Home Forums Discussions Problems Would you choose AC again?

For whatever reason, whenever I add a custom order, and then use the "Print Orders" button in the Orders window, the order requisition form generated has a blank "requested studies" area. But I've digressed. We were talking about how orders get documented in the chart.
____

"Why do we need Custom Order" && "Why is CBC on the first line?" && "Why do we need parentheses?" - Short answer, MU/structured data requirements. Long answer. Each Order that is logged in the program is supposed to correspond to a single "real" life order. All orders should have a corresponding CPT code if possible. Let's face it, tracking data is valuable, and I imagine it only becomes feasible after a certain amount of codification. However, there are situations in which codifying a value(s) is not appropriate/possible or [too cumbersome AND not justifiably so] or just a pain: enter the Custom Order that you can make with free text. However, it's important to differentiate Custom Orders from codified orders. Why? It makes the life of auditors/external reviewers easier.

RECAP/EXPANSION

So why does "Custom Order" have to be there? && "Why do we need parentheses?" For clarity in the eyes of others. And I imagine there are some users that find the parentheses helpful. The parentheses serve to isolate the text.

"Why is CBC on the first line." Because some of the programers had 1 order per 1 real-life order in mind whenever they wrote that code. If you only have 1 order, then you don't run into that problem. Yet, AC provides us with the option of using templates in the Other tab of the Orders window; they do this to help us reduce our clicks; it is an invitation to put multiple labs/orders in a single order. They probably could have added a little bit of code to bump the starting line 1 line down, just for the Other Orders templates; however, that kind of spoils the consistency/uniformity of how templates function. If you want to bump the line down yourself, you can always add an extra "." and "enter" at the beginning of every Order template. That would produce something like this:

ORDERED/ADVISED: - Custom Order (.
CBC
ESR
CMP
LDH)

(Unfortunately, just adding an enter to the template will not work.)
___

What I wrote above is what I imagine the developer thinks about this. Supposition. Personally, I agree with the you on the "tell the program to put the first lab two lines down" point. However, I don't see too much harm from "Custom Order" and the "()."

___________________________________


My guess is that the number of scripts you write compared to the number of scripts I write approaches infinity. You make a fair point.




I never argued that the utility of the allergies feature was its saving grace; I just said I didn't find the allergies feature that distracting. I have already conceded that I have little authority when it comes to determining how distracting it is.

Why stop at seconds?
____________



I think that templates exist best as lists. For a hypertension template, I'd use some variation of the following:

Hypertension Symptom Checklist:
[n]=patient denies symptom
1. peripheral edema-
2. chest pain -
3. epistaxis -
4. headache -
5. syncope -
6. SOB -


For that patient, it would turn out like this:

(filling this out quickly requires you to use the arrow keys on the keyboard quite well; also, notice how I cascaded each line so that pressing the "down" arrow will take you the end of the next line)

Hypertension Symptom Checklist:
[n]=patient denies symptom
1. peripheral edema- ankle swelling after a long day of standing
2. chest pain - n
3. epistaxis - occasional nosebleeds in dry weather
4. headache - n
5. syncope - n
6. SOB - n

Whenever I make these type of implicit questions, I try not to pass judgement. More than anything, I want to know the "what are the reasons for which x accepts y." Like "why are people okay with getting bullied into data plans for smart phones?" or "why aren't more people vocal about how they feel about the banking crisis a few years ago."

Most people are busy living their lives (work, groceries, kids, recreation). I get that. In fact, that's why we appoint leaders to handle the behind-the-scenes details. It would be ineffectual for a solitary doctor to stage a one-man protest for an issue (e.g. against EHRs that don't have easily accessible trial periods). Public, grandstanding demands only work for visceral issues. Rather, the doctor/office manager should contact his/her representatives. Congress. The AMA. Other medical organizations/associations. Certainly, these entities could have put weight on CME to make x a necessary requirement for ONC-ACTB certification.

But back to your original question, I honestly have no idea when doctors have made demands; I know not of the behind-the-scenes things (where I imagine is where most medical policy is determined).

Hm. I should probably write my congressmen some emails.

I agree, but would point out that it took 10.3 seconds just now to dictate the note from scratch using Dragon, 14.5 seconds to fill out the checklist. Other than not forgetting things, it didn't do much. Checklists for not forgetting are very useful, but the way AC is marketed it is not to be thorough, but to be fast. Everyone wants the note to be done when they leave the room.

At the risk of hijacking the thread, Congress and the AMA ARE the problem. And, while I am likely painting to broad a stroke, I don't think doctors have ever stood up against much of anything.

@David Good post. I agree. I will throw in though that Brian Cotner made a similar list but with a clever twist such as:

Epistaxis [Y] [N] You then clicked on the letter that was wrong and hit delete or do a double tap and make No the default and replace with yes if positive. Again, just throwing it out there.

Bert, I think that the thread was long ago hijacked.
Ah. Congress, being a problem; that I could see. But I always thought that the AMA stood up for doctors. And before everyone stands up to tell me otherwise, just let me say that I now remember, from the postings I've read on this forum, how many of you feel about the AMA.


Interesting. I suppose there are trade-offs with all the different documenting tools.

[But I always thought that the AMA stood up for doctors. And before everyone stands up to tell me otherwise, just let me say that I now remember, from the postings I've read on this forum, how many of you feel about the AMA.]

First one standing.

Dave

Doctors are a very heterogeneous lot. I think the AMA tries, but whom should it represent? Years ago when the E&M codes were being developed, I got simultaneous e-mails from the ACP urging I support them (which would have much improved reimbursement for cognitive skills), and from the American Society for GI Endoscopy urging me to work against them (since they threatened to decrease reimbursement for procedures). Everyone said "fine idea to increase fees for cognitive skills, but it can't be in a budget neutral environment." The times in which doctors had a common goal are long past.

The thread has been hijacked in about six different directions...following up on one of them:


The AMA is a dying dinosaur, only propped up by its steady income stream from the sale of CPT codes. They own them and ANYONE who uses them (Medicare, all the insurance companies) pay the AMA for their use. If you don't think that is a conflict of interest, what is? I mean how many of us are motivated to keep the RBRVS system in place...not many. But the AMA is totally dependent on it for financial survival. It dominates AMA's policy support in ways we can only guess at.

The AMA claims to have over 200,000 doctors, about 15% of all physicians in the country. Few people believe that number. It is a tiny, tiny sample but someone posted a thread on Sermo, "who still supports the AMA" and of 62 responses, not one answered favorably. There may be a few out there, but 200k is hard to fathom.

David, we are very heterogeneous. Specialists/pcp's, liberal/conservative, big government/private sector advocates. Maybe there was a time when we could have a single lobbying group speak for us (and maybe not) but it is hard for me to imagine any group now speaking for more than a fraction. Which of course plays right into the hands of the (rather unified) insurance industry, big pharma, and AHA.

And who is to blame for that?

And now from the broad to the super-specific. Namely, Bert's point about AC's responsiveness (or lack thereof) and orders.


Suppose I told you that my documentation looks like this:
ORDERED/ADVISED: - CBC
- ESR
- CMP
- LDH

Trivially different? Perhaps...but no custom order, no parentheses, and if you just have one order, CBC on line 1 might be better.
This is not to undercut your point about AC's responsiveness; I think most would agree that the Orders section is ripe for significant change. On the other hand, it does illustrate there are often different ways to accomplish things within the program.

I'm going to take the position that at this late date blame is somewhere between unproductive to useless.

In this season of meet-ups, social action, ad-hoc collaboration, it is time for Doctors and Providers to begin a very public conversation about what will supersede the AMA. Not that the AMA will go away (as long as it has a revenue stream), rather that it is *no longer* THE authoritative voice representing Physicians and Providers. Your average American has NO CLUE how low esteem the AMA is help by the folks that it is supposedly representing.

Now, I know that the subject of collusion, anti-trust etc immediately comes up, and I am going to counter and stipulate that we are talking about first and foremost communications, not market action.

I have been mulling this over for the last few years, and I believe that there are some trans-formative things on the horizon. The tools are now available and coming that break the status-quo.

Would someone please explain to me why it is legal for airline pilots to have a union who negotiates better wages and benefits on their behalf, but it is illegal for physicians to do so? This is one of those things I really don't "get."

Well, if you and a bunch of physicians are employed by a company (say, Kaiser) maybe it is. You form a union and negotiate pay and work rules.

What is illegal is for independent businesses to collude on the fees they charge.

But we wouldn't be colluding on the fees we charge. Our fees mean nothing. We would be colluding on our reimbursement.

The issue of independent physicians organizing and engaging in collective bargaining came before the Supreme Court in 1943 -- and the doctors lost. Labor unions engaged in collective bargaining are exempted from the anti-trust laws (forbidding price-fixing by competitors). But the Court found that the labor laws protect "disputes affecting the employer-employee relationship", and that they were not meant to have "application to disputes over the sale of commodities." Physicians in today's proposed unions are not and do not want to be anyone's employees. Rather, they want more bargaining power in the sale of the service they are providing, but that is not a legal justification for an agreement on price among competitors.

Sorry for the fancy legalese. My sister is an attorney and regularly shoots down my grand schemes.

ah. A more formal and thorough explanation. Thanks John.

Yes but some of the most important rules that the IRS uses to determine whether or not either side falls under an employer, employee status or a purchaser of services, customer and private contractor are more and more moving towards the employment side.

1) Does the Employer Have a "Vested" interest in the outcomes of the services provided. Well like heck ya in our case, right?

2) Does the Contractor in question have control over things such as "Hours Worked", (24/7 coverage & call in all primary contracts says NO),

3)Final authorative choice of actions taken, fully "Independent" which I would say certainly NO Again. In today's ever increasing amount of "Mommy May I" or you must ask before you might get the test, drugs, or even allowed to move forward with referral or procedures again NO.

Compare this:

A) You doctor walk into exam room, Dx and patient and decide on "Possible" course of treatment. We all know and totally accept both us and insurance carriers, that there is a decent probability according to situation, kind of test or med, treatment or procedure that Yeah, you're gonna need to first file the May I Please, paperwork, barriers to care and payment for such care... Clearly you are NOT the final arbiter (besides REAL should be customer the patient) of your own professional judgments. Instead you have an overseeing supervisor relationship with this paying contracting 3rd party the insurance carriers.

B) I skate out on the ice for a weekend of youth hockey to do your average Pee Wee Bantam level youth game. I and my partner of equal authority on that ice, divided up by basic learned positioning of who should be where when, to cover the ice best, and in consult when necessary are the one and only Final Arbiters of what is or is not any given penalty, off-sides, icing or what have you. MY CALL IS FINAL. As a matter of fact once the puck has dropped in 99% of any instances that's it whatever was reported to the official scorer by me and recorded on the score sheet is FINAL. The penalty or goal can not be undone, or one suddenly awarded or given either. FINAL. If I choose to make a good NON-Call too, that was incidental contact and not some sort of a foul as players converge that too is MY CALL, My "Professional Opinion & Judgement".

And So, as I have said here so many times before I believe we have reached this highly insane Monty Python like stage here in the US where the average youth hockey or soccer, football, baseball & basketball official truly has more Professional Freedom to properly classify them as Independent Contractors than the average doctor, especially primary care docs who have the entire world coming down on them lately.

The one real sticking point to all of this (because the state of 3rd party reimbursement was not what it is today back when the Supreme Court last visited this issue, I bet it could be overturned today if brought back to them) is the federal rule of the Mcclarren Fergerson Act (not sure of spelling pardon please) of 1948. This law grants the insurance carriers an anti-trust waiver so that they can share information supposedly so that they can better set the community rates.

And IMHO, this might actual work in doctors favors if the case return to the high court. Now we have what we all recognize as an out of balance situation which is inherently unequal. One side can collude and share all they want back and forth and do so to control the market of their industry, while the smaller contractors that they are colluding against do not have that same protection or right. And as we know this has been used against us so many times before with both the FTC getting involved and more frighteningly more recently the DOJ stuck its nose in on some recent cases meaning not only Civil and Contractual problems and penalties we could be facing some serious Criminal Charges and Penalties too. Put that in your pipe and smoke it if you will.

I think it is interesting that the case referenced above occurred five years before congress created this act of law that really has been the largest piece of leverage that the insurance carriers have used and abused against us, no less many times playing both sides of the fence in different cases and locations as needed to make things come out as well as possible for their side while we continue to slide into the abyss here. I really do wonder what the court's opinion and decision would be today in light of managed care, RUC & CMS, prior auth's and this act of 1948....

I really do wonder if they would throw the entire system out that this system of Not Free Trade and totally restricted commerce would stand up to a good constitutional challenge. Would they strike down the Act and make various HMO managed care like entities illegal because it really is collusion and over control, manipulation, grabbing up anti-trust like, buy into the Cartel or have no access to your own source of income as anti-competitive and collusion like behavior, that restricts and distorts prices, access and entire local, regional and national markets???

Clearly the market and set-up is radically different than it was back during WWII when almost all docs were solos and almost all admitted to the local hospital of their town or area. Personally, I think its worth a shot...

Paul

I'm behind ya', Paul. All the way to the Supreme Court.

I am as well.

Go for it!

Paul,

Your comments above bring to the forefront the answer to the original question on a visceral level.
With the risk of sounding a bit histrionic or grandiose, I would like to pose another question.
Did you choose AC or did AC choose you?
On an objective rational level the world of medicine is as you describe for the small office based physician. The entire world is out to squash us into oblivion so we are forced to become another cog in the wheel working for someone else.
I think AC has allowed me to maintain the FREEDOM to continue running my own pop-sickle stand, with all of the challenges you describe.
Looking backwards in time over the last several years, the AC community and the product itself reminds me on a daily basis what a sacred Profession we are in and it is worth fighting for.
So on an objective level AC does not have a PM currently and it has the list of 81-84 on the to do list, so it is not the perfect EHR, but on a visceral level, this little imperfect EHR has given me a breath of fresh air, so that I can continue doing what I love.
On this lovely Easter morning I am reminded of April 18, 1521, Martin Luther appearing before the Diet of Worms, the quote, "I cannot and I will not recant anything, for to against conscience is neither right nor safe. God help me. Amen."

It ain't in my bones to work for someone else, so that is why I would choose AC in a heartbeat again, and again, and again.

jimmie,

I couldn't disagree with you more. Standing still or going backwards no matter how good you are does not a good product make. It only takes looking at GM and Dell to see this. Yes, Dell is selling their company.

When Microsoft updates from Office 2010 to 2013, they do so for two reasons. One it's more expensive and two, it is an improvement. Now you can argue that this update wasn't that improved. As you know, I practically worship Backup Assist for a backup program. It is heads and tails above the rest for SMB backup. The moment they come out with a new version, they are back to the drawing board. New version, better version. Bugs 0 Perfection 1. You don't even try it, you install it.

I have never understood the PM. AC is the best at making an inexpensive EMR that works. They had/have a niche market that NO other company had. Working on it every day and fixing the "81" problems and requests and more, they could already have a patient portal, Mainpine faxing, etc.

I used to drive a BMW 3 series. The best car I ever drove with the exception of the Datsun 280Z. Just like AC "sucked" you in, I had to go with a Lexus because A) they had AWD and B) they had remote car start. BMW went backwards to rear wheel drive. Why? They lost my sale right there. And, no remote car starter? They told me why, but you are telling me that the German engineers can't figure it out when the Japanese can. What if I called them up and said I want a 2012 BMW delivered to my door. Please tell me the improvements. Well, we have none. But, we did slip backwards, because we though AWD was a dumb option in New England.

In any business, one must continue to improve. I have hard Jon say many times the lab portion has to be changed. The immunization section is a mess with having to go to two or three different pages to get to them.

Don't get me wrong, it is still the best. I won't jump ship. But, these little things have got to be fixed. The last update's improvements were all about billing. That is to be fixed with the PM.

Just my two cents. I have been told that as an admin I need to be careful about negative comments. These aren't that negative. They are ways to improve and not just stand still. It may work for you, but even though this thread has been overwhelmingly positive, it is because there is no competition. It shouldn't even be a question. Would I buy Win 7 again? Of course. And, I am super mad that Microsoft went in this direction of OS, tablets, phone. Sound familiar?

Bert,

I am suggesting that with all AC's current flaws, my office efficiency has improved significantly. From e-prescribing, e-faxing, educational teaching at point of contact, etc. so forth and so on. The current EHR plays well with other products such as Dragon and Updox. Instituting Updox has allowed communicating with patients through the portal I never even envisioned just a couple of years ago.
With that being said, I am not at all suggesting to keep this product static and am excited about all the intended upcoming changes as recently delineated by Chris from AC. If a PM can be done to play to a larger audience, and it seems quite a few AC users would benefit from this, I am all for it.
It is this freedom to continue to work for my patients and not someone else that the current AC EHR has afforded me. Which I think is directly related to improved efficiencies and workability with other products that I am constantly humbled by.
Now I have not been with AC as long as some so have a much shorter user experience, and quoting a stubborn controversial man from the past probably did not help my argument.

Bert, I agree with Jimmie and I can see your points as well. Like Jimmie, I have only used AC since late 2011, but I have been well-immersed in it. My question to you, as an Admin, what is your insight as to why AC has not had better rapport with you and taken the user board comments more seriously? Is it just too small of a company? I fear them being sold, just as Dell is being sold. What are the possible scenarios? If they pull the plug, does that mean the end of using AC?

I don't think they would pull the plug and we would be out a program. Pri-Med or another company would buy it. There have been many talks about working together to use the board to work with AC.

The problem, as I see it, is that AC hasn't made that their priority. In their defense, the has been a bad time to have an EMR with the government basically forcing Jon to incorporate things into his EMR that he would otherwise have not done. This is a lot more taxing on a small company.

I still think what Jon did (working full time in a FP practice while learning VB and/or C++) while literally designing what may be the best EMR ever made. Unfortunately, the program was and may still be a gold mine. This is just my opinion and Leslie's opinion, but I always wonder where AC would be as a company and an EMR, if the only goal had been to continue to improve it and quash the bugs that still hinder it. I think that when Jon worked full time, he must have thought well this isn't good so I am going to fix it. Do, they have doctors that work directly for them. I think it is one thing to hear from many doctors but spread all over without a vested interest; only wishes they would like to see. When Ed, my developer, and I developed F.A.P., VIPER and Amazing Labels, we worked on it five nights as week. He programmed during the day, and I told him the issues that night. Worked pretty well.

I don't want to think I don't like AC. I think it is a great program and, if I didn't have it, I would be lost. I still talk to quite a few people on the phone about the program, maybe with not quite the excitement and vigor. For me, it is somewhat like Windows without Outlook. Would it still be a great OS (minus the Linux worshipers)? Yes, and I would use it. But, I would be emailing Microsoft on a daily basis asking where Outlook was.

It is kind of like the game Jinga....in your quest to be taller and bigger, if you do not continue to reinforce the supporting tiles, the whole thing will collapse. Even the Egyptians got it right when they built their pyramids. You have to have a solid foundation made up of many, many solid stones. There may only be one or two stones at the top but the jewels and important things are kept in the foundation. And many of the pyramids have, over time, lost their tops while the foundations still stand.

Well put. And, what a surprise, I agree with Leslie.

Yup, you were both right. The approach taken to practice management was a mistake. The question is, now what? Call me a foolish optimist if you like, but I think there is a good case to be made that AC has turned a corner. Clearly they are taking a step back on PM, trying to provide a solution for those who still need it, but no longer is the mantra "we will only get to other things after PM is done". Communication and status updates are more frequent. A user advisory board is being established, with members that include some of the active people on this board.
The proof will be in the results, and we are still waiting to see them. How about this, though: looking back at Bert's survey in 2011 which led to a list of 81 requested improvements, it appears that after V6.5 is available, over a dozen of them will have been implemented in some form, with another few available with the addition of Updox.
The role of Pri-Med in these changes is unclear, but it would be hard to argue that the purchase has had a negative effect.

I must completely agree with Jon. Having realized that PM may not be the best direction is a major step. The real question is where they go from here.

It would seem that they are committed to correcting the problems of the current program, but time will tell how this is accomplished. I think a User's Advisory Board will hopefully assist in keeping us in the loop.

Kelly Johnson, the legendary head of the Lockheed Skunk Works and developer of the SR-71 had one cardinal rule that summarized his genius: "Simplicate, and make lighter."

That pretty well summarizes my feelings towards software in general. Developers love to put in "cool things" to programs, what I have heard the military refer to as "the good idea fairy." I'm in there with Leslie; every "enhancement" that is done is one more thing to go wrong. I want the most minimalist product that will do precisely what I need, and no more. AC is already fairly bloated by my standards.

Leslie wasn't saying that. She was simply saying to do away with the PM.

We can differ on whether or not it is bloated. I and, I think Leslie, just want to fix what is there. And, add some features which make the ones there work better.

Sorry if I misattributed, Leslie. I was reacting to several posts over the years that way predate version 6, MU and PM and which reminisced what a lovely simple program it was in the beginning. For my part, I just wish I could customize it to get rid of all the parts I don't use. It would be a lovely, lean and mean little program.

My impression is that the improvements in v6.5 is what could be salvaged from the effort to develop a PM and other improvements in v7, whether or not the list of 81 was involved.

I assume they failed due to lack of money to hire the right talent to get it done. I assume now that there is more money, time to market is more critical and choosing a preferred PM to either buy or meld with is the plan.

I'm sure that there is a lot of transition as the right talent is brought in. These are critical days for the next stage and it will the end of the year before we see the benefits of Pri-Med. hopefully they have plenty of money and get the right people.

Now I'm confused. I thought the Pri-Med buy out was supposed to bring the working capital to get the job done. Wish they had sold it to the users.

Still, the support we get from the GAS and from these boards is so much better than anything else out there. No such things as a perfect EMR.

Vicki,

I'm sorry if I confused you. I certainly do not know what is happening at AC, and from our number of posts, you know 10x more about AC than I do. I also do not want you to be pessimistic about AC, I'm not. Pri-Med and AC have every chance for success.

My point is that I do not think that AC development has decided to turn from a PM to the list of 81.

I think that last year they realized that it was not going to happen. They didn't have the money for either hiring the key talent to design and supervise the programming of the PM or to hire enough programmers to do the basic programming.

This is the team that built AC and probably expanded to accomplish CCHIT and Meaningful Use. So it probably seemed like they would be able to take the next bridge with a PM. But this was something completely different from a EMR, so they had to hire more programmers, which raised prices. Last year they realized that this was a bridge too far.

Successful people are willing to look at their failures completely and honestly so they can change. It is not every "man" who has had success that is willing to accept that they need help. This is my reason for being very hopeful for AC's success in the future.

I assume that as soon as the development team realized that v7 was not going to happen, they started to salvage their efforts to make 6.5

I assume that as soon as the Pri-Med purchase was complete and a plan was developed, new staff were hired that would do what it takes to graft in a purchased PM or make a perfect bridge to a preferred partner.

I assume that right now the final touches are on v6.5, and as soon as it is out the door, everything in the development team revolves around accomplishing v7.

To me that doesn't leave a lot of attention for the list of 81, unless there is plenty of money to do what it takes to do an overhaul of AC.

We can be hopeful that Pri-Med understands that they purchased the most usable small practice EMR, and will invest in keeping it that way.

Count me as hopeful.

Actually I was not necessarily saying do away with the PM. What I am saying is you must first shore up your foundation before trying to get bigger or taller. Continue to IMPROVE the thing you already do best (not just add cool or useless stuff. Paperport, for instance, took a perfectly good version 9 and crapped it up in V12 with "tweaks" which have threatened its functionality). When that is secure, then, if needed, look for ways to climb higher. I personally do think, however, the quest for a new PM was a mistake. If partnering with UPDOCs and partnering with Lab Corp and partnering with others was the right move for AC then why not partner with a billing company that is already doing it right? Why try to re-invent the wheel? Now, in fact, I DO have a problem with AC partnering with UPDOCs in order to achieve a federally mandated patient portal for health information. I would much rather see AC make that an integral part of THEIR program and not have to pay for another piece of software, the most of which I would not use.

I am with you on this one Leslie.

I have no need for UpDox but will need a patient portal if I am to continue with MU Stage 2. AC originally indicated that they were committed to helping us achieve MU, so I think a portal should be integral part of AC going forward.

I do not want to have to keep adding and maintaining other software to accomplish what will be required daily functions.

I was hoping that ACs PM would have been adequate to allow me to give up my separate PM program, so I am disappointed that it has not worked out. Linking to yet more software is, again, a less than ideal solution.

What is the "List of 81"?
Can someone give me a link?

I know AC doesn't want to hear this over and over, but v7 was rather shortsighted. You simply cannot have a hiccup in a practice management program. I just don't see how AC thought it was a good idea except to bring on more customers. I think the customers lost would have been other customers gained.

Part of the problem is Jon's very kindhearted kind capitalism. My idea would have been to get AC as perfect as possible by adding some of the 81 and getting rid of the bugs and then being less kind. It is already one of the most inexpensive programs out there. I think most would have been willing to pay more.