned to the leasing company. This represents just a few of the many scenarios reported on the HHS web site.

There has been a steady increase in the number of breaches on ‘the wall.’  For example, in 2004, there were 2 incidents posted in the HHS database; in 2013 that number soared to 242. This year already shows more than 100 reported breaches. Again, these are breaches where PHI for more than 500 individuals is involved. As one might expect, there is a noticeable jump in reported cases in 2010, after HITECH went into effect, incorporating not just covered entities but business associates as well.

The advancement of technology in healthcare documentation has the potential to improve the coordination of patient care and improve productivity for providers; however, with the increased number of avenues where information may be breached, we must be ever vigilant to protect that data.

Want to learn more?  Join us for AHDPGTM‘s free online HIPAA training. This training is an Association for Healthcare Documentation Integrity (AHDI) Preapproved Activity for 2 CEC (Medicolegal).

As the healthcare industry marches towards Stage 2 of Meaningful Use, there is a large population of physicians that have not yet accepted the requirements put forth by CMS in the EHR Incentive Programs. Dr. Daniel F. Craviotto Jr., an orthopedic surgeon in Santa Barbara, California, took to the Wall Street Journal earlier this week to protest the restrictive chains of EHR adoption, quality penalties, shrinking Medicare reimbursements, and bureaucratic red tape that prevent a physician from focusing on what’s really important: engaging with and treating patients.

As noted in a previous blog post (Doctors or Data Entry Clerks?) we have been wondering when physicians, other healthcare practitioners and more importantly, healthcare executives were finally going to see the Emperor’s true clothes and begin to push back against the $30 billion dollar machine which is perverting healthcare delivery and any true efforts to reduce the rise in healthcare spending in this country.

Now do a quick Google search and all of a sudden there is a growing list of articles questioning the implementation, cost and patient safety benefits arising from this national initiative.  Here is a sample of some of the most recent articles:

U.S. Electronic Health Record Initiative: A Backlash (IEEE Spectrum)

Electronic Health Records Rife with Flaws (Albuquerque Journal)

Report Finds More Flaws in Digitizing Patient Files (NY Times)

Is EHR “mania” Hiding Serious Patient Safety Flaws? (EHR Intelligence)

To be clear we are not against the implementation of technology in healthcare.  In fact, there are any number of proven technologies that we have all benefited from and there will be new technologies that we will benefit from moving forward in the future.  What we are saying is two things:

First, if the technology is truly of value to the marketplace (any marketplace, but in this case the healthcare delivery marketplace) then we have a great system setup in this country where that technology will be embraced (sold and implemented) and it does not require a $30 billion push from the government to make it happen.

Secondly, since one of the largest cost drivers in any business (including healthcare) is people, then one of the best and simplest ways to reduce costs is to ensure you have the right people, doing the right activities in the most cost effective manner.  Using highly educated, highly compensated physicians as data entry clerks is not the solution.

For all our sake’s we hope this groundswell continues to grow!

Over the past several decades, new and interesting healthcare roles have been created to reflect the changing complexities of our health care system. We have seen the proliferation of hospitalists, surgicalists and laborists (in-hospital obstetrical specialists) on the physician side, and patient navigators, physician extenders and patient ombudsmen in the non-physician side. Now, there is an additional and intriguing job title that may gain some traction even in the high-tech era of the electronic medical record (EMR): the “medical scribe.”

The medical scribe, also known as a “clinical information manager,” “medical scribe specialist” or “ER/ED scribe,” is a trained medical information manager who specializes in charting physician-patient encounters in real time. Although originally spawned as an adjunct in the emergency medicine environment, this clerical resource is seeing wide-spread use in the inpatient and outpatient/ambulatory care settings.

The use of scribes has exploded in direct relationship to the negative consequences of EMR use.

In the inpatient setting, the time that physicians are spending at the patient bedside has been drastically reduced in order to spend more time with EMR data entry. The same applies to the outpatient, ambulatory or office setting where physician face-time with patients has seen an equally significant reduction, by some estimates by as much as 30 percent! Not only is productivity negatively impacted but the time that physicians spend during a patient visit capturing and entering data rather than focusing on the patient can be a major drag on the overall quality of care, patient satisfaction and revenue generation. Here is where the medical scribe may serve a very important role.

The medical scribe is an unlicensed individual hired to enter information into the EMR or chart at the direction of the physician or licensed independent practitioner. Through the use of medical scribes, organizations can improve the overall quality of documentation for both granularity and specificity; which in turn improves billing and revenue generation. In addition, by shifting the vast majority of real-time documentation responsibility to the scribe, physicians are able to see more patients, generate more revenue and better manage their time overall so that at the end of a busy day there is no need to finalize one’s charts or enter additional data in the EMR – increasing regulatory compliance!

The positive effects created by working with a medical scribe are legion:

Quality of Care Increases
Patient Volume Increases
Revenue Increases
Patient Satisfaction Increases
Physician Satisfaction Increases
Regulatory Compliance Increases

As more and more healthcare organizations look to implement medical scribes two methods of implementation are being used. Some healthcare organizations look to engage a medical scribe management company while others choose the homegrown method. Each option brings with it certain advantages and disadvantages.

By partnering with a medical scribe management company a healthcare organization is typically entering into a multi-year agreement where the scribe management company will recruit, hire, train, manage, monitor and deliver a medical scribe program. The fees for this service typically fall into two categories – a one-time implementation fee to get the program up and running (typically between $25,000 – $100,000 depending upon the size and scope of the program) and a per hour fee for each scribe used (typically in the $20 – $26 per hour range). So for each scribe FTE the healthcare facility is paying about $48,000 per year (using $24/hour). A nice premium over the $10 – $14 per hour a typical scribe earns.

And for those organizations who choose the homegrown method the task of recruiting, hiring, training and developing competent resources in sufficient numbers becomes a bit of a challenge.

But now there is a third option.  The American Healthcare Documentation Professionals Group, a Certified Academic Partner of the American College of Medical Scribe Specialists will partner with you to recruit, hire, train and oversee the use of medical scribes at your facility. Whether you need one or 100 scribes our online/on-site medical scribe training program might be just what the doctor ordered!

The benefits of our program include:

  • No upfront implementation cost.
  • No ongoing per/hour per scribe fee.
  • An all-inclusive training fee of less than $2,000 per scribe which covers each scribes tuition, books, materials, membership in the American College of Medical Scribe Specialists and certification exam.
  • Flexibility to “customize” the training program to meet the specific needs of your facility.

Contact us today if you need a medical scribe or 101?

In a recent article by Patricia Kirk, published on Wednesday, November 13th, 2013 by the enews/management briefing service Dark Daily, the article makes reference to a claim made by EHR vendors who “contend that the need for medical scribes is temporary because eventually EHR use will evolve in ways that will make scribes obsolete.”

I hope not for a number of reasons.

First off, with a well-documented shortage of well-trained physicians I cannot imagine a scenario where we as a country would want to burden our scarce resource of physicians with the responsibility of doing data entry.  As I have said before this would be analogous to having the CEO of Macy’s operate a cash register or having Tom Brady work the concession stand at half-time.  Unless I was doing some type of wacky marketing thing, if I owned stock in Macy’s (which I do not) or the owner of the New England Patriots (which I am not) I would certainly want to make sure I was getting the most value from my investment and having doctors doing data entry is clearly not the solution. I bet getting the most value from an investment is taught on a regular basis at Harvard!

Secondly, and this one might get a chuckle from many readers, if Obamacare truly increases the number of people with health insurance (40M more people) and those newly enrolled seek additional healthcare services what physician is going to have time to provide these additional services and do the increased level of administrative tasks associated here? This is simply a question of supply and demand…another topic I am sure is taught at Harvard.

And finally, one of the biggest reasons it doesn’t take an MBA from Harvard to see the value of today’s medical scribes is simply this…you do not lower the cost of healthcare by replacing a $12 – $20 per hour resource (a medical scribe or a medical transcriptionist) with a $200 – $500 per hour resource (the physician).  That’s madness and begs the question, why aren’t more hospital CEOs, CFOs, CIOs and physicians themselves seeing this?

To effectively lower the cost of healthcare we need to have the right people, with the right tools (technology), in the right roles, doing the most cost effective work possible.  This includes Healthcare Documentation Specialists of all types, including Medical Scribes and Medical Transcriptionists.  This is why it doesn’t take a Harvard MBA to see the value of today’s medical scribes!

Read more: Medical Scribes Move Outside the ER to Help Clinicians in Other Healthcare Settings Make the Switch From Paper Charts to EHRs

The recent news coming out of the largest providers of medical transcription services to U.S. hospitals paints a clear picture of the turmoil going on behind the scenes at these organizations.

M*Modal Shakes Up Leadership, Names New CEO

Moody’s Downgrades M*Modal; Outlook Negative

Carl Icahn Increases Nuance Stake, May Seek Board Seat

But what does this mean to the individual healthcare provider or the 5,500 hospitals scattered across the U.S and most importantly, the patients they serve? If these two organizations are responsible for creating a significant portion of the healthcare documentation created today, could turmoil at the top be a precursor to:

  • An increase in poor quality healthcare documentation on the front lines?
  • Non-compliance with desired/needed turnaround times?
  • Reduced customer service and responsiveness to client inquiries?
  • Increased physician re-work at a time physicians are already being pulled in multiple directions?
  • Decrease in physician productivity and satisfaction?
  • And ultimately, increased legal exposure for physicians and hospitals?

How could this not ultimately impact the level of patient care being provided in our hospitals nationwide?

At a time when the healthcare industry is spending billions of dollars to implement electronic medical records, move to a new coding system (transitioning from ICD-9 to ICD-10) and otherwise position themselves for the launch of ObamaCare (the Patient Protection and Affordable Care Act), maybe, just maybe, it’s time to get back to basics?

In the not too distant past many healthcare entities leveraged the services of a contingent of medium sized medical transcription services organizations who pride themselves on providing:

  • Premium level clinical documentation services;
  • Leveraging well-trained U.S. based labor resources;
  • With flexible, scalable solutions and/or the flexibility to use the hospitals internal systems;
  • Functioning on a variety of platforms including 3M, MModal, Nuance/Dictaphone/eScription, Dolbey, Infraware, Arrendale, McKesson, Meditech, Epic, etc.
  • With a single point of contact between the client and those able to effectively respond to client inquiries/needs without having to navigate multiple layers of an organization;
  • A well-defined and documented Quality Assurance program;
  • A proven proved track record with reference-able client sites; and
  • A commitment to pricing transparency and pricing competitiveness.

With turmoil at the top and patient care hanging in the balance…maybe it’s time to consider moving your business back to a medium-sized provider of medical transcription services.

For a list of medium-sized service providers leveraging strictly U.S.based labor resources, please feel free to contact us at 1.800.407.1186, extension 803 or email us at sales@ahdpg.com.

It’s well known that, in the vast majority of cases, Electronic Medical Records (EMRs) make doctors far less efficient when seeing patients.

Why? Because it’s rather difficult to tend to the computer when you’re supposed to be focusing on the patient. It’s relatively easy to write with pen and paper while listening and explaining. It’s far harder to keep two hands on a keyboard, a third hand on the mouse, one eye on the screen and another eye on the patient and any family members that may be in the room with you. And the fact that most EMRs and user interfaces are designed by computer geeks with no knowledge of clinical care or workflow certainly doesn’t help matters. As soon as EMRs are deployed, physician productivity typically goes down by about 40% and it rarely ever gets back to where it was prior to installation.

Employing “scribes” is an increasingly common way physician’s and healthcare organization’s use to get around this mess. Since physician time is scarce and expensive, the thinking goes, why not hire a somewhat less expensive person to handle all the new busywork generated by computers? As a result, an entirely new industry has arisen whose main function is to type patient information directly into electronic medical records.

A medical scribe or clinical information manager is a person trained in medical documentation who assists a physician throughout his or her work day. They serve as a personal assistant to doctors to help make them more efficient and productive. The primary function of a scribe is the creation and maintenance of the patient’s medical record, which is created under the supervision of the attending physician. The scribe will document the patient’s story, the physician’s interaction with the patient, the procedures performed, the results of laboratory studies, and other pertinent information. Additional functions of a scribe may include ordering laboratory/radiology studies, assisting with the patient’s disposition, documenting consultations, and notifying the physician when important studies are completed.

Here is a list of characteristics that contribute to the success of a medical scribe.

  • Strong English grammar skills
  • A compelling interest in healthcare
  • Outgoing and friendly personality
  • Strong desire to work onsite in a clinical setting
  • Superior analytical and resource skills
  • Strong computer and keyboarding skills
  • Keen listening skills
  • Self-starter
  • Strong hand-eye coordination
  • High level of concentration
  • Attention to detail
  • A commitment to lifelong learning
  • Looking for a career that has an excellent future

If you are interested in pursuing a career as a Certified Medical Scribe, visit our online Medical Scribe training program information  page!

In today’s day and age, everything seems to be about technology, instant gratification, quicker turn around as well as more for less.  I can say that I have seen and worked within the concept of “more for less” for many years and it just seems to be the nature of our society today, or so it would seem.  So as we look at the transition of health care and the migration of medical records to electronic health records, this has actually managed to create a new vein of career paths in the health care field within our environment, which is great.  Along these same lines now emerges electronic encoders.  It is the opinion of this blog writer that encoders are positive and negative in a few different ways in the coding world for the profession coder and I am going to share why.

Encoders are great tools to help increase production standards because you can save time searching for your codes by having the system do the work for you.  They have built in references that are wonderful to have at your fingertips and not have to leave your work station to locate or search the all mighty web.  Not all working environments give their employees access to the internet so the fact that the encoder programs could possibly provide medical dictionaries, CPT Assistants, drug listings, Coding Clinics, anatomy diagrams, ICD-9 guidelines, and GEM guidelines would be invaluable to the work flow for a coder.  Not to mention the space it would safe from having all of these references in the work space.  Some encoders also come with other administrative functions that assist us to conduct research on specific procedures as well as individual payer information.  So there are some real great benefits that come with an encoder software package, depending on what is purchased and implemented in the working environment.

So you probably are wondering then, why would I even be asking why an encoding product would be a Foe in the world of a coder?  Here is my reason why.  Coding is a skill that we work extremely hard to learn and perfect.  Hours, months and years of time go into learning what we know and how we do what we do in our line of work.  Encoders are a great tool but can also spoil and ruin us as coders, if we allow them to.  If a coder becomes too reliant on an encoder, this is a bad thing.  If a coder becomes to “comfortable” coding with an encoder, this is a bad thing.  A coder needs to use their skills that they have built or they lose these skills over time.  They may not lose them completely but they can become very rusty for sure.  It is good practice to still manually code from time to time.  It is good for the brain to keep your fingers in your coding references so you remember how your books work, where to find everything, keeping your skills fresh on crosswalks and modifiers.

Things to keep in mind is that even if your working environment is using an encoding product, not everything in the coding world is and remember that to maintain your coding certification, you have tom complete continuing education credits.  Many of these continuing education credits are manual coding exercises.  If you look to gain any additional certifications above the certifications you already carry, these will be manual coding exams.  Not to mention, it is really difficult to put your personal coding notes in an encoder program but you have the luxury to place them anywhere you would like in your personal coding reference.

As a healthcare documentation specialist – whether our title is medical transcriptionist, editor, or medical language specialist – our pay may be largely based on productivity.  Often it may seem that productivity becomes front and center – after all, this is our livelihood.  More lines means more money!

Well, yes, BUT (and it’s a big but).  At the risk of sounding preachy, let’s not forget that our first responsibility is to the patient and ensuring that the information we are documenting for them is accurate.  Look at it this way:  Sometimes, you are the patient.  How do you want the healthcare documentation specialist to treat your record?

Fear not.

There are ways to maximize productivity without sacrificing quality, and vice versa.  Efficient use of references and research skills, reducing interruptions, taking rest breaks, and having an ergonomically sound workstation are all important.  There is one tool, however, that most specialists use or rely on in some way – the expander program.  This can be either through the use of the automatic text features in word processing programs, through the expanders/normals feature of a documentation platform, or through commercial software that we can purchase that will “pair up” with the systems we are using.

With expander use comes great responsibility.  While expanders will save many, many keystrokes (and sometimes full paragraphs of text), there can be some drawbacks to their use.  Probably the most obvious is the increased chance of inserting incorrect text.  Your doctor asks you to keep a diary for your headaches, not a diarrhea.   The patient’s name is Bob, not bowel or bladder.  The expander software I’m using right now tells me that my entry of AAA can be either abdominal aortic aneurysm, after adequate anesthesia, or awake and alert; if I’m not paying attention, the awake and alert patient could have some more pressing problems at hand.

Clearly, in addition to being responsible in our expander usage, proofreading the reports is just as important regardless of whether or not we use expanders.

Another drawback to using expanders is the potential of dampening our skills over time.  If we consistently use shortcuts, we may not immediately recall how to spell hydrochlorothiazide, uvulopalatopharyngoplasty, and gentamicin.  Should the patient be seen for a follow up visit or a followup visit?  It may be worthwhile to turn off the expanders from time to time; this will likely pay off in the long run.

What has been the most important tool or practice for you in increasing your productivity and maintaining accuracy? 

Medical Scribes are individuals trained in medical documentation who assist a physician throughout their shift. The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on what is most important, the patient.

A summary of a Medical Scribes duties include performing all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. You also must be able anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care.  Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe.  You must be adaptable and versatile since you will be responsible for many tasks. Good attendance is also an important element of this job since you will be hard to replace.

Some of the more detailed job duties and responsibilities of a Medical Scribe are:

1.         Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:

  • Patient medical history and physical exam,
  • Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
  • Patient education and explanations of risks and benefits.
  • Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
  • Prepare referral letters as directed by the physician

2.         Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribe also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.  You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.

3.         Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.  All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record.  Alert physician when chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

4.         Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance.

5.         Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

Qualifications:  To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.         Language Skills – The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production. Handwriting must be clear and legible.

2.         Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.

3.         Mathematical Skills – Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.

4.         Reasoning Ability – Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.

5.         Computer Skills – To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software. Must accurately enter data into a database, search for information, send and receive email and attachments. Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents. Must use Microsoft Excel to prepare flowcharts and organize data. Must use the internet to access schedules, research information, etc.

6.         Other Skills and Abilities – Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information.

7.         Physical Demands – While performing the duties of this Job, a Medical Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The Medical Scribe must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

As you can see, Medical Scribes are an invaluable asset to physicians in busy emergency departments, hospitals, or clinics. With more time to focus on interacting with their patients, doctors see more patients while the Medical Scribe is documenting the patients visit and care plan – alleviating that burden from the doctor. Medical Scribes are fast becoming more and more important to a doctor and a profession that is in high demand.

Do you have what it takes to become a Medical Scribe? Find out more!

Updates and Changes happen very frequently in the billing and coding profession.  One day you may be using a code set a specific way only to find out a month later that the process has changed and the way you were using the code is no longer the proper way to apply the code.  Changes happen every day and it is vital to stay abreast of these changes in our profession.

As we are getting ready to start September already (I know, very hard to believe) we are preparing for new ICD-9’s, new CPT’s, and new HCPCS codes and now more than ever we need to find out what codes are new, what codes are changed and more importantly what codes have been deleted for the 2013 calendar year.

If you have the opportunity, this is the time to attend webinar’s or seminar’s to find out what changes are occurring.  Many organizations offer these meetings that can be as general as you are looking for and as detailed as you are looking for if you attend a specialty specific session to find out the changes that are up and coming.   Remember that the 2013 ICD-9 code book goes into effect on October 1  and the 2013 CPT and HCPCS books go into effect on January 1, 2013.  This becomes one of the busiest parts of the year for coders and billers to be sure that we are updated and ready for the 2013 calendar year.  Be sure you are ready for the updates and changes so that you are not caught unprepared.  Start planning now…..