Randall Wong, MD: RSS Feeds, Aggregators, and E-mail News

I write for two different “eye” blogs weekly. Finding time to write is an issue, but I’ve found a very quick and organized way to keep current with ophthalmic news. By using feeds and accumulators, I am able to keep up to date on everything that interests me in ophthalmology. Period.

I have news and health information sent to me. Every day.

Readers and aggregators are services that will track any “subscription” that you may be interested in following. For instance, I used to receive Ocular Surgery News in the mail. It is one of the more comprehensive free magazines we receive that covers all subspecialties in ophthalmology. I don’t read the magazine any more. Takes too much time. I subscribe only to retina articles (I am a retina specialist) published by OSN.
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So instead of going to the Web site to search for new stuff, the Web site comes to me. I don’t have to sift through a Web page only to find there is nothing new in retina news today. A huge time saver.

I follow this blog on a reader. If the featured article of the day interests me, I click on it.

I use Google Reader and Bloglines. Both are free. All you need to do is establish an account. Did I mention it’s free?

E-mail is still worthwhile and may be a very satisfactory substitute for readers and aggregators for receiving new posts or articles on sites that you follow. For instance, readers that subscribe to my blog can receive an e-mail any time a new article is published on my site.

I have set the blog up to send subscribers an excerpt of my article along with the title. If the reader is interested in reading the whole article, she may follow the link to my site and read the entire article. Simple.

Some subscription services send the entire article for you to read. You never have to even visit the Web page.

E-mail is great if 1) the Web site allows you to subscribe via e-mail and 2) you don’t want to follow lots of sites. The more sites you follow (some people follow hundreds of sites), the more you might want to consider RSS feeds and aggregators.

Hope this was helpful as you plan your technology resolutions for next year.

Randall Wong, MD, is a retinal specialist in private practice in Fairfax, Va. Wong has a strong interest in Web 2.0, the Internet, and social media, and will write regularly about how social media can help build your practice and even improve healthcare.

Gerald O'Malley, DO: Dreams from the 'hood, part 1

In my emergency room, I recently treated a 14-year-old girl that had been pregnant twice and was now on Depo-Provera birth control. While talking to this young lady about her sore throat, I became increasingly distracted by the small tattoo on the side of her face, by her right eye. Who would allow their 14-year-old girl to get a tattoo on her face? My 11-year-old still watches SpongeBob Squarepants. What happened to this 14-year-old?

I became curious as to what plans this girl and the other adolescents in my ED have for their future. Do they think about the future? What are their hopes and dreams?

Every summer we have medical students spend time in our ED to do research. I put them to work. We developed a series of five questions to ask people between the ages of 13 to 18. The questions were:

1. What are you doing right now? Are you in school or are you working or are you doing something else?
2. Where do you see yourself in 5 years?
3. Where do you see yourself in 10 years?
4. With whom do you live?
5. Do you have any children?

The results of our little survey were astounding.
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Almost all the teenagers — whether they were in school or not, working or not, had children or not — had some plans or goals. Some wanted to be doctors. Others wanted to be nurses or other healthcare workers. One kid wanted to be an astronaut. Of the two dozen teenagers that we spoke to, only one or two had no dream for their future. Only one teenage boy said that he expected to be in jail.

I must say, I was thrilled. Maybe things weren’t so bad. Maybe the girl with the tattoo was the exception.

The medical students were also excited. They wanted to know more. During a meeting, the idea came up to try to identify potential obstacles to the goals so the survey questions were amended. The results were slightly less reassuring.

Many of the teenagers in our survey had children. Several of the boys had no idea how many children they had fathered. Some 15- and 16-year-olds laughed as they tried to remember all the girls they had slept with and count up all their children; others didn’t want to talk about it and seemed almost embarrassed that they fathered children that they subsequently ignored.

The teenage single moms all seemed to be doing well. Many of them were in school learning some trade. Four of them lived alone, in their own apartments and had no contact with their families. Three of those four were enrolled in school to become nurses.

“How can a 17-year-old girl support an infant, have her own apartment, not work a job, and go to school and not have any financial or child-care support from their families?” I asked.

“State tuition assistance, city-supported child care, a housing subsidy grant, and WIC,” the students said. “From a financial or childcare standpoint, there really aren’t any obstacles for teenage moms to pursue their goals.”

This isn’t the case, of course. Our subsequent surveys (more on those later) demonstrated that even with enormous amounts of financial assistance, educational and career targets are frequently derailed by unplanned pregnancies.

I mentioned to a colleague that it seemed a shame that these girls had no contact with their families, and he said, “Family interaction is a two-way street. If the family isn’t willing to work through problems, then you can’t expect the teenage mom to do it.” That seemed like excuse-making to me. Why bother working through family problems when the alternative is to just move out and get your own place?

When I mentioned that it seemed remarkable to me that the city of Philadelphia is broke, shutting down libraries and fire stations and laying off cops and teachers, yet there is money to give to teenage single moms to pursue nursing degrees, one colleague actually said, “Well, I rather see my money go to support single moms than for other things – like supporting war.”

I could be wrong, but I don’t think that the city of Philadelphia has ever declared war on anyone.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Jennifer Frank, MD: Intimacy

I am both amazed and humbled by what patients share with me. They volunteer the most intimate details of their lives and allow me to examine the most intimate parts of their bodies. I hear things that no spouse, parent, counselor, or priest hears. Something about the trust patients place in their doctors and a desire to share important information motivates patients to reveal these intimate details.

The knowledge I have about my patients is sacred. Indeed it is so sacred, that I have both taken an oath to protect it and am under strict legal obligation to safeguard it.

I was pondering this recently as I chatted with our housecleaner in my kitchen one morning before I left for work. She enters our lives and our home every other Monday morning. She arrives early, when we are still in our pajamas, and vacuums around us as we eat breakfast, get ready for work and school, and handle the inevitable morning meltdown (usually one of the kids, but occasionally one of the parents). It is hard to hide your true self from someone who vacuums under your refrigerator and cleans your toilet bowl.
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In many ways, the relationship I have with my housecleaner is even more intimate than the one I share with my doctor. I tell my doctor that I eat healthy, but my housecleaner sees me eat a chocolate chip cookie for breakfast. When asked about my stress level, I tell my doctor that I am doing fine. My housecleaner sees the difficulty I have balancing the multiple demands made by four young children. She sees the inner workings of my family, what books are on my bedside table, the food we eat, how tired we are.

I often wonder what she thinks about us. Is she as horrified as I am that it took her seven hours to clean our windows this past spring or is that “normal”? Does she silently judge the way we parent our children? How do we compare to other families in trying to get everyone out of the house in the morning?

My patients must feel similarly. Do they sense that I am perfectly accustomed to the “oh, by the way” symptom of erectile dysfunction offered at the conclusion of a visit? Do they perceive me judging them for failing to take their diabetes medication? Are they concerned that I may discover too much or pick up on secrets they wish to keep hidden? It reminds me of the unique vulnerability patients experience.

I also realize how limited my vision is. Sure, I can ask (and have asked) almost every question imaginable, including some that probably made me blush. But, 15 minutes is hardly a window into someone’s life. How much different it would be if I could get the “housecleaner” view of my patients’ lives. I can ask those probing questions that allow me to visualize what I can’t see. What did you have for breakfast this morning? What time do you go to bed? Who lives in your home? Hopefully, this will fill in the gaps that are not revealed, so that I can get a sense of the whole person and hear beyond their words.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Healthcare reform roundup

Here's a roundup of some of the coverage of the Senate vote last week.

MedPage Today

Wall Street Journal

New York Times

Please let us know what you think about the healthcare reform debate. What's your take on the legislation? How do you think it will affect your practice?

Randall Wong, MD: Why I e-mail with patients

I have two Web sites, one of which is technically a blog. Blogs allow readers to comment, and commenting allows patients to communicate with others, and with me. It empowers them. They become active participants.

I encourage patients to e-mail me as well. (To you nay-sayers, my patients are aware that it is for non-emergencies). Allowing my patients to communicate with me via e-mail or the blog has a lot of advantages.
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One of the advantages of having a Web site is that it is a useful resource. I direct patients to the site to read more about their particular problem. Not only does it reduce their anxiety about forgetting to ask me something during the visit, but it gives patients a nice resource to learn about their disease. Most importantly, they have the opportunity to ask better questions — when they are ready.

Answering questions via e-mail is convenient. To me, it is more efficient than returning phone calls and is easier too. No need to make a phone call and make a note in the chart.

I am not an attorney, but e-mail does create a legitimate paper trail. If you are not comfortable, you could always “cc:” your office manager, print the e-mail, and stick in chart.

The best thing about communicating over the Web is that it makes me more accessible to my patients. It erodes the image of docs living in an ivory tower and allows us to be more human. It removes the barrier of the front desk answering the phone and taking a message, leaving the patient skeptical about my ever returning a call.

In return, it gives me the luxury of responding when convenient for me and not just when I’m in the office.

The bulk of my practice deals with patients with diabetic retinopathy and macular degeneration. I see these patients chronically. Getting to know them is a by-product of seeing them year after year. The Web facilitates this nicely.

You may not prefer this mode of communication, but for my practice, it works very well. Patients are empowered to communicate.

By the way, I don’t carry a BlackBerry and I am not crazy — I do not let patients call me directly on my cell.

Randall Wong, MD, is a retinal specialist in private practice in Fairfax, Va. Wong has a strong interest in Web 2.0, the Internet, and social media, and will write regularly about how social media can help build your practice and even improve healthcare.

Trendspotter: Health information exchange raises new liability issues

By Ken Terry


When physicians are asked how an EHR might affect their malpractice risk, they usually think about their own documentation and orders. More comprehensive records, better access to those records, and automatic alerts might help them avoid an error that could result in a suit, they say. System crashes, diversion of their attention from the patient, and “charting by exception” could increase the possibilities for liability.

But what you do with your own EHR is not the only source of potential difficulties. As EHRs become increasingly interlinked with outside information systems, including those of other practices, hospitals, labs, pharmacies, and health information exchanges, the greater availability of data from these other sources could also raise malpractice risks, say some experts.
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In a recent Dr. Kevin blog post, attorney Robert J. Mintz points out that, as access to data on patient treatment outside your practice grows, you might also be held accountable for a higher standard of care. “Even as quality increases, the legal standard of care will keep rising too, so that rather than fewer mistakes and fewer lawsuits, there are more of each since the information you ‘should have known’ is now right at your fingertips,” Mintz writes.

Mintz cites a case involving a pharmacist who was sued after a patient to whom he dispensed a painkilling drug caused a fatal car accident. Because the pharmacist had access to records showing that this patient had gotten prescriptions for a large number of similar drugs before, the plaintiff alleged that he should have known the patient was abusing these medications. Mintz believes that similar suits could be brought against physicians who have access to the records of other physicians, as well as to community medication histories.

Other observers are concerned about the unintended effects of the information revolution on physician liability. Gerald “Jud” DeLoss, a healthcare and malpractice defense attorney in Fairmont, Minn., notes that when one physician’s EHR is interlinked with those of other doctors, “faulty information that may have been inputted into the system by a physician or staff member outside their facility could result in some type of incorrect treatment or an allergic reaction that could injure the patient.”

Steve Waldren, a family physician who is director of the AAFP’s Center for Health Information Technology, is concerned that if a physician has access to lab results in a colleague’s EHR and doesn’t integrate those results into his own record, he might be held liable.

And Washington, D.C., internist Peter Basch, a leading health IT expert, says that if you even open a colleague’s e-mail that contains information about a patient and don’t file it in your EHR, you could be held accountable because the audit trail would show that you had opened the e-mail.

Electronic prescribing is another can of liability worms. First, as mentioned earlier, physicians who prescribe online to pharmacies, either through an EHR or a standalone e-prescribing system, have access to Surescripts’ community medication history, based on claims data from pharmacy benefit managers and health plans. In some areas, prescribers may also be able to access a point-of-sale database that shows all of the medications, both prescription and OTC, that a patient has purchased in participating pharmacies.

What this means is that the e-prescribing physician either knows or should know what other medications a patient is taking when he prescribes a drug that might have an adverse interaction with one of those other pills. If everybody looked up this information, it would be a great leap forward for patient safety. But Surescripts says that in 2008, only 16 million prescription histories were routed to physicians who ordered 68 million prescriptions online. So doctors were checking their prescriptions against community records less than a quarter of the time.

The other liability risk associated with e-prescribing comes from the new ability to find out whether a patient has filled his prescription. (Surescripts includes the fill status as part of the medication history.) If a physician does not check on whether a patient has filled his prescription, is he liable if the patient doesn’t get the medication and has an adverse event as a result? If the doctor does know that the patient isn’t taking or refilling his meds, should he follow up immediately or wait until the next visit, and what responsibility does that entail?

The list of possibilities is endless. But, perhaps because legal experience in this area is sketchy, relatively little attention has been paid to the liability implications of health information exchange. That is likely to change, however, as more physicians acquire EHRs and as HIEs emerge across the country.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Gerald O'Malley, DO: Emergency surgery on a horse

One of the best things about practicing emergency medicine is the fact that people think you can do anything. Work at this job long enough and you begin to believe that too.

I spent two of the best years of my life stationed with the US Navy in Okinawa, one of the most idyllic spots in the world. I worked with a young corpsman from Oklahoma named Barbara who wanted to pursue a career in animal husbandry. She was enrolled in classes and planned to apply to vet school when her time in the Navy was up.

Barbara was incredibly persuasive. She became friends with a local Okinawan man who owned a pony that he would bring down to the beach and allowed tourists to ride. Horses aren’t native to Okinawa so Barbara convinced the man to purchase three horses from the local meat market and keep them in stables that she had built from driftwood.

Barbara and I became friends and I began to hang around the stables and help her care for the horses. The horses weren’t ill, but they were all damaged and old. One of them had injured its neck and its head was cocked at a 45 degree angle when you looked at it head-on.

One day I received a frantic call from Barbara.
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She told me that one of the horses must have fallen down overnight and sustained a large, deep laceration to its right front shoulder or haunch. Barbara was distraught. “I’ve seen horses have to be put down for injuries like this,” she said “The flies are already getting into it. Do you think there is anything you can do?”

“Why don’t we call a vet?” I suggested.

“None of the vets on this island treat large animals. They are all dog and cat practices. The Army has a vet but he has been ordered not to help me.”

I went over to the ER and collected up a laceration tray, heavy gauge suture material, a stapler and some cast material and drove to the stables. Sure enough, the healthiest horse in the stable had a large gash high on her right shoulder and the flies were laying eggs in it. I confessed that I had no idea what to do. I remember Col. Potter on M*A*S*H* saying that despite their size, horses are remarkably fragile animals. What was the appropriate dose of lidocaine for a full grown horse? Plus, there was the issue of how to not have this 800-pound animal kill me while I tried to repair the laceration. Barbara reassured me that she would apply a nutcracker-type device to the horses’ snout and keep the animal from biting or kicking or stomping me while I was underneath it. Barbara probably weighed 100 pounds soaking wet. “I should have my head examined,” I thought.

There was no way to get to the laceration without getting partially underneath the horse, so I said a prayer and crawled up under the beasts’ belly. I waved away the flies, Barbara applied the nutcracker, and I plunged an 18 gauge needle into the horses shoulder and injected 200 mg lidocaine all around the wound. The horse jumped, but Barbara held on and I managed to get the lidocaine into the wound without getting my head caved in by the rear legs or being smooshed by the animal falling over on me.

The real test came when I scrubbed the wound with a Hibiclens sponge. The horse didn’t seem to mind, so I cleaned all the dirt out of the wound and tried to staple it, but the staples just popped out when the horse moved, so I did a three-layer closure with absorbable sutures for the muscle and fascia and some heavy grade silk for the skin.

I tried to dress the wound a number of ways using tape and Plaster of Paris cast material, but the horse would just shudder and the whole thing would fall apart. Barbara had the great idea to make an elastic dressing by cutting the foot off of a pair of pantyhose and slipping it onto the horse’s leg and tying it to the other leg of the pantyhose, which we wrapped around the horse’s neck. It worked like a charm.

We took the dressing down a week later and the wound was healing well. We left the sutures in place for three weeks. We didn’t ride her for another several weeks and the first time that I got back on the horse, she threw me about 10 feet and I landed on my back, knocking the wind out of me. As I lay there with my face covered in dirt, gasping for breath, spitting out sawdust, I watched the horse gallop away to the far side of the pen, Barbara in hot pursuit one thought crossed my mind.

I don’t get paid enough for this.

Can health courts cure the malpractice system?

Considering the recent discussions about tort reform (and the fact that it's not included in the healthcare reform legislation) makes next month's article on health courts particularly interesting.

Health courts, based on the idea of workers' compensation courts, are becoming an increasingly popular idea for malpractice cases. They include experienced judges, neutral experts, reasonable awards, and a change in the standard of negligence.

Read the Physicians Practice story and comment here. Are health courts a good option for malpractice cases?

Jennifer Frank, MD: The balance

This week has been crazy busy at work as each day has turned out much different than my day planner predicted. After a long weekend, Monday was predictably hectic, but as I perused my schedule for the remainder of the week, I was optimistic that it was manageable and would allow me to get everything done that was necessary on my to-do list.

Tuesday morning I was in a meeting (dutifully recorded in my calendar) when I received an urgent page informing me that I was already 45 minutes late to staff the residents in clinic. I quickly glanced at the clinic’s schedule to see that, yes, I was scheduled for staffing duty that morning. A change must have been made that did not make it to my personal calendar. Frustrated, I worked hurriedly to get through the staffing back up while trying to find a time to reschedule the meeting that was abruptly cut short.

Tuesday afternoon’s planned lunch-hour swim at the YMCA never occurred, as I attended another meeting, addressed a number of urgent issues, and made it out the door 20 minutes late to meet my husband for the kids’ swim lessons.
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Wednesday’s schedule was packed full with clinic and staffing duties. Shortly after waking up in the morning, I received sign-out from a colleague (did I mention I was on call too?) with two laboring patients. I quickly showered, ran to clinic to perform a procedure I had scheduled, and worked with colleagues and staff to rearrange my morning before heading over to the labor deck. While supervising the resident managing the two women in labor, I was able to finish resident evaluations and a self-assessment module for my board certification requirements. I am fortunate that my colleagues are understanding of the urgency of OB practice and covered my patient care and staffing duties for me. The second patient delivered at about 8 p.m. and I was able to leave the hospital by 8:30, having missed dinner, bath, and bedtime.

Thursday seemed ideally planned out – a full morning clinic but administrative time in the afternoon allowing me to attend my daughter’s preschool holiday concert and catch up on charts prior to a vacation day planned for Friday. I finished my 11:15 a.m. patient at 1:10 p.m. (having elected to pursue an overly ambitious agenda for this visit) and was walking back to my desk when a resident stopped me in the hallway to tell me that we were scheduled to do a vasectomy together.

There was no way I could do the vasectomy and make it to the concert (I had promised to attend) on time. None of my colleagues were available to help out and I was torn between doing the right thing for the patient and honoring my promise to my daughter. I tried to figure out where the mix up had occurred but quickly abandoned that exercise as both irrelevant and a time waster. The patient, having been poorly prepared for the amount of time the procedure would take actually requested to reschedule, so that part of the problem was solved. However, working with the front desk to reschedule him, soothing the patient’s ruffled feathers, giving instructions to the resident, and explaining the situation to colleagues took up precious minutes, so that I arrived at my daughter’s preschool just as the concert ended.

So frustrating to be extremely busy but fail to meet your obligations. In moments (days and weeks) like this, I rely on the common sense voice in my head which reminds me that all weeks are not like this one. I am thankful for a husband who records those events I miss and appreciative of the opportunity to share cookies and juice with my daughter who is unaware of my absence. Finally, I am reminded that so little of the pressure I feel to perform is real – much of it is my own drive for perfection. It’s okay to be imperfect, which is good because I am.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Health reform on the horizon

Is it really possible? Will the Senate actually pass a healthcare bill this week?

It looks like they will pass the legislation on Christmas Eve, the WSJ reports. The Senate’s bill would extend health insurance coverage to some 30 million Americans, create a national insurance exchange, and include subsidies for low- and middle-income to comply with an insurance mandate.
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It also is tough on insurers, barring them from denying coverage to children with pre-existing conditions (and adults with pre-existing conditions starting in 2014).

But it also includes cuts of $480 billion over a decade in payments to Medicare providers.

Meanwhile, new, last minute provisions hiked the cost of the bill up by $23 billion to $871 billion over ten years. Reasons for the increase include expanding the small business tax credit and deleting provisions for increase payment rates under Medicare.

Senators scrapped a one-year fix to the Medicare payment rates because doctors don’t just want a temporary fix, Reid told MedPage Today. This leaves the door open for Congress to permanently repeal the flawed SGR-based payment formula. Last week, the House and the Senate passed two-month fixes, delaying the cuts until March 2010 or until a more permanent solution can be passed.

The Senate’s healthcare bill does raise some revenue by increasing the payroll tax on higher income individuals and families (from 0.5 percent to 0.9 percent for individuals making $200,000 and families making $250,000), according to HealthLeaders Media.

And unsurprisingly, the bill includes funding benefiting specific constituencies, inserted to clench certain lawmakers’ support, the NY Times reports, such as “victims of environmental hazards,” i.e. people exposed to asbestos from a mine in Montana – home state of Finance Committee chairman Sen. Max Baucus.

Melissa Young, MD: What to do about benefits?

One of the great things about being an employed physician was that I never had to worry about benefits like insurance. I had health insurance, vision and dental coverage, life insurance, and a retirement plan. My staff also had excellent benefits, and I didn’t have to worry about who paid for what.

Now, not only do I have to look for coverage for me, but I also have to consider my employees. And of course, I have to pay for at least part of it.
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I thought four choices were too many when I had to pick health coverage offered by my former employer, but now I have to choose among dozens of options. Blue Cross, Oxford, HealthNet? PPO, HMO? And what about vision and dental?

I have dentists and doctors that I already go to, and I want to pick a plan that they participate in. And my staff has their favorite providers, too. Maybe, I am being too nice. Maybe I should just make my choice, and they’ll have to live with it.

How do you know? How do you choose? And how much of the premium should the employer pay?

I’d love feedback from any reader.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Healthcare reform game changers

By Don McDaniel

There’s so much discussion about health reform – how to bend the cost curve, how to drive a higher take-up of insurance coverage, etc. All of the banter seems to ignore, or worse, disabuse any notion that the virtues of free enterprise and competitive markets can free our health care system of its run-away costs, marginal quality, and opportunistic innovation.

They say, “Markets have been tried and don’t work in healthcare; look at the evidence.” Well, as complex as healthcare is, there are a small handful of changes that, if implemented, could be game changers.
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Of course, probably the biggest single game changer of them all would be true payment system reform – moving third-party payments away from evil fee-for-service to a payment system focused on paying for the care of a population or true outcomes-based payments.

Don’t get me wrong, there is still room for fee-for-service payments in medicine – especially in cases where the diagnosis of the ailment is highly speculative, requiring a necessarily iterative problem-solving approach. However, as science evolves, and as diagnosis becomes more predictable, we should need less and less of fee-for-service and more fee-for-outcomes.

That being said, following payment reform, my list of game changers is as follows: reforming medical malpractice; eliminating state’s coverage mandates on health insurers; allowing individuals to purchase health insurance in any jurisdiction; either eliminating the tax deduction for employer-sponsored plans or extending the deduction to individuals as well; and only providing tax deductibility for “true” insurance policies.

Malpractice reform will eliminate most or all of the costs of the practice of defensive medicine – most experts peg this at 10 percent of total health system expenditures or about $250 billion per year, predominantly in over-ordered procedures and diagnostics to protect from frivolous lawsuits.

Many states mandate that insurers cover certain procedures or services regardless of the size or class of the employer purchasing the insurance. This creates an artificial cost floor that places health insurance out of the reach of many employers. To add insult to injury, large employers are typically not impacted by mandates as they are self-insured and exempted by the ERISA law. These mandates can add at much as 5 percent, 10 percent, or more to premiums in many states – and I thought the goal was to innovate products to provide coverage to more folks, not less!

According to the Council for Affordable Health Insurance, my home state of Maryland mandates over 60 benefit requirements, which add at least 15 percent to the insurance premiums of health plan subscribers.

President Obama’s administration claims there’s not enough competition? There are well over 1,000 insurers in the domestic U.S. But I do agree on one thing, there’s not enough competition among differentiated products, payment methodologies, and benefit designs. To nip this in the bud, we ought to allow those seeking the purchase of health insurance to buy it from any insurer sanctioned in any state. This would create significant competition not only among insurance products, but among states that want to become a haven for health insurers.

Finally, with respect to true insurance market reform, there’s a valid argument that the tax-advantage of employer sponsored plans ought to be eliminated, for many reasons. It would raise almost $200 billion in tax revenue, individual purchasers lose out, and the system is regressive in that lower wage earners gain less of a benefit. Let’s create a market for true insurance in healthcare by allowing deductibility only for policies that provide insurance for events that are uncertain, infrequent, and financially significant, forcing Americans to become true consumers of healthcare – and provide that deduction to both individual market consumers and those purchasing through an employer group.

The current lack of consumer sovereignty and prevalence of third-party payments, even for mundane services, creates an artificial supply/demand dynamic that undervalues health care services, thus creating an incentive for overconsumption. We need to pressure of the consummate to truly reform healthcare.

Don McDaniel, president and CEO of Sage Growth Partners, LLC, is an entrepreneur, economist, technologist, educator, speaker, and writer. He is a skeptical contrarian, and writes about the power of free markets, disruption, innovation, and technology in healthcare.

Randall Wong, MD: How I started my Web presence

Last week I proposed various ways doctors could embrace the Internet. I have been slowly implementing several projects using the Internet and Web 2.0 strategies. I have spent many hours learning these new ways, and though I have no authority, I do have a pretty good idea of how social media and the Web interact.

(Caution: As you read, do not get offended by the words “traffic,” “marketing,” “goods,” “selling,” etc. These are terms used on the Internet. It may offend doctors.)

As physicians, we have something to sell. We sell ourselves. We have our services.
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I have two Web sites (it just happened that way). Both are informational sites; they are my “goods.”

Total Retina is a typical informational Web site covering every element of an ophthalmic retina practice: health information, maps, hours, etc. Retina Eye Doctor is my second Web site, which is technically a blog and is a specialty site. It offers credible information about diabetic retinopathy and macular degeneration.

I want to get as much Internet traffic as possible. My demographic is obviously patients with macular degeneration and diabetes. I am therefore marketing to find this type of relevant traffic. One way, a slow way, is to tell every patient that I physically see with either ARMD or diabetes to check out my site. This does work, but it is slow. These patients already know me and I use the sites to fortify my relationship with them. They may tell others.

Another way to build traffic is through social media (see below).

An even more effective way (and is what I am working on) is to have my sites appear within the top ten listings of a Google (or Yahoo or Bing) search. For instance, when a patient searches “macular degeneration” or “diabetic retinopathy,” I am hopeful my sites will eventually show up on the first page of results. Thousands of people type in these keywords daily. You can see how much faster this will increase traffic. From your own experience after searching, how many times do you click on something either “below the fold” or after the first page?

(I have been successful, to date, with keyword phrases “retina eye doctor” and “retina specialist Virginia.”)

Some of this traffic turns into patients. Depending upon the keyword phrases (the words typed into the search bar), I may come up in the search. Patients will click on my Web site, like what they see or read, and call and make an appointment. These patients would obviously be searching using key words that limit searches to their area (e.g. retina specialist northern Virginia).

A larger vision I have is to attract as much traffic as possible. I have a lofty goal of attracting 5,000 visitors per month by the spring. This may attract pharmaceutical companies or open doors for relevant advertising to create some revenue — I just don’t know. Achieving this goal will legitimately allow me to be somewhat of an authority of Web 2.0 technologies.

By the way, there are physicians building their practices by creating a national following. Some patients will travel for the best doctors.

Finally, social media creates a following. I contribute almost daily to my own blog. After each posting, I will “tweet” about the new article on Twitter. This is also picked up by other social networks; Facebook and LinkedIn.

Why? The power of social media is reaching many people, simultaneously. Literally hundreds of people know the instant I have a new article on my site. Intriguing? Social media allows people who are interested in you to follow you in real time.

Randall Wong, MD, is a retinal specialist in private practice in Fairfax, Va. Wong has a strong interest in Web 2.0, the Internet, and social media, and will write regularly about how social media can help build your practice and even improve healthcare.

Trendspotter: Obama campaign against Medicare fraud emboldens RACs

By Ken Terry


Since last March, the domain of Medicare’s new Recovery Audit Contractors (RACs) has expanded from four states to nearly the whole country.

During the three-year pilot that preceded this expansion, the RACs focused mostly on hospitals, and 85 percent of the $900 million-plus in overpayments that were returned to the Medicare trust fund from 2005 to 2008 came from hospitals. Nevertheless, some experts warn that the RACs will eventually pay more attention to physician practices. And, with the Obama administration ramping up its rhetoric against Medicare “fraud and abuse,” the RACs are getting plenty of encouragement.
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President Obama announced the new direction in his healthcare address to Congress in September. “The only thing this [reform] plan would eliminate [from Medicare] is the hundreds of billions of dollars in waste and fraud, as well as unwarranted subsidies in Medicare that go to insurance companies,” he said.

Then, in November, the White House announced that the Centers for Medicare and Medicaid Services (CMS) had made $54.1 billion in improper payments in fiscal 2009, and that the number of erroneous payments by the fee for service Medicare program had roughly doubled to $24.1 billion from the previous year’s level. As a percentage of total Medicare fee for service payments, that represented 7.8 percent, compared with 3.6 percent in 2008. The implication was that if these improper payments could be eliminated, the galloping rise in Medicare costs could be curtailed.

However, as White House Budget Director Peter Orszag quickly acknowledged, the apparent increase in Medicare overpayments was largely due to a change in accounting methods. For example, he said, payments on claims supported by poor documentation or illegible signatures were now being regarded as errors; before, they had generally been disregarded. And this is where the RACs may see an opening to harass physicians who have submitted Medicare claims in good faith for services they actually performed.

According to David Glaser, a Minneapolis attorney who specializes in defending physicians against Medicare audits, the RACs “are nailing people on things like unsigned notes that don’t necessarily take a lot of work. It’s clearly unfair to the doctors, because you’re fighting over that stuff even though there’s no doubt the service was provided. And recently, the RACs have been hinting that if your signature is illegible, that’s a basis for a denial.”

Then there’s the small matter of the RACs’ contingency fees for recovering government money. Those range from 9 percent to 12.5 percent of the funds they collect, depending on the region. This bounty hunting, which Glaser calls a “legitimate concern” for doctors, reflects another new approach of the Obama Administration. For example, the Office of Civil Rights in the Health and Human Services Administration is now empowered to support its investigation of HIPAA privacy violations with a portion of the fines it imposes on physicians and hospitals.

The RACs’ bounty hunting may have one positive aspect, Glaser notes. If the RACs go after physicians for minor rule violations and most of the doctors win on appeal, the RACs won’t get any money in those cases. “So that holds out some hope that they’ll be more rational than the past Medicare audits have been,” he says.

In any case, you should remember that Medicare carriers are still actively auditing physician claims, as well. So, even if the RACs don’t aggressively pursue physicians for some time, you could still feel the sting of an auditor’s letter. And, if the government continues its aggressive campaign against Medicare fraud, those audits might occur more frequently. So mind your Ps and Qs.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Update on the Senate debate

In case you blinked in the past few days, Senators were considering — then scrapped — expanding Medicare to people starting at age 55.

They ditched the idea almost as fast as they pitched it, thanks to Sen. Joe Lieberman’s comments on television Sunday. He said he wouldn’t support the healthcare legislation if it included Medicare expansion or a public option.
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So there went those provisions. The Democrats need his vote to pass the legislation, so they agreed to do away with those parts of the legislation.

Lest you think they have gutted the bill of controversial items, the WSJ health blog notes that there is still plenty to fight over: “People will still be required to buy insurance or pay a penalty. Insurers will still be required to sell policies to people with pre-existing conditions. And some people who don’t get insurance through work will still get federal subsidies to help them afford insurance, with subsidies sliding based on income.”

In other news, a provision that would allow the import of prescriptions drugs was narrowly defeated.

And an amendment that would have banned the sale of doctors’ prescription data for marketing purposes is still alive but has been shelved. Staffers have said it is unlikely to be a part of the healthcare overhaul.

Jennifer Frank, MD: The family in family medicine

I open the door, greeting the older couple, patients of mine for the last three years.

“Let’s see the picture,” the husband demands good-naturedly. I know what he means; he wants to see a picture of my new baby. “I don’t have one on me right now,” I admit sheepishly. He looks disappointed and I promise to retrieve one from my office before the visit is over.

Today’s visit focuses on the wife’s slow and inevitable decline. I try to focus on the myriad social, medical, and logistical issues that assault the couple as they progress through their 80s, trying to live together at home. They do their best to sidetrack me.

“Is he sleeping through the night yet?” “What’s his name again?” “Our great-grandson is 3 years old now.” As a family physician I both recognize the value of the details of my patients’ lives and relish the opportunity to share those details with my patients.
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However, I am also trying to determine whether this couple can continue to live at home safely and for how long. I wonder whether my patient is falling more often than she lets on and attempt to discover whether her memory loss is reflective of dementia, depression or both.

“I’m in charge of all the pictures,” the husband interrupts me as I question his wife. He describes how he cropped a digital photograph recently to accompany a friend’s obituary. “I am keeper of all our family photos,” he explains. He has two external hard drives each containing his family’s pictorial history. There is one hard drive for each of his children, “in case something happens to me,” he says.

After repeated attempts at questioning the pair, I come to the conclusion that things are, for the meantime, stably unstable. Not as good, or as safe as they could be, but pretty close to baseline. I adore this older couple and the playful affection they show for each other, especially while bickering. I am saddened by the future I can see for them and realize that there is little I can do to ease the numerous challenges in their normal day.

“Let me go get that picture,” I say. I return with two photos, one of my newborn son, hair standing on end in a post-bath mohawk, the other of my husband holding him during an outing to the park. The husband positions them each on the exam table and whips out his digital camera. He adjusts the pictures under the fluorescent light just so, trying to avoid a glare as he takes a picture of my pictures. I use the opportunity to probe his wife. “How are you sleeping?” “Are you still taking the Celexa?” “When did you notice your memory being a problem?”

“I got a good one,” the husband announces and shows me some remarkably clear pictures of pictures. I imagine they will end up in his family’s photographic archive, leaving his children to wonder which distant relative is pictured. I can’t say a lot was accomplished medically during this visit, but I am flattered that this couple thinks of me and my family as part of their own. I hope this bond will allow me to gently explore how well they are coping as they decline together.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Melissa Young, MD: Employee No. 2

When I started my new office, I knew I wanted to keep expenses at a minimum. Less overhead equals more profit for less work. I did want to make what I felt were smart investments. I paid for a wireless computer network and an EMR. I spent money on renovating my office space to make it pleasant and efficient. And I wanted to pay reasonably well for good, reliable, trust-worthy staff — even if that meant just having one staff member to start.

When I opened the office, I figured all the patients would be new, and even “old” patients from my prior practice would need to be treated as if they were new (even if I didn’t get paid for a new patient visit), because all their information had to be entered into the EMR. So, patient appointments were relatively long at 45 minutes a piece, which meant that on any given day, I saw about eight patients. So my one and only employee, my front office person, could handle the phones and the faxes and the mail, and I could handle entering clinical into the computer, taking my own vitals, calling patients and pharmacies back.

Now, into my third month (wow, can it really be true?), the follow-up patients are coming in — meaning shorter visits, more patients per day, more prescription refills and more phone calls. I recently hired my second employee, a medical assistant.
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She is helping to enter patients’ histories and medication lists, and she is taking the vital signs. This affords me a few extra minutes to spend with patients, to return phone calls, and to just take a breather from time to time.

Bringing in a third person is tricky. My receptionist and I have been doing this for two months. We have established a rhythm, a flow. We know who’s supposed to being doing what and when. And we get along fabulously. It helps that we are of similar age and have compatible personalities. I was anxious about bringing in someone new. Of course, I had interviewed her and thought she would easily fit it, but you never know.

She has been with us for a week now. So far, so good. She is eager to learn, eager to work. Again, she is in the same age group as we are, and maybe that helps. We are still in the orientation/training phase, and we are going to have to rethink our workflow. My MA has to remind me to stop cleaning up the exam rooms between patients, and I have had to rearrange some computer space, and I’ll have to order different sized gloves for her, too.

It’s an additional expense (my husband thinks perhaps a premature one), but it frees me up for what I think is more productive time, and despite the need for change, has given me a little peace of mind.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Ten years later

Being surrounded by nurses and doctors and fancy medical gadgets always seemed like the safest of places to be when struck down by illness. However, ten years ago this month an IOM report with the somewhat ironic title, To Err Is Human, was released, shattering the perception that hospitals are indeed safe, or at least as safe as we wanted to believe.
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The single most uncomfortable piece of the report was the figure 98,000, representing the estimated number of Americans who die each year in hospitals from preventable medical error.

A good slice of error-related deaths in our hospitals are caused by preventable hospital-acquired infections (HAIs), which, according to CDC data, are on the rise. Medical malpractice lawyers are already champing at the bit—HAIs are seen as the new asbestos!

So, on the tenth anniversary of the IOM’s groundbreaking study, perhaps we should take a breather from all the bitter infighting about healthcare reform and ask ourselves why untold numbers of Americans are dying in hospitals from preventable infections. Maybe asking the question will lead to an answer.

Isn’t that healthcare reform?

"Another day, another data breach"

Managed care company Health Net has lost the health, personal, and financial data for 446,000 Connecticut residents, and the state AG’s office is investigating.

The AG is also investigating why Health Net waited six months to inform consumers and the state, “an inexcusable and inexplicable delay, ” Attorney General Richard Blumenthal said in a statement. “Another day, another data breach… ,” he added. “Casual and cavalier attitudes toward data protection and breaches are intolerable and must stop.”

The data – which was not encrypted - was on a hard drive that disappeared from Health Net’s office.

Time to invest in some encryption software, if you haven’t already, to protect your patients’ health and financial data. Here’s some information on how to secure data on laptops and the large databases in your office.

Randall Wong, MD: Authority - learn to use it

“Whatever you say, you’re the doc!” That was the old days.

Establishing trust between a patient and doctor is easy. How is it we gain our patients’ trust? How do we convince them so easily to follow our recommendations?

We have authority.

We earned our degrees. We earned the white coat. We earned the authority that comes with the territory of being a doctor. With the authority comes trust. People inherently trust authorities.

Let’s face it, most patients come to you naively. Usually through recommendation from someone they trust; be it their own doc or a friend or a neighbor. Do they really know the difference between doctors? How can they? They act on the word of someone they trust.

In the old days, we’d treat patients, patients got better, we’d gain respect. Appreciative patients tell others, you lecture periodically at the hospital, retirement homes, etc., and your practice grows.

Then the Internet ruined everything.
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Doctors don’t like the Internet. That’s nowadays.

Nowadays, it is pretty common that patients arrive at your office with lots of questions, usually off-target, printouts of articles and their own, preconceived, treatment plan. The “authorities” on the Internet have empowered our patients by providing them information — but usually wrong information.

How frustrating it is to “unteach” from the Internet. How difficult it is to be challenged due to the bogus information provided by these perceived authorities. How disappointing to be blind-sided by a “few more questions” only to witness pages of questions emanating from a manila envelope.

We can change this.

Alas, the Internet can build your practice; it can make you a better doctor. How to change this? Remember, we are the authority. With authority comes trust. On the Internet, there is no difference between authority and perceived authority. You and I are used to the concept of peer review (as in peer-reviewed journals). It validates our writings, publications and establishes true authority.

The Internet is about perceived authority. He who publishes becomes the authority. He who makes the effort, becomes the authority. This is the problem (and the opportunity). There are not enough (or any) authorities contributing to the Internet. At present, any “yahoo” (Ok, bad pun) can publish and become an authority. While this seems harmless for trying to fix the refrigerator or come-up with the best way to slow cook ribs, there is a problem when it comes to health information.

Does this invalidate the Internet? No.

This creates a tremendous opportunity for physicians to become active contributors to the Internet. Why not create sources of credible information on the health issues that you deal with everyday? Why not change the quality of the information on the Internet to benefit your patients, yourself and beyond?

Let’s pretend you are not the world’s expert on, say, colds, but you know a lot about colds and treat patients everyday with colds. You could say that you are an authority on the common cold. Now, let’s now pretend that you have a Web site. Everything you wrote about, just like everything you tell your own patients, would carry the same clout to your readers. You would write about everything you know about colds.

You don’t have to give medical advice (that’s kind of a grey, lawsuit area anyway). You just have to write down, preferably in the same manner in which you speak in the office, what you know about the common cold. The difference? Your Web site would be straight forward, contain useful information, and would be credible.

Get the idea? You’d be sharing the same knowledge with many over the Internet instead of one at a time as you do now. The same trust that is imparted to you in the office is imparted to you on the Internet. The only difference is you are not face to face — yet.

Remember that Clairol commercial? A woman told two friends about the shampoo, and they told two friends and so on … Let’s suppose that someone develops a cold. He uses Google, Yahoo, or Bing to search colds. Up comes your page on “Colds: Signs, Symptoms and Treatments” authored by you, Dr. Joe, MD. This person might decide to call you about his cold. He has read what you have written, understands what you have to say, and is impressed.

Not only does he call your office and keeps his appointment, but he comes in already informed about colds. He found a good source on the Web. You don’t have to “unteach” him. He has been taught properly the first time. He has no anxiety, he know what you are going to say. He asks good questions, he seems really appreciative.

Who wins? You both do. He has had a great experience and feels that he should share it through the world via social media. He’ll tells lots and they tell lots and so on and so on.

Perhaps it is an example using the extremes, but the potential is definitely there for us to reshape the healthcare information dispersed to our communities and farther on.More and more patients rely on the Internet. Why don’t we meet them there?

Randall Wong, MD, is a retinal specialist in private practice in Fairfax, Va. Wong has a strong interest in Web 2.0, the Internet, and social media, and will write regularly about how social media can help build your practice and even improve healthcare.

Trendspotter: Will EHRs save money?

And if not, what does that mean for physicians’ “meaningful use” payments?

By Ken Terry


The Obama Administration’s push for widespread adoption of EHRs is based on the premise that it will lead to a reduction in healthcare costs.

During the presidential election campaign, then-candidates Barack Obama and Hillary Clinton both cited a RAND Corp. study that predicted savings of nearly $80 billion a year. But some observers assailed that conclusion after the RAND study was released, and recent research has clouded the issue further.

A new study published in the American Journal of Medicine’s online edition found that, while U.S. hospitals increased their use of health IT between 2003 and 2007, the technology was not correlated with lower clinical or administrative costs in the institutions that adopted it. In fact, the hospitals that computerized most rapidly had the biggest increases in administrative outlays, the researchers said.
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It should be borne in mind that two of the three Harvard professors who conducted this study, David Himmelstein, MD, and Steffie Woolhandler, MD, are single-payer supporters who oppose the Democratic approach to healthcare reform. Showing that health IT will not help save our system is part of their agenda.

Still, their study has statistical power. The researchers linked a HIMSS survey of computerization at 4,000 hospitals with administrative cost data from Medicare Cost Reports and cost and quality data from the 2008 Dartmouth Health Atlas. The impact of health IT on quality, they found, was mixed. “Higher overall computerization scores correlated weakly with better quality scores for acute myocardial infarction…but not for heart failure, pneumonia, or the three conditions combined,” they concluded.

On the other side of the coin, a study by Ashish Jha, David Bates, and other experts found that adverse events in hospitals and redundant tests ordered by multiple physicians—both of which could be mitigated through the use of health IT—contribute significantly to hospital costs. In 2004, they calculated, preventing adverse events could have reduced hospital spending by $16.6 billion, or 5.5 percent of inpatient costs. Prevention of redundant testing would have cut costs by an additional $8 billion, or 2.7 percent. Of course, the use of health IT, even if it were ubiquitous, would eliminate only part of this waste.

There’s also evidence that it takes a long time for the use of EHRs to improve the quality of care or reduce costs significantly. In a recent survey of 200 large physician groups by the American Medical Group Association (AMGA), 63 percent said they’d had EHRs for two years, and 25 percent had had them for five years. Yet only half were using their systems to drive clinical protocols, 27 percent were using them for population health management, and a quarter were using the EHRs to improve clinical cost effectiveness.

In a commentary on the KevinMD blog, Glen Laffel, MD, Ph.D., points out that some other studies have shown that EHRs can improve the quality of care delivered. But it’s still unclear whether they will save money at a societal level.

This issue, Laffel notes, has implications for the government incentives for meaningful use of EHRs under the HITECH Act. Originally, it was reported that the legislation had allocated $19 billion to help physicians and hospitals acquire EHRs. The CBO estimated that the total cost would be $30 billion and that health IT-related savings would save about $12 billion from 2011 to 2019. Recently, the Office of the National Coordinator of Health IT (ONC) has been floating a figure of $47 billion for the total cost, although that may change, according to an ONC spokesman. As the late Senator Everett Dirksen memorably quipped, “A billion here, a billion there, pretty soon it adds up to real money.”

The real savings from EHRs will come from networking them together so that clinicians know what everyone else is doing for a patient and so they can work together across care settings to produce the best outcomes. We are still in the early stage of building such networks and getting EHRs from different vendors to communicate with one another. But when those goals are achieved, and when we create the right incentives for physicians to collaborate, the resultant increase in quality and efficiency could have a major impact on the sustainability of healthcare.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Gerald O'Malley, DO: A rant on malpractice insurance

The state government of Pennsylvania is a corrupt failure. Over 40 different hospitals, health clinics, and surgical centers have closed in the last 10 years, all under Governor Rendell’s watch. I’m tired of reading about all the excuses. I’m not listening anymore.

My state representative from the 61st congressional district is a very nice woman. Her name is Kate Harper. She invited me to a constituents breakfast several years ago at which I was the youngest attendant (it was the social event of the week for the area retirement communities).
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Kate seemed earnest when talking about her passions like environmental legislation, and she was insistent that her votes supported doctors. But she couldn’t resist relating a grotesque story about a drunken OB/GYN that she had heard second- or third-hand (Kate is a Republican and a lawyer, so she seems to have an internal struggle with that existential inconsistency). We began an e-mail correspondence and Kate was kind enough to speak to my residents on the issue of medical malpractice. She even brought another lawyer with her, and the two of them put the fear of God into the residents with a mock med-mal trial. One resident participant, after being cross-examined during the mock trial, said, “I have never had anyone speak to me like that,” and he was visibly shaken. (Having been a defendant in two malpractice trials, I have been talked to “like that” for real).

Kate sent out an electronic update/newsletter recently. The newsletter described the process by which the Pennsylvania state budget was recently passed and detailed what will in all likelihood be the final nail in the coffin of our attempt to keep any resident physicians in this state.

This year’s budget approved the use of MCARE (Medical Care and Availability and Reduction of Error) funds for general purposes, rather than for what it was originally created for — settling medical malpractice lawsuits and compensating victims of medical malpractice (and their lawyers). General purposes include police overtime for the Phillies tickertape parade, trash collection, and libraries, among other things.

MCARE is essentially an insurance fund (run by the state) that charges an annual assessment on physicians, hospitals, nurse midwives, podiatrists, and nursing homes to pay current claims and operating expenses. In 2008, the fund paid out claims totaling $174 million.

Since 2003, high-risk specialties such as neurosurgeons, OB/GYNS, and emergency physicians were allowed to apply for an “abatement,” which eliminated their contribution to the MCARE fund. The abatement program allowed doctors that don’t practice in high-risk specialties to reduce their contribution by 50 percent (creating an adversarial situation among specialties). The MCARE abatement program was eliminated last year. The MCARE fund itself ended this year so that all physicians will be forced to obtain insurance privately at exorbitant rates (the average malpractice premiums for an ED physician in PA is $60,000 per year higher than in neighboring Delaware).

So the governor of Pennsylvania has collected money from doctors specifically for the purposes of paying lawyers that have sued doctors and now they want to take $808 million of the money that the doctors have already paid into this account and use it to pay for other things.

In addition, since the MCARE fund only covers expenses from year-to-year, eliminating MCARE and using the existing funds to pay for parks landscaping and school lunches creates an unfunded mandate for lawsuits and settlements currently in progress that equals $1.7 billion. Who will get stuck with that bill?

Never mind keeping resident physicians in Pennsylvania – I can’t afford to live here anymore.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

More on the public option evolution

A public option compromise could be in the works, as Senators look to their own health plan as a model for the government-run insurance.

Instead of a purely public option, they are looking at the Federal Employees Health Benefits Program (which covers some 8 million government employees – including Congress) as a possible blue print. This could make the public option piece of the legislation a little more palpable for its opponents.
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The idea is the option would provide several different private insurance plans, but it would be overseen by the federal government which negotiates prices – as is done now with the federal employees’ program.

As the NT Times notes, “Giving many Americans the same coverage as members of Congress is a politically potent – and potentially appealing – concept for both lawmakers and the people they serve.”

Another idea being floated is allowing uninsured people age 55 to 64 to buy into Medicare. It’s not a new idea, but it’s coming up now as a way to keep liberal backing for the bill as the public option morphs into this more private-nonprofit option, said the WSJ health blog.

Jennifer Frank, MD: On sleep and coffee

As I was driving to work this morning, I thought about the cup of coffee that waits for me at work. I need that coffee this morning. I stayed up too late last night and am facing a full day of work with a little (okay, a lot) less energy than I need. Coffee is the answer. Well, actually, a better night sleep is the answer, but coffee will have to do.

Motherhood and medical training compete, fairly equally in my book, for the degree to which they can drive a person to utter fatigue. Being a physician who still takes call and does OB, I occasionally have an all-nighter with a patient. As a resident, this happened every third or fourth night for three years. I was chronically fatigued. I am still trying to work off a sleep debt that I started accumulating over 10 years ago.
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As a mother to young children, I experience sleep deprivation in a different way than I did during residency. It is less like the flood of an all-nighter and more like the constant drip-drip-drip of a leaky faucet. I get some sleep every night, but it is always interrupted at least once or twice and frequently three or four times. The baby is the most likely to wake me up but the other three take turns as well with bad dreams, nighttime accidents, and requests for water.

Like many parents I have spoken with, the mind-numbing fatigue that is present from the time I wake up until the time the last child is in bed lifts as that last little person whispers “good night.” Suddenly, I am free. Free to do laundry. Free to exercise. Free to spend my precious time surfing YouTube for the latest funny cat video. This freedom is energizing and often pushes me past a reasonable bedtime to the barely-going-to-make-it-through-the-next-day bedtime.

It is a careful balance and one each must cultivate personally. For me, the minimum time in bed (minus interruptions) is six hours. My husband, having carefully cultivated sleep deprivation over many years, can get by on four.

So, I rely on coffee. One cup is my usual when life is in perfect balance. More recently with a new baby at home, I am up to two cups. The dose-response curve beyond two cups is not friendly to me and there is nothing more to be gained from a third or fourth cup except jitteriness and a hangover.

What amazes me, though, is how well I can function on so little sleep — both in my role as a doctor and my role as a mom. Somehow, despite being fatigued, I can remember the details of my kids’ homework. “Weren’t you supposed to finish your poster project this week?” I also can perform procedures in the office, recall distantly-learned factoids, and remember that I forgot to order the lead screen for the 1-year-old I saw at 3 p.m. yesterday.

This is not to say that I am operating at my best. I still call home, in the haze of my exhaustion, and leave cryptic messages like the one I left for my husband last week: “Honey, when I get back from the conference I’ll be ready to leave for the conference.” I still don’t remember what I meant. But I do remember making the call.

As the ACGME and other organizations try to solve the problem of physician fatigue, I struggle with my own experiences as a fatigued physician. For me, the most important part is recognizing when I am so tired that I can no longer be a safe physician or an effective parent. That sometimes requires me to go home early post-call to sleep or bargain with my husband for a Sunday afternoon nap. It also means that while I can occasionally push my bedtime later, that I have to try to get eight hours of sleep most nights.

However, it also makes me recognize two truths about sleep deprivation and fatigue. First, things that are really important have a way of pushing their way forward in your mind and grabbing hold of your attention so that you can kick into the stress response and get the emergent job done. Second, you are able to perform rote things pretty well. As a physician, this can include some pretty complex tasks.

The bottom line is that fatigue is a part of life, maybe just a little bit more so for moms and doctors. It remains imperative to care for oneself by (among other things) resting so that you can care for others. However, the ongoing ability of both moms and doctors to function well on little sleep indicates that our understanding of the effects of sleep deprivation on, for example, patient safety is far from complete.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Podcast: When religion and medicine collide

Religion and medicine can interact — at times uncomfortably. Religion is a sensitive subject, but one that can't be ignored when it comes to patient care.

For this month's podcast, I spoke with Joyce Dubensky, of the Tanenbaum Center for Interreligious Understanding, a secular organization that just developed a guide to help physicians better understand and deal with their patients' beliefs.

We also covered the topic in a recent article.

Have you ever encountered difficulty navigating spirituality and patient care?

Melissa Young, MD: Reading what I write

I have been blogging for several weeks. I have gotten responses primarily from people I don’t know. I have received a couple of responses from people I know only over the phone or through different Internet venues. And somehow it did not occur to me that people I actually know, or may soon know, would read my blog.

Tonight, I was at a hospital function, and I met, for the first time, one of my “competitors.” I had heard about him. I had seen his picture. I was told that I may never actually meet him in person because he isn’t big on social functions.

So imagine my surprise when I saw him at this dinner. I wasn’t sure it was really him. Like when you think you’ve seen the Loch Ness Monster — you see what you see, you’ve heard that it’s out there, but you didn’t really think that you would see it in your lifetime. But nonetheless, I walked up and introduced myself, and, lo and behold, it was him.
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And imagine my even bigger surprise when he said he had read my blog. He even knew what my latest post was about. I was flattered. Then as he walked away, I began to wonder — was there anything I said in the comfortable distance of my own home that may have offended my neighbor and colleague? I don’t think so. I certainly hope not.

It is so much easier in this day of computer anonymity to freely voice not only one’s opinions, but also one’s biases and sometimes an exaggerated sense of one’s self. I have certainly been witness to others’ rantings, beratings, and just down-right rudeness. I admit to being much more free about my opinions online than I would ever be in person. Still, in retrospect, I’d like to think that I have maintained a sense of decorum and professionalism.

And it just occurred to me, that two days ago, a patient had mentioned to me that she had read my blog, too.

Why write this now? Maybe it’s because I’m tired of the ill-mannered postings on other sites. Maybe it was the startling realization that, yeah, people actually do read what I write, even though only one person responds. Or maybe it was the open bar at the function this evening. I don’t know.

But I do know, that from now on, whether I write for this blog, or another site, or the local paper, I have to remember, idle as my ramblings may be, there are people out there who read them. And it may be a colleague, a hospital administrator, or a patient. And if I don’t have the guts to say it to someone’s face, well, then, maybe I shouldn’t’ say it at all.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

On dealing with bad behavior

What do you do when a partner physician engages in some seriously bad behavior, on the order of yelling, cursing, or berating staff? Does your practice know how to deal with it?

This kind of disruptive behavior is far more common – and in some cases extreme – that you might think. A recent ACEP survey found some 97 percent of respondents witnessed this behavior between doctors and nurses, and both parties were guilty.

So perhaps it’s time to put a plan in place for recognizing and handling these disruptions.
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Last year, the Joint Commission introduced standards requiring accredited healthcare organizations to create a code of conduct defining acceptable and unacceptable behavior and a formal process for managing the bad behavior. Those requirements took effect in January 2009.

What about your practice? I spoke today with folks from Physician Wellness Services, which helps physicians and healthcare organizations manage stress and behavioral issues. They suggested that practices consider putting in place a similar policy.

PWS’ medical director Dr. Alan Rosentein said it should be a part of the HR policy, outlining the standard behavior expectation of the office. It’s a business after all, and treating coworkers poorly can lead to costly staff turnover, decreased productivity and job satisfaction, and even compromised patient safety, he said.

A policy also gives your practice some guidance on what to do when a physician acts out. It helps it not be a personal issue, said Lori Brostrom, PWS’ director of marketing. “If you don’t have a standard set of guidelines in place, it devolves into something personal,” she said. It also sets a tone for staff and new recruits, stating that this is not an office that will tolerate such behavior.

It seems like this kind of bad behavior has been accepted for so long, and now providers are beginning to see the implications for the business and patient care.

Randall Wong, MD: What social media means to me

I like social media. I like the Internet. I love Web 2.0. I love being a physician.... Still with me?

For several reasons, I started a blog last spring. It is a little different than most blogs in that it is written by a physician, it provides a credible source of information about diabetic retinopathy and macular degeneration, it does not express any of my opinions, and I try not to offer medical advice. My blog is basically a compilation of what I have been telling my retina patients for the past 17 years.

But medical blogging has a bad rap.
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To me, medical blogging offers opinions regarding medical issues, such as healthcare and politics. It does not necessarily have to be authored by a physician. Check out medical bloggers such as kevinmd, dr. rob and dr. val. These are a few of the physician pioneers that have entered the blogosphere. They commonly write and inform about health policy, politics, etc., and there is usually no medical advice.

Can’t medical blogging also mean blogging by physicians or other healthcare professionals writing about health information? (The answer is “yes.”)

I believe that physicians, using our authority, have the ability, and responsibility, to create credible sources of health information on the Internet. Who else can combat the plethora of misinformation? Hence, the reason for my blog, which is written solely for educating both patients and their (non-retina) doctors about eye disease. Not my opinion about eye disease, but a source of useful, credible information.

There are practical reasons for us to engage over the Internet even if you don’t share my zest. The Internet is where our patients turn for information — right or wrong. Shouldn’t we help them find the right stuff?

“An educated consumer is our best customer,” said Sy Syms many years ago. I agree with him. Imagine if your patients were truly better informed and educated about their health. Think of the time you could spend with them talking specifically — and only — about the stuff that is relative to their disease. Right now, I spend a lot of effort “unteaching” patients because of the misinformation they have received. What is even harder is “unteaching” the information they learned from their doctor.

Just as a professor or teacher learns more by teaching, it would force you to be a better, more knowledgeable doctor. An educated patient has a more meaningful visit. They will learn more, listen better, and probably have fewer compliance issues. Why? Knowledge and understanding gained by a source other than the doctor.

Lastly, wouldn’t the patient just love the visit? The visit would have gone as planned as it met expectations. The patient had an inkling of what was to be expected. For instance, “I have a retinal detachment, and, as expected, Dr. Wong told me this, this, and this….”

More importantly, wouldn’t this also fortify the relationship between the referring doc and his or her patient? “Dr. Smith really cares for me. He sent me to this fantastic……” Well, you get the idea.

Social media is more than “I just walked the dog.” Facebook, Twitter, LinkedIn, etc. are places where people share information about… well, everything. This is the power of social media. It is e-mail on speed. It is about proactively finding people of shared interests and following how they “roll.” It allows people to find others to share information — albeit, sometimes simply about walking the pooch. Regardless, social media makes us aware, in real time, what’s going on with others of shared interests and talents. It allows us to be content producers instead of just content consumers (wow!).

My goal is to promote the use of the Internet, Web 2.0, and social media to physicians. I believe we should embrace the use of the Internet and social media. There are implications to improving the quality of the healthcare we deliver, to growing and improving the function of your practice, and imminently allowing us, as physicians, to improve healthcare overall.

Randall Wong, MD, is a retinal specialist in private practice in Fairfax, Va. Wong has a strong interest in Web 2.0, the Internet, and social media, and will write regularly about how social media can help build your practice and even improve healthcare.

CCHIT certifies first EHRs for stimulus money

The first round of EHR products has been certified for federal stimulus funding.

Four companies' products have been approved for meaningful use by providers who want to receive 2011-2012 incentive money under the American Recovery and Reinvestment Act (ARRA), the Certification Commission for Health Information Technology (CCHIT) announced this week.
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The commission has received about 25 applications and inspections are continuing, the commission’s executive director Alisa Ray said in a statement.

Three of the products were approved under the Preliminary program, which only tests the products against the federal standards. This is intended to give providers more flexibility in meeting the incentive funding requirements. The products don’t have to meet every criterion, and CCHIT lists which objectives each product supports. Here are the products:

• eHealth Made EASY, Version 3, by eHealth Made EASY, LLC
• KIS Track, Version 5.1, by Kaulkin Information Systems
• Medios, Version 4.5 by IOS Health Systems


One product was certified under the CCHIT Certified 2011 Comprehensive program, which is a more rigorous inspection and full compliance with the federal standards, intended to give providers “maximum assurance” that they will qualify for financial incentives. The product is ABELMed EHR-EMR/PM, Version 11, by ABEL Medical Software Inc.

The catch is that the certification component of both programs related to the federal stimulus incentives is considered preliminary, because the definition of meaningful use hasn’t been finalized by HHS yet. Companies testing products against the standards now will have a chance to “quickly close any gaps after the final rules are published in the Federal Register in spring 2010,” the commission said.

Trendspotter: New technology choices will help you with PQRI

By Ken Terry

Welcome to Trendspotter, a new weekly blog feature that bears the same name as the monthly column I’ve been penning for Physicians Practice over the past year. In this blog, I am not only going to report the news, but also will endeavor to supply some insights that you might find useful. Please post a comment if you agree or disagree with any of my entries, and also feel free to contribute your own insights and information.

That said, let’s turn to this week’s topic: CMS’ Physician Quality Reporting Initiative, or PQRI, as it’s known to most of you. This is going to become more important to practices, and not just because of the 2 percent Medicare bonus that you can now receive if you report quality data to CMS successfully.
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If Congress passes healthcare reform legislation, it may well include new Medicare reimbursement methods like those in the current Senate bill. Under that measure, after tracking the utilization of every physician in the Medicare program, CMS would be empowered to reward doctors who provide high-quality, cost-efficient care, and punish those who don’t. While we don’t yet know how big the carrots and sticks will be, it’s clear that the quality piece will be based on measures like those of PQRI. So it’s time to start reporting this data, if you’re not doing it already.

According to a new CMS report, more than 85,000 physicians and other eligible professionals met PQRI requirements in 2008 and received a total of $92 million and change. (Individual payments averaged more than $1,000.) This was viewed as a smashing success, considering that only 56,700 eligible professionals received incentives in 2007, and that those payments totaled just $36 million.

But the latest figures suggest a story that is not quite as upbeat as CMS’ spin.

Let’s start with the fact that of the 153,600 providers who applied for PQRI incentives in 2008, 45 percent did not make the cut. Of course, this has nothing to do with their relative scores on these measures. Their ability to obtain the government payments depended purely on whether they met the statutory requirements for data submission. So we can assume that they or their staffs did something wrong, such as putting in the wrong G codes or selecting the wrong patients for the measures they were submitting data on.

This was also a serious problem in 2007, and not just on the physician side. CMS has just announced that, after resolving several “data issues,” it will make payments to 3,900 physicians who were erroneously excluded from the 2007 incentive pool.

One reason for the improved 2008 performance is that physicians were allowed to report their PQRI data through approved electronic registries run by third parties. About 8 percent of those who applied for the PQRI incentives availed themselves of these services, and nearly all of them received bonus payments.

The 2009 PQRI program raised the incentive from 1.5 percent to 2 percent of allowed Medicare payments. Fifty-two new measures were added, raising the total to 153 and broadening the areas in which physicians can qualify for bonuses.

In the 2010 PQRI round, the incentive will again be 2 percent , and 36 new measures have been added. For the first time, practices will be able to qualify for incentives at the group level, rather than the individual provider level. And, most important, CMS will begin accepting data from “qualified” EHRs on 10 of the measures and applying that data to meeting the requirements for PQRI incentives.

Because the ability to send quality data to CMS from your EHR is one of the criteria for “meaningful use,” you must do this if you want government subsidies for your EHR investment. Moreover, being able to use your EHR to collect and submit performance data automatically, instead of having to enter G codes in the billing system, will take a burden off of many physicians and their staffs. When more measures are added to the EHR reporting menu, it will become a no-brainer to submit data in return for a 2 percent pay bump.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Gerald O'Malley, DO: Something special

I’ve worked for the National Board of Medical Examiners (NBME) and Educational Commission for Foreign Medical Graduates (ECFMG) as a patient note rater for the last five years.

Every medical student and international medical graduate that wants to train in a U.S. residency program has to take and pass a series of licensure exams, including a Clinical Skills Assessment in which the examinee interacts with an actor in a mock examination room setting and writes a note detailing history, physical, differential diagnosis, and proposed work-up. I, along with about 88 other physicians, get paid to rate about a half million notes every year.

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There are five testing centers in major cities throughout the U.S. Students and international medical graduates show up to examine fake patients. All of the patient encounters are incredibly realistic. Some of the actors have been portraying the same patient and the same illness for years and have a very good understanding of how a patient with renal colic or alcoholism or pneumonia or GI bleeding presents. The examinees receive instruction and then have a set amount of time to interview and examine the “patient” and write a comprehensive note.

This is a high stakes test. It’s expensive ($1,050 for U.S. students, $1,200 for international medical graduates), plus travel, lodging, and Pepto-Bismol. The anxiety level in the waiting area of the ECFMG testing center on exam day is palpably high. There is usually a table with bagels and coffee that remain untouched by the examinees as they sit around the room in silence waiting to be called to begin the exam. Each examinee has the look of a long-tailed cat in a roomful of rocking chairs. Given the complexity of the exam, the comprehensive nature of the monitoring, and the necessary integration of technology and human interaction to simulate the doctor-patient interaction, it is really amazing that testing goes so smoothly.

The first time I saw the testing center I remember feeling a certain pride. My wife is an international medical graduate and I’ve been involved in international medical education through my work as a Navy medical officer in Japan. The international medical graduates who come to this country and sit for this test cannot help but be impressed and maybe a little intimidated by the attention that is given to this test and the seriousness that surrounds the whole testing process.

This week, all the patient note raters attended our annual refresher training, which is a four-hour process and like everything else that the ECFMG does, it was highly organized and valuable. We sat in a large room and performed exercises and discussed problems with the rating process and ways to improve quality, accuracy, and reliability of our note rating. We received feedback on the notes that we have rated and we were given details about our statistical scoring averages and ranges and standard deviations and skew and kurtosis (tells something about rating bias - by the way, you don’t want to be too leptokurtotic — too peaked — or platykurtotic — too flat — but more mesokurtotic, in case you we were wondering) with histograms illustrating our rating history.

Some of us have already seen this data in private remediation sessions held with Tom the friendly physician medical director. The oversight and double and triple checking and analysis are endless. Each note is rated several dozen times by several dozen different raters. The first attempt failure rate for U.S. graduate is about 3 percent and for international medical graduates, it’s about 30 percent.

I think that every physician that practices in the U.S. should feel the same sense of pride that this program is run so competently. This is the face that we present to doctors all over the world. The fact that this whole process is so arduous and comprehensive and professionally administered demonstrates to the rest of the world that we take medical education and training very seriously and being a physician in the United States is something special.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.