Events Calendar

Mon
Tue
Wed
Thu
Fri
Sat
Sun
M
T
W
T
F
S
S
26
27
28
29
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Events

Articles

Jan 03: Meet the 2014 EHR Game Changers

hitpc

Following are profiles of the winners of Health Data Management’s fourth annual EHR Game Changers recognition program. The program seeks to honor those throughout the health care industry who have made substantial contributions to the development and use of clinical I.T. Candidates are nominated by their peers and the program is open to staff working in any health care organization or health I.T. firm (see box, page 18, for complete criteria).

The program was created by HDM to honor individuals who have been true game changers in the design, advocacy, deployment and development of electronic health records technology.

The judges of this year’s program included Stephen Beck, M.D., and Vince Ciotti. Beck serves as chief medical information officer for Catholic Health Partners, a Cincinnati-based integrated delivery system. In recognition of his leadership in implementing an enterprise EHR, Beck was among the winners in the 2013 Game Changers program.

Ciotti has more than 40 years’ experience in the HIS industry: 15 years working for vendors in sales and implementations, as well as 25 years consulting for hospitals in I.T. assessments, system selections and contract negotiations. He is principal at HIS Professionals. Greg Gillespie, Joe Goedert and Gary Baldwin from the HDM staff also judged this year’s entries.

 

Ascending the EHR Ladder

Name: Mike Mistretta

Position: Vice president and CIO

Organization: Medcentral Health System, Mansfield, Ohio

Accomplishment: Integrated EHR Platform

When Mike Mistretta joined Medcentral Health System in February 2006, the 351-bed facility was not exactly highly automated: “We had document scanning” and not much else, he says. Today, Medcentral stands at Stage 6 on the HIMSS Analytics EHR adoption scale and is eyeing Stage 7-the pinnacle-later this year. It has automated its inpatient documentation, built out an electronic order entry system, added bar code technology to medication administration, deployed boutique applications in high-risk service lines such as surgery and obstetrics, implemented an ambulatory EHR among its 20 employed physicians, and tied it all together in a common data repository-part of which it now pushes out to a regional health information exchange that connects some 50 nursing homes, the local federally qualified health center and a group of 250 independent physicians with staff privileges. “We have been adding to the mix along the years,” he says. “Our strategic plan goal has been to create one longitudinal record across both the health system and the community. Being the dominant player in our area, we can do that.”

The health system’s ascension without doubt is a tribute to Mistretta’s leadership. But he is quick to downplay his role in the ongoing “Project Expert Care,” the name Medcentral has assigned to the effort. “This is not an I.T.-driven initiative,” he says. “This is a performance improvement-driven initiative.”

Ironically, Mistretta’s first major task on the job had almost nothing to do with a system rollout. The health system had just signed a major contract with its EHR vendor, Siemens, and charged Mistretta with evaluating the system it had just bought. “We did not understand what we were doing when we signed,” he acknowledges. As a result, the CIO spent six months analyzing both Siemens’ capacity, matching it against the hospital’s strategic vision and analyzing the EHR’s contractual terms. And Medcentral was willing to bail out on the contract, he recalls. “We were eying an estimated $30 million total investment in Project Expert Care and wanted to make sure the EHR was up to the task,” he says.

It was. Today Siemens’ Soarian system serves as the hub of the inpatient EHR as well as patient accounting. It also serves as the practice management system for employed physicians. As the rollout unfolded, Mistretta added boutique applications to the mix to supplement Siemens. For example, the surgery center relies on an EHR from Surgical Information Systems (deployed in 2008) while the employed physicians document on a NextGen ambulatory platform (2010). Before he turns to best-of-breed applications, however, Mistretta considers modules native to the Soarian suite. Siemens’ lab and pharmacy system components now stand as the backbone of the order entry set-up-as well as driving a number of quality and safety alerts to the medical staff. The data repository is built on Siemens’ platform as well. “It is a very flexible system,” he attests.

The adoption of all this technology has not always been well-received, however, Mistretta acknowledges-largely due to the way I.T. can upend well-traveled workflows, and if not correctly architected, can be an impediment to clinicians rather than a time saver. That’s one reason Project Expert Care has been driven by a senior-level executive group that includes the CMO, CNO, COO, vice president of finance, vice president of quality and even department administrative leaders when appropriate. Mistretta sits on the committee, but serves in more of an advisory role when it comes to setting overall targets. “The leadership decides the metrics to measure, prioritizes which workflows need to be modified and the best way to handle regulatory issues,” he says.

That delegation of authority has paid off for Medcentral-particularly in such potentially controversial areas as physician order entry. After launching a CPOE pilot three years ago, Medcentral has deployed the order entry system throughout the hospital, eliminating paper orders and all the risks and inefficiencies they represent. Today, about 80 percent of orders are placed directly by physicians, with the remainder coming in either verbally or over the phone, in which case a nurse enters the order. Gone are the days when faxes used to come into the pharmacy with medication orders.

Mistretta recalls the CPOE pilot with a certain amount of amusement. “We began with four nephrologists,” he says. “Two of them were computer-savvy and two of them were computer-phobic. We knew if we could succeed with this group at the two extremes, we could hit the cross section of the organization.”

Attaining the high degree of physician-entered orders was “very difficult to accomplish,” Mistretta says. “When you have two physicians giving an opinion on an order, you have two opinions. Getting them to agree on an order set is extremely challenging.”

To manage the creation of the specialty-oriented order sets, Mistretta assembled a physician advisory group to serve as the governing body. The multispecialty group would vet and approve order sets created by specialists before turning them over to Mistretta’s I.T. group to build out in Siemens. At the department level, medical directors were charged with leading the creation of suggested order sets. “We set standards of excellence,” Mistretta recalls. “Order sets needed to be based on clinical evidence.”

Now physician orders appear on an electronic worklist they use to review what a patient needs. And orders are dispatched immediately to the pharmacy staff, who no longer have to interpret physician handwriting. When meds are prepared, nurses use the order system in tandem with a bar code system to document the entire transaction. Meds are bar-coded at the unit dose, explains Mistretta. At the bedside, nurses pull up the relevant order, scan the med, scan the patient’s wristband and then scan their own ID card. The EHR then reviews the entire configuration to make sure the correct medication is being administered to the correct patient in the correct dose. Medication delivery has been streamlined as well, with a 45-minute reduction, on average, in delivery time from order to administration, Mistretta says. “If it is a critical medication, that 45 minutes can be significant.”

Medcentral has also used its EHR to help prevent patient falls. As part of the admission assessment, the system calculates a risk score for patients. If one of their patients is at risk for a fall-based on an algorithm that considers multiple factors including diagnosis, age and procedures done-nurses get an electronic task on their worklist, reminding them to check the patient at regular intervals to provide assistance if needed to use the bathroom. “Patients often fall because no one has checked on them to take them to the bathroom” and they try to do it on their own, Mistretta says.

Looking to the future, Mistretta says Medcentral is well-positioned to take on an accountable care contract, which he figures is inevitable. Mistretta predicts the bundled payment model will come first, a set-up in which a health system receives one payment for a set of services across multiple care settings as opposed to a number of individual payments. “We will look at the ortho area first,” he says. “We are putting a lot of effort into joining outpatient and inpatient.”

 

Ensuring Quality Deliveries

Name: Barbara LaBranche, R.N.

Position: Senior Director, Clinical Design and Usability

Organization: Banner Health, Phoenix, Arizona

Accomplishment: Minimized Early Elective Deliveries With Data Reporting

Among large, multistate health systems, Banner Health-its 24 hospitals span seven states-is an EHR standout. In mid-2012, 17 of Banner’s facilities won recognition as Stage 7 enterprises, the highest rung on the HIMSS Analytics adoption measure. Only a small percentage of hospitals nationwide have attained this level: The 17 Banner facilities are among just 126 at the peak.

That is a major accomplishment in itself. But Barbara LaBranche was honored as an EHR Game Changer for a project relatively small in scope-but of substantial impact on quality outcomes. Under LaBranche’s guidance, Banner set about to use its EHR technology to address what she describes as a slowly emerging quality issue nationwide for obstetrics departments. In recent years, she explains, an increasing number of babies have been being delivered prior to their 39-week gestation period. There may be sound medical reasons for an early delivery, but unless there are, babies are better off when nature is not rushed by contraction-inducing drugs, a common method to promote early delivery. “We are seeing more induction to promote labor and scheduling of C-sections for no clinical reasons,” she says. “Across the country, the age considered safe to deliver a baby has seen creep. We are seeing babies delivered at 37 weeks for convenience, rather than allowing nature to finish its work.”

The early deliveries, she says, are usually sparked by patient demand. Beyond that, health care providers are not always fully aware of the risks associated with inducing early delivery. These babies, she says, stand at greater risk of developing respiratory illnesses. “The OB physician doesn’t see it, but the pediatrician and the parents do,” she says. “When babies are born at the right time, everybody’s life is happier that first year.”

As a result of applying EHR technology-in a straightforward effort that required no customization-Banner was able to reduce the number of elective deliveries under 39 weeks by 22 percent within a six-month timeframe from 2011 to 2012. That represents more than 2,600 babies per year being delivered at term at Banner Health facilities. “We still have deliveries before 39 weeks, but they are all medically necessary,” she says.

Here’s how Banner went about the job. First, in mid-2011, it gathered historic data from its EHR to determine just how many babies were being delivered in advance of 39 weeks. Nearly 40 percent of deliveries were done anywhere from 35 to 39 weeks. Banner then broke the data down by physicians, a move which for some of the medical staff was an eye-opener, she recalls. “One physician claimed that the data would not impact him, but in fact, he was making deliveries several days before the 39-week period ended,” she says.

Banner extracted the data from its PeriGen system, an EHR used solely in its obstetrics department. The EHR is designed to track both physician and nursing documentation before, during and after delivery. It’s been in place since 2006. “Data has always been hard to get for obstetrics,” she says. “To pull it so easily out of the EHR was phenomenal.”

At the same time it was analyzing the delivery data, Banner changed its medical policy. Now physicians who deliver babies at any of the system’s 19 hospitals with obstetrics programs agree to deliver at 39 weeks, unless they can document a sound medical reason to do otherwise. As it worked to change the policy, Banner got a boost from the March of Dimes, which has compiled state by state statistics on both the incidence and risk of the practice. It also cited research from the Institute of Medicine, which in 2006 found that the annual societal costs-medical, educational and in lost productivity-associated with preterm births were at least $26 million. The medical staff quickly supported the policy.

To help uphold the policy, Banner added an order entry alert to its EHR. If a physician documents an induction of labor as part of the plan of care, he or she gets an alert to document the medical reason. Physicians can override the alert, but are required to document. Banner also began issuing daily quality reports to its obstetrics facilities that revealed the number of babies delivered the previous day and how many met the quality standard. The real-time nature of the reporting-each night the system generates a report at midnight-prompted quick change among the medical staff, she says. “You can look at the data the next day and give physicians immediate feedback. It didn’t take long for the docs to embrace the idea; they know it is the right thing to do.”

Although LaBranche can review enterprise data from her Phoenix office, she left it up to local medical executives to review the obstetrics scorecards and review the results with their medical staff. Local hospitals can also see how they stack up against other Banner facilities in upholding the quality measure, but only designated leadership staff at each hospital can drill down to the performance level of individual physicians. The data is extracted from the PeriGen system and displayed on a homegrown dashboard on Banner’s corporate intranet, LaBranche explains.

There was more to the program, however, than documenting what physicians do. “Physicians told us patients were the ones pressuring them to delivery early,’ she recalls. “They were tired of being pregnant or wanted the baby born on a certain day. The docs wanted information to share with patients [explaining] that is not a good idea.”

Banner’s PR department devised patient educational materials on the topic and the hospital also appeared in local news accounts. “We won the support of the community,” says LaBranche, who monitored online reader forums when the news accounts appeared to detect any negative pushback. “There were just a few comments on how the hospital is getting in the way of a woman’s right to choose,” she recalls. “Overall, people were not aware of what the risks were. Your sister-in-law may have delivered early without any problems, but what if your baby is the one who ends up in the NICU?”

 

Setting the Stage for Accountable Care

Name: Kyle Johnson

Position: Chief Analytics and Integration Officer

Organization: CHE/Trinity Health, Michigan

Accomplishment: Created Analytics Platform

It’s often said that EHR projects may have clearly defined beginnings but never actually end. That’s the case with Trinity Health, a sprawling faith-based delivery system that-since its merger with Catholic Health East last May-that spans more than 84 hospitals in 21 states. Kyle Johnson’s a veteran at Trinity, having worked at the Livonia, Mich.-based system for more than a decade. In her long-time role as vice president of application services, Johnson played a leadership role in one of the industry’s biggest-and most ambitious-EHR rollouts. “Project Genesis,” as the effort is called internally, sought to standardize Trinity’s 50 premerger hospitals on a common EHR platform, namely Cerner’s inpatient EHR with an adjoining revenue cycle management suite of applications from McKesson. The idea was to supplant a variety of systems and paper processes with a common platform-a goal that required extraordinary patience. “It took 12 years,” says Johnson, noting that the last hospitals came on line in early 2013.

Now, Johnson has embarked on a second, almost equally ambitious challenge: deploying an analytics platform across not only Trinity’s original hospitals, but among the Catholic Health East members as well. The analytics effort began in May 2012 and during that time Johnson helped orchestrate the foundation of an analytics platform that she says will prepare member hospitals to enter the era of accountable care.

Compared with Project Genesis, the analytics effort seems downright speedy. The first pilot was launched in April 2013 and had largely concluded by November, at which point the health system began deploying the platform enterprise-wide. The effort has come in the nick of time, as nine of the 14 hospitals in the pilot are participating in Medicare’s shared savings ACO program, a pay-for-performance initiative that puts providers at risk for not meeting certain quality targets and lets them share in the money they save if they do.

The analytics platform is from Explorys, a software firm with which Trinity signed in January 2013. In the set-up, Explorys runs the analytics platform in the cloud, receiving multiple data feeds from Trinity, parsing and combining them per various payer contractual requirements, and then displaying the data on a dashboard. At a glance, Johnson and other leaders at the enterprise level can see select delivery areas-Trinity has carved out its delivery metrics on a regional basis, rather than provider by provider-and see how they are stacking up in such critical areas as controlling clinical indicators for at-risk patients, such as diabetics. Care managers at the local level see their own performance as well across a much broader spectrum of data sets.

Trinity took a methodical approach in devising the analytics platform, Johnson recalls. First, it met with representatives from the three regions where it wanted to run pilots. These are geographically, and demographically, diverse areas with varying payer contracts: Boise, Idaho; Columbus, Ohio; and Grand Rapids, Michigan. In sum, these provider clusters, known as “clinically integrated networks,” span 14 hospitals and nearly 1,500 employed physicians.

After Johnson met with representatives from the networks, she helped lay out a set of metrics they would need to uphold payer contracts. “We wanted a proof of concept running in under seven months,” she says. “We had to focus on priorities. We could not meet the timeline if we took on their entire book of work and data sources.”

Once the foundational measures were established-they include HEDIS standards in addition to the 33 quality indicators used by CMS in its shared savings program-Trinity turned over the deployment to Explorys. “It took them 90 days for the mapping and curation of data,” Johnson says, adding that before Trinity granted the vendor access to its system, Explorys had to sign off on a HIPAA business associates privacy agreement.

Explorys receives data feeds from multiple sources to support the warehouse underlying the analytics platform. These include hospital data (from Cerner), physician billing and clinical data (from NextGen, another component of the Genesis standardization work), other data from Trinity’s own data warehouse and, lastly, claims files, pharmacy fulfillment records and patient eligibility files from a number of key payers with accountable care contracts (BlueCross BlueShield among them). Johnson says the eligibility files are crucial to assigning patients to providers. In addition to supporting the HEDIS set (an NCQA-certified set of metrics widely used by health plans), the platform enables Trinity to crunch data around a number of measures Explorys had developed, such as MRI and readmissions per 1,000 patients.

The analytics platform is embedded with five distinct tools: a patient registry, quality measures, patient outreach, ad hoc queries and a separate data reporting mart, where cost data is currently housed. Johnson says the registry-which spells out which patients are assigned to which physician and can be organized by disease state-is fundamental to improved care. “We can track gaps in care, by disease or by population,” she says. “It is the start of the care management conversation. It lets the care managers know who the most high-cost diabetics are and make sure they are receiving health care in the most cost-effective manner.” The patient engagement module fires off correspondence, either letters or e-mails, to patients with overdue tests or as appointment reminders.

At the practice level, physicians can log in and review their entire patient population at a glance, with various quality metrics color-coded to green or red to indicate compliance, or lack thereof. Drilling down through the metrics will reveal a list of patients associated with the measure, Johnson says. The analytics platform currently resides in an application distinct from the EHR (the two can be seen side-by-side on the same screen), but at some point Trinity will feed data directly back into the ambulatory EHR. “We are not in agreement yet about what data gets fed back,” she says. “There are a lot of varying opinions.”

Working that out represents another challenge for Johnson. An even bigger one awaits: Catholic Health East’s hospitals run on different EHR platforms (Siemens and Meditech predominate) and use yet another analytics vendor. “They are still rolling the analytics platform out and eventually we will do a side-by-side comparison,” she says, adding that Trinity’s remaining member hospitals will add the Explorys tool to their portfolios during the next two years. “Then we will plan what to do with the CHE members,” she says. “It takes a lot of time to bring data sources in and make sure it is all accurate.”

Streamlining the Practice

Name: Shannon McCracken

Position: Founder and Executive Director

Organization: Commonwealth Case Management, Somerset, Kentucky

Accomplishment: Developed EHR to Serve Special Needs Population

When Shannon McCracken formed her own company devoted to serving individuals with intellectual and developmental disabilities, she had one overarching vision-eliminate the burden of paper record documentation. McCracken’s case management firm employs 10 managers who oversee and monitor care delivered to some 250 participants, predominately adults, who are the beneficiaries of a special Medicaid waiver. The waiver is designed to help these adults-many of whom have Down’s Syndrome-avoid living in large institutions. McCracken’s staff do not provide care directly, but rather work as delegated case managers who serve as the participants’ advocates. The participants live in a variety of community-based residential facilities and some even get assistance to live on their own.

The documentation requirements imposed by Medicaid on firms like McCracken’s are steep-and the majority of case management companies rely on paper charts. “The charts can easily become five inches thick and include 500 pages for a year,” she says. The content is all regulation driven, and McCracken must keep track of medical files, physician appointment records, residential records, consent forms and individual goals for each participant. The storage costs alone with the charts can be imposing, says McCracken, who worked in the industry for more than a decade before launching Commonwealth Case Management in November 2011. “Case managers spend half their day on paperwork,” she laments.

To streamline the operation and free up case managers to spend more time in the field with program participants and their service providers, McCracken decided to help develop an EHR tailored to her case management services. She reached out to a Lexington, Ky.-based I.T. services firm, Integrity IT, because she knew a nurse who worked there. Integrity consults on a variety of acute care EHR projects, so McCracken figured the company might be able to help her. “I shared my vision of an EHR for us,” she says. “They saw the potential and brought in a programmer. We have been working together the last two years.”

Initially, as a stop-gap measure, in January 2012 Integrity IT set up a Microsoft Sharepoint site, which enabled some document sharing and could house scanned images, such as faxes. McCracken and her staff used the site for the next 18 months, while the programmers worked with her to devise a new application from the ground floor. The program, now hosted by Integrity IT, went live in June 2013 and is used by her entire staff. It’s not exactly like the conventional inpatient EHR, she notes. “The software has a social media feel to it,” she says. Adorning the front page of the individual record is a photograph of the participant. Clicking on the photo yields a profile, which summarizes key information, such as relevant demographics, current care or residential providers, and any “crisis issues or things you need to know to keep them safe, happy and healthy,” says McCracken.

When the system went live, case managers manually entered much of the data, but now certain data, such as Medicaid ID numbers, auto-populates other documentation forms the agency must present upon demand to auditors. Staff access the system via tablet computers they tote to residential sites. The system is set up to accept faxes directly as electronic images. These wind up in a work queue, which the staff sassign to the appropriate chart.

Within a few months after go-live, McCracken documented substantial EHR benefits. She recently abandoned her rented office, an 1,100-square foot space where she had set aside room for case managers to work, because it was no longer needed. “If I meet with staff, I do it at the coffee shop,” she says. McCracken also reduced-via attrition-one FTE, an administrative assistant who was tasked with processing paper during the pre-EHR days. “I have eliminated administrative functions,” she says.

Shortly after go-live, McCracken endured a billing audit from Medicaid. The agency pays her firm on a PMPM basis to serve as case manager for an assigned population. In these annual reviews, the agency sends in a request prior to the review of a select group of charts it would like to review, a sampling that usually represents about 25 percent of the available charts. Missing information typically results in a financial penalty, or recoupment, says McCracken, who adds that the EHR includes an alert function that flags documentation folders missing required information.

Preparing for these reviews in the paper world can be remarkably tedious, says McCracken. “You can spend days getting ready, pulling charts, organizing files and getting paper cuts,” she says. And the audit is not particularly easy on Medicaid staff either, as they pore through chart by chart. For McCracken’s first audit, Medicaid dispatched four reviewers who planned on spending several days with the firm. McCracken assigned electronic access to the right files and turned the reviewers loose on her EHR. “They were done in five hours,” she says. “And we had zero recoupment.”

Integrity IT is now promoting the software to other service providers in the area who work with McCracken. The system is architected in such a way as to facilitate data sharing among the providers and case managers via a portal. To date, five of the residential and service facilities McCracken monitors have begun to deploy the software.

How the Program Works

Individuals from any health care industry stakeholder organization are eligible for the EHR Game Changers Awards. Judges evaluated entries submitted via e-mail. Nominations included the following:

1. A short biography of the nominee including full name, job title and job responsibilities, education, work history and the number of employees under the direct management of the nominee.

2. Name of the nominee’s organization and details including location, number of employees and number of licensed beds for a hospital, number of physicians for a group practice or number of covered lives for a health plan.

3. In-depth explanation in 1,000 words or fewer of why the nominee should be recognized as an EHR Game Changer, including information on:

– Specific projects during which the nominee designed, implemented and/or championed health I.T. Included should be a brief project timeline that describes the goal of the project, what technology was used, and key milestones and when they were met.

– How the nominee’s involvement in health I.T. improved the care quality of the organization. Must include quality metrics and other demonstrable clinical benefits from the technology.

– All I.T. projects that make a real impact run into technological/managerial hurdles. Please list one or two hurdles encountered and discuss how they were overcome.

– The names and contact information of key internal and external partners on the project. Source

HIMSS Special Part 1: HIT Visionary Zach Fox
Check out industry insight from HIT visionary and DrFirst Executive VP and GM, Zach Fox. Visit DrFirst at HIMSS Booth 6232.
We respect your privacy. Your information is safe and will never be shared.
Don't miss out. Subscribe today.
×
×
WordPress Popup
HIMSS Special Part 1: HIT Visionary David Lareau
Check out industry insight from HIT visionary and Medicomp CEO, David Lareau. Visit Medicomp at HIMSS Booth 3421
We respect your privacy. Your information is safe and will never be shared.
Don't miss out. Subscribe today.
×
×
WordPress Popup
casipoldiyarbetetabetetabetw88w88w88betfokusbetfokuslordbahisparobetparobetbuzbahisbullbahiscasino sérieuxcasino sérieuxcasino sérieuxcasino sérieuxcasino en ligne populairemeilleur site de jeux casino en lignemeilleur site de jeux casino en lignecasino en ligne en francecasino en ligne en francecasino en ligne de confiancebetbinanstwinplayistanbulbahisistanbulbahisistanbulbahisparis sportifs hors arjelonwin üyeliksahabet üyelikrestbet girişpulibetsüperbetinbtcbahiscanlı casino sitelerionline casino1xbet mobilligobet mobilcapitolbetmostbet üyelikbizbet üyelikgobahis girişmatbet girişikimisli girişbordobet girişbetcio girişalfabahisalfabahisbetgoowinxbetwinxbetwinxbetwinxbetbetkanyontaksimbetrexabetrexabetrexabetenobahisbookmaker hors arjelparis sportifs en Italieparier sur les cornersparier sur le nombre de tirsmystake chickenparis hippiques en ligneplinko francecasino diceBetzinoVasyCbetCasino Lucky8betkanyonbetkanyontaksimbettaksimbettaksimbettaksimbetbetistbetistbetistenobahisenobahisenobahisbetkolikbetkoliksmartbahissmartbahissmartbahistrendbettrendbetgamabetgamabetgamabetgamabetaspercasinoaspercasinoaspercasinonisanbetnisanbetnewbahismelbetonbahisbetonredbetonredromabettipobettipobetefes casinobetandreasfixbetbetbababetbababuzbahisbuzbahisbullbahisbullbahisbetsofbetsofall right casinokombinebetbetbinansbetbinansbetbinansmaksatbahisbetbabaorisbetorisbetbizimbahissiyahbethayalbahishayalbahishilbetsantosbettingsantosbettingsantosbettingsantosbettingnerobetnerobetswordbetswordbetswordbetinbahislevabetlevabetlevabetcasiveracasiveracasiverakordonbetkareasbetprincessbetkikbetkikbetkikbetbetmarketbetmarketbetmarketyapbahsinibetingoasyabahishipercasinocasinoperbahisnowsüpertotobetalibahisfaulbetfaulbetrelaxbahisbetingoasyabahiscasinopercasinoperbahisnowbahisnowpiyasabetpiyasabetyonjabetcasinoslotbetibombetibomredwinbitslercresus casino