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Med Monthly August 2015


pg. 40

Telemedicine: Have You Gone Virtual Yet? pg. 36

How to Improve Medical Care of the Non-compliant Patient pg. 34

the DoctorPatient ication Commun issue

HIPAA, E-mails, and Texts to Patients or Others pg. 24

How to Build a Channel of Effective Doctor-Patient Communication pg. 30






practice tips

insight 6






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Med Monthly August 2015 Publisher Creative Director Contributors

Philip Driver Thomas Hibbard Ashley Acornley, MS, RD, LDN. Naren Arulrajah Peter Dizikes Barbara Hales, M.D. Laura E. Marusinec, MD David McNamee Carrie Noriega, MD Cara N. Parcell Julia Solooki, MBA Kim C. Stanger Vikas Vij Walter L. Williams

contributors Ashley Acornley, RD, LDN holds a BS in Nutritional Sciences with a minor in Kinesiology from Penn State University. She completed her Dietetic Internship at Meredith College and recently completed her Master’s Degree in Nutrition. She is also an AFAA certified personal trainer. Her blog can be found at:

Barbara Hales, M.D. is a skilled expert in promoting your health services. As seen on NBC, CBS,ABC and FOX network affiliates as well as Newsweek, Dr. Hales writes all the content you need to promote your medical services. Her latest book is on the best seller list and she can do the same for you. Check out her site at

Laura E. Marusinec, MD

Med Monthly is a national monthly magazine committed to providing insights about the health care profession, current events, what’s working and what’s not in the health care industry, as well as practical advice for physicians and practices. We are currently accepting articles to be considered for publication. For more information on writing for Med Monthly, check out our writer’s guidelines at

P.O. Box 99488 Raleigh, NC 27624 Online 24/7 at

is a board-certified pediatrician and medical writer with experience in general pediatrics, pediatric dermatology, and pediatric urgent care. She has supported an electronic health record implementation and optimization and is pursuing further medical writing education and opportunities.

Carrie Noriega, MD is a board certified obstetrician/ gynecologist who has worked in both private practice in the US and a socialized medical system. As an adventure racer and endurance mountain bike racer, she has developed a special interest in promoting health and wellness through science and medicine.

Julia Solooki, MBA is a 10 year veteran to the Healthcare IT/Services sector and is the Director of Business Development and Marketing for ClinicSpectrum, Inc., a healthcare services company providing outsourcing and back office solutions for medical billing companies, medical offices, hospital billing departments, and hospital medical records departments. Contact Julia at WWW.MEDMONTHLY.COM |5


Why Are Doctors So Guilty of Working While Sick?

By David McNamee Medical News Today 6 | AUGUST 2015

The results of a small survey published online by JAMA Pediatrics suggest that many clinicians show up for work when sick, despite knowing that this could put patients at increased risk Infections occurring while a patient is being treated can significantly exacerbate their illness and also lead to increased costs. Previous studies have shown that sick health care workers are the main source of influenza, Staphylococcus aureus and Norovirus within health care facilities. Newborn babies and people with compromised immune systems are known to be especially at risk from these infections, which can prove fatal. To find out why physicians and advanced practice clinicians continue to work while sick, despite the risks, researchers at the Children’s Hospital of Philadelphia, PA, polled workers at their hospital in an anonymous survey. A total of 280 attending physicians and 256 advanced practice clinicians - including registered nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists and certified nurse midwives - completed the survey. The vast majority of respondents - 95.3% - agreed that patients are put at risk by health care providers working while sick. However, 83.1% of respondents reported working while sick at least once in the past year, and 9.3% reported working while sick at least five times. Physicians and advanced practice clinicians reported the following reasons why they continued to work while sick: • Not wanting to let colleagues down (98.7%) • Staffing concerns (94.9%) • Not wanting to let patients down (92.5%) • Fear of being ostracized by colleagues (64%) • Concerns about the continuity of care (63.8%). Resourcing, stigma and culture of ‘soldiering on’ contribute to problem Analyzing the comments provided by respondents, the researchers found three main areas that drive

health care providers to continue working while ill. These are logistical or resource problems with arranging for someone to cover their work, a culture of reporting for work unless extremely ill, and ambiguity over what symptoms make someone too sick to work.


The authors write: “The study illustrates the complex social and logistic factors that cause this behavior. These results may inform efforts to design systems at our hospital to provide support for attending physicians and [advanced practice clinicians] and help them make the right choice to keep their patients and colleagues safe while caring for themselves.”

Dr. Jeffrey R. Starke, of the Baylor College of Medicine, Houston, TX, and Dr. Mary Anne Jackson, University of Missouri-Kansas City School of Medicine write in an accompanying editorial that a culture change is required in order to decrease the stigma associated with not turning up for work when ill. To do this, they argue that health care workers require a “more equitable system of sick leave.” “Identifying solutions to prioritize patient safety must factor in workplace demands and variability in patient census and emphasize flexibility,” they add. “Also essential is clarity from occupational health and infection control departments to identify what constitutes being too sick to work.”  Source: McNamee, D. (2015, July 7). “Why are doctors so guilty of working while sick?.” Medical News Today. Retrieved from WWW.MEDMONTHLY.COM | 7


CDC Awards $216 Million to Community-based Organizations to Deliver the Most Effective HIV Prevention Strategies to Those in Greatest Need

The Centers for Disease Control and Prevention announced today that it has awarded $216 million over five years to 90 communitybased organizations (CBOs) nationwide to deliver effective HIV prevention strategies to those at greatest risk, including people of 8 | AUGUST 2015

color, men who have sex with men (MSM), transgender individuals, and people who inject drugs. “Community-based organizations have been vital to our nation’s HIV prevention efforts since the earliest days of the epidemic,” said Jonathan Mermin, M.D., director

of CDC’s National Center for HIV/ AIDS, Viral Hepatitis, STD, and Tuberculosis Prevention. “The organizations we’re funding have a strong foothold in the hardest-hit communities. They have the credibility and experience needed to deliver the most effective HIV prevention

strategies to those who need them most.” CBOs will use the new funding to deliver high-impact HIV prevention strategies, including: • Providing HIV testing to those at high risk to increase the proportion of people who are aware of their HIV status • Engaging HIV-positive people in ongoing care and treatment, helping them adhere to antiretroviral therapy, and ensuring they receive prevention and support services • Ensuring high-risk, HIV-negative individuals have access to prevention and support services such as pre-exposure prophylaxis (PrEP), postexposure prophylaxis (PEP), high-impact behavioral interventions, and screening for sexually transmitted infections • Distributing condoms to HIVpositive and high-risk, HIVnegative individuals For the first time in its nearly 30year history, the funding program includes a component that allows organizations to pool their expertise and resources into “Prevention Partnerships.” Of the 90 organizations receiving funding, 30 will serve as the lead of a partnership comprised of several organizations. Through these partnerships, 47 additional organizations will contribute their own unique expertise to help deliver more comprehensive prevention services to those in greatest need. “It’s clear that we need to focus our limited resources on strategies that can have the greatest possible impact,” said Eugene McCray, M.D., director of CDC’s Division of HIV/AIDS Prevention. “This funding targets local communities to help maximize the impact of ev-

ery federal prevention dollar. By delivering powerful prevention tools where they’re needed most, we can have a transformative impact on the epidemic.” The funded organizations are in the 50 geographic areas that reported the highest number of HIV diagnoses in 2011. Each organization has demonstrated experience and expertise working with the populations most affected by the epidemic. Of the 90 directly-funded CBOs, 67 (74.4 percent) primarily serve African Americans and 15 (16.7 percent) primarily serve Hispanics; 64 (71.1 percent) primarily serve MSM. A full list of funded CBOs is available at hiv/funding/announcements/ps151502/organizations.html. CDC provided extensive preapplication guidance and technical assistance to help interested CBOs apply for the funding. Funded CBOs will be required to monitor program impact and behavioral outcomes. Moving forward, CDC will provide technical assistance and support – directly and through funding for its capacity-building partners – to help ensure funded CBOs are successful in meeting key goals associated with the funding, such as increasing HIV testing among those at-risk and increasing the number of people with HIV who are linked to medical care. “Birmingham AIDS Outreach has been working since 1985 to reverse the devastating impact of HIV in our community – and now, with this new funding from CDC, we can do even more, along with our community partners AIDS Alabama and the Aletheia House,” said Karen Musgrove, executive director of Birmingham AIDS Outreach. “We’re grateful for and excited about the opportunity to invest in

delivering the cutting edge of HIV prevention to those who need it most across the state of Alabama.” CBO funding is one critical piece of CDC HIV prevention investments CDC supports HIV prevention at national, state, local, and territorial levels, and these awards represent just one part of CDC’s nearly $700 million annual investment in domestic HIV prevention. The bulk of that annual funding goes directly to state and local health departments – and, indirectly, to many additional community-based organizations across the nation – to prevent HIV infection among those at greatest risk. The awards announced today reflect CDC’s focus on a high-impact prevention approach, which prioritizes strategies that are scientifically proven, cost-effective, scalable, and targeted to the geographic areas and populations that need them most. Nationally, CDC’s approach to HIV prevention primarily focuses on: • Identifying undiagnosed HIV infections through increased testing • Ensuring that people with HIV receive ongoing care and treatment to improve their health and reduce transmission to others • Ensuring those at highest risk for HIV have the knowledge and tools needed to protect themselves For additional information, visit newsroom.  Source: WWW.MEDMONTHLY.COM | 9


Dermatologists Share Tips for Treating Hives in Children 10

| AUGUST 2015

Has your child broken out in an itchy rash? If so, it could be a case of hives. Fortunately, hives are usually harmless and temporary. Common symptoms of hives include slightly raised, pink or red areas on the skin; welts that occur alone, in a group, or connect over a large area; and skin swelling that lessens or goes away within minutes or hours. “The best remedy for hives is to try to avoid whatever triggers them, although identifying this is often difficult,” said board-certified dermatologist Bruce A. Brod, MD, FAAD, clinical professor of dermatology, University of Pennsylvania, Perelman School of Medicine. “One way to help identify your triggers is to keep a log of your child’s symptoms, including the day and time the hives occur and how long they last. You should also pay attention to any changes to your child’s regular environment that may be contributing to the problem, such as dust, animals or the outdoors.” According to member dermatologists from the American Academy of Dermatology, many things can trigger hives, including: • An allergic reaction to food or medication • Infections, including colds and viruses • Exercise • Stress • Cold temperatures • Scratching the skin • Insect bites and stings • Pollen • Sun exposure If your child has hives, Dr. Brod recommends the following tips to help care for your child at home: 1. Consider using an over-the-counter oral antihistamine for children: This will help relieve the itch and discomfort. Always follow the directions on the label and use the correct dose. 2. Apply a cool washcloth to the hives: This will bring additional relief to your child. 3. Try to reduce scratching: Whenever possible, try to keep your child from scratching, as scratching may worsen the rash. One way to do this is to keep your child’s fingernails short. You can also consider applying an over-the-counter anti-itch cream with pramoxine or menthol to your child’s hives. Always use the product as directed. 4. Bathe with lukewarm water: Bathe your child as normal, but make sure the water is lukewarm, not hot, and limit the bath to 10 minutes. You can also ease the itch by adding a product with colloidal oatmeal to your child’s bath water. Use a gentle,

fragrance-free cleanser, and avoid bubble baths and scented lotions. After bathing, pat the child dry with a towel and apply a gentle moisturizing cream or lotion to damp skin. 5. Maintain a comfortable environment for your child: In summer, air-conditioning may be preferred, and in winter, it is helpful to have a humidifier. You should also dress your child in comfortable clothes that are loose-fitting and 100% cotton. Cover the skin to prevent scratching, but make sure your child is kept cool to avoid overheating. 6. Keep a log of your child’s symptoms: If a particular trigger is suspected, take note and avoid exposure. It may also be helpful to keep a diary of your child’s foods and medicines. “Hives can happen within minutes of exposure to the trigger or two hours later,” said Dr. Brod. “If your child’s hives persist or continue to recur, make an appointment to see a board-certified dermatologist. If your child’s hives seem to worsen or your child is experiencing more serious symptoms, such as difficulty breathing or vomiting, go to the emergency room immediately, as these symptoms can be more serious or even life-threatening.” These tips are demonstrated in “Hives in Children,” a video posted to the Academy website and the Academy’s YouTube channel. This video is part of the Dermatology A to Z: Video Series, which offers videos demonstrating tips people can use to properly care for their skin, hair and nails. A new video in the series posts to the Academy’s website and YouTube channel each month.  Headquartered in Schaumburg, Ill., the American Academy of Dermatology, founded in 1938, is the largest, most influential, and most representative of all dermatologic associations. With a membership of more than 18,000 physicians worldwide, the Academy is committed to: advancing the diagnosis and medical, surgical and cosmetic treatment of the skin, hair and nails; advocating high standards in clinical practice, education, and research in dermatology; and supporting and enhancing patient care for a lifetime of healthier skin, hair and nails. For more information, contact the Academy at 1-888-462-DERM (3376) or Follow the Academy on (American Academy of Dermatology), (@AADskin), or YouTube (AcademyofDermatology). Source: WWW.MEDMONTHLY.COM | 11

practice tips

Why Your Practice Shouldn’t

Fear ICD-10? By Julia Solooki, MBA Clinicspectrum


| AUGUST 2015


ith the deadline of the switch to ICD10 from ICD-9 coming closer, the healthcare industry is under immense pressure. The main reason being the adjustment from one coding system to another. However, ICD-10 is supposed to be an improvement and is no way as villainous as it is thought to be. Let us look at the reasons why. 1. Higher Reimbursements The main complaint physicians have about the ICD-10 is the numerous codes it has. While ICD-9 comprised of about 18,000, ICD-10 will come with well over 150,000 codes. However, with the high number of codes, will come the specificity of claims. The increased specificity will help billing patients for services rendered.

Providing more detailed diagnosis and treatment information to payers should, in theory, result in higher reimbursements. So, once your coders get used to the new codes, your practice will see a substantial increase in revenue. 2. No Need to Learn Every New Code The amount of codes are no doubt huge. But your coders can still be just as efficient without learning every single one. They just need to learn the codes that your practice will use most. And looking up for doubtful codes occasionally, will not affect productivity. Moreover, if you have adopted a practice management software that has code scrubbing capabilities, then the mistakes will be caught prior to submission, and there would not be any denials.

3. Better Data The healthcare industry has immense data. Most of it is not utilized to its fullest extent. ICD-10 will help you incorporate those big data principles into individual practice levels. The single biggest flaw of ICD-9 was that it wasn’t detailed enough. It was not equipped to document the multitude of conditions that physicians treat. With its increased specificity, ICD-10 allows just that. With more detailed data sets, the physician will be able to better diagnose patients and improve outcome. While many physicians clamor for another delay, it is least likely to happen. It is time now. Embrace the change and it will ultimately lead to improved coding. Resisting the change will only obstruct your transition. 


practice tips

Leveraging our Electronic Clinical Data: A New Source of Income

By Barbara Hales, M.D.


bstacles that the bio-medical industry face involve the availability or recruitment of participants for their clinical trials and the expense of amassing clinical trial data in their quest for bringing new drugs or healthcare innovations to market. A study reported in CMR International R&D briefing: Benchmarking for Efficient Drug Development, that almost fifty percent of the trial process time was spent on site and patient recruitment. Linking Electronic Health Records to Clinical Trials Now, drug companies are posting information on


| AUGUST 2015

their clinical trials, including eligibility for the participants in the trials. If a doctor sees that a patient matches the selection criteria, that clinician can now complete a screening within moments by getting any additional data needed, recording the information in the electronic health records (EHR) and electronically transmitting the data to the investigational entity. Healthcare providers also have the ability to search the electronic database with a simple query to identify possible candidates eligible for a particular trial. Criteria results could be easily accessed. Added Income Opportunities With adoption of an electronic medical record sys-

tem in your practice, a vast opportunity now arises for added revenue that your practice can generate. Clinical trial participation has the potential to generate a profit of thousands of dollars annually. Incorporating data from EHR systems is a win for doctors, patients and sponsoring companies of the clinical trials as well as the healthcare system as a whole. According to the Research and Development department of Greenway Medical (an EMR vendor), studies conservatively demonstrate that a solo practitioner can generate up to $100,000 annually with no additional expense. Other studies reflect up to $700,000 additional income for a 2-provider family practice annually. PricewaterhouseCoopers reported that EMR data would be the most valuable commodity in any healthcare office. Data will enable participation in clinical trials, studies and registries, facilitating revenue generation. One would think that participation in clinical trials would be more popular. Yet, studies show that only ten percent of medical practices are involved in trials. Reasons cited in the past include the laborious task of collecting data on doctor and staff ’s time.

will need collections within a secured system. Specific consent for research and data collection must be discussed and signed by patients as part of the controls for security without hampering the amassing of needed clinical data. Once granted, data extraction is then enabled. Compliance with Meaningful use helps this challenge as data accuracy and discretion is part of the system. Hopeful Prospect With adherence to security concerns and data collection at the site of healthcare, clinical research from the electronic health record system is promising. It cannot supply one hundred percent of the data for the trial but can make major inroads when considering research recruitment, drug or device efficacy and adverse reactions. Though initial attempts at participation in clinical trials may seem laborious, once you have established a system using your electronic health record, you are open to thousands in additional revenue. 

EHR Possibilities When it comes to clinical trials, EHRs have the potential to: • Identify potential trial subjects that meet the criteria* • Screening of patients for trial • Enter data through trial-specific data fields that can appear during office encounters • Scout out the appropriate clinical trials open and available Integrating exclusion and inclusion criteria into your digital program, clinical trial alerts can appear so that a discussion about the trial can take place with the patient. By purchasing software from the right vendors, the EHR software has the ability to capture data needed for trials, ensuring efficiency. Security Concerns In the current climate of medical identity theft, greater vigilant efforts are called for in screening for data breaches and monitoring of this must be implemented. Health information must be protected and

The Write Treatment

Ezines and NewslettersCost Effective Powerful Tools • Drive traffic to your business website • Build relationships between yourself and patients • Get new patients • Announce a new service or product • Give great impact Have you got a newsletter yet or want to spread a message? Contact Barbara Hales, M.D. for a free consultation. 516-647-3002


practice tips

CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10


| AUGUST 2015

With less than three months remaining until the nation switches from ICD-9 to ICD-10 coding for medical diagnoses and inpatient hospital procedures, The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) are announcing efforts to continue to help physicians get ready ahead of the October 1 deadline. In response to requests from the provider community, CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set. Recognizing that health care providers need help with the transition, CMS and AMA are working to make sure physicians and other providers are ready ahead of the transition to ICD-10 that will happen on October 1. Reaching out to health care providers all across the country, CMS and AMA will in parallel be educating providers through webinars, on-site training, educational articles and national provider calls to help physicians and other health care providers learn about the updated codes and prepare for the transition. “As we work to modernize our nation’s health care infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics.” said Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services. “With easy to use tools, a new ICD-10 Ombudsman, and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition.” “ICD 10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD. “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs. The actions CMS is initiating today can help to mitigate potential problems. We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.” The International Classification of Diseases, or ICD, is used to standardize codes for medical conditions

and procedures. The medical codes America uses for diagnosis and billing have not been updated in more than 35 years and contain outdated, obsolete terms. The use of ICD-10 should advance public health research and emergency response through detection of disease outbreaks and adverse drug events, as well as support innovative payment models that drive quality of care. CMS’ free help includes the “Road to 10” aimed specifically at smaller physician practices with primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation. CMS has also released provider training videos that offer helpful ICD-10 implementation tips. The AMA also has a broad range of materials available to help physicians prepare for the October 1 deadline. To learn more and stay apprised on developments, visit AMA Wire. CMS also detailed its operating plans for the ICD10 implementation. Upcoming milestones include: Setting up an ICD-10 communications and coordination center, learning from best practices of other large technology implementations that will be in place to identify and resolve issues arising from the ICD-10 transition. • Sending a letter in July to all Medicare fee-for-service providers encouraging ICD-10 readiness and notifying them of these flexibilities. • Completing the final window of Medicare end-toend testing for providers this July. • Offering ongoing Medicare acknowledgement testing for providers through September 30th. • Providing additional in-person training through the “Road to 10” for small physician practices. • Hosting an MLN Connects National Provider Call on August 27th. In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes. Also, at the request of the AMA, CMS will name a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center.  Source: WWW.MEDMONTHLY.COM | 17

research & technology

Rates of New Melanomas – Deadly Skin Cancers – Have Doubled Over Last Three Decades

Without community skin cancer prevention efforts, melanoma rates will continue to climb

18 | AUGUST 2015

Melanoma rates doubled between 1982 and 2011 but comprehensive skin cancer prevention programs could prevent 20 percent of new cases between 2020 and 2030, according to this month’s Vital Signs report. Skin cancer is the most common form of cancer in the U.S., and melanoma is the most deadly type of skin cancer. More than 90 percent of melanoma skin cancers are due to skin cell damage from ultraviolet (UV) radiation exposure. Melanoma rates increased from 11.2 per 100,000 in 1982 to 22.7 per 100,000 in 2011. The report notes that without additional community prevention efforts, melanoma will continue to increase over the next 15 years, with 112,000 new cases projected in 2030. The annual cost of treating new melanoma cases is projected to nearly triple from $457 million in 2011 to $1.6 billion in 2030. This Vital Signs report shows that melanoma is responsible for more than 9,000 skin cancer deaths each year. In 2011, more than 65,000 melanoma skin cancers were diagnosed. By 2030, according to the report, effective community skin cancer prevention programs could prevent an estimated 230,000 melanoma skin cancers and save $2.7 billion dollars in treatment costs. Successful programs feature community efforts that combine education, mass media campaigns, and policy changes to increase skin protection for children and adults. “Melanoma is the deadliest form of skin cancer, and it’s on the rise,” said CDC Director Tom Frieden, M.D., M.P.H. “Protect yourself from the sun by wearing a hat and clothes that cover your skin. Find some shade if you’re outside, especially in the middle of the day when the dangerous rays from the sun are most intense, and apply broad-spectrum sunscreen.” Researchers reviewed data from CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology and End Results Program (SEER) to help determine the increase in melanoma rates. “The rate of people getting melanoma continues to increase every year compared to the rates of most other cancers, which are declining,” said Lisa Richardson, MD, MPH, Director of the Division of Cancer Prevention and Control. “If we take action now, we can prevent hundreds of thousands of new cases of skin cancers, including melanoma, and save billions of dollars in medical costs.” This Vital Signs report highlights the recommendations for communities from the Community Guide for Preventive Services. Communities can increase shade

on playgrounds, at public pools, and other public spaces, promote sun protection in recreational areas, encourage employers, childcare centers, schools, and colleges to educate about sun safety and skin protection, and restrict the availability and use of indoor tanning by minors. Everyone is encouraged to protect their skin with protective clothing, wide-brimmed hats, broad-spectrum SPF sunscreen, and seek shade outdoors. Through the Affordable Care Act, more Americans will qualify to get healthcare coverage that fits their needs and budget, including important preventive services. Behavioral counseling is now provided with no cost-sharing to counsel people aged 10–24 years with fair skin about limiting their exposure to UV radiation to reduce risk of skin cancer. Visit or call 1-800-318-2596 (TTY/TDD 1-855-889-4325) to learn more. To learn about CDC’s efforts to prevent skin cancer, visit:  Source: p0602-melanoma-cancer.html

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research & technology

3 Questions:

Carlo Ratti on Big Data and Health Predictions

MIT researcher discusses a new study on correlations among medical problems By Peter Dizikes MIT News What can big data tell us about the predictability of medical conditions? A new study by MIT researchers published in the journal Scientific Reports digs into this question by looking at anonymous data from over 500,000 patients. Among the findings is that for 43 percent of the 20

| AUGUST 2015

patients, the data can help predict which of 1,719 subcategories of diseases are most likely to occur next. The co-authors of the paper are Carlo Ratti, director of MIT’s Senseable City Laboratory, and two former computer science researchers at the lab, Dominik Dahlem (who is

the lead author) and Diego Maniloff. The data originated with General Electric, which collaborated with Senseable City on a 2011 project on visually plotting health care data. MIT News spoke with Ratti about the new study.

Q. What is your central finding in the new study? A. The results are quite interesting: This is one of the first analyses of large data you get from using electronic health records, and it just became available. This is a big amount of data we got from General Electric. What we tried to look at is, when you go to see the doctor, you’ve got a certain [medical] history, and you’re perhaps looking at a [medical] problem. When you look at that problem, is there any predictive power in the history that comes before? We looked at that from a pure computer science point of view — and it turns out there is predictive power.

it’s a mathematical way that guides you, gives you more [than] than you might get by going through [one patient’s medical history]. Q. Your lab has a focus on applying data to urban issues. So what was the genesis of this research project on health care?

A. Our focus is looking at how information is changing our knowledge of cities. And information from medical records is a very important type of information we can use. The question came about, can we actually look at these time sequences and try to understand — from just an information-theory point of view, can we actually predict — what comes next? Q. In the paper, you state that That is one of the things we have “shuffling individual disease hisstarted doing with the data, looking tories only marginally degrades at the data over space, and yes, we the predictability bounds.” That is, can see differences between differcertain diseases correlate with each ent regions. And really you start other largely apart of the order in understanding that interplay, about which they occur, is that right? the individual, and quantifying the environment around ourselves … A. You might want to reshuffle it [a and that then becomes something patient’s history] over time, to see that leaves a signature in medical how the predictability changes. And records. In some sense, looking at what we found was that you can medical records and the environpredict even if you shuffle. Which ment in certain regions becomes in a certain sense tells you there are very important.  a series of diseases that occur together. … They are not necessarily The authors were partially funded by developing in a strict order, but it’s General Electric, the AT&T Foundaabout a cluster of things that come tion, the National Science Foundatogether. tion, the National Defense Science At the level of the individual, this and Engineering Fellowship Proallows you to compare the medical gram, and Audi Volkswagen. history to other people, and give additional information to the docReprinted with permission of tor. Doctors can get additional inMIT News put from this analysis of the medical history. Of course this is what Source: doctors already do — they look edu/2015/3-questions-carloat the past in order to understand ratti-big-data-and-health-predicwhat might be the problem. But tions-0707

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research & technology

Further Evidence That Solanezumab Slows Mild Alzheimer’s Disease


he trial, which followed 1,322 people with mild Alzheimer’s disease, showed that the drug was able to slow the decline in memory and thinking skills over time, and suggest that the treatment may be able to slow the underlying disease process. The anti-amyloid treatment solanezumab completed two phase III trials in 2012 (Expedition and Expedition 2), failing to reach its pre-defined endpoints in patients with mild to moderate Alzheimer’s disease. Detailed analysis of the trial results showed that those with mild Alzheimer’s did show some improvements in memory, thinking and function and the drug is currently entering another phase III trial (Expedition 3), only in people in the mild stages of the disease. The researchers then carried out an extension study of the initial Expedition and Expedition 2 trials. In this extension, all patients with mild Alzheimer’s were moved onto solanezumab, which included those originally being given the placebo. The researchers observed the treatment response over a two-year period. The results show that people who had been treated with the drug initially as part of the trial continued to have slower decline than those moved over to the drug from placebo at the start of the extension, with thinking and memory problems reduced by around a third. This treatment effect of solanezumab was maintained over the three and a half year extension study, suggesting the drug could be having a disease-modifying

22 | AUGUST 2015

effect. Dr Eric Karran Director of Research at Alzheimer’s Research UK, the UK’s leading dementia research charity, said: “While everyone was disappointed when solanezumab failed to meet its primary outcome measures in two phase III trials, there was evidence that the treatment was slowing down the disease process in people with mild Alzheimer’s. “The results of the extension study show that those who were treated with solanezumab in the phase III study, and then continued on the drug, saw a sustained improvement over patients initially treated with the placebo and then moved over to the drug later. The results provide encouraging evidence that solanezumab could indeed be acting on the disease processes that drive Alzheimer’s. Although this effect represents a small improvement for people experiencing mild symptoms, it will be important for longer trials to explore whether this treatment could produce greater benefits in the long-term. “While this could be evidence of the first diseasemodifying treatment for Alzheimer’s, the ultimate test will be whether these promising effects repeat again in the third, more targeted, phase III trial in people with mild Alzheimer’s due to finish late next year. We await the results of that trial with great interest.”  Source:

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HIPAA, E-mails, and Texts to Patients or Others

By Kim C. Stanger Holland & Hart LLP

The HIPAA Privacy and Security Rules require covered entities (including healthcare providers and health plans) and their business associates to implement certain safeguards when e-mailing or texting electronic protected health information (“e-PHI�) to patients or others. 24 | AUGUST 2015

E-mails and Texts to Patients The HIPAA Privacy Rule not only allows but requires covered entities to communicate with patients via e-mail or text if requested by the patient. (See 45 CFR 164.522(b)). However, the Privacy Rule requires covered entities to implement appropriate safeguards

when e-mailing or texting e-PHI to patients. The Office for Civil Rights (“OCR”) explained: The Privacy Rule allows covered health care providers to communicate electronically, such as through e-mail, with their patients, provided they apply reasonable safeguards when doing so. (See 45 CFR 164.530(c)). For example, certain precautions may need to be taken when using e-mail to avoid unintentional disclosures, such as checking the e-mail address for accuracy before sending, or sending an e-mail alert to the patient for address confirmation prior to sending the message. Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail. In addition, covered entities will want to ensure that any transmission of electronic protected health information is in compliance with the HIPAA Security Rule requirements at 45 CFR Part 164, Subpart C. (OCR FAQ dated 12/15/08, available here). The HIPAA Security Rule generally requires covered entities and business associates to “[i]mplement technical security measures to guard against unauthorized access to [e-PHI] that is being transmitted over an electronic communications network.” (45 CFR 164.312(e)(1)). Encryption is an addressable implementation standard, meaning that the covered entity or business associate must encrypt the e-PHI if it determines that doing so is “reasonable and appropriate” and, if not, the covered entity or business associate must “(1) Document why it would not be reasonable and appropriate to [encrypt the data]; and (2) Implement an equivalent alternative measure if reasonable and appropriate.” (Id. at (e)(2)). Again, the OCR explained: The Security Rule does not expressly prohibit the use of email for sending e-PHI. However, the standards for access control (45 CFR 164.312(a)), integrity (45 CFR 164.312(c)(1)), and transmission security (45 CFR 164.312(e)(1)) require covered entities to implement policies and procedures to restrict access to, protect the integrity of, and guard against unauthorized access to e-PHI. The standard for transmission security (45 CFR 164.312(e)) also includes addressable specifications for integrity controls and encryption.

This means that the covered entity must assess its use of open networks, identify the available and appropriate means to protect e-PHI as it is transmitted, select a solution, and document the decision. The Security Rule allows for e-PHI to be sent over an electronic open network as long as it is adequately protected. (OCR FAQ available here, emphasis added). Thus, to communicate e-PHI to patients via e-mail or text, the covered entity or business associate has two options: 1. Secure the Transmission The covered entity or business associate may encrypt the e-PHI and/or use other appropriate means to ensure that the e-PHI is secure. As HHS recently stated: In this environment of more online access and great demand by consumers for near real-time communications, you should be careful to use a communications mechanism that allows you to implement the appropriate Security Rule safeguards, such as an email system that encrypts messages or requires patient login, as with a patient portal. If you use an EHR system that is certified under ONC’s 2014 Certification Rule, your EHR should have the capability of allowing your patients to communicate with your office through the office’s secure patient portal. If you attest to Meaningful Use and use a certified EHR system, you should be able to communicate online with your patients. The EHR system should have the appropriate mechanisms in place to support compliance with the Security Rule. You might want to avoid other types of online or electronic communication (e.g., texting) unless you first confirm that the communication method meets, or is exempt from, the Security Rule. (HHS Guide to Privacy and Security of Electronic Health Information at p.31, available here). 2. Warn the Patient If the network or means of communication is not secure and/or the e-PHI is not encrypted, a covered entity or business associate may still communicate with patients via e-mail or text so long as they warn the patient in advance. In its Omnibus Rule commentary, the OCR confirmed: continued on page 26 WWW.MEDMONTHLY.COM | 25

continued from page 25

covered entities are permitted to send individuals unencrypted emails if they have advised the individual of the risk, and the individual still prefers the unencrypted email. We disagree that the “duty to warn’’ individuals of risks associated with unencrypted email would be unduly burdensome on covered entities and believe this is a necessary step in protecting the protected health information. We do not expect covered entities to educate individuals about encryption technology and the information security. Rather, we merely expect the covered entity to notify the individual that there may be some level of risk that the information in the email could be read by a third party. If individuals are notified of the risks and still prefer unencrypted email, the individual has the right to receive protected health information in that way, and covered entities are not responsible for unauthorized access of protected health information while in transmission to the individual based on the individual’s request. (78 FR 5634). E-mails and Texts from Patients The foregoing rules apply to e-mails or texts by the covered entity or business associate to patients; the same rules do not apply to e-mails or texts from the patient. “The Security Rule … does not apply to the patient. A patient may send health information to you using email or texting that is not secure. That health information becomes protected by the HIPAA Rules when you receive it.” (OCR Guide at p.31). Moreover, Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual. If the provider feels the patient may not be aware of the possible risks of using unencrypted e-mail, or has concerns about potential liability, the provider can alert the patient of those risks, and let the patient decide whether to continue e-mail communications. (OCR FAQ, available). In the wake of the Omnibus Rule commentary quoted above, covered entities and 26 | AUGUST 2015

business associates should warn patients of the security risks before responding via unsecure e-mail or text. E-mails and Texts to Other Providers, Employees or Third Parties The HIPAA Privacy and Security Rules also apply to e-mails and texts to persons or entities other than patients. Unlike communications with patients, simply warning the third party that the communication may not be secure is not enough. Thus, although many providers do not think about it, they should generally not communicate e-PHI with their staff or other providers via unencrypted e-mail or text unless they have implemented appropriate safeguards consistent with Security Rule requirements. HHS recently posted the following FAQ for providers: Question: Can you use texting to communicate health information, even if it is to another provider or professional? Answer: It depends. Text messages are generally not secure because they lack encryption, and the sender does not know with certainty the message is received by the intended recipient. Also, the telecommunication vendor/wireless carrier may store the text messages. However, your organization may approve texting after performing a risk analysis or implementing a third-party messaging solution that incorporates measures to establish a secure communication platform that will allow texting on approved mobile devices. (Available here). Suggestions for securing e-mail and text communications are discussed on HHS’s website. Conclusion HIPAA allows covered entities and their business associates to communicate e-PHI with patients via e-mails and texts if either (1) the e-mails and texts are encrypted and/or are otherwise secure; or (2) the covered entity or business associate first warns the patient that the communication is not secure and the patient elects to communicate via unsecure e-mail or text, anyway. When it comes to communicating with non-patients, the covered entity or business associate must generally ensure that its e-mail or texts comply with relevant Privacy and Security Rule standards.  Source:


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Under Stark, “Value” Doesn’t Mean “Expensive”

By Walter L. Williams, Member, and Cara N. Parcell, Associate Steptoe & Johnson PLLC

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The federal Stark law prohibits physician referrals of “designated health services” payable by Medicare to entities with which the physician or an immediate family member has a financial relationship, unless the arrangement meets an exception. Enforcement initiatives aim at extending the reach of Stark to Medicaid as well. Various types of arrangements create financial relationships and, subject to certain defined exceptions and among other types of arrangements, a financial relationship will exist when a referring physician or an immediate family member receives “remuneration.” The Centers for Medicare & Medicaid Services (“CMS”) has interpreted remuneration as including items of limited value. For that reason, the provision of anything of value, no matter how little, must be carefully considered, as the consequences of having a financial relationship that does not meet an applicable Stark exception, if any, can have catastrophic legal and financial consequences. Guidance from CMS and one enforcement case reveal just how expansive the reach of Stark can be. In a 2013 CMS Advisory Opinion, a provider of clinical laboratory services wanted to give free Pap smear specimen collection kits to physicians for use in collecting and submitting samples to the lab. According to one commentator, the kits had limited value. The lab would ensure that the number of kits provided to a physician was consistent with the physician’s practice needs. In addition, the free devices were disposable, were not reusable, and had no practical use other than the intended specimen collection. CMS determined that the devices fell within an ex-

ception to the definition of remuneration because they were “used solely to collect, transport, process or store specimens.” The arrangement therefore did not violate the Stark law, but the agency cautioned that an arrangement for items other than “single use” devices may result in a different conclusion. As an example of just how fine that distinction may be, in another 2013 opinion, CMS determined that a different single use device resulted in remuneration and constituted a financial relationship under the Stark law. In that scenario, a laboratory services corporation wanted to provide physicians with free devices used in obtaining abnormal cervical biopsies. According to a pathology blog, one such possible device may have been valued at approximately $10.80. As with the prior scenario, the device was single use. In this case, however, CMS determined that the biopsy of abnormal cells, rather than a routine Pap smear, constituted a surgical procedure, making the device at issue a “surgical device” (i.e., not “used solely to collect, transport, process or store specimens”), resulting in an exchange of value to the recipient and causing the arrangement to fall within the Stark law. (The opinion did not address whether the arrangement met any exception to the self-referral prohibition.) A 2014 Florida case also highlights the potential liability an entity faces when it crosses this delicate line. In Ameritox, LTD v. Millennium Laboratories, Inc., Millennium Lab provided free urine collection cups to physicians for use in urine analysis. The cups were relatively inexpensive (valued at approximately $11.00 according to one commentator and


For that reason, the provision of anything of value, no matter how little, must be carefully considered, as the consequences of having a financial relationship that does not meet an applicable Stark exception, if any, can have catastrophic legal and financial consequences.

approximately $5.00 by another) but included testing strips for immediate sample analysis. Because the cups included testing strips, the government took the position that they did not fall within the laboratory supplies exception and constituted remuneration for Stark purposes, even though the physicians had agreed not to bill for the cups. A jury subsequently imposed $2.755 million in actual damages for violation of the Stark law and Anti-Kickback statute and over $8.5 million in punitive damages based on unfair competition and tortious interference. These examples underscore the importance of ensuring that any arrangement with a referring physician or immediate family member involving any item of value, however small, falls within an enumerated Stark exception and/or does not fit within the definition of “remuneration.” Failure to do so, even for seemingly inexpensive items, can lead to significant penalties.  Source: http://www.steptoe-johnson. com/content/under-stark-valuedoesn-t-mean-expensive WWW.MEDMONTHLY.COM | 29


How to Build a Channel of Effective Doctor Patient Communication

By Naren Arulrajah with Vikas Vij Ekwa Marketing

Effective communication is one of the most important facets of a doctor patient relationship. This fragile and delicate relationship 30

| AUGUST 2015

needs to be nurtured carefully. And the best way to do this is by building a channel of clear and effective communication. Patients come to

you because they trust in your skills and expertise as a doctor. They also expect their doctor to adopt a clear and compassionate approach to

communicating with them. However, in today’s time driven environment, developing a channel of effective communication is big challenge. Doctors are hard pressed for time as there is an increased emphasis on clinical productivity. The window of opportunity thus for building the doctor patient relationship is becoming smaller. In such a situation, is it possible for doctors to focus on improving patient relationship and experiences? The answer is yes. Here are a few things to keep in mind.

The Listening Doctor Effective communication between a doctor and a patient can only happen when the trust factor is established and reinforced at every stage of patient interaction. Start by listening to your patients more. Listening implies a personal interest and this is what patients want from their doctors. When your patients talk – try not to interrupt or dominate the conversation. Help the conversation along by asking open-ended questions. This not only encourages patients to clearly describe their condition but it also allows them to openly discuss their fears and concerns about an illness. The greatest advantage of improving listening skills – is that it allows doctors to take better treatment decisions while also building care plans that are more in accordance to patient expectations. When this happens, patients are not only encouraged to actively be a part of their treatment options but they find it easier to follow the care plan. Another benefit of listening – is that doctors can easily tune into

any patient questions or fears or any kind of confusion or misunderstandings that a patient might have. Incomplete information is just as dangerous as incorrect information. To counter this situation, ask your patients to summarize their understanding of the treatment and care plan.

Compassion, Empathy, Sensitivity – Don’t forget the Human Angle As a doctor you meet a wide section of patients from different cultural backgrounds and gender preferences, as well as different race and religions. Effective communication in these cases becomes as much a matter of clearly communicating information as it is about being sensitive to these differences. What goes unspoken can often introduce a certain bias in the doctor patient relationship. The biggest danger here is that it can limit patient choices which in turn can put a patient’s health at risk. Awareness and sensitivity is the only way to avoid being presumptuous; what you say and what you don’t say, the kind of counsel you provide, as well as the kind of follow-up care you suggest can heavily impact your patient interaction. Doctor patient interaction lasts beyond just a moment – • It is based on a culture of establishing a connection. • Ensuring that patients are aware of and understand their options. • Responding to patient needs and expectations. • Helping patients achieve their desired outcomes. The best way to meet the above four goals is by increasing the duration of patient visits whenever

possible. This makes it easy for doctors to address not only the core issues and concerns of a patient, but it allows doctors an opportunity to address multiple patient concerns. Again, it allows for a more personalized doctor patient interaction as the scope for better understanding a patient’s condition and his subsequent worries gets expanded.

9 Steps to Improving Patient Interactions • Instruct and train your staff to be alert and responsive to patient questions, needs and expectations. • Limit the use of medical jargon. Quality healthcare after-all is less about showing what you know, and more about imparting information in a way that is easy to understand and of maximum use to your patients. Realworld analogies and simple language always work best. • Don’t rush through information that is important. If you are hard pressed for time, you can always ask your patients to communicate via email or even suggest the patient asks his questions in the next visit. Make sure you repeat important elements of your discussion and don’t forget to ask if your patient understands the information. • Keep an open mind to patient fears and concerns. The best way to put your patients at ease is by displaying kindness and empathizing with them. • If a patient comes in with a companion, patiently respond to questions from the companion. continued on page 32 WWW.MEDMONTHLY.COM | 31

continued from page 31

• If you need to discuss complications or any kind of negative information, encourage the patient to ask questions or to air their doubts. Try to be candid and provide as much information and assurance. • If a patient has been referred from another physician first help the patient better understand the facts and details of his condition before suggesting treatment options and care plan. • Encourage patients to write down their questions prior to an appointment. You can make these question forms available at the office or even provide them online. This can help save time and provide a more meaningful direction to your conversations. • One of the best ways of dealing with time restrictions is by hiring non-physician health care providers. An advanced practice nurse or physician assistant who has good patient-centric interviewing skills can help with established patients.  About the Author: Naren Arulrajah is President and CEO of Ekwa Marketing, a complete Internet marketing company which focuses on SEO, social media, marketing education and the online reputations of Dentists and Physicians. With a team of 130+ full time marketers, helps doctors who know where they want to go, get there by dominating their market and growing their business significantly year after year. If you have questions about marketing your practice online, call Naren direct at 877-249-9666. 32

| AUGUST 2015

PRESS RELEASE July 27, 2015

For Immediate Release

Physician Solutions Offers Step Discounts to North Carolina County Health Departments Raleigh, North Carolina - Today Physician Solutions, North Carolina’s oldest Physician and Dental staffing agency, announced a step reduction in their rates for short and long term medical doctors, physician assistants, nurse practitioners, dentist and registered dental hygienist staffing. For 26 years, we have been the go-to agency for NC County Health Departments. “We provide dozens of doctors and dentist on ‘As Needed’ bases every week in all parts of the state. Many times our staffing request arise suddenly, so we have to be ready to respond with the phone rings”, Philip Driver, CEO of Physician Solutions states. “County health departments receive a 20 to 30 percent discount from private practice clients. This is due in large part because of relationships that have been developed and proximity of the providers to the health department in many cases. Physician Solutions also supports North Carolina County Health Departments with charitable contributions, specialized shirts, food and event funding to help promote health care in the local communities through their local county health department”, Driver continues. This Press Release can be re-printed by Medical Boards, Medical Associations, News Agencies, Reporters and State and County agencies. You can also download a copy of this Press Release at WWW.MEDMONTHLY.COM | 33


How to Improve Medical Care of the Non-compliant Patient By Carrie A Noriega, MD


e have all had the patient that just won’t follow the medical recommendations that they are given, no matter how many times we explain to them why it is so important. My worst experience was with a pregnant diabetic who refused to follow a diabetic diet and kept trying to overcompensate for this by adjusting her insulin. At 31 weeks gestation, she was brought to the hospital unconscious with a blood sugar of only 31. In the process of evaluating her in the labor and delivery triage area, she went into cardiac arrest. While the resuscitation team was performing CPR, the operating room team was taking her back to the O.R for an emergency cesarean for severe fetal bradycardia.

34 | AUGUST 2015

In the end, I was able to deliver a viable baby girl safely, who was immediately taken to the NICU for what was to be a rough few months. During the cesarean, the patient got a pulse again and was stabilized. The mom spent a few days in the ICU, eventually recovered and went home. When it was all over, I was left wondering if this entire situation could have been prevented if I had only done things differently and convinced the patient to comply better with her care. I began researching for better ways to communicate with non-compliant patients and found several good ideas. One method that I did find useful in working with patients to achieve better compliance was the following ‘SIMPLE’ mnemonic [Atreja 2005].

S- Simplify the regimen I- Impart knowledge M- Modify the patient’s beliefs P- Patient communication L- Leaving the bias E- Evaluating adherence This method recommends making the treatment course or the drug regimen as simple as possible to help patients achieve better compliance. One thing that may help patients take their medications as prescribed is to reduce the number of pills a patient has to take every day by using a combination medication, if available. Trying to find medications with fewer dosing requirements or a more comfortable delivery system may also motivate patients to take their medications regularly. Writing everything down for patients while they are in the office is also useful in reducing any confusion about what was discussed during their office visit and may motivate the patient to follow the written instructions when they are at home. Helping the patient understand what the illness is that they are being treated for and how the recommended treatment is going to make them feel better or improve their quality of life is key. It is important to take the time to explain the patient’s medications or treatment, how it will impact their illness, and why it is important to the patient’s health. If you can convince the patient that what you are asking them to do will have a real benefit on their health, they may be more willing to follow the recommendations. In general, the more the patient understands about their disease and treatment, the more likely they are to follow the recommendations they were given. Managing patients with a chronic disease can be especially challenging because there is no specific end point to their care. You can’t just tell them to take something for 10 days and then they are cured. It

takes a long-term commitment from the patient, so it is important to take the time to understand what the patient believes about their disease and what their intentions are for treating it. Addressing the following has been shown to help improve compliance [Atreja 2005]: - The patient needs to understand their disease is serious - They have to perceive that they are at risk if they don’t comply with healthy behavior - They need to believe their medical regimen will improve their outcome - They must have methods to address their fears about their disease or the treatment - They need to believe that they are capable of changing so they can follow the medical recommendations All of these can only be accomplished through good patient-physician communication, plenty of time, and sometimes, a lot of patience. One challenge in dealing with non-compliant patients that is frequently overlooked by physicians is the physician’s own bias. While treating patients, it is always important to never assume a patient is following the recommended treatment based solely on their education, sex, race, income, occupation, or ethnicity. Studies don’t support compliance of a patient based on any of the previously mentioned factors. Every patient needs to be evaluated for compliance by simply asking them if they ever forget to take their medications or are careless about taking them and whether or not they are following the medical recommendations they were given. By directly asking the patients what they are and are not doing, it can help better direct conversations about compliance. By following the SIMPLE method, compliance can be improved and so can outcomes. However, this clearly will not solve all patient compliance problems. Sometimes the physician-patient relationship just won’t work and in these situations, it is frequently best for both parties to end the relationship. But, when possible, putting in a little extra time and effort with a patient may significantly enhance the results the patient is able to achieve with their health.  References: Atreja A, Bellam N, Levy S. Strategies to enhance patient adherence: Making it simple. Medscape General Medicine. 2005; 7(1): 4. WWW.MEDMONTHLY.COM | 35



Have You Gone Virtual Yet? What exactly is telemedicine? And, how has telemedicine evolved from traditional phone calls, consults, or nurse triage that you have been doing for years to communicate with and care for your patients? According to the American Telemedicine Association, telemedicine can be defined as “the use 36

| AUGUST 2015

of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology.”¹

As a part of telemedicine, a virtual consultation is “an internet physician consultation for which, depending on the diagnosis, medical therapy may be prescribed.”²

Types of telemedicine: • The most basic form of telemedicine includes a phone consultation with a patient

website or patient portal, or use of an app on a computer, laptop, or smartphone. • One of the more recent and growing forms of telemedicine adds a video component, finally allowing the provider to see the patient, providing a basic form of physical exam and more personal interaction. • Finally, specialized technology and equipment can be used to allow a physician to complete a more thorough physical exam, by using tools such as an electronic stethoscope or remote vital sign monitoring, or by having a nurse at a location with the patient performing the exam while the specialist provider watches and guides the exam. In addition to the different forms telemedicine may take, several different situations exist where virtual visits may provide care:

By Laura E. Marusinec, MD Urgent Care Pediatrician, Medical Writer

by a provider with access to the patient’s electronic health record. It can also be as simple as a provider reviewing an x-ray taken at the hospital from his or her office computer. • The next step would be to add an internet function such as symptom or other health questionnaires, email, use of a

• A specialist helping manage patients in remote, rural, or other underserved areas via a virtual consult is one of the most accepted uses of telemedicine. Specialists may consult with the primary care provider or directly with the patient, reducing the need for the patient to physically attend a visit with a specialist that may be hundreds of miles away. • Primary care or specialists also use telemedicine to help manage patients with chronic conditions, who may require frequent contact. This can reduce the number of in-office visits, which can be especially helpful for patients with decreased mobility or other difficulties getting to appointments.

• Finally, the most controversial use of telemedicine is for acute care visits, especially when provided by providers without an established relationship with the patient. Acute care virtual visits are growing rapidly, similar to the growth in retail and freestanding urgent care clinics.

Benefits of telemedicine: To patients: • As noted above, telemedicine can give patients access to providers, both generalists and specialists, for routine care that they may not otherwise have due to geography, shortage of providers, or difficulty with mobility or transportation. • Convenience is a large factor in many acute care virtual visits. Patients don’t have to leave home or work to get care, nor do they have to wait in long lines at an urgent care or emergency department. They can often obtain a virtual consult almost any time of the day or night with little delay. • Many virtual visits provide significant cost savings to patients. Direct fees are often around $50, compared to hundreds of dollars for an office, urgent care, or emergency department visit. And, many insurance companies are starting to cover virtual visits similar to office visits. In addition, patients would not lose income from missing work to attend a traditional visit.

To providers: • Telemedicine can help providers maintain better contact and continuity with their patients, continued on page 38 WWW.MEDMONTHLY.COM | 37

continued from page 37

strengthen the doctor-patient relationship as well as communication between patients, primary care providers (PCPs), and specialists. This also helps improve compliance and can lead to better health outcomes.

especially those with chronic conditions. Providers who choose to incorporate virtual visits into their practice can also improve patient satisfaction and help satisfy various criteria for a Patient Centered Medical Home Challenges: (PCMH). • One significant challenge to • Providers can now receive comvirtual visits is the inability to pensation for virtual visits that perform a complete physical in the past would have been exam. Even with video, withuncompensated telephone calls. out the specialized technology • Virtual visits may reduce some currently available to just a few, of the caseload in the office and you can’t listen to lungs, look can reduce overall work hours. in ears, or palpate abdomens. • A primary care provider may This increases the risk of overalso obtain a virtual consultaand misdiagnosis. And, while tion with a specialist, which video consults can be “face-tobenefits the patient, but also face”, they still lack the personal benefits the provider in the interaction of being in the same form of increased knowledge room and perhaps providing a and education, which often comforting touch to a patient extends beyond the specific you know well whose health is patient. fading. • In addition, some providers • When the patient is in your may choose to practice within office, you may easily check a a telemedicine group, allowpulse ox or run a rapid strep ing them flexibility in hours, test or urinalysis. Patients may the ability to work from home, often walk down the hall for an decreased stress, and an added x-ray and wait for the results source of income. which will immediately guide To Society: the therapeutic plan. Not so for virtual visits. • Cost savings provided when • Virtual visits have the potenvirtual visits replace a portion tial to increase costs if they are of traditional office visits benefit used when home treatment society as well as individual would otherwise suffice, again, patients. Virtual visits are usuespecially if obtained with a ally associated with decreased provider outside their medical insurance costs from provider home. As patients can access and facility charges, as well these visits easily and with low as decreased lost income and costs, they may be more likely productivity from missed work. to use these services for minor In addition, nurse practioners conditions that could be mancan often provide many of these aged without a visit. In addivisits, also reducing total costs tion, virtual visits apart from and physician workload. the PCMH may lead to duplica• Telemedicine conducted as tion of services. part of the PCMH can help 38 | AUGUST 2015

• Telemedicine, especially using new technology such as Skype, must meet the same strict privacy and security requirements for HIPPA as traditional healthcare entities. Currently, this is not always clear, and a provider may put himself at risk of violations if a breach occurs, unless HIPPA compliance is strictly met. • Virtual visits can increase fragmentation of care and threaten the goals of the PCMH when conducted separate from the medical home. In addition, patients seeking care outside of the medical home leads to missed opportunities for preventive care. Although most providers recognize the importance and value of preventive care and a relationship with a PCP, unfortunately, not all patients do.

How can you examine patients without being there physically? • While limits exist, video consults at least allow a physician to see the patient. Sometimes you just need to see how your patient looks. Do they “look sick”? This is especially important in pediatrics, when the parents are very nervous and worried that their child is sick. Just being able to see the patient and see–are they active? Are they breathing fast or having trouble breathing? Do they have a cough, wheeze, or stridor? Do they appear well-hydrated? Are they uncomfortable or in pain? Do they have a rash? • You may be even able to examine a few more things with the help of a flashlight and perhaps a family member, such as a look

at the throat and eyes. However, most of us and our patients won’t have access to an electronic stethoscope or otoscope. With providing a limited physical exam, a video consult does give added benefit to a traditional phone visit and can function like a hybrid between a phone call and an actual office visit. In some cases, the information gathered may be enough to provide a diagnosis and treatment plan. In others, it may help you decide if the patient may continue treatment at home, follow-up in the office in a few days, or if they should be seen in an urgent care or ED.

such as the AAP find most concerning is the potential fragmentation of the primary doctor-patient relationship when patients seek virtual visits outside of the PCMH. This is especially true when the virtual providers do not share comHow can telemedicine fit munication and medical records into our evolving health- with the PCMH team, most often seen in independent virtual consulcare system and maybe tation services. even in your practice? In fact, the AAP just released a In general, a certain subset of policy statement, “The Use of Teleacute conditions that don’t require medicine to Address Access and a full exam are best suited for acute Physician Workforce Shortages”³, virtual consult such as rashes, which finds significant benefits of colds, sinus infections, minor skin increased access, efficiency, cost, wounds, pinkeye, allergies, gastroand quality of care with telemedienteritis, bug bites, and UTIs in cine provided as part of the PCMH. adults. Many providers of acute vir- However, the committee strongly tual visits have a list of symptoms cautions against the use of telemedor diagnoses that can be evaluated, icine for episodic care outside of allowing that the patient still may the medical home, especially when be referred for a traditional visit if used to replace the medical home the situation warrants. Services are or disrupt continuity of care. usually more restrictive for pedi Like traditional urgent care clinatric patients. Telehealth providers ics, telemedicine shouldn’t attempt should clearly define that virtual to replace a relationship with a PCP, visits should not be used for medibut done correctly, it can complecal emergencies. ment that relationship. In addition, In addition, as noted prior, many virtual consults can even be part follow-up visits for chronic condiof the medical home if the PCP oftions, especially to discuss sympfers these services to their patients toms and treatment compliance, as or has a close relationship with a well as certain specialty consults, provider of these visits. Similar to may be appropriately done virtually. urgent care, independent providers The area which most primary of virtual visits can align with PCPs, care providers and organizations healthcare organizations, or hos-

pitals instead of being completely separate from and competing with them. And, like urgent care, telemedicine and virtual consults are likely here to stay and are going to continue to increase in number and scope. Virtual consults definitely have a place in medicine, and, as long as they are structured to complement the goals of the PCMH and not try to replace it, they can help improve the quality of your patients’ care and their satisfaction, while improving efficiency and access to care, and reducing costs. Chances are many of your patients are interested in or already getting care by telemedicine. If you haven’t gotten on board yet, you may want to get more information about how you can use telemedicine in your practice.  Resources: 1. 2. 3. doi/10.1542/peds.2015-1253. 4. http://www.telehealthtechnology. org/sites/default/files/documents/ HIPAA%20for%20TRCs%202014. pdf 5. http://www.nytimes. com/2015/07/12/health/moderndoctors-house-calls-skype-chat-andfast-diagnosis.html?_r=0 WWW.MEDMONTHLY.COM | 39


One Doctor’s Approach to Better Doctor-Patient Communication By Christine Chen, M.D.

40 | AUGUST 2015

In today’s time-pressured healthcare environment, doctors (especially those of us in primary care) have more to do than ever before. Between patient visits, charts, computer glitches, prescription refills, and emergency walk-ins, it’s tempting to shave off time wherever possible. But there’s one area where we should invest more time, rather than less: communication. Good doctorpatient communication is crucial to the therapeutic relationship. It can improve patient compliance, resulting in better medical outcomes—and it may help us avoid litigation. Here are some of the techniques I’ve used to enhance my communication with patients. Some are well-known and taught in most medical schools. Others, however, are the product of 10 years of personal experience.

Be gracious. • Make eye contact, smile, and offer a firm handshake. Seems elementary, but the advent of EMR (electronic medical records) means that many doctors now carry laptops or other computing devices into the examination room. Computerization has definite advantages, including automation, searchability, and legibility; however, one of its biggest disadvantages is the tendency for users to focus on the computer screen without acknowledging the patient. A friendly greeting goes a long way to counter this. Make sure you and your staff don’t inadvertently turn your backs to the patient while entering electronic information. I also try to look at the patient whenever asking a question, and if the conversation turns especially emotional or sensitive, I ignore the computer altogether. • Apologize for a lengthy wait, if applicable. If the patient’s been waiting for more than half an hour, most likely he’s growing more resentful with each passing minute. A brief but sincere apology restores some goodwill, and makes the patient more receptive to the rest of your explanations and instructions. • Acknowledge the patient’s discomfort. Recently, I’ve found myself opening my visits with the empathetic phrase, “I’m sorry you’re not feeling 100 percent today.” This statement lets the patient know, from the outset, that you care. It also helps if you’ve diagnosed the patient with a troublesome but self-limited condition for which there

is no definite treatment—for example, a viral sore throat. You can empathize with the patient’s plight while highlighting that time is the only likely cure: “This is probably a virus, which means there’s not a magic bullet for it. I know it feels rotten, though.” • Wrap up the visit with a wish for a speedy recovery. Simply say, “I hope you feel better soon.” Again, this phrase might seem elementary, but it builds rapport and empathy, and increases the chance that the patient will return to your office.

Consider your audience. • Address fears and anxieties first. I love to share my medical knowledge; it’s satisfying to know I’ve expanded a patient’s understanding. But most patients are less interested in an encyclopedic review of disease pathophysiology than they are in the following questions: Is this serious? If so, could I die? If not, how do I fix it fast? Do I need an antibiotic? Am I having a heart attack? Could I have cancer? The patient may never ask these out loud. But these questions are borne of fear and anxiety, and until they’re addressed, the patient probably won’t hear any of the other information you have to share. • Feed your patient with a small spoon. Once you’ve addressed the patient’s worries, feed your patients bite-sized chunks of information—no more than 2 or 3 sentences at a time. Studies in health literacy have shown that patients understand medical information better when it’s presented in small chunks. • Use simple language and avoid jargon. According to a 2005 article in American Family Physician1, most patients—even those who have completed higher levels of education--prefer to read at a grade school level. Generally, I try to use words with fewer syllables; “infected bowel” is easier to understand than “diverticulitis.” Occasionally, of course, a patient will express an interest in knowing the more technical aspects of their condition, and I’m happy to oblige them. continued on page 42 WWW.MEDMONTHLY.COM | 41

continued from page 41

• Draw pictures or use analogies to illustrate concepts. A picture is worth a thousand words. I’ve found these most helpful when explaining ductwork/circulation/plumbing or hormonal feedback loops. You don’t have to be Leonardo da Vinci, as long as the patient grasps the proper spatial relationships. Analogies are also helpful, because they quickly capture the essence of difficult concepts and translate them into common, straightforward situations. When my patients ask how their water pill helps lower blood pressure, I ask them to imagine letting some liquid out of a near-bursting water balloon. Make sure, though, that the analogies you choose are easily relatable to the patient. • Use an interpreter when appropriate. This is important to consider if you have doubts about your patient’s English proficiency. To preserve the integrity of the translated information, it’s best if the interpreter has formal training and is not simply a bilingual family member. The Association of American Medical Colleges provides information on how to properly select and use medical interpreters.2 Some offices have translator phones set up in certain rooms to facilitate this process.


But there’s one area where we should invest more time, rather than less: communication. Good doctor-patient communication is crucial to the therapeutic relationship.

Anticipate post-visit needs. • Invite questions and check for understanding before the patient leaves. When it’s especially important for a patient to understand my instructions, I’ll ask them to repeat back what I said. This is sometimes known as the “teach-back method.” If your instructions contain more than 2 steps, consider writing them down. • Provide written instructions or reference material at the end of the visit. Most popular sources agree that people remember only a fraction of what they’re told. Counter this by providing written material for patients to refer to at home. Some EMR programs can link directly to health education websites, which means you can generate handouts with the click of a button. Alternatively, you may want to create your own library of commonly discussed topics (symptomatic treatment of viral colds, for example) and hand paper copies to patients as they leave. If you do provide handouts, remember the basic literacy guidelines discussed above: make sure the articles avoid jargon and are written at a grade-school level.

Listen more than you talk. • Ask open-ended questions. Most medical students learn this during medical school, but once they graduate to the time constraints of real-world practice, there’s a temptation to proceed straight to rapid-fire “yes or no” questions. However, when used correctly, open-ended questions can actually elicit more information than you originally intended. Instead of asking, “Is the pain sharp?” consider saying, “How would you describe the pain?” • Observe the patient. Another advantage of openended questions is that they buy you time to watch the patient and notice what’s behind the words. Picking up and responding to nonverbal cues is an important part of good communication. Did the patient’s eyes glaze over? Maybe you’re hitting him with too much information too quickly. Did she suddenly tear up? Maybe it’s been a stressful week. Did he just frown? Maybe he’s unhappy with the treatment you’re suggesting. Did he meet your gaze, or avoid it? Maybe he isn’t telling you the whole story. 42 | AUGUST 2015

Remember, good doctor-patient communication is key to keeping our patients healthy…but they’re not the only ones who benefit. For me, there’s something intrinsically satisfying about connecting with a patient and knowing they understand a medical condition better than they did before. The above techniques help get me there, and hopefully they can help you too. Good luck!  Safeer RS, Keenan J. Health Literacy: The Gap Between Physicians and Patients. Am Fam Physician. 2005 Aug 1;72(3):463-468. 2 Juckett G, Unger K. Appropriate Use of Medical Interpreters. Am Fam Physician. 2014 Oct 1;90(7):476-480. 1

What’s your practice worth? When most doctors are asked what their practice is worth, the answer is usually, “I don’t know.” Doctors can tell you what their practices made or lost last year, but few actually know what it’s worth. In today’s world, expenses are rising and profits are being squeezed. A BizScore Performance Review will provide details regarding liquidity, profits & profit margins, sales, borrowing and assets. Our three signature sections include:  Performance review  Valuation  Projections

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healthy living

Blackberry Jam By Ashley Acornley, MS, RD, LDN There is nothing better than fresh berries in the summertime and July happens to be the perfect time to get them. This blackberry jam is not only delicious and simple, but also naturally sweet and loaded with nutrients. Add it to your morning toast and English muffin or enjoy on your lunchtime PB&J. Why go out and buy store bought jam, filled with added sugars and preservatives, when you can make your own!

Ingredients: Servings: 6 Servings Yields: 1 cup of Jam 1 cup blackberries 1 medium peach, peeled, cored and cut into cubes 1 tablespoon lemon juice 1 tablespoon honey (or agave if preferred) 2 tablespoons chia seeds

Nutrition Facts Per Serving Preparation: In a small saucepan over medium heat, combine the blackberries, cubed peach, and lemon juice. As the fruit heats up and the juices bubble, smash the fruit using the back of a fork or a masher until they break down. This should take 3 to 5 minutes. Sweeten the mashed fruit with about one tablespoons of honey (more if you prefer sweeter jam). Add the chia seeds and stir once. Remove from the heat and let the jam set for about 5 minutes to thicken. Cool and transfer to an airtight container and refrigerate. (This jam will keep for 2 weeks in the fridge!) 44

| AUGUST 2015

Calories: 52 Fat: 1.1g Carbs: 10.6g Fiber: 2.7g Sugars: 7.4g Protein: 1.1g Sodium: 1mg

U.S. OPTICAL BOARDS Alaska P.O. Box 110806 Juneau, AK 99811 (907)465-5470 cbpl/ProfessionalLicensing/DispensingOpticians.aspx Arizona 1400 W. Washington, Rm. 230 Phoenix, AZ 85007 (602)542-3095 Arkansas P.O. Box 627 Helena, AR 72342 (870)572-2847 California 2005 Evergreen St., Ste. 1200 Sacramento, CA 95815 (916)263-2382 Colorado 1560 Broadway St. #1310 Denver, CO 80202 (303)894-7750 Connecticut 410 Capitol Ave., MS #12APP P.O. Box 340308 Hartford, CT 06134 (860)509-7603 ext. 4 asp?a=3121&q=427586 Florida 4052 Bald Cypress Way, Bin C08 Tallahassee, FL 32399 (850)245-4474 Georgia 237 Coliseum Dr. Macon, GA 31217 (478)207-1671 plb/20 Hawaii P.O. Box 3469 Honolulu, HI 96801 (808)586-2704 dispensingoptician/

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U.S. DENTAL BOARDS Alabama Alabama Board of Dental Examiners 5346 Stadium Trace Pkwy., Ste. 112 Hoover, AL 35244 (205) 985-7267 Alaska P.O. Box 110806 Juneau, AK 99811-0806 (907)465-2542 ProfessionalLicensing/BoardofDentalExaminers.aspx Arizona 4205 N. 7th Ave. Suite 300 Phoenix, AZ 85103 (602)242-1492

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Illinois 320 W. Washington St. Springfield, IL 62786 (217)785-0820

California 2005 Evergreen Street, Suite 1550Â Sacramento, CA 95815 877-729-7789

Indiana 402 W. Washington St., Room W072 Indianapolis, IN 46204 (317)232-2980

Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7800

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Florida 4052 Bald Cypress Way Bin C-08 Tallahassee, FL 32399 (850)245-4474 46

Georgia 237 Coliseum Drive Macon, GA 31217 (478)207-2440

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Louisiana 365 Canal St., Suite 2680 New Orleans, LA 70130 (504)568-8574

Maine 143 State House Station 161 Capitol St. Augusta, ME 04333 (207)287-3333 Maryland 55 Wade Ave. Catonsville, Maryland 21228 (410)402-8500 Massachusetts 1000 Washington St., Suite 710 Boston, MA 02118 (617)727-1944 dentist/ Michigan P.O. Box 30664 Lansing, MI 48909 (517)241-2650,4601,7154-35299_28150_27529_27533---,00. html Minnesota 2829 University Ave., SE. Suite 450 Minneapolis, MN 55414 (612)617-2250 Mississippi 600 E. Amite St., Suite 100 Jackson, MS 39201 (601)944-9622 Missouri 3605 Missouri Blvd. P.O. Box 1367 Jefferson City, MO 65102 (573)751-0040 Montana P.O. Box 200113 Helena, MT 59620 (406)444-2511 boards/den_board/board_page.asp

Nebraska 301 Centennial Mall South Lincoln, NE 68509 (402)471-3121 crl_medical_dent_hygiene_board.aspx

Ohio Riffe Center 77 S. High St.,17th Floor Columbus, OH 43215 (614)466-2580

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Rhode Island Dept. of Health Three Capitol Hill, Room 104 Providence, RI 02908 (401)222-2828

New York 89 Washington Ave. Albany, NY 12234 (518)474-3817

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Texas 333 Guadeloupe St. Suite 3-800 Austin, TX 78701 (512)463-6400 Utah 160 E. 300 South Salt Lake City, UT 84111 (801)530-6628 Vermont National Life Building North FL2 Montpelier, VT 05620 (802)828-1505 and_commissions/dental_examiners Virginia Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4538 Washington 310 Israel Rd. SE P.O. Box 47865 Olympia, WA 98504 (360)236-4700 West Virginia 1319 Robert C. Byrd Dr. P.O. Box 1447 Crab Orchard, WV 25827 1-877-914-8266 Wisconsin P.O. Box 8935 Madison, WI 53708 1(877)617-1565 aspx?Page=90c5523f-bab0-4a45-ab943d9f699d4eb5 Wyoming 1800 Carey Ave., 4th Floor Cheyenne, WY 82002 (307)777-6529


U.S. MEDICAL BOARDS Alabama P.O. Box 946 Montgomery, AL 36101 (334)242-4116 Alaska 550 West 7th Ave., Suite 1500 Anchorage, AK 99501 (907)269-8163 ProfessionalLicensing/StateMedicalBoard.aspx Arizona 9545 E. Doubletree Ranch Rd. Scottsdale, AZ 85258 (480)551-2700 Arkansas 1401 West Capitol Ave., Suite 340 Little Rock, AR 72201 (501)296-1802 California 2005 Evergreen St., Suite 1200 Sacramento, CA 95815 (916)263-2382 Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7690 Connecticut 401 Capitol Ave. Hartford, CT 06134 (860)509-8000 asp?a=3143&q=388902 Delaware Division of Professional Regulation Cannon Building 861 Silver Lake Blvd., Suite 203 Dover, DE 19904 (302)744-4500 District of Columbia 899 North Capitol St., NE Washington, DC 20002 (202)442-5955 48 | AUGUST 2015

Florida 2585 Merchants Row Blvd. Tallahassee, FL 32399 (850)245-4444 DesktopDefault.aspx?tabid=115

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Massachusetts 200 Harvard Mill Sq., Suite 330 Wakefield, MA 01880 (781)876-8200

Illinois 320 West Washington St. Springfield, IL 62786 (217)785 -0820

Michigan Bureau of Health Professions P.O. Box 30670 Lansing, MI 48909 (517)335-0918,4601,7154-35299_28150_27529_27541-58914-,00.html

Indiana 402 W. Washington St. #W072 Indianapolis, IN 46204 (317)233-0800 Iowa 400 SW 8th St., Suite C Des Moines, IA 50309 (515)281-6641 Kansas 800 SW Jackson, Lower Level, Suite A Topeka, KS 66612 (785)296-7413 Kentucky 310 Whittington Pkwy., Suite 1B Louisville, KY  40222 (502)429-7150

Minnesota University Park Plaza 2829 University Ave. SE, Suite 500  Minneapolis, MN 55414 (612)617-2130 Mississippi 1867 Crane Ridge Drive, Suite 200-B Jackson, MS 39216 (601)987-3079 Missouri Missouri Division of Professional Registration 3605 Missouri Blvd. P.O. Box 1335 Jefferson City, MO  65102 (573)751-0293

Montana 301 S. Park Ave. #430 Helena, MT 59601 (406)841-2300 boards/med_board/board_page.asp Nebraska Nebraska Department of Health and Human Services P.O. Box 95026 Lincoln, NE 68509 (402)471-3121 state-licensing-boards/nebraska-boardof-medicine-and-surgery Nevada Board of Medical Examiners P.O. Box 7238 Reno, NV 89510 (775)688-2559 New Hampshire New Hampshire State Board of Medicine 2 Industrial Park Dr. #8 Concord, NH 03301 (603)271-1203 New Jersey P. O. Box 360 Trenton, NJ 08625 (609)292-7837 New Mexico 2055 S. Pacheco St. Building 400 Santa Fe, NM 87505 (505)476-7220 New York Office of the Professions State Education Building, 2nd Floor Albany, NY 12234 (518)474-3817 North Carolina P.O. Box 20007 Raleigh, NC 27619 (919)326-1100

North Dakota 418 E. Broadway Ave., Suite 12 Bismarck, ND 58501 (701)328-6500

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Vermont P.O. Box 70 Burlington, VT 05402 (802)657-4220 Virginia Virginia Dept. of Health Professions Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4400 Washington Public Health Systems Development Washington State Department of Health 101 Israel Rd. SE, MS 47890 Tumwater, WA 98501 (360)236-4085 West Virginia 101 Dee Dr., Suite 103 Charleston, WV 25311 (304)558-2921 Wisconsin P.O. Box 8935 Madison, WI 53708 (877)617-1565 Board-Pages/Medical-Examining-BoardMain-Page/ Wyoming 320 W. 25th St., Suite 200 Cheyenne, WY 82002 (307)778-7053


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Med Spa

Location: Coastal North Carolina List Price: $550,000 Gross Yearly Income: $1,600,000.00 Year Established: 2005 Average Patients Per Day: 25 to 30 Total Exam Rooms: 4 Building Owned/Leased: Leased Contact: Cara or Philip at 919-848-4202

Practice Type: Mental Health, Neuropsychological and Psychological Location: Wilmington, NC List Price: $110,000 Gross Yearly Income: $144,000 Year Established: 2000 Average Patients Per Day: 8 Building Owned/Leased/Price: Owned Contact: Cara or Philip at 919-848-4202

Practice Type: Internal Medicine

Location: Wilmington, NC List Price: $85,000 Gross Yearly Income: $469,000 Year Established: 2000 Average Patients per Day: 25 Building Owned/Leased: Owned Contact: Cara or Philip at 919-848-4202

Dental Practices Place Your Ad Here

Optical Practices Place Your Ad Here

Special Listings Offer We are offering our “For Sale By Owner” package at a special rate. With a 6 month agreement, you receive 3 months free.

Considering your practice options? Call us today. 52 | AUGUST 2015

PRIMARY CARE PRACTICE - Hickory, North Carolina This is an outstanding opportunity to acquire one of the most organized and profitable primary care practices in the area. Grossing a million and a half yearly, the principal physician enjoys ordinary practice income of over $300,000 annually. Hickory is located in the foot-hills of North Carolina and is surrounded by picturesque mountains, lakes, upscale shopping malls and the school systems are excellent. If you are looking for an established practice that runs like a well oiled machine, request more information. The free standing building that houses this practice is available to purchase or rent with an option. There are 4 exam rooms with a well appointed procedure room. The owning physician works 4 to 5 days per week and there is a full time physician assistant staffed as well. For the well qualified purchasing physician, the owner may consider some owner-financing. Call us today. List price: $425,000 | Year Established: 2007 | Gross Yearly Income: $1,500,000

Medical Practice Listings Selling and buying made easy | | 919-848-4202

Wanted: Urgent Care Practice


or family medicine doctor needed in


Urgent care practice wanted in North Carolina. Qualified physician is seeking to purchase an established urgent care within 100 miles of Raleigh, North Carolina. If you are considering retiring, relocations or closing your practice for personal reasons, contact us for a confidential discussion regarding your urgent care. You will receive cash at closing and not be required to carry a note. Comfortable seeing children. Needed immediately.

Medical Practice Listings Buying and selling made easy

Call 919-848-4202 or e-mail 54 | AUGUST 2015

Call 919- 845-0054 or email:

Women’s Health Practice in Morehead City, NC

MD STAFFING AGENCY FOR SALE IN NORTH CAROLINA The perfect opportunity for anyone who wants to purchase an established business.

Newly listed Primary Care specializing in Women’s care located in the beautiful coastal city of Morehead City. This spacious practice has 5 exam rooms with one electronic tilting exam table and 4 other Ritter exam tables. Excellent visibility and parking make this an ideal location to market and expand. This practice is fully equipped and is ready for a new owner that is ready to hit the ground running. The owning MD is retiring and will be accommodating during the transition period. This medical building is owned and is offered for sale, lease or lease to own. The gross receipts for the past 3 years exceed $540,000 per year. If you are looking to purchase an excellent practice located in a picturesque setting, please contact us today.

Medical Practice Listings

l One

of the oldest Locums companies l Large client list l Dozens of MDs under contract l Executive office setting l Modern computers and equipment l Revenue over a million per year l Retiring owner

Buying and selling made easy

Call 919-848-4202 or email

Please direct all correspondence to Only serious, qualified inquirers.

Modern Med Spa Available

Located in beautiful coastal North Carolina Modern, well-appointed med spa is available in the eastern part of the state. This Spa specializes in BOTOX, facial therapy and treatments, laser hair removal, eye lash extensions and body waxing as well as a menu of anti-aging options. This impressive practice is perfect as-is and can accommodate additional services like; primary health or dermatology. The Gross revenue is over $1,500.000 during 2012 with consistent high revenue numbers for the past several years. The average number of patients seen daily is between 26 and 32 with room for improvement. You will find this Med Spa to be in a highly visible location with upscale amenities. The building is leased and the lease can be assigned or restructured. Highly profitable and organized, this spa POISED FOR SUCCESS. 919.848.4202 WWW.MEDMONTHLY.COM | 55


Practice for Sale in Raleigh, NC Primary care practice specializing in women’s care Raleigh, North Carolina The owning physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however, that could double with a second provider.  Exceptional cash flow and profit will surprise even the most optimistic practice seeker.  This is a remarkable opportunity to purchase a well-established woman’s practice.  Spacious practice with several well-appointed exam rooms and beautifully decorated throughout.  New computers and medical management software add to this modern front desk environment.    List price: $435,000

Physician Solutions has immediate opportunities for dentists and hygienists throughout NC. Top wages, professional liability insurance and accommodations provided. Call us today if you are available for a few days a month, on-going or for permanent placement. Please contact Physican Solutions at 919-845-0054 or

Call Medical Practice Listings at (919) 848-4202 for details and to view our other listings visit

Eastern North Carolina Family Practice Available Well-appointed Eastern North Carolina Family Practice established in 2000 is for sale in Williamston, NC. This organized practice boasts a wide array of diagnostic equipment including a GE DEXA scanner with a new tube, GE case 8000 stress testing treadmill and controller and back up treadmill, Autoclave and full set of operating equipment, EKG-Ez EKG and much more. The average number of patients seen daily is between 12 to 22. The building is owned by MD and can be purchased or leased. The owning physician is retiring and will assist as needed during the transition period. The gross receipts for the past three years are $650,000 and the list price was just reduced to $240,000. If you are looking to purchase a well equipped primary care practice, please contact us today. Contact: Cara or Philip at 919-848-4202 56 | AUGUST 2015

PRIMARY CARE PRACTICE East of Raleigh, North Carolina We are offering a well established primary care practice only minutes east of Raleigh North Carolina. The retiring physician maintains a 5 day work week and has a solid base of patients that can easily be expanded. There are 6 fully equipped exam rooms, a large private doctor’s office, spacious business office, and patient friendly check in and out while the patient waiting room is generous overlooking manicured flowered grounds. This family practice is open Monday through Friday and treats 8 to a dozen patients per day. Currently operating on paper charts, there is no EMR in place. The Gross revenue is about $235,000 yearly. We are offering this practice for $50,000 which includes all the medical equipment and furniture. The building is free standing and can be leased or purchased. Contact Cara or Philip at 919-848-4202 to receive details and reasonable offers will be presented to the selling physician.

Medical Practice Listings Selling and buying made easy | | 919-848-4202

NC MedSpa For Sale MedSpa Located in North Carolina

Pediatrics Practice Wanted

We have recently listed a MedSpa in NC

Pediatrics practice wanted in NC

This established practice has staff MDs, PAs and nurses to assist patients. Some of the procedures performed include: Botox, Dysport, Restylane, Perian, Juvederm, Radiesse, IPL Photoreju Venation, fractional laser resurfacing as well as customized facials. There are too many procedures to mention in this very upscale practice. The qualified buyer will be impressed with the $900,000 gross revenue. This is a new listing, and we are in the valuation process.

Considering your options regarding your pediatric practice? We can help. Medical Practice Listings has a well qualified buyer for a pediatric practice anywhere in central North Carolina.

Contact Medical Practice Listings today to discuss the practice details.

For more information call Medical Practice Listings at 919-848-4202 or e-mail

Contact us today to discuss your options confidentially. Medical Practice Listings Call 919-848-4202 or e-mail WWW.MEDMONTHLY.COM | 57

PHYSICIANS NEEDED: Mental health facility in Eastern North Carolina seeks: PA/FT ongoing, start immediately Physician Assistant needed to work with physicians to provide primary care for resident patients. FT ongoing 8a-5p. Limited inpatient call is required. The position is responsible for performing history and physicals of patients on admission, annual physicals, dictate discharge summaries, sick call on unit assigned, suture minor lacerations, prescribe medications and order lab work. Works 8 hour shifts Monday through Friday with some extended work on rotating basis required. It is a 24 hour in-patient facility that serves adolescent, adult and geriatric patients. FT ongoing Medical Director, start immediately The Director of Medical Services is responsible for ensuring all patients receive quality medical care. The director supervises medical physicians and physician extenders. The Director of Medical Services also provides guidance to the following service areas: Dental Clinic, X-Ray Department, Laboratory Services, Infection Control, Speech/Language Services, Employee Health,

Pharmacy Department, Physical Therapy and Telemedicine. The Medical Director reports directly to the Clinical Director. The position will manage and participate in direct patient care as required; maintain and participate in an on-call schedule ensuring that a physician is always available to hospitalized patients; and maintain privileges of medical staff. Permanent Psychiatrist needed FT, start immediately An accredited State Psychiatric Hospital serving the eastern region of North Carolina, is recruiting for permanent full-time Psychiatrist. The 24 hour in-patient facility serves adolescent, adult and geriatric patients. The psychiatrist will serve as a team leader for multi-disciplinary team to ensure quality patient care/treatment. Responsibilities include:

evaluation of patient on admission and development of a comprehensive treatment plan, serve on medical staff committees, complete court papers, documentation of patient progress in medical record, education of patients/families, provision of educational groups for patients.

Send copies of your CV, NC medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624 PH: (919) 845-0054 | email:

Primary Care Practice For Sale

Med Spa in the Raleigh-Durham, NC Area

Wilmington, NC Established primary care on the coast of North Carolina’s beautiful beaches. Fully staffed with MD’s and PA’s to treat both appointment and walk-in patients. Excellent exam room layout, equipment and visibility. Contact Medical Practice Listings for more information.

Medical Practice Listings 919.848.4202 | 58 | AUGUST 2015

Beautiful Med Spa located in the Raleigh-Durham is among our newest listings. This very upscale facility is established and boosts consistent gross revenues of a million plus. Some of the procedures performed are: Botox, Dermal Fillers, Minimal light based treatments, laser hair removal, cool sculpting (external cooling treatment that freezes the hair and the body metabolizes the fat). This practice is ideal for the Plastic Surgeon or Dermatologist. Established: 2010 l Annual Revenue: $1,000,000 Average Patients per Day: 15 to 25

Call 919-848-4202 or email

Adult & pediAtric integrAtive medicine prActice for sAle This Adult and Pediatric Integrative Medicine practice, located in Cary, NC, incorporates the latest conventional and natural therapies for the treatment and prevention of health problems not requiring surgical intervention. It currently provides the following therapeutic modalities: • • • • •

Conventional Medicine Natural and Holistic Medicine Natural Hormone Replacement Therapy Functional Medicine Nutritional Therapy

• • • • • •

Mind-Body Medicine Detoxification Supplements Optimal Weigh Program Preventive Care Wellness Program Diagnostic Testing

There is a Compounding Pharmacy located in the same suites with a consulting pharmacist working with this Integrative practice. Average Patients per Day: 12-20

Internal Medicine Practice for Sale Located in the heart of the medical community in Cary, North Carolina, this Internal Medicine practice is accepting most private and government insurance payments. The average patients per day is 20-25+, and the gross yearly income is $555,000. Listing Price: $430,000

Gross Yearly Income: $335,000+ | List Price: $125,000

Call 919-848-4202 or email

Primary Care Specializing in Women’s Health

Call 919-848-4202 or email

Located on NC’s Beautiful Coast, Morehead City

Practice established in 2005, averaging over $540,000 the past 3 years. Free standing practice building for sale or lease. This practice has 5 well equipped exam rooms and is offered for $20,000. 919.848.4202 WWW.MEDMONTHLY.COM | 59

Physician Solutions, Inc. Medical & Dental Staffing

The fastest way to be $200K in debt is to open your own practice The fastest way to make $100K is to choose

Physician Solutions

THE DECISION IS YOURS Physician Solutions, Inc. P.O. Box 98313 Raleigh, NC 27624 Scan this QR code with your smartphone to learn more.

phone: 919-845-0054 fax: 919-845-1947

Med Monthly August 2015  

The Doctor-Patient Communication issue of Med Monthly magazine.

Med Monthly August 2015  

The Doctor-Patient Communication issue of Med Monthly magazine.