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Summertime a u g u s t

In this issue: EHR Buyer Beware - Contracting with EHR Vendors

Physician Spotlights - Drs. Ludwig A. Michael and John Noack

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Cover Photo

Ludwig A. Michael, MD, in a file photo. Dr. Michael recently stepped down from the Communications Committee after serving for 44 years.

Dallas County Medical Society PO Box 4680, Dallas, TX 75208-0680 Phone: 214-948-3622, FAX: 214-946-5805 Email:

DCMS Communications Committee Roger S. Khetan, MD.............................................. Chair Robert Beard, MD Gene Beisert, MD Suzanne Corrigan, MD Seemal R. Desai, MD Daniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MD Ludwig A. Michael, MD David Scott Miller, MD

DCMS Board of Directors Shelton Hopkins, MD....................................... President Richard W. Snyder II, MD..........................President-Elect Steven R. Hays, MD..........................Secretary/Treasurer Stephen Ozanne, MD.............. Immediate Past President Garret Cynar, MD Sarah L. Helfand, MD Michael R. Hicks, MD Jeffrey Janis, MD Rainer A. Khetan, MD Dan McCoy, MD Todd Pollock, MD Cynthia Sherry, MD Jim Walton, DO

DCMS Staff Michael J. Darrouzet................... Chief Executive Officer Lauren N. Cowling................................ Managing Editor Mary Katherine Allen........................... Advertising Sales Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2011 DCMS

According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish legislative advertising in the DMJ: Michael J. Darrouzet, Executive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.

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Pr es i de nt’s Pa ge Summertime


Phy s i ci an S potl i ght Ludwig A. Michael, MD

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EHR Buy er Be wa re: Issues to consider when contracting

with EHR vendors

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Phy s i ci an S potl i ght John Noack — Cyclist, MD

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Don’t F r ack wi th Me DCMS member leads fight against


164 Communi ty Feeling

under siege?

DCMS is on facebook.

Dallas Medical Journal (ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.

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$12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.

Postmaster Send address changes to: Dallas Medical Journal, PO Box 4680 Dallas, TX 75208-0680.

submit letters to the editor to lauren@dallas-cms. org visit us online at • August 2011 •



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o you enjoy reading managed care contracts? How about completing multiple applications? Do you know if you are being reimbursed correctly? Could a physician-operated IPA be the answer?

What do you get out of SPA Membership? Contracting: SPA reviews hundreds of pages of legal terms with the cooperation of the health plan and presents you with an objective summary of the terms in a format which is standardized. Then, "SPA Compare" allows you to analyze the fees offered compared to local Medicare and to other commercial plans in a way that is customized to your practice. Operations: The contract summary and SPA Compare may easily be used by your collections operation to be sure that you are being paid properly under the SPA Contract. SPA maintains relationships with its contracted health plans which help you receive what you are entitled to under the SPA Contract.

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President’s Page

Summertime It’s summertime, and the Texas legislative show, including the encore presentation, is over. Medicine and the State enjoyed wins and suffered losses. Maybe cuts will allow better future reallocations when the economy and tax revenues improve, or maybe they just set back health care for the impoverished, public education for all, and the number of residents being trained in Texas, and thus the future number of physicians for Texans. We’ll just have to wait and see. This is when I make the first plug for you to get involved in the legislative process and to give to TEXPAC. Please get involved the next time around, and give to TEXPAC now and again and again. It’s summertime and, somewhere, the livin’ is easy. Actually, although the number of people living in desperate straits is at an all-time high, the percentages living the good life are better than ever. I recently had the pleasure and privilege of touring several grand chateaux in the Loire River Valley. During the tours, it’s easy to imagine oneself as the duke or the prince or even the king, living life at the top of a social structure shaped like a flat pyramid. A moment’s reflection reminds one that an enormous number of courtiers, courtesans, soldiers, artisans, cooks, muleskinners, and assorted go-fers were needed to support the aristocrats’ wants and needs. And the whole structure was built on the work of the miserable peasants — those poor folks. But let’s face it: what could be better than having the finest clothes, the best wines and foods, the grandest architecture and gardens, and legions of servants? Well, how about a warm room in the winter and a cool room in the summer? How about clean potable water? How about well- and safely prepared food from all over the world, including cheap spices for which Francis the 1st would have paid a fortune? How about a nice hot bath and flush

toilets? Fabrics that are comfortable? True, I still could go for the legions of servants, even though the paper work involved with servants is a tad more extensive today. I’m just not sure what I would need them to do that modern technology doesn’t do better. Your computer simply works better than the carrier pigeons (certainly not as cool, though, and you can’t eat your computer once it gets a bit old). I noticed when these old chateaux were purchased by wealthy folk in more modern times, the first thing they did was lower the ceilings, panel the walls, and put in wooden flooring, except in the famous rooms, which were saved in the original state to impress the guests. So the bottom line in comparative easy living: if you live in the developed world and you are not in grinding poverty, you live more comfortably than the First Renaissance King or the Sun King. Of course, the aristocrats did enjoy some perks that are not now easily available to most of us. As Mel Brooks so aptly put it in “History of the World, Part I,” “It’s good to be the king.” It’s summertime, and we’re in Texas. That means it is hot! That means that, if you can arrange it, you get out of town. San Miguel de Allende used to be a Dallas favorite — maybe down a few notches now with the threat (perceived or real) of violence. Colorado and northern New Mexico still are high on the list. For those of us who work, however, those are nice places to visit now, until you get out of the car around Vernon on the return trip or off the airplane at Love Field or DFW. A wilting blast of heat and reality hits you: vacation is over. Now that the energy from the cool weather has dwindled, it’s a good time to lie back with a cool one and contemplate the Big Questions. Don’t worry about answering them until around October, when the temps are in a reasonable range. Now is the time for musing, for searching for that “Mmmmm” moment, not so much a “Eureka!” moment. Why are we here? What is the nature of love? How is medicine a noble profession? Why do some cooks believe they must put beans in chili? (Not all summertime musings have to be profound.) The reality is that we cannot KNOW these things. We only can approximate an answer, and, most importantly, learn to live with the unanswered questions. We feel a sense of purpose in life, we experience love, and we are ennobled by our practice of medicine. That may be all we can say without turning into Sophists. And while those truths may not seem like adequate answers, they’ll get me through another Dallas summer. Enjoy the summer, and, as you’re musing on the Big Questions, think about being a bigger player with TEXPAC and DCMS.

Shelton Hopkins, MD

visit us online at • August 2011 •


COME CELEBRATE WITH US! It’s time for the DCMS Medical Student Dinner. For 35 years, DCMS physicians have hosted the freshman class of the University of Texas Southwestern Medical School at this special event to welcome them into the family of medicine. During dinner, students sit with physicians who share their experiences of surviving medical school and choosing a specialty. Students will have completed just one week of classes, and they’ll have many questions about their medical future. Who better to welcome them than you — a practicing physician? YOU HAVE TWO WAYS TO PARTICIPATE: • Attend the dinner and sponsor students — this one is the most fun. • Sponsor students — this tax-deductible donation is greatly appreciated. THE DETAILS: • Mark your calendars now for Sunday, Aug. 21, at 6 p.m. • Doubletree Hotel Campbell Center, 8250 N. Central Exwy. (Across the highway from NorthPark Center) • All contributions for student meals are tax deductible. Your contribution will be acknowledged through various DCMS communication tools. RESERVE YOUR SPOT BY FRIDAY, AUG. 12: Mail the form below with your check payable to DCMS Foundation, PO Box 4680, Dallas, TX, 75208, OR Call Deanna Wooten, DCMS vice president of IT, at 214.413.1431, OR Fax credit card payments to 214.946.5805.

2011 DCMS Medical Student Dinner RSVP Form I will attend.

My spouse/guest also will attend. Spouse/Guest name

I will support 2 students or a student and spouse/significant other. I am unable to attend; however, I will sponsor Payment enclosed for


people @ $40 each = $

Physician Name

Circle Card Type





Credit Card #



E-mail Address Exp. Date

Security Code

Fax credit card payments to 214.946.5805 or mail checks payable to DCMS Foundation, PO Box 4680, Dallas, TX 75208. Reservations must be received by Friday, Aug. 12.


visit us online at • August 2011 •


DCMS Physician Spotlight Lu d wi g A . Mi c h a e l , M D

by Lauren Cowling, director of communications

When Ludwig A. Michael, MD, joined DCMS in 1948, the society had approximately 700 members and Harry S. Truman was US president. During the better part of his 73 years as a DCMS member, he served on the Communications Committee for 44 years, with 24 of those as the chair.

Dr. Michael came to Dallas via New York where he attended medical school at the NYU College of Medicine, and St. Louis, where he completed part of his internship before serving in the US Army in Chickasha, Okla. Dr. Michael volunteered to serve overseas, but his valuable skill set in regard to dealing with hearing loss rendered him too valuable for the rehabilitation facility to lose. He finished his residency with a specialty in otolaryngology at Barnes Hospital in St. Louis and worked at Walter Reed Army Medical Center in Washington, DC, with soldiers who had hearing losses. Dr. Michael says that his choice of otolaryngology as a specialty may have been influenced by an event from his childhood. “When I was 6 or 7, a young neighbor boy had his tonsils removed and bled to death after coming home,” he recalls. “Maybe unconsciously that was still affecting me. When I started out, tonsillectomy was the No. 1 operation in children.” At the suggestion of a friend, Dr. Michael visited Dallas. He’s never moved away from the city he says was “up and coming” upon his arrival because he married his Dallas-born and raised wife, Carmen Miller, in 1956. Although Dr. Michael has led a fabulous life and had an illustrious career, he says he’s most proud of his wife. “I’m more proud of Carmen than anything I’ve done,” he says. “She’s just a terrific person. She’s contributed so much to this community.” He’s quick to note his wife’s many accomplishments. She served as the first psychologist in the Department


• August 2011 • Dallas Medical Journal

of Neuropsychiatry at UT Southwestern. She was chief psychologist until 1958, when she began working part time so she could devote more time to their two children. Those children are Andrew, an ophthalmologist in Richmond, Va., and Susan. When Susan was about a year old, she contracted viral encephalitis. This resulted in neurological problems, and she now lives in a supervised group home in Dallas. Because of Susan’s condition, Mrs. Michael founded the Dallas Epilepsy Association. She also formed Community Homes for Adults, Inc., which are residential group homes for adults with cognitive difficulties. During his decades of practice, Dr. Michael saw his fair share of interesting patients. He recalls an outof-town patient who wrote on her patient information sheet that she was an artist and her husband was in an orchestra. Dr. Michael’s receptionist told him about the patient, opining that “she likely wouldn’t be able to pay for the visit.” Dr. Michael then met the “artist,” Gloria Vanderbilt, and the musician, orchestra conductor Leopold Stokowski. Dr. Michael notes that when Liberace was his patient, “he still had two names.” He says Liberace was “a nice guy; very interesting.” Dr. Michael describes his career as “wonderful,” which is why he continued to practice until 2010. His primary focus was audiology, and for his first 15 years in Dallas, he was area consultant in audiology for the Veterans Administration. He was the first Dallas member of the American Academy of Facial Plastic Surgery and in 1955 was the first in Dallas to perform a stapes mobilization operation on the ear, a surgery to improve hearing and which involves fracturing of the tissue that has immobilized the stapes. To list Dr. Michael’s accomplishments would take volumes, but they include being chief of otolaryngology at Baylor University Medical Center and professor emeritus of otolaryngology at UT Southwestern Medical Center. He served on the Home

Study Course faculty for audiology for the American Academy of Otolaryngology and on the advisory board of the National Institutes of Health, Institute on Deafness and Other Communication Disorders. Dr. Michael’s dedication to audiology is evidenced by his work with the Callier Center for Communication Disorders, which affiliated with the University of Texas at Dallas in 1975. Dr. Michael helped establish the center in 1963, and it since has grown into a regional and national resource for children and adults with speech, language and hearing disorders. He saw and embraced tremendous improvements in medical technology during his career, from the use of ear tubes, which peaked in the 1970s, to powerful visualization allowed by today’s microscopes, to computers taking a prominent place in every medical office. Never shying away from technology and the Internet, while on the DCMS Communications Committee, he offered valuable insight to the redesign of the DCMS Web site in 2009. Dr. Michael has witnessed tremendous changes in his years with the medical society, which now boasts more than 6,400 members. Bringing to bear all his experiences, he offers simple advice to young physicians. “Fight to keep medicine a healing profession — not a business,” he says. “Keep your eye on what medicine means. We can heal a whole lot better than we used to. We can do so much more.” And this comes from someone who already has done so much.

Ludwig A. Michael, MD, on the cover of the April 2009 Dallas Medical Journal

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EHR Buyer Beware:

I ssue s to Co ns ider When C ontracting with EHR Ven d ors

He a lth I nform ati o n Te c h n o l o g y Practice Management Services INTRODUCTION Electronic health record (EHR) contracts typically are vendor-favorable. This paper discusses eight important EHR contract terms your medical practice should consider before signing an EHR contract. It is not an exhaustive list of considerations that could be important to a specific medical practice in selecting the right EHR vendor. Before you sign a contract, have your attorney carefully review it, and make sure you understand its terms. Although this paper primarily addresses the contract terms, you also should make sure the product meets your needs and will live up to its advertised potential. You are likely to use the product a long time and have a long-term relationship with the vendor. You should be confident the vendor is capable of fulfilling its obligations and providing support and training whenever you and your staff need it. You should ask questions and seek confirmation through references and other methods to evaluate the product and the vendor. DISCUSSION 1. A MULTIPLICITY OF FEES — EVALUATING THE TOTAL COST TO THE PRACTICE One important consideration in selecting an EHR vendor is the total out-of-pocket cost to the practice. Of course, in addition to the total cost, you should consider the quality of the product and the continuing support, along with your expected return on the investment. Your return on the investment would include increased revenues through cost savings, improved billing practices, improved records, improved staff morale, and efficiency. The quality of the product and the vendor will significantly impact your overall net benefit. For a variety of reasons, many EHR contracts do not provide a single, bottom-line price or consistent pricing structures for a simple comparison of costs. Instead, they often provide numerous specific fees in exchange for specific products and services. In addition, some EHR contracts do not clearly define the products and services the vendor will provide, raising the possibility that the vendor later will charge you additional fees for services you may have thought were included in the original price. To avoid these unwelcome surprises, the EHR contract should clearly list the fees the practice will have to pay. (a) An Overview of Specific Fees. As discussed above, instead of providing a single, bottom-line price, many EHR contracts provide numerous specific fees in exchange for specific services. Such fees may include the following: • Licensing Fees. These are the basic fees the practice pays in exchange for the right to use the vendor’s software. Additional discussion regarding the factors affecting the pricing of licensing fees appears below. • Equipment and Third-Party Software Fees. If the practice

decides to install and operate the software on its own hardware, the practice may need to purchase additional equipment from the vendor or a third party at an additional cost. Additionally, the practice may be required to purchase additional third-party software in order to operate the hardware. You also Health Information Technology Practice Management Services need to consider the cost of local information technology (IT) support to maintain the software and your local network. However, if the practice elects instead to have the vendor install the software on the vendor’s equipment, it may incur additional costs from the vendor in exchange for this service. Accordingly, you should evaluate and balance the hardware, software, and maintenance costs incurred in installing the software on your own hardware against the cost of having the vendor install the software on its hardware. • Maintenance Fees. These fees are paid to the vendor in exchange for maintaining the software and, depending on the model, the equipment. As discussed below, the contract’s definition of covered “maintenance” determines exactly what level of service the practice will receive for this fee. For example, this fee may or may not include the vendor’s upgrades to new versions of the software. •P  rofessional Services Fees. These are fees the practice pays the vendor in exchange for consulting and similar professional services. Professional services often are procured through separate contracts with separate terms and conditions, and likely have separate deliverables. • Implementation Services Fees. These are fees the practice pays in exchange for services the vendor provides in setting up the software for the practice’s use, such as data conversion, software loading, equipment installation, software testing, services set-up, and training. You should ascertain if there will be an additional charge for any desired on-site vendor training; many vendors include webbased training with the standard fees but charge extra for on-site training. • Interface Fees. These fees are paid to the vendor for developing interfaces to other health IT systems. Examples include interfaces to third-party laboratory systems such as Quest and LabCorp, interfaces to practice management systems (if the EHR and practice management software are not integrated), and interfaces to radiology information systems (RIS) and picture archive communication systems (PACS). • Fees for Additional Features. Many EHRs have various levels of functionality and features beyond what one could call “basic” — personal health records, advanced patient portals, e-visit or virtual credit card swipe services, or health information exchange (HIE) functions. You should clarify which services and features a base quote will include and

visit us online at • August 2011 •


which will require an additional subscription or other fees. (b) Key Definitions That Affect Costs. As discussed above, factors in addition to the fee rates determine the actual cost to the practice under an EHR contract. Frequently these additional factors are hidden in the definitions in the EHR contract. • Definition of a Provider. Many EHR contracts are priced based on a fee rate that is multiplied by the number of “providers” covered under the contract. Accordingly, to ensure the fee rates are comparable between vendors, the EHR contract should clearly define what the vendor considers to be a “provider.” For example, the following EHR contract language achieves this goal by providing a clear definition: “Provider” means individuals who are employed by or under contract to provide health care services for the practice or its affiliates and who are legally licensed to either provide healthcare services to patients or to assist physicians in providing healthcare services to patients. •D  efinition of a User. As an alternative to pricing on a perprovider basis as discussed above, EHR contracts may be priced on the basis of the number of authorized users or the number of concurrent users. If this is the case, it is important to note that a “user” generally is defined to be personal to a specific individual, rather than being interchangeable among different employees of the practice. For example, a “user” frequently may be defined as follows so as to make the definition personal to a specific individual:  ser is defined as a particular individual who has U been identified by name and user authorization ID, regardless of whether the individual is actively using the software at any given time. If a “user” is defined in this manner, as it generally will be, you will need to pay additional fees to allow any additional individual, such as an assistant, to access the data. •D  efinition of Services. Many EHR contracts carefully limit the exact services the vendor will provide, and this limitation is especially true for “maintenance.” Pay careful attention to the applicable definitions to ensure the services included in the standard fees are comparable from contract to contract. For example, an EHR contract may define “maintenance” with the following exclusions, resulting in the practice incurring significant additional costs down the road when it requires services that are outside the scope of the definition: aintenance Services do not include services M required: (a) as a result of improper use, abuse, accident or neglect; (b) as a result of modifications or additions; (c) with respect to more than the two most current releases of the software; (d) as customizations; (e) to implement upgrades; (f) to correct improper installation or integration of the software that was not performed by vendorauthorized personnel; (g) system administrator functions; (h) help desk services; (g) enhancements; or (h) to correct problems arising from abuse of the system or custom changes. Accordingly, to avoid additional costs outside the basic service fees, you should ensure the defined services to be provided are clearly understood and not unreasonably


• August 2011 • Dallas Medical Journal

limited. Additionally, if, as is typical, your contract excludes from “maintenance” services to correct problems arising from abuse to the system, custom changes, work performed by unauthorized personnel, or service performed not in accordance with the vendor’s directions, you will need to be cautious when servicing the software without the vendor’s assistance. Before commencing any self-service of the software, you should obtain the vendor’s permission and ensure that any work is performed in accordance with the vendor’s specifications. • Site Definition. Many EHR contracts limit the software to a particular geographic location — a “site restriction.” Understanding this limitation is important if the practice has multiple office locations, all of which will use the same EHR. If your practice has multiple offices, you should make sure the contract expressly allows the EHR to be deployed in all practice locations. (c) Limiting Subsequent Fee Increases and Negotiating Fees Up Front. Even when you identify all the individual fees and word all the important definitions favorably, there is still the risk that the vendor may increase fees at a later date. Many EHR contracts allow the vendor to increase fees in the future. To address this risk, the EHR contract should carefully limit the circumstances, both in terms of amount and frequency, in which the vendor can increase its fees. For example, the following contract language achieves this goal: Vendor may increase its fees for services once every 12 months upon 60 days written notice to the Practice. The amount of any such increase will not exceed 3% or the percentage annual increase in the Consumer Price Index. Similarly, practices should attempt to negotiate fees for items at the time the EHR agreement is negotiated. Examples include subsequent employee training, interfaces, and additional user licenses. (d) Sales or Other Tax. You should make sure that any applicable sales or personal/business property tax is included in the purchase price and that the vendor will remit this amount to the proper taxing authority. 2. ENSURING THAT ALL SIGNIFICANT TERMS ARE INCLUDED IN THE EHR CONTRACT — THE EFFECT OF “MERGER” CLAUSES Most EHR contracts contain a “merger” or “entire agreement” clause. Generally, these clauses state that the signed EHR contract includes all the terms upon which the vendor and the practice have agreed, and that any other prior oral or written promise made by the vendor’s sales representative is not binding on the vendor. The typical merger clause is easy to identify, and may read as follows: ntire Agreement. This Agreement, including any E documents incorporated by reference, is the complete and exclusive agreement between the parties with respect to the subject matter hereof, superseding and replacing all prior agreements, communications, and understandings (both written and oral) regarding its subject matter. Terms and conditions on or attached to customer purchase orders will be of no force or effect, even if acknowledged or accepted by the vendor. While the inclusion of a merger clause in an EHR contract is not in itself a problem, it is important to remember its effect.

Essentially, any special concession or other promise made by the vendor’s sales representative needs to be referenced and incorporated into the final, written EHR contract. Otherwise, it is not binding upon the vendor. 3. THE CONTRACT TERM — RENEWING, OR GETTING OUT OF, AN EHR CONTRACT Most EHR contracts remain in force for a specified length of time, usually a year, subject to various renewal provisions. EHR contracts can renew at the end of the original term in two general ways. First, the contract could automatically terminate unless a new contract is signed. These contracts typically simply do not say anything as to what happens at the end of the term. Secondly, the contract could automatically renew unless either the practice or the vendor provides notice of termination to the other prior to the end of the original term. A typical auto-renewal or “evergreen” provision can be identified in that it may read as follows:  ollowing the expiration of the original term, subject F to customer’s continued payment of applicable fees, vendor will continue to provide services for successive, automatically-renewable terms of twelve (12) months unless either party provides the other party with written notice of termination no less than 30 days prior to the end of the original term or a renewal term. While neither renewal provision is necessarily preferable to the other, it is important for you to recognize which provision is included in your EHR contract. If the EHR contract contains an auto-renewal provision, you will need to take affirmative action only if you want to terminate the contract and switch to another vendor. If the contract does not contain an autorenewal provision, you will need to enter into a renewal contract before the end of the term, assuming that you do not wish to switch vendors. 4. TRANSFERABILITY OF DATA — WHAT HAPPENS WHEN THE PRACTICE WANTS TO SWITCH VENDORS OR WHEN THE VENDOR GOES OUT OF BUSINESS Many EHR contracts do not discuss whether the practice can access its data after termination of the contract or after the vendor goes out of business. Either of these scenarios ultimately would force you to quickly transfer the records to a new EHR vendor, print the records, or — worst of all — lose the data forever. In general, you should know where your data will actually reside, what type of database will be used, and whether or not removing the data from the server would affect the data. To avoid the risk of losing the data, it is important that (1) the EHR vendor maintain the data in a format that allows it to be transferred from one vendor’s software to another’s, and (2) the EHR vendor will help accomplish such a transfer. You should consider asking for appropriate language to be included within or as an addendum to your final contract to address this possibility. (a) Ensuring That EHR Data Is Maintained in a Transferable Format. You should negotiate termination issues up front so that you do not incur additional costs when the agreement terminates. You should require the vendor to provide you a copy of patient data stored in the EHR in an industry recognized, nonproprietary format. The vendor should provide this format at no additional cost to you. (b) Obtaining the EHR Vendor’s Assistance in Accomplishing a Data Transfer. Even if the EHR data

B ecause accessing EHR data is essential to the daily operatio n s of a medical practice, it is impo rtan t to address and reduce the ris k t h at the practice will be unable to ac c e s s the data due to service outage s or defects in the software. To ad d re s s this risk , the EHR contract shou l d provide assurances that the s oft ware and equipment will perform t o gi v e n specifications, usually in the form of a warranty. is maintained in a transferable format, you will need the vendor’s assistance in actually accomplishing such a transfer. You can secure this assistance by ensuring the EHR contract specifically provides that the vendor will help with the transfer. For example, the following EHR contract language would achieve this goal: If Vendor goes out of business or upon termination or expiration of this Agreement, Vendor will allow the Practice a one-time data transfer, to the Practice’s new EHR system and/or provide the data securely onto a storage medium in a market standard format (e.g., HL-7), for no additional fee, or for a mutually agreed-upon fee at the initial contracting, and will allow the Practice to continue to use the software until all data is transferred to a new system. Such data shall be provided to the Practice in an industryrecognized, nonproprietary format. Additionally, as discussed in part 8 below, you should maintain periodic backup copies either to an on-site server or other storage medium. 5. REGULATORY COMPLIANCE Medical practices generally operate in an environment that is subject to significant governmental regulation. These governmental regulations, such as HIPAA, change from time to time. Additionally, new regulations, such as the availability of federal stimulus funds for meaningful users of certified EHR technology under the Health Information Technology for Economic and Clinical Health Act, are periodically enacted. Such regulatory changes will require changes in the functionality of the EHR software in order to maintain compliance with all the regulations. Accordingly, the EHR contract should require the vendor to provide software updates to maintain compliance. For example, the following provisions achieve this goal: To the extent that an amendment to HIPAA requires a modification of a Practice business process that is supported by functions of the software and support is necessary for such modified business process, Vendor will instruct the Practice as to reasonable methods for using the software to support the modified business process. If, despite the instructions, the modified business process cannot be reasonably supported by the software, Vendor will issue a regulatory update of the software within a reasonable time to support the Practice’s use of the software in compliance with

visit us online at • August 2011 •


the applicable regulatory requirement. During the initial and any subsequent terms of this Agreement, Vendor shall provide any and all updates of the software at no additional cost to the Practice so that Software at all times complies with the Standards, Certification Criteria, and Implementation Specifications for Certified EHR Technology promulgated by the Office of the National Coordinator for Health Information Technology (ONC) and the Meaningful Use criteria promulgated by the Centers for Medicare & Medicaid Services. Furthermore, vendor guarantees and warrants that during the term of this Agreement, software will be certified by an appropriate ONC-recognized certification body such as the Certification Commission for Healthcare Information Technology (CCHIT). Vendor represents and warrants that the EHR shall, at all times during the term of this Agreement, comply with the Section 13402 of the Health Information Technology for Economic and Clinical Health (HITECH) Act and any implementing regulations related to breach notifications and that all data contained in the software shall meet the definition of secured protected health information. 6. PRODUCT WARRANTIES AND LIABILITY LIMITS — PROTECTING THE PRACTICE FROM PRODUCT DEFECTS AND SERVICE OUTAGES Because accessing EHR data is essential to the daily operations of a medical practice, it is important to address and reduce the risk that the practice will be unable to access the data due to service outages or defects in the software. To address this risk, the EHR contract should provide assurances that the software and equipment will perform to given specifications, usually in the form of a warranty. However, the scope of the warranty and the level of protection provided vary from contract to contract. Additionally, EHR contracts contain terms that limit the vendor’s liability under the warranty. (a) The Scope of Contractual Warranties. As discussed above, the EHR contract should provide assurances that the software will perform as advertised. Typically this assurance comes in the form of a contractual warranty such as the following: Vendor warrants that, during the term of the Agreement, the software (i) will perform in all material respects in accordance with the functional specifications set forth in the documentation that accompanies the software; and (ii) will operate together with the versions of the applicable ThirdParty software specified in the order form. It is important to note the general, broad scope of the warranties in the foregoing. In contrast, some EHR contracts significantly limit the scope and duration of their warranties, as in the following: Vendor warrants that, for a period of 90 days following the first live use of the software, the software will perform substantially in accordance with the applicable documentation. This warranty does not cover equipment or 3rd Party software delivered with the software and does not apply if the Practice operates the software on equipment other


• August 2011 • Dallas Medical Journal

than that certified by the Vendor or if anyone other than the Vendor modifies the software. The scope of the typical warranty will, of course, fall somewhere in between that of the two contrasting examples given. (b) Limits on the Vendor’s Liability to the Practice. As discussed above, EHR contracts will contain additional provisions that limit the vendor’s liability under the warranty. These limitations often generally function to (1) cap the dollar amount of the vendor’s total liability, and (2) disclaim liability for any indirect loss to the practice such as lost profits. The latter limitation is less objectionable because the vendor cannot reasonably know the extent of the loss that the practice might suffer. For example, the following provision achieves both of these functions to the detriment of the practice: Limitation of Liability. Vendor’s liability to the Practice for any losses in contract, tort, or otherwise, arising out of the subject matter of this Agreement shall be limited those actual and direct damages which are reasonably incurred by the Practice and shall not exceed the fees paid by the Practice over the months in which the liability occurred, not to exceed twelve (12) months. Vendor will not be liable for special, punitive, indirect, incidental, exemplary or consequential damages or loss of data, lost profits, loss of goodwill in any way arising from this Agreement, even if the Vendor has been notified of the possibility of such damages occurring. Because these provisions affect the operation of the warranties, you should carefully review the limitations included in the EHR contract when evaluating the level of protection the warranties provide. As stated above, it is typical in all software contracts to contain these limitations. However, because the exact limitations may vary somewhat, you should take note of the exact limitations contained in each vendor’s contract for purposes of comparison. 7. CHOICE OF LAW AND FORUM PROVISIONS — AVOIDING UNNECESSARY EXPENSE IN THE DISPUTE RESOLUTION PROCESS Most EHR contracts specify which state’s law applies to any dispute arising under the contract, as well as the location in which any dispute will be resolved. Because these contracts are written by the vendors, they often specify both that disputes will be governed by the law of the vendor’s state (which would be a state other than Texas) and that they will be resolved in a location that is convenient to the vendor. This specification can cause you to incur significant additional expense should a dispute ever arise, in that you would be required to travel to another state and potentially hire out-of-state counsel to resolve the dispute. These contractual provisions can be easily identified, and may read as follows: Governing Law. This Agreement is governed and will be construed in accordance with the laws of the State of Georgia, exclusive of its rules governing choice of law. Each party agrees that exclusive venue for all actions, relating in any manner to this Agreement, will be in a federal or state court of competent jurisdiction located in Fulton County, Georgia.

While these provisions generally are not negotiable, you should be aware of them when comparing different EHR vendors. Selecting a vendor whose contract specifies that disputes will be governed under local law and settled in a convenient location could save you from incurring unnecessary expenses should a dispute ever arise. Although not usually negotiable, it is still worth pursuing a more advantageous choice of law or venue provisions. For example, the agreement could provide that the law of the state of the vendor’s choice applies, but any dispute between the parties concerning the agreement must be brought in the county where the customer is located, or in sparsely populated counties, a major metropolitan location in Texas. Another alternative to a lawsuit for the resolution of any disputes is binding arbitration under the rules of the American Arbitration Association or another nationally recognized arbitral body. 8. OPTION FOR PERIODIC BACKUP TO ON-SITE SERVER OR STORAGE MEDIA A growing technical model for EHR is the web-based, ASP/cloud model, whereby the main hardware, storage, and software of the EHR is located off site and is maintained by the vendor, and the group accesses the system via the Internet. In a case of Internet failure, or destruction of the data warehouse, patient health information stored on the EHR would be lost temporarily or permanently or access interrupted, preventing effective patient care in the interim. One possible safeguard involves the vendor providing periodic downloads of the contracted group’s patient data (e.g., monthly or weekly) either to a server hosted by the PETCT ad_DMJ_Final.pdf 3/14/2008 10:07:04 group’s clinic or hospital facility, orAM in DVD or other storage medium securely stored on site. The contract should

guarantee this service, as well as training on how to access the stored data in such case as the need arises. Conclusion Be sure you understand the contract, and ask for clarification of terms you may not understand or for additional terms you would like to have. Throughout your relationship with a vendor, you should be confident the vendor will be able to meet your expectations and fulfill its contractual obligations. In addition to the out-of-pocket costs and the contractual terms, please remember to consider the quality of the product and the quality of the vendor to achieve your best overall value. questions or more information For questions or more information about health information technology, please contact TMA’s Department of Health Information Technology at or by calling (800) 880-5720. Visit the TMA web site HIT page at NOTICE: This information is provided as a commentary on legal issues and is not intended to provide advice on any specific legal matter. This information should NOT be considered legal advice and receipt of it does not create an attorney-client relationship. This is not a substitute for the advice of an attorney. The Office of the General Counsel of the Texas Medical Association provides this information with the express understanding that 1) no attorney-client relationship exists, 2) neither TMA nor its attorneys are engaged in providing legal advice and 3) that the information is of a general character. Although TMA has attempted to present materials that are accurate and useful, some material may be outdated and TMA shall not be liable to anyone for any inaccuracy, error or omission, regardless of cause, or for any damages resulting therefrom. Any legal forms are only provided for the use of physicians in consultation with their attorneys. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought.

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Family Doctors. Convenient Care. visit us online at • August 2011 •


Spruce up your referral base, network with colleagues and have fun. Active practicing DCMS member physicians will have 3 minutes to network one-on-one with a colleague or DCMS Circle of Friends member before moving to the next person.

S p e e d N e two rk in g Thursday, Sept. 15 6 — 8 p.m. Ti m e s Te n C e lla rs 6324 Prospect Avenue Dallas, TX 75214

6:00 p.m. cocktails 6:30 p.m. speed networking begins

Each physician will get 3 minutes of face time with every physician in the room. Imagine speed dating, without the romance! Remember to bring your business cards. Questions? Contact Kelly, director of membership development, at 214.413.1446 or

RS V PFAX to 214.946.5805 or e-mail information to name:



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• August 2011 • Dallas Medical Journal

John Noack, MD by Lauren Cowling, director of communications John Noack’s path into medicine was a direct one, as he says he’s always had an affinity for biology and life science. Medicine was a natural fit for the boy whose uncle was a physician in town and whose parents encouraged him to do whatever he was passionate about.

DCMS Physician Spotlight When Dr. Noack, born and reared in Dallas, set off for the University of Texas at Austin, he was the first in his family to venture south on I-35 rather than head to Texas A&M. After graduating from UT, he returned Resttoofcomplete the text medical school at UT Southwestern. home Although he had planned to try urology during his first elective rotation, he thought the field was too crowded, so he opted for orthopaedics. Dr. Noack and orthopaedics clicked right away. “I’m impatient, and in orthopaedics you get immediate results,” he explains. “You can put your hands on something and fix it. There’s not only instant gratification for surgeons, but for patients, too.” After stops in Kansas and Houston for residency and fellowship training, he found his way back to Dallas in 2004. He’s been in private practice in Dallas for 7 years and specializes in treatment of traumatic and sportsrelated injuries as well as degenerative conditions of the leg, ankle and foot at the Center for Foot and Ankle Restoration. He most enjoys the day-to-day interactions with patients and the “wonderful and unique privilege to affect lives” that his practice provides. This led him to the “practice what he preaches” mentality he takes with his patients. In the last 5 years or so, Dr. Noack, 39, has become an avid cycler, riding with the Texas Irish, a team of 60 cyclists that was formed in 2006. Dr. Noack got into cycling for numerous reasons and has stayed involved for even more. “I want to practice what I preach to my patients and do a low-impact exercise like cycling, but it’s become more than cycling. My team does so much to give back to the community,” he says. Formed as a nonprofit group, the Texas Irish raises money for local and national charities by riding in

events such as the MS 150 for the Multiple Sclerosis Society and the Tour de Cure for the American Diabetes Association. The team also raises funds for area organizations including Genesis Women’s Shelter, Children’s Medical Center of Dallas, and Toys for Tots. Members have raised more than $350,000 for these charities. Dr. Noack serves on the team’s board of directors. The team is preparing for the aptly named “Hotter’N Hell 100,” which is the largest single-day 100-mile bicycle ride in the nation. Dr. Noack will be riding in the race for the fifth time as he joins some 12,000 riders on Aug. 27 in Wichita Falls. He usually participates in around eight races a year, ranging from 60 to 100 miles. He says he lacks the patience to ride much farther. Dr. Noack loves cycling because it provides lowimpact exercise and the opportunity to give back to the community in a different way. “Cycling can be anything you want it to be,” he says. “It can be a relaxing quiet time, a super, über workout or a social outing.” In addition to his fund-raising rides, Dr. Noack gives back to the community through Project Access Dallas, for which he has been a physician volunteer since 2007. One of his PAD patients said that at Dr. Noack’s office, he was treated “like a top-dollar patient. I got the maximum of the maximum.” Dr. Noack is a cheerful giver and credits PAD for making it easy to help. “I’m more than happy to volunteer my time and services, but when you have a network of support like that to back you up, it’s much easier.” When Dr. Noack isn’t cycling or in the office, he enjoys spending time with his family — wife Alexis, and children, Luke (7) and Lyla (4).

visit us online at • August 2011 •


be a part of the circle.

DCMS Circle of Friends DIAMOND Texas Medical Liability Trust TMA Insurance Trust

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GOLD American Physicians Insurance Co. Southwest Diagnostic Imaging Center The Reynolds Company SILVER Allscripts-Misys Healthcare Solutions, Inc. Goldin, Peiser & Peiser US Medical IT, LLC Lincoln Harris, CSG Rebecca Harrell, Medical Office Specialist The Health Group Shaw & Associates, PC

The Dallas County Medical Society offers a valuable benefit to help members with their medical practices—DCMS Circle of Friends. This program provides information about medical-related businesses that serve Dallas-area physicians. For questions about the DCMS Circle of Friends, contact Mary Katherine Allen at 214.413.1456 or

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• August 2011 • Dallas Medical Journal

Anson Jones Award Winners

• • • •

Each year Texas’ best healthcare/medical news reporters compete in TMA’s Anson Jones, MD, awards. The awards are presented to honor members of the Texas news media for excellence in communicating health information to the public. Winners receive a plaque and a $1,000 cash prize. Citation of Merit winners receive a certificate and a $250 cash prize. Deborah Fuller, MD, DCMS member and TMA Council on Health Promotion chair presented awards to the following Dallas-area winners: • Janet St. James and Greg Johnson, WFAA-TV, Citation of Merit, In-Depth Television News Category, for “Proton Therapy.” • Kim Horner, The Dallas Morning News, Citation of Merit, Large Circulation Print Publications Category ,for “Genetic test offers women another weapon in fight against breast cancer.” • Lee Hancock The Dallas Morning News, Citation of Merit, Large Circulation Print Publications Category, for WFAA-TV’s Janet St. James and Deborah Fuller, MD “In crisis, healing hands.” Jason Roberson, The Dallas Morning News, First Place, Large Circulation Print Publications Category, for “Blue Cross-Texas Health spat may raise patient costs.” Sue Goetinck Ambrose, Reese Dunklin, Brooks Egerton, Miles Moffeit, The Dallas Morning News, Citation of Merit, In-Depth Print Category, for “First, do no harm.” Brandon George, Mark Dent, Rainer Sabin, The Dallas Morning News, Citation of Merit, In-Depth Print Category, for “Hidden dangers: Concussions in high school sports.” David Tarrant, Sonya Hebert, The Dallas Morning News, First Place, In-Depth Print Category, for “PTSD: Private battles.”

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972-720-9032 visit us online at • August 2011 •


18 Pain Relievers

D.R.S. is a network of highly experienced independent businesses and professionals offering medically related products and services specific to physicians. Members are selected for their high standards and uncompromising service.

Accountant (CPA) / Tax Services Paula Allgood, CPA……Beaird Harris & Co, P.C. 972.503.1040…… Lori A. Eads, CPA……Bland, Garvey, Eads, Medlock + Deppe, P.C. 972.231.2503…… Design / Build Medical & Dental Contractor Grady Herzog……Structures & Interiors Inc. 817.329.4241…… Electronic Medical Records Leslie Warren……EMR Advisory Group 972.898.5671…… Employee Benefits Amy Rickman……Lockton Dunning Benefits 940.380.1245…… Financing / Banking Gary West……BB&T 469.791.4502…… Financial / Estate / Insurance Planning Mark A. Trewitt, CFP®, CLU, ChFC, AEP Integrated Financial Solutions Group 972.312.1337…… Linen / Laundry Services Gary W. McDaniel……ImageFirst 214.769.6677…… Legal Services Michael H. Saks*……Wright, Ginsberg, Brusilow, PC 972.788.1600…… *Not board certified by the Texas Board of Legal Specialization

Legal Services cont. W. Darrell Armer*……Looper, Reed & McGraw, PC 214.922.8923…… *Board Certified-Health Law by The Texas Board of Legal Specialization

Marketing / Public Relations Barbara Steckler……Concepts in Medical Marketing 972.490.7636…… Medical Malpractice / Commercial Insurance James Patterson, CIC, AAI……Agapé Healthcare Partners Metro 817.329.4200…… OSHA Compliance Jessica James 469.360.1367…… Personnel Recruitment Jan Harris, CPC……J. Harris Co. Personnel Services Inc. 214.369.9545…… Practice Management / Billing / Consulting David Loomis……The Health Group 972.792.5700…… Promotional Products / Wearables / Filing Systems Nance Lindstrom……Safeguard Business Systems & Promotional Products 972.596.8282…… Real Estate (Commercial) M.W. (Hugh) Resnick……Pizel & Assoc. Commercial Real Estate 972.404.0008…… Telecommunications Charlie Hubbard, PMP……HUBCO Communications, Inc. 469.293.3081……

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• August 2011 • Dallas Medical Journal

Don’t frack with me by Tracy Casto, director of legislative affairs and advocacy

When Joe Public can find out what chemicals gas and oil well operators are using underground in his neighborhood, he can include the Haley family in his thank-yous. Texas is the first state to pass such a law requiring that drillers publicly disclose the chemicals they use when extracting oil and gas from dense rock formations. They also must cite the total water usage, which can be upwards of 5 million gallons for each well that is fracked. The issue has taken on national importance as hydraulic fracturing, or fracking, is used in more states to extract once out-of-reach hydrocarbons from impermeable shale formations. Fracking increases production of natural gas by injection of fluids at high pressure between rock layers to crack the rock. Environmental and public health groups worry that the chemicals could taint aquifers and water supplies; the industry says the process is safe. Several other state agencies have regulations forcing some disclosure, but none have made it a law. Under the new law, companies will have to list the chemicals and the amounts used on, an industry site that operates now on a voluntary basis, beginning in July 2012. However, Elizabeth Ames Jones, chair of the Texas Railroad Commission, which oversees the oil and gas industry in the state, has said she hopes the agency will have its rules drafted by mid-August, followed by a 30-day period for public comment and implementation before the end of the year. Only in the case of hazardous chemicals will companies have to disclose the amount or concentration used, and the law provides a broad exemption from disclosing chemicals that a company deems “trade secrets.” Landowners and state workers can challenge that “trade secret” claim. Resolution 203, written by Robert W. Haley, MD, and which DCMS submitted to the TMA House of Delegates in May, asked the TMA to request that the Environmental Protection Agency and the Legislature act to protect Texas water from the risks of fracking, protect Texas air through increased monitoring of air quality, and provide additional safeguards for pipelines, including those carrying fracking fluids. The resolution as adopted by the TMA House of Delegates requests that TMA “ask the Texas Legislature … to protect our water from the risk of fracking by requiring disclosure of fracking fluid components.” The resolution notes that the EPA had found that emissions from fracking exceeded emissions from all cars and trucks in the DFW area combined, and

that these emissions include smog-forming nitrogen oxides and volatile organic compounds, benzene and other carcinogens, and methane. The RRC chair has said that “it is still geologically impossible for fracturing fluid or natural gas or oil to migrate upward through thousands of feet of rock, sometimes miles, to adversely affect ground water.” However, the new law “will provide the additional assurance to the public that a common-sense disclosure policy affords, and it will provide operators uniformity and reliability regarding the disclosure process for all wells that are hydraulically fractured in Texas.” The passage of the bill grew from a meeting of Dr. Haley and a small group of like-minded physicians and business leaders. Dr. Haley has been interested in public health and air quality his entire career, but credits his sister-in-law Margie Haley (wife of DCMS member John Haley, MD) as the impetus behind the project. “She’s a prime mover in the environmental movement in Texas and Colorado,” he says. She determined that physicians should be more involved in the air quality movement, given the impacts of poor air quality on public health. So, in Summer 2007, Dr. Haley asked DCMS and TMA to get behind the effort. At the group’s first meeting, most participants shared the last name of Haley (John, Charles, Robert, Steven, Margie). That group requested involvement from the newly formed coalition Texas Business for Clean Air. “Through that, we developed the critical mass needed to get the job done,” Dr. Haley recalls. “Texas Business for Clean Air had the contacts and we had the neutral spot to have meetings.” In preparation for the January 2009 legislative session, the group commissioned a study on how to clean up the environment and ensure a sustainable energy supply. The study was completed in time for the group to begin working on proposed legislation for that session. “This was the first report anyone had seen on this topic,” Dr. Haley says. “No one had a comprehensive scientific report about how we’d meet our energy needs 20 years in the future and protect the environment. The legislators used it, the lobbyists used it, and the House of Delegates made it TMA policy.” The group continued its efforts through the interim and during the 2011 legislative session, resulting in the passage of HB 3328 during the Legislature’s special session in June.

visit us online at • August 2011 •


Community Feeling Under Siege?


By Jim Walton, DO, MBA, PAD Medical Director

“The capitalist system is under siege. In recent years, business increasingly has been viewed as a major cause of social, environmental and economic problems.” —Harvard Business Review, January-February 2011 My Project Access Dallas volunteer work brought me face to face with AJ, a precocious teenager previously diagnosed with PTSD. The 13-year-old boy was caught in a complex web of domestic violence, child protective services and the judicial system. This clinical vignette provides a window into the economic, social and medical complexities that vex our current healthcare system. Rejected by his biological father, AJ endured turbulent years of verbal and physical abuse by his father which set in motion a grinding anger and bitterness that led to appointments with judges, school principals, psychiatrists, and counselors. As he tumbled from one to the other, his confusion and anger turned into his own expression of verbal and physical violence, causing him to strike out at the very people trying to help him. Repeatedly, I questioned whether I wanted to continue to be this young boy’s doctor. The complexities of his story tested my resolve to be accountable for his care. Like most Americans, physicians are coming to realize that the economic health of our nation lies within the successful reform and redesign of a broken healthcare financing system. The “fee-for-service” market-based model of private practice is under siege, in great part due to the population’s insatiable appetite for health care, combined with the exponential increase in the number of American healthcare consumers. No one would have planned for our country to be in a position where Medicare’s increasing debt negatively affects the growth in the nation’s jobs and GDP. To be fair, our healthcare financing system inadvertently incentivizes physicians to compound the economic problem because we serve as the catalyst in the chain reaction of healthcare consumption. Indeed, we must confess that up to this point, physicians have been a financial beneficiary of the “economic progress” that Adam Smith envisioned in a free-market system. To say that things (“things” being continued economic growth and prosperity for physicians) are becoming precarious is an understatement. As such, there are no shortages of good ideas. One idea takes me back to AJ’s story. One way to reform healthcare financing is to reward a “network of providers” for working together to help high-risk patients such as AJ. The average patient in need of preventive health care doesn’t need a “network of providers,” and the current financing system might


• August 2011 • Dallas Medical Journal

continue to work well for this group. However, most people end up with some degree of medical complexity requiring a network of physicians and healthcare organizations to alleviate their suffering and prevent complications. For example, without a coordinated intervention, AJ may require frequent hospitalizations for potentially avoidable complications. He needs a “network of providers” coordinating his care and incentivized by financial rewards beyond a traditional fee-for-service average payment rate. In this new model, if the “network of providers” avoids the financial and societal costs of complications (particularly, the medical ones), then the network should be rewarded with some of the saved dollars. This financing arrangement acknowledges and then rewards the creative innovation that is taking place in both social and medical spheres of care. As an example, I met with AJ and his mother on a number of occasions over the last 6 months. We had long conversations about his journey and the medical expressions of PTSD. Because of time constraints and patient volume, these conversations might never have happened in my fee-for-service Internal Medicine practice. To my surprise I was able to connect with AJ — so much so that he shared details he never had discussed with others. With this “unveiling,” he became more adherent to his regular psychiatry and counseling appointments and more compliant with taking his prescribed medications. He successfully finished seventh grade and avoided truancy court. His housing situation stabilized as he and his mom settled into a new apartment, and he gained better control of his anger. AJ’s response is just one hopeful sign that we are still capable of innovation. However, I think it is more than fair to ask ourselves, “Are we willing to be the physician for some very difficult patients?” With recent healthcare reform legislation, we need not shrink from this question because we can begin to collaborate with colleagues in new healthcare financial arrangements to better coordinate health care, holding ourselves accountable for the quality and outcomes of our work. These new relationships, called Accountable Care Organizations (ACOs), are emerging in the DFW area, and they may benefit our efforts to assist the historically underserved patients we desire to serve.

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Dallas Medical Journal  

August 2011 Dallas Medical Journal

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