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medicare part D and vaccines

naturowhat Feb 20th, 2016 231 Never
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  4.         weyrich_comp

Message 1 of 31 , Nov 30, 2015 



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I was talking to a colleague (Dr. Bob Gear, NMD) today and he said that CMS has a new rule that all NMDs must register as "Nonparticipating Providers" using the same form used by pharmacies to register or else CMS (Medicare part D - not sure if this also affects AHCCCS/Medicaid) will no longer pay for prescriptions, effective June 1 2016.


Has anyone else heard of this and are there any thoughts?  Is there a hidden gotcha to ensnare unwary NMDs? (I shudder to think of being sued by the government for "fraud, waste and abuse" if my treatment model differs from the Allopathic model CMS embraces.)


Is this just a nuisance piece of paperwork we have to sign, or is this a trap?


Orville Weyrich, Jr. PhD NMD
Scottsdale/Phoenix/Payson AZ
SCNM 2007




  5. Mona Morstein
  6.  
  7. Message 2 of 31 , Dec 1, 2015
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  9. View Source
  10.  
  11. Orville, I guess this may not apply to me. I’m an ND! ;-)
  12.  
  13. Mona Morstein, ND, DHANP
  14. Tempe, AZ
  15. www.diamend,info
  16. Official Sponsor of NatChat—Doctor’s Data Labs
  17.  
  18.  
  19.  
  20.  
  21. Brian
  22.  
  23. Message 3 of 31 , Dec 2, 2015
  24.  
  25. View Source
  26.  
  27. This actually will apply to all of us NDs. Currently the AZNMA has been working with the state branch of AARP and has a meeting at the federal level to try and ensure that Naturopathic Doctors will be able to continue to write prescription for our Medicare patients and have them covered as they are currently.
  28.  
  29. With this new rule change, which initially went into effect January 1, 2016 we would no longer be able to have our Rx covered for our Medicare patients, which affects some doctors more then others. The date has been extended. But the AzNMA has been working diligently to ensure continuity.
  30.  
  31. This is just another great example of how your state association is working to ensure your practice's viability. If you are not already a member of your state association, please consider joining and involved as we are constantly working on many items such as this on an daily basis.
  32.  
  33. Thanks you
  34. Dr. Brian Archambault
  35.  
  36.  
  37.  
  38. weyrich_comp
  39.  
  40. Message 4 of 31 , Feb 5 5:07 PM
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  42. View Source
  43.  
  44. I would appreciate more information and less sales propaganda.
  45.  
  46. The letter I got does NOT say that NDs will be prohibited from prescribing, but that we need to officially opt-out of being a "participating provider."  The implication of the letter is that we will still be able to prescribe for part D.  Is this a lie?  Or do we really not know?
  47.  
  48. I stopped participating with the AzMMA after I got an "official" e-mail from them (their e-mail address) encouraging me to attend a rally in favor of ObamaCare.  This was after their lobbyist previously tried to make a deal with other medical professionals to allow ND's to have "insurance parity" in exchange for our support for eliminating low cost insurance policies (called "Swiss Cheese" because they did not have all the bells and whistles that backers of single payer insurance want). My patients want basic services at low cost and freedom to choose their form of treatment.  They are best served by a catastrophic major medical policy plus a health care savings account.  The AzNMA apparently lobbied AGAINST this idea!
  49.  
  50. If they want to regain my trust they need to be a LOT more transparent, rather than operating as a "secret society" that requires joining to find out what they are REALLY up to.
  51.  
  52. The national organization is apparently no better - trying to railroad NDs into blanket support of all vaccine programs!
  53.  
  54. Just my $2.00 (adjusted for inflation)
  55.  
  56. Orville Weyrich, PhD NMD
  57. Payson/Phoenix AZ
  58. SCNM 2007
  59.  
  60.  
  61.  
  62. natmedworks
  63.  
  64. Message 5 of 31 , Feb 6 1:13 PM
  65.  
  66. View Source
  67.  
  68. Dr. Weyrich,
  69.  
  70. IMHO I feel you are being short sighted by not joining your state organization. And Yes you do have to "join" to find out what they are up to. I am not in AZ, however you can thank your state organization for getting you the licensure you now use to practice. Instead of being part of the problem, be apart of the solution. Get involved and move the organization in a direction you like. The organization is built to help you. It is self defeating to fight against it.
  71.  
  72. Dr. Coleen Murphy
  73. Orange County, CA
  74.  
  75.  
  76.  
  77. Eric Blake
  78.  
  79. Message 6 of 31 , Feb 6 10:07 PM
  80.  
  81. View Source
  82.  
  83. Orville please feel free to say your peace. Good for you. There are others out there with a similar feeling. 
  84.  
  85. I am a member of the OANP and have been for quite some time - I still have no idea what they are up to. After over a decade as a member I have never really been voluntarily asked for input or surveyed.
  86.  
  87.  I did attempt to help them with how to survey after I saw some really sad attempts at consumer surveying.  I brought in a PhD research led team to develop a consumer research agenda.  In the end it was a waste of time.  It was shocking to me that there was no effort to identify WHAT the public wants from NDs or HOW they are viewed - just throw some ideas out that we believe in and see if they stick. Terrible.  When we recently rebranded our website for example we did a 1000 patient survey and analyzed why.  If you think other associations have done any - well let me tell you we shopped it out and the financially strapped profession kept thinking it was a good idea but no $$.Too busy putting the cart before the horse.  Eventually through a research institute involvement it went to NIH grant application and the NIH said exactly what we thought they would - this is not public health research it is political research, talk to your association. LOL. 
  88.  
  89. In Oregon, aside from expanding insurance coverage and getting expanded Rx rights and an annual conference to cover the 10 pharmacy as a part of the 50 hours of annual required CE (part of the bargain to expand Rx rights was extensive annual allopathic pharm training. Probably a good idea but...be assured there is a trend in Oregon for NDs who resemble the DOs of the 50s and 60s.)   it is really just an insurance lobbying organization as far as I know. All their updates and news centers around that. Thats all that it is focused on as far as I can tell. At least mostly. I am sure someone would argue why that is necessary, I'm not interested in arguing that, but as a member running a successful clinic, that sees a substantial number of patients/public primarily from Oregon (as one clinic seeing 8-10k patients annually currently we see the equivalent of 1/4 of the ENTIRE NCNM clinic system from the numbers I saw last) - well let me tell you membership doesn't give you any privileges. And because I am not an insurance please pay me practice getting involved in expanding insurance credentialing coverage is not worth my time. If they worked on better OON coverage it would represent me and a LOT of other NDs, but everything they communicate is getting in network credentialing.  
  90.  
  91. They do now have a lawsuit against an insurer to attempt to get parity. And asking for donations to pay for it.  Perhaps it will win out but from a legal perspective it is weak. And it will be a long expensive process if it does get wings.  That is based on my familiarity with 20th century case law as it affected our profession (my familiarity pales in comparison to the lawyer I collaborate with who is extensively familiar with it - And we both think it is poorly positioned.) But why ask me?  Perhaps it has something to do with this very odd 'nature cure' reputation that I seem to have, which is absurdly untrue and ironic to me. Thats not my clinic at all.  We are cutting edge. Apparently familiarity with history makes one anachronistic by association? 
  92.  
  93. Members are not surveyed - at least I have never been that I can remember- we do get regular invites to 'free CE' which is frequently a compounding pharmacy simply selling their products or some other allopathic Rx. But it gets covered as CE. 
  94.  
  95. Perhaps Arizonas Association is better. I agree with you regarding patients desires to not be railroaded into the ACA. So many are now paying outrageously higher rates for supposedly better coverage that is not and they no longer have the option for insurance - i.e. emergency medical disaster coverage only.  
  96.  
  97. Apparently our director is the one that approves state board candidates for consideration after they are nominated - at least that is the word on the street.  Board candidates are run by and if approved by the director they get endorsed for consideration by the Governor.  If that is the case and the board and the OANP are not staying separate, I would find that unsettling. But....Thats politics. 
  98.  
  99. So don't be goaded.....non participation protest is a legitimate political act.  Consider my dues coverage for you.
  100.  
  101.  
  102. --
  103. Dr. Eric Blake
Naturopathic Physician and Diplomate of Acupuncture
  104.  
  105.  
  106.  
  107. Eric Yarnell
  108.  
  109. Message 7 of 31 , Feb 7 10:56 AM
  110.  
  111. View Source
  112.  
  113. Dr. Weyrich,
  114.  
  115. Respectfully, the AANP vaccine position paper process was not driven by a desire to railroad anyone into supporting anything and I resent this straw man characterization of a nuanced, complex process that involved many people with a whole range of motivations and objectives.
  116.  
  117. The AANP immunization position paper was intended to respond to the growing criticism our unlicensed state organizations are hearing which is that the perceived opposition to vaccination in the profession is causing more and more difficulty getting states licensed. I most heard about this from folks in the Maryland licensure organization who did manage to get licensed in the end of course but I’ve heard from others in states that haven’t that this is an obstacle. Furthermore, after conducting a thorough scientific review, the AANP could not support its existing position paper on vaccination. Furthermore, many of us identified public health personnel as being our best and most natural allies within conventional medicine, sharing all of our ideals really, but that we are frequently blocked from working with them or being supported by them because of the perception we are all anti-vaxxers. Finally, for better or for worse, it is also becoming clear that if we want the option (again, not the requirement) for NDs to participate in Medicare in the future, perceived opposition to vaccination could be a major stumbling block. So, far from being motivated by some kind of fascist drive to force the membership to support something, the process was driven by four main motivations that were entirely focused on helping our profession advance, a primary stated goal of the AANP. You may agree or disagree with those motivations, but at least please accurately characterize them and don’t pretend there was some kind of ridiculous conspiracy. I was involved at various points in the process and there was no conspiracy.
  118.  
  119. Position papers from national organizations generally don’t commit anyone to doing anything in a particular way in their own practices. It does create an additional burden on those who choose to go against the position paper to document that their way of doing it is supported at least as well as the national position.
  120.  
  121. I have no knowledge of the AzNMA dealings or the Medicare part D situation currently.
  122.  
  123. Eric Yarnell, ND, RH(AHG)
  124. Seattle, WA
  125.  
  126.  
  127.  
  128. weyrich_comp
  129.  
  130. Message 8 of 31 , Feb 7 11:45 AM
  131.  
  132. View Source
  133.  
  134. Thanks for the information.  
  135.  
  136. I would have welcomed a nuanced discussion - I saw none.  It seemed to be either ALL vaccines are good and the CDC schedule is golden, or we oppose ALL vaccines. 
  137.  
  138. Neither position is acceptable to me (especially regarding the MMR and flu vaccines); nor is the political strategy the DOs followed to gain recognition - they are now indistinguishable from MDs.  I do not want to see NDs go down that road.
  139.  
  140. If a state organization wants to mount a public campaign in support of vaccinations, LET THEM!  But don't try to paint me with their brush. If a wanna-be state organization wants diffuse the vaccination issue, all they have to do is include in their proposed practice act the specific POWER (not responsibility) to administer vaccinations. [By the way, I do not believe that ND in AZ have that power - last time I looked at our practice act, the question of what we were allowed to inject was rather convoluted but limited to nutrient solutions].
  141.  
  142. By the way, recognition of NMD by CMS does NOT hinge on support for vaccinations.  It hinges on our SURGICAL skills, which vary from "none" in some states to "minor surgery" in the state of Arizona [somewhere I have a letter from CMS that spells out this legislative requirement for recognition by CMS, which was created by Congress].  
  143.  
  144. Our state organization COULD be pushing this issue - that NMD in AZ have the same surgical skills as any other PCP, but they have not.  Instead, they appear to want to distance themselves from the two naturopaths in AZ who REALLY are most responsible for our current scope of practice - Drs Robert Gear and John Brewer. [I recently asked Robert Gear, who is a lifetime member of the AzNMA, served multiple terms as a board member of the Az Board of Medical Examiners, and worked as a lobbyist who successfully guaranteed our scope of practice (actually MORE than we have now) what is going on with Medicare part D.  His answer (aside from agreeing with me regarding the surgery issue) was that the AzNMA tells him nothing.  I have not seen Dr. Brewer lately, so I do not know his opinion.]
  145.  
  146. Regards,
  147. Orville Weyrich, PhD NMD
  148. Payson/Phoenix AZ
  149. SCNM 2007
  150.  
  151.  
  152.  
  153. Dr. Nan Dunne Byington
  154.  
  155. Message 9 of 31 , Feb 8 6:34 AM
  156.  
  157. View Source
  158.  
  159. Thank you Eric Y, for clarifying the motivation and process the AANP position paper effort represents. I wish our community would give each other the benefit of the doubt regarding intentions, motivation and inclusiveness. As someone who has volunteered in leadership pretty steadily for decades, I am always astonished at the bitterness and even snarling disdain of criticism leveled at each others efforts, especially from people I have never seen at the work tables. I also find it really bizarre that anyone is irritated by the fact that no one always gets exactly what they want in any community effort.
  160.  
  161. Our whole society is at a point of divisiveness among extremes. The naturopathic community shares a philosophy that can unite us, can inspire us to compassion, patience, thoughtfulness and respect at the least for each others’ dignity, if not earned behavioral outcomes.
  162.  
  163. With admiration and respect for our collective efforts at peace and love,
  164.  
  165. Nancy Dunne Byington, ND
  166. Executive Director
  167. Montana Association of Naturopathic Physicians
  168.  
  169.  
  170.  
  171. weyrich_comp
  172.  
  173. Message 10 of 31 , Feb 9 12:30 PM
  174.  
  175. View Source
  176.         
1 Attachment 1.4 MB
  177.  
  178.  
  179.         PDF
1.4 MB

Medicare Part D.pdf

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  180. Returning to the original topic of this thread, and without further discussing the merits of the member of AzNMA's post suggesting that only dues paying members are entitled to any information on the subject, let me summarize the current situation (which, it appears, is not widely known by practicing NDs).
  181.  
  182. I have received notification from CMS (see attachment) that states in part: "Dear Prescriber: You have been identified as a provider who currently prescribes drugs for Medicare patients, but who is not enrolled in (or validly opted-out of) Medicare ... Beginning June 1, 2016, we will enforce a requirement that Medicare Part D prescription drug benefit plans may not cover drugs prescribed by providers who are not enrolled in (or validly opted out of) Medicare ... These new CMS rules will enable federal officials to better combat fraud and abuse in the Part D program through verification of providers' credentials via the Medicare enrollment/opt-out process."
  183.  
  184. I find this alarming, since it is not clear to me that NDs can "validly opt-out" since they are not recognized by CMS as being health care providers.  My concern is that after this policy is enacted, the next step will be to deny prescriptions written by NDs anyway - there is no way we can win. [Call me paranoid, but it is not clear to me how being officially "opted out" helps prevent fraud and abuse in the Part D program, unless the intent is to identify and eliminate those prescribers who are recognized by the states (and DEA) but not CMS - i.e. NDs!]
  185.  
  186. I do not want my Medicare patients to find out on June 1 that they have to pay for any prescriptions I write - if I have to tell them to look for a new doctor, I want to give them as much warning as possible. My practice can survive the loss of Medicare patients (I just increase my focus on concierge medicine) but my patients are the ones who will be hurt.
  187.  
  188. Can we have some honest discussion of this important subject without further posturing by representatives of state associations?  For an example of the kind of transparency I expect from a professional membership organization, see the following link published by the Association of American Physicians and Surgeons:
  189.  
  190.  http://www.aapsonline.org/index.php/article/opt_out_medicare/
  191.  
  192. This link is freely published for all to see.
  193.  
  194. [Again, call me paranoid, but I note in passing the massive ethical (conflict of interest) problem with having the government in charge of both Social Security and Medicare - the faster seniors die due to inadequate medical care, the less money SSI has to pay out].
  195.  
  196. Regards,
  197. Orville Weyrich, PhD NMD
  198. Payson/Phoenix AZ
  199. SCNM 2007
  200.  
  201.  
  202.  
  203. Sally Boyd-Daughtrey
  204.  
  205. Message 11 of 31 , Feb 9 2:40 PM
  206.  
  207. View Source
  208.  
  209. Perhaps a collective liver cleanse this spring would be helpful. . . . :)
  210.  
  211.  
  212.  
  213. Eric Yarnell
  214.  
  215. Message 12 of 31 , Feb 9 2:58 PM
  216.  
  217. View Source
  218.  
  219.  
  220. Show message history
  221.  
  222.  
  223. Neither position is acceptable to me (especially regarding the MMR and flu vaccines); nor is the political strategy the DOs followed to gain recognition - they are now indistinguishable from MDs.  I do not want to see NDs go down that road.
  224.  
  225. This doesn’t mean that attempting to expand our scope will make us follow the DOs. I would argue history has already solidly proven we are not going down that road. NDs remain by far and away very distinctive from MDs and DOs on average.
  226.  
  227.  
  228. If a state organization wants to mount a public campaign in support of vaccinations, LET THEM!  But don't try to paint me with their brush.
  229.  
  230. I am not sure how they are painting you with anything. But a state naturopathic organization somewhat represents you in name whether you like it or not. I agree with others who have posted that engagement is more likely to result in shifts toward your positions rather than opposition or non-engagement. But of course it is your choice.
  231.  
  232. If a wanna-be state organization wants diffuse the vaccination issue, all they have to do is include in their proposed practice act the specific POWER (not responsibility) to administer vaccinations.
  233.  
  234. You make that sound easy, when in fact it is not the state organizations who have power of the practice acts but the legislatures in each state. It is a huge undertaking to change a practice act. Anyway, I would say vaccination should absolutely be in our scope of practice in all licensed states.
  235.  
  236. [By the way, I do not believe that ND in AZ have that power - last time I looked at our practice act, the question of what we were allowed to inject was rather convoluted but limited to nutrient solutions].
  237.  
  238. Intriguing.
  239.  
  240. By the way, recognition of NMD by CMS does NOT hinge on support for vaccinations.  It hinges on our SURGICAL skills, which vary from "none" in some states to "minor surgery" in the state of Arizona [somewhere I have a letter from CMS that spells out this legislative requirement for recognition by CMS, which was created by Congress].  
  241.  
  242. I am sorry if I implied this was the sole issue, which I do not believe. It is one issue among many, but still an important issue. I can see Medicare making an exception for primary care providers not doing major surgery far more readily than those who don’t provide vaccination (as this impacts far more people). But who knows.
  243.  
  244. Eric Yarnell, ND, RH(AHG)
  245. Seattle, WA
  246.  
  247.  
  248.  
  249. lauraroy
  250.  
  251. Message 13 of 31 , Feb 9 4:37 PM
  252.  
  253. View Source
  254.  
  255. This is the information I received from OANP:
  256.  
  257. Many of you received a notice like the one above inviting you to enroll in Medicare in order to continue prescribing for your Medicare patients. Several people, including staff at OANP, contacted CMS to figure out how and if this applies to Naturopathic Physicians since Medicare does not recognize NDs as an eligible provider type. Unfortunately, we all received wildly different answers ranging from “you can apply,” to “your patients are out of luck, they need to find another prescriber.” 
  258.  
  259. After 4 calls and several different people, OANP was finally able to get some straight answers. 
  260.  
  261. The Bottom Line:
  262. If you have any Medicare patients for whom you manage prescriptions OR do any kind of referrals to specialists or other Medicare providers, you MUST register with CMS as an “Eligible to Order and Refer” provider. 
  263.  
  264. Step 1: Download and complete Form CMS8550. Under Medical Specialty Information, remember that CMS does not recognize naturopathic doctors in its definitions as a “physician” or a “physician specialty.” In their eyes, NDs are a “Non-Physician Specialty” and in this category you would check the box “Unlisted Non-Physician Practitioner Type (Specify).”
  265.  
  266. Step 2: Send the application to the following address, depending on your preferred method:
  267.  
  268. USPS Mailing Instructions
  269. Medicare Part B
  270. Attention Provider Enrollment
  271. PO Box 6702
  272. Fargo, ND 58108-6702
  273.  
  274. Fedex/UPS
  275. Medicare Part B
  276. Attention Provider Enrollment
  277. 900 42nd Street South
  278. Fargo, ND 58103
  279.  
  280. It should take 60-120 days to process. Effective June 1, 2016, CMS will no longer cover prescriptions or referrals written by a provider unless you are registered in this way with CMS. So to avoid interruptions in care with your Medicare patients, you should submit the application ASAP. 
  281.  
  282. The Deeper Explanation:
  283.  
  284. In 2014, CMS issued rules that providers needed to either enroll in Medicare or Opt Out officially of Medicare in order for prescriptions or referrals to be covered under Medicare Part D. CMS subsequently became aware that there are many providers, including certain pharmacists and providers like naturopathic physicians (among other provider types) who have state authority to prescribe, but do not meet the CMS definition of “physician” or “eligible professional.” 
  285.  
  286. One year later, CMS recognized that valid prescriptions and referrals written by these non-eligible professionals would be denied because the prescriber is neither enrolled in nor opted-out of Medicare. The rule was modified in May, 2015 accordingly: 
  287.  
  288. “To prevent unintended interruptions in coverage and potential harm to beneficiaries, this IFC requires that pharmacy claims and beneficiary requests for reimbursement for Medicare Part D prescriptions, written by prescribers other than physicians and eligible professionals who are permitted by state or other applicable law to prescribe medications, not be rejected at the POS by the plan if all other requirements are met. These prescribers are defined in this IFC as “other authorized prescribers.” 

  289.  
  290. But Medicare still wants to know who are these “other authorized prescribers” before it will authorize payment for prescriptions or referrals. This is why many of you have received notice from CMS like the image above, inviting you to “enroll” – but really they are inviting you to register in their category of “Eligible to Order and Refer.”
  291.  
  292. If you do not register (i.e., your paperwork completely processed) by June 1, 2016, prescriptions or referrals written by you for your Medicare patients will not be covered. 
  293.  
  294. The many different confusing answers we have received stem from the email invitation that asks you to “enroll” or “opt out.” 
  295.  
  296. Please be clear: NDs may not enroll in Medicare. And if you cannot enroll, Medicare also cannot recognize you as eligible to opt out. 
  297.  
  298. By completing CMS8550, you are neither enrolling in nor opting out of Medicare, you are simply registering yourself as an “Eligible to Order and Refer” non-physician provider to prevent any potential interruption to your Medicare patients’ access to prescriptions and needed referrals. 
  299.  
  300.  
  301.  
  302.  
  303.  
  304. Hope that helps clear things up a little! I, for one, already sent in my form as my patients would suffer a great deal if they were not able to get prescriptions that I write covered and I cannot afford to lose my Medicare patients!
  305.  
  306. Laura Blevins, ND
  307. Klamath Falls, OR
  308.  
  309.  
  310.  
  311. Colleen Huber, NMD
  312.  
  313. Message 14 of 31 , Feb 10 5:13 AM
  314.  
  315. View Source
  316.  
  317.  
  318. "I continue to say to those who don’t support the CDC schedule to present evidence of something better."
  319. -Dr. Yarnell
  320.  
  321. Abundant evidence exists that the CDC schedule, and that most vaccines used in the United States, are both dangerous and ineffective.
  322.  
  323. Over 400 studies in fact, that have been published in the medical literature, including in journals such as: Pediatrics, Lancet, BMJ, JAMA, Infection, Neurodegeneration, showing the risks and failures of vaccines.  Many of these studies are referenced in Neil Z. Miller, Critical Vaccine Studies.  This book would be a good place for you to start.
  324.  
  325. If you are interested in learning about the history of vaccines, the most comprehensive and objective book that I have read is Suzanne Humphries, MD, Dissolving Illusions.
  326.  
  327. It is impossible for you to read either of these and be willing to give even one more vaccine, having learned of the damage already done, the evidence that the vaccinated suffer so much more than the unvaccinated, both from infectious diseases and vaccine side effects.  First Do No Harm requires that naturopathic physicians not administer vaccines, at least not in their present form.  If a much safer, more effective vaccine is developed in the future, I will keep an open mind, but will not administer it until proven safe and effective in credible, uncorrupted double-blind studies.  Those studies have not happened with current vaccines.
  328.  
  329. Again, please start with Miller, Critical Vaccine Studies, and Humphries, Dissolving Illusions.  Other sources do not seem to be anywhere near as comprehensively researched as these two.  All are of course on Amazon.
  330.  
  331. Colleen Huber, NMD
  332. Naturopathic Oncologist (FNORI)
  333. President, Naturopathic Cancer Society, NatOnco.org
  334. Secretary, ANRI / NORI / INCRI, NaturopathicStandards.org
  335. Medical Director, NatureWorksBest Cancer Clinic, NatureWorksBest.com
  336.  
  337.  
  338.  
  339. weyrich_comp
  340.  
  341. Message 15 of 31 , Feb 10 8:45 AM
  342.  
  343. View Source
  344.  
  345. Thank you so much for this information.  However, this raises a new question (opportunity?)
  346.  
  347. The category “Eligible to Order and Refer” seems to suggest that not only are we able to "order" but we might also be able to "refer"?
  348.  
  349. But maybe not.  I am still confused.  Last I checked, NDs could not order lab tests (or  durable goods).  I have always written a letter to a patient's PCP suggesting a referral, but never written a referral directly for a Medicare patient.  This puts a burden on many of my patients in Payson (under-served rural mountain area of Arizona), who have trouble finding a local Medicare-approved PCP. Does "order" really mean "prescribe only" in this context?
  350.  
  351.  
  352.  
  353. weyrich_comp
  354.  
  355. Message 16 of 31 , Feb 10 9:00 AM
  356.  
  357. View Source
  358.  
  359. Under AZ state law you can call yourself either a ND or NMD.  I prefer to use the designation NMD, which emphasizes that I can prescribe drugs (you know, like insulin), and in order to distance myself from the "un-d's" (people who are not licenceable but style themselves as "naturopaths").
  360.  
  361. Orville Weyrich, PhD NMD
  362. Payson/Phoenix AZ
  363.  
  364.  
  365.  
  366. weyrich_comp
  367.  
  368. Message 17 of 31 , Feb 10 9:21 AM
  369.  
  370. View Source
  371.  
  372. Thanks for the excellent references on the subject.
  373.  
  374. However, I would suggest that it would be in each state's best interest to insert into their scope of practice the RIGHT to administer vaccines, both because bigger scope means more credibility and because it would remove the perception that ALL ND are anti-vaxers.  No, it would not be wise to go out of our way to make sure that ND in AZ (or elsewhere) can prescribe and administer vaccines, but (in AZ) we have periodic sunset reviews where we must defend our current scope and have the opportunity to push for greater scope.  It MIGHT we useful to add vaccination to the scope at that time (we might have pushback from our own ranks, but not from the state legislature - which would probably be inclined to say "yes" - which is a good way to get the ball rolling for them to say yes to other issues as well).
  375.  
  376. But back to my original point, which was that if a state is trying to "sunrise" a naturopathic scope of practice, that adding vaccination to the listed scope might deflect criticism that all ND are anti-vaxers and therefore not to be trusted.
  377.  
  378. On the other hand, I feel that our professional organizations should either be silent on this controversial subject, or note that a practitioner should individualize treatment for the patient, and consider both the advantages and disadvantages of each vaccine for the individual patient, as well as the best timing of administration for the individual patient.
  379.  
  380. Regards,
  381. Orville Weyrich, PhD NMD
  382. Payson/Phoenix AZ
  383.  
  384.  
  385.  
  386. Eric Yarnell
  387.  
  388. Message 18 of 31 , Feb 10 10:49 PM
  389.  
  390. View Source
  391.  
  392. I am familiar with the “arguments” made in these books and have reviewed the scientific literature and the logical fallacies rife in them do not withstand scrutiny. These clear up nothing and do not support your extreme position Dr. Huber. But I guess “abundant evidence” (funded by the tobacco companies) proved that cigarettes were harmless for decades and now “abundant evidence” (funded by the petroleum and coal industries) proves there is no human contribution to climate change and everything is fine, just keep burning as much oil and coal as you want it can’t possibly hurt anything. Anyone who selectively cites the literature and makes suppositions and uses correlations to prove the point they set out to prove is not a scientist, is not doing anyone any good, and can play on emotions to make any point they want, damn the facts.
  393.  
  394. And to avoid committing the same errors (like vaguely citing “400 studies” and listing a bunch of journal names without saying what these studies are, which is the same thing as saying “I have here in my hand a list of 205 [State Department employees] that were known to the Secretary of State as being members of the Communist Party and who nevertheless are still working and shaping the policy of the State Department” by McCarthy when of course what he had was nothing and he never provided any evidence), here is the extremely extensive documentation from the Institute of Medicine on the safety and efficacy of vaccination according to the CDC schedule:
  395.  
  396. http://www.cdc.gov/vaccinesafety/research/iomreports/index.html
  397.  
  398. The full text of these are available online so one can freely assess the detailed and complete reviews of scientific evidence they present.
  399.  
  400. Eric Yarnell, ND, RH(AHG)
  401. Seattle, WA
  402.  
  403.  
  404.  
  405. Colleen Huber, NMD
  406.  
  407. Message 19 of 31 , Feb 11 5:00 AM
  408.  
  409. View Source
  410.  
  411. Very true, Dr. Weyrich.  I would not want our scope to exclude vaccines.
  412.  
  413. I do want our profession to be by far the most knowledgeable about vaccine risks and vaccine history. 
  414.  
  415. For example, almost all conventional practitioners and many naturopaths consider vaccination to be safe and effective against pertussis. 
  416.  
  417. However, studies since the 1970's, and every decade since, have shown neurological injury to some children from the vaccine.  But the acellular pertussis shot is not even effective.  Documented pertussis outbreaks have occurred in fully vaccinated populations.    This 2012 study found higher pertussis incidence among those vaccinated for it than among the unvaccinated:
  418.  
  419. Maxwell A. Witt, Paul H. Katz MD MPH, David J. Witt MD. "Unexpectedly limited durability of immunity following acellular pertussis vaccination in pre-adolescents in a North American outbreak."  Clinical Infectious Diseases.  March 15, 2012.
  420.  
  421. Similar studies have also appeared in such publications as Pediatrics and Pediatric Infectious Disease Journal.  I could go on all day. . . .
  422.  
  423. I can't recommend highly enough the 2013 vaccine history text by Suzanne Humphries MD, Dissolving Illusions.
  424.  
  425. Colleen Huber, NMD
  426. Naturopathic Oncologist (FNORI)
  427. President, Naturopathic Cancer Society, NatOnco.org
  428. Secretary, ANRI / NORI / INCRI, NaturopathicStandards.org
  429. Medical Director, NatureWorksBest Cancer Clinic, NatureWorksBest.com
  430.  
  431.  
  432.  
  433. Eric Blake
  434.  
  435. Message 20 of 31 , Feb 11 10:18 PM
  436.  
  437. View Source
  438.  
  439. Yarnell - The tobacco science and petroleum industry science arguments parallel would be the vaccine industry science promoting their agenda.... Not the other way around... If you were trying to work with parallelisms. 
  440.  
  441. If you are suggesting that any science of disease complications of vaccination is pseudo science - there have been acknowledged problems since inception. 
  442.  
  443. For example https://en.m.wikipedia.org/wiki/Eczema_vaccinatum
  444.  
  445. And if No one with eczema should receive the smallpox  vaccination - and this was and is well established - I wonder as eczema is such a common and ubiquitous disease what other less dramatic associations may be obscured as we proceed with a mass experiment that increasingly is being enforced without consent. A violation of the principles of ethics established at Nuremberg in the trials of the Nazis. Unless you can show me a comparative longitudinal study on vaccinated and non according to any schedule. It doesn't exist. And for that reason it is an experiment and choice to participate is a fundamental human right.
  446.  
  447. The argument that the benefits outweigh the harm is very different than there is no harm to be considered. And unfortunately the latter has become the sounding board of the vaccine industry and its trumpeters. 
  448.  
  449. Sincerely
  450. Dr. Blake
  451.  
  452. Eric Blake ND, DAc
  453. Naturopathic Physician,
  454.  
  455.  
  456.  
  457. Eric Yarnell
  458.  
  459. Message 21 of 31 , Feb 11 10:31 PM
  460.  
  461. View Source
  462.  
  463.  
  464. Show message history
  465.  
  466. Part of the reason acellular pertussis was introduced was to make the very rare neurological effects temporally associated with whole-cell vaccines even rare (Kuno-Sakai H, Kimura M. Safety and efficacy of acellular pertussis vaccine in Japan, evaluated by 23 years of its use for routine immunization. Pediatr Int 2004;46(6):650-5.). When an adverse effect occurs within a few hours of vaccination, it is attributed to the vaccine, but is that really proof it caused it? What about the millions of kids who get the vaccine with no reaction? And what about kids who get a “healing crisis” when they take a homeopathic remedy or some other natural treatment? Why does that get to be a good thing when they get a fever or even have a seizure, but if associated with a vaccine it is cause to say we should ban all vaccines?
  467.  
  468.   But the acellular pertussis shot is not even effective. 
  469.  
  470. See meta-analysis above clearing showing it is.
  471.  
  472. Documented pertussis outbreaks have occurred in fully vaccinated populations.
  473.  
  474. What is your citation? I could find no evidence of this.
  475.  
  476.    This 2012 study found higher pertussis incidence among those vaccinated for it than among the unvaccinated:

Maxwell A. Witt, Paul H. Katz MD MPH, David J. Witt MD. "Unexpectedly limited durability of immunity following acellular pertussis vaccination in pre-adolescents in a North American outbreak."  Clinical Infectious Diseases.  March 15, 2012.
  477. I have just finished reading this paper and it does not show what you say it shows. I quote directly from the results section of the paper:
  478.  
  479. "In children aged 13–18 years and in the entire cohort of those aged 2–18 years, there was a highly significant increase in cases [of pertussis] among unvaccinated children (P = .009 and .01, respectively; Table 1)."
  480.  
  481. The authors state that the problem in vaccinated children is, as I suspected, insufficient frequency of the vaccine. Basically as kids got older, despite having been vaccinated when younger, they started to get more pertussis. This is due to the vaccine losing potency over time. This is not unlike the situation with the tetanus vaccine, which we all know has to be given every 10 years as the effects wear off. Does this mean the tetanus vaccine “doesn’t work”? Of course not. It just means the effect wears off. So why aren’t you recommending more frequent vaccination instead of no vaccination on this one?
  482.  
  483. This paper also states that their cohort (in Marin County, CA) has a very high level of pertussis and general vaccine refusal (11% of kids not fully vaccinated). They cite evidence that this means the herd immunity thresholds are not reached (Pediatr Infect Dis J 2005;24(5 Suppl):S75-82.). This acknowledges that, like most vaccines, they are not perfectly effective (don’t give 100% immunity to the recipient) and that it is important to have as widespread as possible of coverage to reduce the number of carriers and sources of disease as low as possible to further protect everyone.
  484.  
  485. I am afraid that citing a study and stating it shows the exact opposite of what it actually reports is not exactly building confidence in me about your other recommendations and citations. Please do double check them (and maybe actually read them at all instead of just re-citing what some anti-vaxx source said?) before posting.
  486.  
  487. An equivalent outcome in a meta-analysis of clinical trials was published here: http://pediatrics.aappublications.org/content/135/2/331.long. Acellular pertussis vaccine works and is safe but the effects wear off and boosters are needed. The study you cite is a retrospective epidemiologic study which is not as powerful as a randomized trial at showing the efficacy of the vaccine, and plenty of those exist for pertussis vaccine in diverse populations (Vaccine 1997;15:1606-12. Lancet 1988;1:955-60. N Engl J Med 1995;333:1045-50.).
  488.  
  489. 
Similar studies have also appeared in such publications as Pediatrics and Pediatric Infectious Disease Journal.  I could go on all day. . . .
  490. Again, without giving specific citations it is impossible to discuss, agree, or refute what you are saying.
  491.  
  492. By the way, this extensive analysis (completely free full text paper) documents that in fact improvements in “hygiene" did not play nearly as big a role in the massive reductions in vaccine-preventable diseases that are often assumed or stated. http://jama.jamanetwork.com/article.aspx?articleid=209448
  493.  
  494.  
  495.  
  496. Eric Yarnell, ND, RH(AHG)
  497. Seattle, WA
  498.  
  499.  
  500.  
  501. Eric Yarnell
  502.  
  503. Message 22 of 31 , Feb 11 10:46 PM
  504.  
  505. View Source
  506.  
  507.  
  508. Show message history
  509.  
  510.  
  511. If you are suggesting that any science of disease complications of vaccination is pseudo science - there have been acknowledged problems since inception. 
  512.  
  513. For example https://en.m.wikipedia.org/wiki/Eczema_vaccinatum
  514.  
  515. And if No one with eczema should receive the smallpox  vaccination - and this was and is well established - I wonder as eczema is such a common and ubiquitous disease what other less dramatic associations may be obscured as we proceed with a mass experiment that increasingly is being enforced without consent.
  516.  
  517. Well since small pox vaccine was phased out in 1972 in the US, I don’t really understand what you are saying. I don’t think smallpox vaccine can be blamed for causing eczema in the modern age. And the CDC states the rate of eczema vaccinatum was <50/1,000,000 which is hardly consistent with everyone with eczema having a severe reaction, given how common eczema is.
  518.  
  519. As for the “enforced without consent” it is clear the vast majority of parents do consent for their children to be immunized. This is do different than any other type of health care, natural or conventional, with children, who are not considered able to consent for themselves until they are adults. And given the enormous benefits of vaccination for almost everyone in the society (except those very rare few individuals who have associated harms, which is terrible, but we have 1/1,000,000 severe harms from herbs too and I don’t hear anyone on this forum saying we should using all herbs because of extremely rare severe adverse effects), it is highly to peoples’ advantages to consent.
  520.  
  521. A violation of the principles of ethics established at Nuremberg in the trials of the Nazis. Unless you can show me a comparative longitudinal study on vaccinated and non according to any schedule. It doesn't exist. And for that reason it is an experiment and choice to participate is a fundamental human right.
  522.  
  523. Almost everything you have posted as a treatment recommendation on this list has been an experiment under this same definition. There are no comparative trials, or usually any trials whatsoever, on most of our therapeutics, so how is that not a problem? Physicians providing what they believe to be the best care possible in light of the best evidence available (whether it is historical, anecdotal, case studies, clinical trials, or whatever) is not experimentation. Anyone providing vaccines under the guidance of experts evaluating complex, multifaceted evidence from large numbers of studies such as the CDC schedule does is not experimentation under the principles that arose after WWII. The best evidence we have currently is for the CDC schedule, and so that is what makes the most sense to follow. It has been proven highly safe and highly effective (see IOM studies cited in my prior email). That no other schedule has been studied in comparison or what not doesn’t invalidate all research on the CDC schedule. By your logic, until and unless a treatment had been compared to all other possible treatments in the universe it would always be unethical which is nihilism and absurd and not useful (not sure in which order).
  524.  
  525.  
  526. The argument that the benefits outweigh the harm is very different than there is no harm to be considered.
  527.  
  528. I agree. I am sorry if I gave that impression. But the extremely rare harms from vaccines definitely are outweighed by the benefits.
  529.  
  530. And unfortunately the latter has become the sounding board of the vaccine industry and its trumpeters. 
  531.  
  532. Trumpetingly yours (and not any part of the vaccine industry, but still in support of vaccination),
  533.  
  534.  
  535.  
  536.  
  537. Eric Yarnell, ND, RH(AHG)
  538. Seattle, WA
  539.  
  540.  
  541.  
  542. Eric Blake
  543.  
  544. Message 23 of 31 , Feb 11 10:58 PM
  545.  
  546. View Source
  547.  
  548. You are missing the consent piece. As for the science behind physiotherapy it is extensive consistent and predictable. And my patients have the right to choose or not.  That is why compulsory vaccination is problematic. 
  549.  
  550. My point on smallpox - vaccines have risks that we don't know and can't quantify or predict typically. And that has long been acknowledged until very recently.  And that needs to be a part of the conversation in consent. 
  551.  
  552. I find your position as radical as dr hubers. And I find both lacking in swaying fully to either pole. 
  553.  
  554.  
  555.  
  556. Sincerely
  557. Dr. Blake
  558.  
  559. Eric Blake ND, DAc
  560.  
  561.  
  562.  
  563. Colleen Huber, NMD
  564.  
  565. Message 24 of 31 , Feb 12 4:56 AM
  566.  
  567. View Source
  568.  
  569. Dr. Yarnell, I have to contradict you.  You said that you read the paper that I cited (Witt, Katz MD, Witt MD in Clinical Infectious Diseases on pertussis.)  If you had, you would have seen this: 
  570.  
  571. "Surprisingly the highest incidence of [pertussis] disease was among previously vaccinated children in the eight to twelve year age group . . . Surprisingly, in the  2-7 and 8-12 age groups, there was no significant difference in attack rates between fully vaccinated  and under- and un-vaccinated children." 
  572.  
  573. It is apparent that the authors are not so much "anti-vaxxers" as you characterize them, as MD researchers who were surprised by the lack of efficacy of the acellular pertussis vaccine.
  574.  
  575. You seem to imply that I should post 400 studies on NatChat.  It would be more considerate of our colleagues and efficient if you would simply get that other book and read it:  Neil Z. Miller, Critical Vaccine Studies.
  576.  
  577. If you had read Dissolving Illusions,  by Suzanne Humphries, MD, you would see that the nearly 1000 studies and reports from the 1700s to 2015, the latest edition, have not been discredited, as you allege, and abundantly demonstrate that human populations are and have been much better able to fight infectious diseases with modern sanitation than with vaccines.
  578.  
  579. As Dr. Thurman Rice said in 1932, paraphrasing, "It should be no surprise to anyone that the elimination of infectious diseases occurred when populations stopped having dilute sewage as the principal beverage."  
  580.  
  581. Ah, how quickly a vaccine discussion descends into the sewer!
  582.  
  583. I hope you all have a wonderful weekend, without exception whatsoever.
  584.  
  585. Colleen Huber, NMD
  586. Naturopathic Oncologist (FNORI)
  587. President, Naturopathic Cancer Society, NatOnco.org
  588. Secretary, ANRI / NORI / INCRI, NaturopathicStandards.org
  589. Medical Director, NatureWorksBest Cancer Clinic, NatureWorksBest.com
  590.  
  591.  
  592.  
  593. Eric Yarnell
  594.  
  595. Message 25 of 31 , Feb 12 2:40 PM
  596.  
  597. View Source
  598.  
  599.  
  600. Show message history
  601.  
  602. The quote you cite does NOT show higher attack rates in the vaccinated as you purport, it shows equal rates, and only in terms of the attack rates not the incidence (see quote I cited: "In children aged 13–18 years and in the entire cohort of those aged 2–18 years, there was a highly significant increase in cases [of pertussis] among unvaccinated children (P = .009 and .01, respectively; Table 1)."
  603.  
  604. Perhaps the technical epidemiologic and mathematical terminology (attacks rates vs. prevalence vs. incidence) has confounded whatever source you were citing that said this paper showed the exact opposite of what it actually shows.
  605.  
  606. 
It is apparent that the authors are not so much "anti-vaxxers" as you characterize them, as MD researchers who were surprised by the lack of efficacy of the acellular pertussis vaccine.

  607. The researchers, who are pro-vaccine not anti-vaccine (it is whatever source you read that quoted this paper as being anti-vaccine that I am calling anti-vaxx, not the researchers), went on to determine why they found what they found, and it was almost entirely because in the older cohort the (the 13-18 group) the benefits of the pertussis vaccine were wearing off enough that is affected the rates for the entire cohort (2-18). But this was emphatically NOT due to failure of the vaccine to work, and most definitely NOT because there was more pertussis in the vaccinated group; QUITE the opposite. It was because the effects were wearing off and basically more frequent boosters (and before age 12 years) are needed. Again, this is not inherently that different than tetanus vaccine which is widely known to lose efficacy. It is argument for more immunization not less.
  608.  
  609. If anything this article argues for developing a better pertussis vaccine and definitely not for getting rid of it altogether.
  610.  
  611. 
You seem to imply that I should post 400 studies on NatChat. 
  612.  
  613. No, citing the ones you are claiming support your positions though. I managed to do that in my posts (three or four key articles that actually support what I say, not a made-up, incorrect conclusion from a partial or inaccurate reading of a single study).
  614.  
  615. It would be more considerate of our colleagues and efficient if you would simply get that other book and read it:  Neil Z. Miller, Critical Vaccine Studies.

  616. I am so doubtful that this book is actually a dispassionate and thorough review of the research that I can’t imagine wasting my time on it. I have read other shorter anti-vaccination pieces before and seen this type of approach before. Is there some reason to think this is different? 
  617.  
  618. 
If you had read Dissolving Illusions,  by Suzanne Humphries, MD, you would see that the nearly 1000 studies and reports from the 1700s to 2015, the latest edition, have not been discredited, as you allege, and abundantly demonstrate that human populations are and have been much better able to fight infectious diseases with modern sanitation than with vaccines.
  619. The sheer volume of references doesn’t prove anything. Many have not been, but by implication, many have been discredited? How can this reflect a high-quality text?
  620.  
  621. How do you account for the ongoing higher rates of diseases for which there is no vaccine? How do you respond to the JAMA data I posted in my prior email? Rather than just stating these things and citing one book, let’s discuss the details of actual primary research and not talk pure theory and supposition.
  622.  
  623. 
As Dr. Thurman Rice said in 1932, paraphrasing, "It should be no surprise to anyone that the elimination of infectious diseases occurred when populations stopped having dilute sewage as the principal beverage.”   

  624. This does not explain enormous reductions in:
  625. Tetanus (not a fecal-oral pathogen)
  626. Pertussis (not a fecal-oral pathogen)
  627. Measles (not a fecal-oral pathogen)
  628. Mumps (not a fecal-oral pathogen)
  629. etc.
  630.  
  631. Of course improved sanitation helped with hepatitis A and shigellosis and oral fecal-oral pathogens. But this would have, and as the JAMA research shows, did not have much if any effect on the incidence of these pathogens spread by other means.
  632.  
  633. 
I hope you all have a wonderful weekend, without exception whatsoever.

  634.  
  635. Likewise,
  636.  
  637.  
  638. Eric Yarnell, ND, RH(AHG)
  639. Seattle, WA
  640.  
  641.  
  642.  
  643. tdtf5
  644.  
  645. Message 26 of 31 , Feb 13 3:58 AM
  646.  
  647. View Source
  648.  
  649. I know a lot of discussion happened last fall concernign choices on EMR system. Naturosoft, Athena, Charm, can any one give any recommendations after several months of use? We are looking for an alternative to charm-who's customer service is non-existent and they have too many bugs in their system.
  650. Anne Hill, ND
  651. Portland, OR
  652.  
  653.  
  654.  
  655. Leslie Batten
  656.  
  657. Message 27 of 31 , Feb 13 10:57 AM
  658.  
  659. View Source
  660.  
  661. I submitted the paperwork and will continue to be able to prescribe meds for my Medicare patients (they have Medicaid as their backup, which is how I am able to do so) when this change occurs in June. It's seriously no big deal. I'm not asked to adhere to Medicare guidelines or rules or anything else. It just allows for me to continue to do what I have been doing. Chill, everyone.
  662.  
  663. Leslie Batten ND
  664. Portland OR
  665.  
  666.  
  667.  
  668. Heidi Peterson
  669.  
  670. Message 28 of 31 , Feb 13 12:07 PM
  671.  
  672. View Source
  673.  
  674. I choose Elation based on a recommendation from someone on Nat Chat.   I have been using it since May and LOVE it more each day.  I combines the best of paper and electronic charting.   GREAT customer service too!  I always get quick response to questions
  675.  
  676.  
  677.  
  678. Mona Morstein
  679.  
  680. Message 29 of 31 , Feb 14 7:10 AM
  681.  
  682. View Source
  683.  
  684. I can highly recommend NaturaeSoft.  Tucker Meager’s company, software and customer service is terrific. 
  685.  
  686. Mona Morstein, ND, DHANP
  687. Tempe, AZ
  688. www.diamend.info
  689. Official Sponsor of NatChat—Doctor’s Data Labs
  690.  
  691.  
  692.  
  693. Chad Aschtgen
  694.  
  695. Message 30 of 31 , Feb 14 9:23 PM
  696.  
  697. View Source
  698.  
  699. I began considering a new EHR/PM system more than five years ago and took about four years to finally commit after investigating the details of more than two dozen options and having a half dozen or more vendor presentations.  (Yes, four years is MUCH too long…)  We have been live with Athena for over six months and couldn’t be happier with the choice made.  Of course this system will not be ideal for some out there, but it is great for our purposes.  Some of the reasons I chose it were because it is an online system, not server based, can be used in multiple locations.  It is a completely integrated system between scheduling, charting, prescribing, billing, faxing in and out, and more.  It is the most paperless system I could identify and does not rely on various add on features or software to make it complete.  One thing is for sure, their customer support and physician resources are solid.  Like any system, it has taken time to grow into, but we have been doing so with more “Ah hah!” moments than painful ones.  For what it is worth, I also have first hand experience with ChARM (I use it one day a week at one of my clinic locations presently), Mac Practice, Epic, Mosaic and MediNotes (now defunct I think), and would be happy to share more for those who are trying to narrow down a decision.  Feel free to send me your questions directly.
  700.  
  701. Chad D. Aschtgen, N.D., FABNO
  702. Seattle Integrative Oncology 
  703.  
  704.  
  705.  
  706. manifesting_health
  707.  
  708. Message 31 of 31 , Feb 15 1:34 PM
  709.  
  710. View Source
  711.  
  712. Chad, thanks for the information on Athena EMR. 
  713. Do you have any insights for what type of practice Athena would not be good for?
  714.  
  715. Sara Rodgers, ND
  716. Boise, ID
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