ADDRESS SERVICE REQUESTED PRSRT STD US POSTAGE PAID
LINCOLN, NE
PERMIT NO. 27
our practice our y
technology in in technology
’s today tilizing U
Digital Docs Digital Fall 2012 | Volume 11, Number 3 Number 11, Volume | 2012 Fall Nebraska Medicine is published quarterly by the
Fall 2012 | Volume 11, Number 3 233 South 13th Street, Ste. 1200 Lincoln, NE 68508 Phone (402) 474-4472 Physicians and Facebook: Implications of Social Media Fax (402) 474-2198 Usage in the Health Care Industry ...... 2 www.nebmed.org Social (Media) Security: Navigating the Pitfalls Nebraska Medical Association 2011-2012 Board of Directors & Promises of the Modern Internet ...... 3 President Chuck Gregorius, MD, Lincoln Using an iPad in Practice ...... 4 President-Elect Daniel Noble, MD, Lincoln Medical Blogging in your Practice ...... 5 Secretary-Treasurer Todd Pankratz, MD, Hastings Digital Technology ...... 6 Immediate Past President Lou Kleager, MD, Scottsbluff Online Reviews: The Best Defense...... 7
Board Members Hyper-connected Digital Doc: Marvin Bittner, MD, Omaha Amit Chakraborty, MD, Omaha True Confessions of “Geek-man” ...... 8 Jose Friesen, MD, Grand Island Jim Gigantelli, MD, Omaha Jon Hedgecock, Omaha Coming soon as an NMA Member Benefit: Valerie Huckaby, Omaha Jason Kruger, MD, Lincoln DocBookMD Mike McGahan, MD, Grand Island What is DocBookMD? > FAST LOOK-UP A smartphone platform designed by Locate a physician fast - by last Arthur Molnar, MD, Lincoln physicians for physicians that provides an or first name or by specialty and con- Zach Rosol, Omaha exclusive, HIPAA-compliant professional tact him/her via multiple means Michelle Sell, MD, Central City network for on-the-go doctors to com- including messaging, Les Spry, MD, Lincoln municate, collaborate, and coordinate. office or cell phone. Features > PHARMACY SEARCH Britt Thedinger, MD, Omaha > ON DEMAND MESSAGING Find and map a local pharmacy with Jordan Warchol, Omaha Communicate with your colleagues via updated contact details near you or Peter Whitted, MD, Omaha HIPAA-compliant messages instantly. near your patient. Mike Zaruba, MD,Auburn You can improve communication effi- > PERSONALIZE ciency by prioritizing outgoing mes- Rowen Zetterman, MD, Omaha Customize your personal info, sages. create a list of your favorite Ex-Officio Board Member > MULTI-MEDIA physicians, add notes and Jan Bausch, Lincoln COLLABORATION detailed contact information. Exchange critical information such as Benefits to the Physician pictures of X-rays or wounds via > Save time The Nebraska Medical Association in no way HIPAA-compliant messaging to > Improve collaboration endorses any opinions or statements in this enhance collaboration. > Enhance patient care publication except those accurately reflecting official association actions. More information is available at docbookmd.com. Page 1 Nebraska Medicine | Fall 2012
Physicians and Facebook: Implications of Social Media Usage in the Health Care Industry by Tara A. Stingley, J.D.* occurs electronically by a physician giv- through such a site, a relationship Cline Williams Wright Johnson & ing medical advice or discussing medical potentially could be formed.4 Physicians Oldfather, L.L.P. conditions and treatments on a social are generally aware of implications media site? Can a physician-patient rela- stemming from the formation ike it or not, social media web- tionship arise if a physician and a of new relationships and Lsites such as Facebook, Twitter, patient become “friends” on Facebook, interactions with the public and LinkedIn play an increased role in or if a physician “tweets” medical advice and are careful to avoid professional settings, including the to his Twitter followers? If so, what are unexpected physician-patient health care industry, and show no signs the ethical and legal implications of relationships; those same of slowing down. Over 1,100 hospitals those relationships? precautions should apply have some type of social networking These questions become increasingly when using social media.5 site, including over 1,000 Facebook important to answer in light of the The American Medical 1 pages and almost 800 Twitter feeds. widespread use of social media by med- Association’s (“AMA”) Council on Not only are medical providers joining ical providers and their patients. Indeed, Ethical and Judicial Affairs has recog- the social media world, but their a recent survey of over 3,000 social nized the same, noting that the AMA’s employees have as well, with “as many as media-using physicians and medical stu- Code of Medical Ethics governs physi- 50 percent of their employees utiliz[ing] dents found that 34 percent of all physi- cians’ communications both with 2 some form of social media.” Both cians and 42 percent of family practi- patients and regarding patient informa- health care providers and patients can tioners received a social media “friend” tion, and that these guidelines apply in benefit from the use of social media. request from a patient or a patient's all settings, including online.6 In early But, providers – and their employees – family member; of the physicians who 2012, the AMA enacted the Council’s should be aware of the inherent risks received such “friend” requests, 57 per- recommendations regarding the use of associated with such use. cent had a blanket policy prohibiting social media within the I. Physicians’Use of Social Media acceptance, while 43 percent considered medical field, which provide as follows: and the Physician-Patient requests on a case-by-case basis.3 a. Physicians should be aware of patient Relationship Simply becoming friends with anoth- privacy and confidentiality standards In Nebraska, a physician must er individual on a social media site likely that must be maintained in all envi- undertake treatment of a patient in does not form a physician-patient rela- ronments, including online, and must order for a physician-patient relationship tionship, but if a physician were to assist avoid posting identifiable patient to arise. But what if that “treatment” or advise someone with medical needs information online. (continued on Page 9) Page 2 Nebraska Medicine | Fall 2012 Social (Media) Security: Navigating the Pitfalls & Promises of the Modern Internet by Jordan Warchol of sharing and privacy when the medi- information that is built in to many M4 um of expression is one that emphasizes social media profiles. Religious beliefs University of Nebraska Medical Center wide-open information sharing? This is and political ideals are generally not not an answer that can be easily found considered appropriate topics of conver- he other day, I was scrolling in one session at a professional meeting sation between physicians and their Tthrough my Facebook home- or laid out in your favorite medical patients, but these are easily accessible page when I noticed some new journal’s editorials; it is an ongoing via the World Wide Web with a few “friends” I wasn’t sure I had conversation that must evolve as quick- keystrokes in the Google search bar. ever met: Bob the Builder and ly as the Internet. With the pitfalls that must be avoid- Ted E. Bear were suddenly in Several well-known entities have ed with social media, it is easy to over- my social circle. Soon I real- already begun this discussion and have look the positive contributions that the ized that these profiles were in started to develop social media strate- added access can provide to the care of fact those of people I actually gies for medical professionals. A recent patients. Many medical practices have know. These users changed editorial from The Lancet discussed the Facebook fan pages, an easy and inex- their names in preparation for guidance currently given in the UK. pensive means of advertising. My den- the thorough scouring of per- The General Medical Council, which is tist’s Facebook page includes weekly tips sonal information that many assume the governing body for medicine, for proper dental hygiene and links to will be undertaken as they apply for “emphasizes the need to maintain articles on the health benefits of regular Residency. patient confidentiality, provide accurate cleanings. The office even posted a Social media sites such as Facebook, information, treat colleagues with birthday wish on my profile. The Twitter, LinkedIn, Flickr, Pinterest and respect, avoid anonymity online if writ- American Society of Nephrology used Instagram are increasingly intertwined ing in a professional capacity, be aware Twitter throughout their annual meet- in the day-to-day living of life. of how content is shared, review privacy ing to demonstrate a means of giving Commercials no longer display individ- settings and online presence, declare the general public easily accessible and ual websites for the products they pres- conflicts of interest, and maintain sepa- accurate information about renal dis- ent, but instead direct consumers to rate personal and professional profiles.” ease. Recently, a hospital in Houston “Check Us Out On Facebook.” Some Mentally checking off each of those used Twitter to let the general public couples choose to create social media boxes before hitting the “send” button follow along with the resection of a profiles for their unborn children, pre- on every post one makes on a social brain tumor, complete with pictures sumably so that all events of the child’s media site would be utterly exhausting, and video from inside the OR. life can be easily accessible for family but that is what is being asked of physi- While use of social media is not the and friends (and the rest of the world). cians who choose to use these sites. A standard practice yet, the integration of This is our new norm, and it would be general recommendation that is less social media and medicine is definitely a shame for those in health care to be daunting to follow is one being dubbed upon us. Take a few extra seconds to left behind the curve. However, the “The Elevator Test”: If you were in a think of the possible repercussions high standards for physician profession- crowded elevator at the hospital would before posting those pictures from your alism as well as the need to keep the you say out loud what you are about to Mexico vacation or ranting about the boundaries of a physician-patient rela- post? Would you want that picture pro- frustrations of implementing a new tionship can make the use of social jected on the ceiling for all to see? EMR. Taking into consideration the media more challenging. This not only is true about the posts expanding audience provided by the The question becomes, then, how we contribute, but also the general Internet before each virtual interaction do we balance these competing forces (continued on Page 10)
Page 3 Nebraska Medicine | Fall 2012 Using an iPad in Practice by Michael L. Zaruba, MD anatomy app. Patients seem to find this families. Prior to tablets, doctors, Auburn helpful and I feel it enhances their visit including myself, would do their as they leave with increased insight and rounds in the wards and then return to Pads have become a commonplace knowledge of their condition. As physi- a desktop computer or the i tool used by many in our society. I cians, we all know that patient satisfac- radiology department to view would like to share my experiences tion is very important to a successful images. This can now be done using an iPad in the everyday practice practice and I feel that patient satisfac- at the bedside utilizing the of medicine. I have found it to be a tion is heightened with the use of the iPad. However, one important very powerful and versatile resource iPad in this manner. There are other factor to remember is that that benefits both patients and me. apps that perform medical calculations iPads or tablets should only be I am able to use my iPad to execute such as BMI, Ideal Body Weight, creati- used when high resolution Practice Partner (the EMR system I use nine clearance, pediatric dosing and LCD monitors are not readily in my clinic) and access the EMR sys- numerous other medical calculations. available. The displays of an iPad or tem at my local hospital. However, the There are apps that can be used to visu- other tablets are not as good as the real power of the iPad is the ability to ally identify pills, crosscheck drug-drug LCD monitors made specifically for access and seamlessly switch between interactions, and provide the most cur- reading X-rays. Nonetheless, they can numerous medical apps to enhance the rent drug information. The Monthly be used to help educate and illustrate clinical encounter for the patient. Prescribing Guide, that many of us are findings to the patients at the bedside. Currently, there are well over 5000+ using every day, is available digitally on Imagine being able to access hun- medical apps available for the Apple the iPad and is much easier to search dreds of medical textbooks, The iPad. Hence, there are many ways the than the paper version. Medical Letter, the Prescriber’s Letter, iPad can be used in everyday practice. The iPad in the hospital or clinic or the UpToDate clinical decision sup- For example, the iPad can be used to setting can be used to view digital port system without being in your illustrate the anatomy of an injury to X-rays. This is very useful in discussing office or sitting at a computer. The iPad the patient utilizing a high definition X-ray findings with patients and their (continued on Page 11)
Apps Popular with Physicians
CPT E/M: Billing codes reference (from the AMA) Mobile Mim: Displays medical images on mobile devices, including single-photon-emission computerized Calculate By Qxmd: Clinical calculator with formulas tomography, PET and CT scans, MRIs, X-rays and ultra- for disease diagnosis and treatment sound images Diagnosaurus: Searchable database by disease, symptom My Medications: Medication tracking for patients or organ system (from the AMA) DocBookMD: Networking and referral Netter's Anatomy Atlas: Database of illustrations Epocrates Rx: Mobile drug reference of the human anatomy iPhone ECG: Turns an iPhone into a medical device Quantiamd: Physician-to-physician educational tool that, when held to the chest, displays, stores and wirelessly Rounder: Continuity of care (winner of AMA app con- transmits an electrocardiogram. test) Lexicomp: Searchable databases on conditions, drugs, Sermo consultation: Network visual and messaging interactions, and laboratory and diagnostic tests consultation Medcalc: Clinical calculator for diagnosis and treatment Uptodate: Drug and clinical reference Medicine Central: Searchable database on drugs and diseases
Page 4 Nebraska Medicine | Fall 2012 Medical Blogging in your Practice
by Les Spry, MD that you created and emphasize things er. Sometimes your spouse can read the Lincoln that you want for patients in your prac- piece and help you simplify. Medical jar- tice. Rather than try to remember all of gon and acronyms should be avoided. e all strive to better commu- the points you want to make with your Do not say “DM,” but rather say “dia- nicate with our patients. In patient, you can write it out once and betes mellitus (DM).” This will make tryingW to communicate, we must use the then post and edit it as new information sure all the readers get all the informa- means of communication that comes along. This information becomes tion you intend. Do not use medical our patients use. When I first current and consistent. abbreviations such as noc, h.s., prn, and started practice, this meant My experience with blogging started tid. This will lead to confusion and frus- one-on-one communication about four years ago when I was tration by the reader trying to under- with my patient in an exam approached by the National Kidney stand the instructions. Do not use abbre- room and occasionally provid- Foundation (NFK) to start an informa- viations for medical tests, such as BMP, ing them with a pamphlet that tional blog for the NKF website. CBC or Lipid panel. Use the names of was developed by a national Fortunately, I had the assistance of spe- the actual tests that you are discussing. organization that I endorsed. cialists in communications and public The length of the article should gen- I often tried to write out instructions for relations teaching me how to do this. I erally be no longer than 800 to 1000 them as well. Currently our patients are had been a member of the NKF Patient words. Patients will not read articles that exposed to a wide variety of communica- Education committee and the Public are any longer than this. After writing a tions and all of these forms of communi- Policy committee for years and helped to rough draft, go back through and ask cation require content that vies for the develop many of those pamphlets that I yourself “Can I say this in fewer simpler attention of the patient. As we see more mentioned above. I initially started just words?” “Can I combine more than one and more patients, we need to develop a writing informational blog articles but sentence into a simpler single sentence?” means of communicating complex issues then started to post answers to patient’s Simple and short should be the goal of to our patients in shorter and shorter individual questions as posted on the any blog piece. Try to use common times allotted to office visits. One way NKF web site. I started doing a blog for phrases that you hear your patients use, to accomplish this is to create written the Huffington Post this year. While I rather than technical jargon that you documents that reflect your personal do not consider myself an expert about might use with your peers. If you need opinions and recommendations for medical blogs, I can offer the following to supply references or technical lan- specific care of the patients in your advice for those who wish to start using guage, use a hyperlink to allow the read- practice and post them to a blog. this form of communication with their er to get further information. Most writ- According to Wikipedia, “A blog (a patients. ing programs, such as Microsoft Word, portmanteau of the term web log) is a My first recommendation is to use provide ways to link words to websites. discussion or information site published simple language. Those who study com- By just highlighting the word and creat- on the World Wide Web consisting of munications for a living recommend that ing a hyperlink, your patients can read discrete entries ("posts”) typically dis- the words and phrases used in the blog the blog article and then, if they want played in reverse chronological order so be aimed at or below a fifth grade read- more information, click on the word and the most recent post appears first.” In ing level. Many times it is better to run go to the web site for more information. this format, it is available to everyone this past your kids rather than just try to Linking to major web sites such as the who can access the World Wide Web dumb down your writing. There are National Kidney Foundation, American from a computer. Suddenly, rather than services that can review your blog and Heart Association or American Diabetes spending 20 or 30 minutes giving an based on the words used, commercial Association is simple and informative. individualized instruction to your services can give you a graded reading I find the most difficult paragraph to patient with diabetes or hypertension, level for your article. Rather than pay the write is the first paragraph. You need to you can give them a web link to the blog money for this, use your kids. It’s cheap- (continued on Page 12) Page 5 Nebraska Medicine | Fall 2012 Digital Technology by Marvin Bittner MD meaning to some people. To physicians, The impact of the scorecard was Omaha though, that kind of terminology sim- striking. My billing doubled. My errors ply isn’t precise. Definitions are needed plummeted. Should I really have been he most outstanding applica- for physicians. We don’t carry those def- surprised that I would get better results T tion of digital technology in my initions around in our heads. The by paying close attention to professional work is one that I use near- application obviates the need to do so. the rules? ly every day. Yet it’s very, very different The application asks me, for example, What is odd about the from typical applications of digital tech- how many systems I examined (and it application is that I don’t run nology. I don’t run it on my iPhone. includes the list of systems from the it from a computer or a smart Nor does it run on my iPad. Let me rules—so I’ll count them the same way phone day after day, patient explain. the auditors do). It guides me through after patient. Using my com- The application that I use nearly the process of scoring my visit, based puter, I developed a very com- every day is a billing scorecard. It’s my on what I have done, so I don’t need to plicated file in Microsoft Word. That response, as an infectious diseases spe- learn the definitions of the nonstandard complicated Word file is my “digital cialist, to the Byzantine rules for coding terminology of the E&M rules. technology.” That file is a concise sum- so-called “Evaluation and Management” That’s part of the reason that my mary of the rules, based on my study of services that I perform when I visit hos- application is so different from typical the rules and my thinking about my pitalized patients. There are two prob- applications of digital technology. Are work. I print the file on paper. I carry lems with those 1995 rules for “E&M” you an AMA member? Do you know that paper score sheet and use that to coding. This application addresses both. about the AMA’s iPhone application, score each visit. Digital technology is The first problem is that the E&M “CPT E/M”? It has the same goal as my simply a tool for expressing the results rules are complicated. For example, application: to assist physicians with of my study of the E&M rules. I they take into account the number of documentation and coding of evalua- depend on digital technology to display diagnoses and treatments considered at tion and management services. CPT, or my summary clearly. Digital technology a visit. To do so, there’s a point system Current Procedural Terminology, is an is not a fancy calculator. Maybe that’s that’s commonly used. Was there a new AMA enterprise. So the AMA applica- why it’s such a success. It’s a case where problem needing additional work-up? tion is authoritative. The problem is study and thought solved a problem! Score four points. Was it an established that it’s vague. It tells you to distinguish Moreover, it’s easy for me to use. problem that was considered? Score one “moderate complexity” from “high Just consider one situation, perhaps the point if it’s stable, two if it’s worsening. complexity” in the number of diagnoses most common one I face: documenting What about a new problem needing no or management options considered by and coding follow-up visits in the hos- further work-up? That’s three points, distinguishing whether the number is pital. There are three possible codes to but you can only score one of those “multiple” or “extensive.” What’s “mul- use. From least complex to most com- each day. If the problem is self-limited tiple”? What’s “extensive”? “CPT E/M” plex, they are: 99231, 99232, and or minor, score one point, but you can won’t tell you. 99233. only score two of those each day. All To me, it’s performance that counts. In the lower right hand corner of my that may seem complicated, but there’s When I thought about smart phone billing score sheet, I have a table. It more! That’s right, even more compli- and iPad applications, I didn’t stop summarizes the requirements to bill for cated rules! The application summarizes thinking with the iPhone app “CPT each of the three codes. It has a head- the rules so it’s easy to score a visit. E/M.” I knew the NMA was looking ing: “Subsequent hospital codes need The second problem is that the for conventional digital apps, but I only 2 out of 3 (history, exam, decision E&M rules use nonstandard terminolo- wanted to tell you about my scorecard, making):” (See table on page 12) gy. “Problem Focused” and “Expanded which is even better. (continued on Page 12) Problem Focused” may have a clear Page 6 Nebraska Medicine | Fall 2012 Online Reviews: The Best Defense...
by Sharla Hooper name in the alert. This can allow you to surveys to your patients that can then Associate Vice President for monitor what is being said online and be reviewed and posted by you or your Communications and Accreditation respond more effectively to negative office staff. Arizona Medical Association comments. Avoid a negative response espite the worst fears of bat- Correct misinformation If at all possible, avoid attacking the tling negative comments from The easiest places to start are web- person through a lawsuit or counter- anonymousD combatants online, a 2010 sites that show up high in Google post on the same website. This can study found that patients reviewing searches and tend to be physician finder backfire if it’s perceived that you’re vali- their physicians online are or rating sites or health plan physician dating their claims. finders. They often include wrong or more likely to praise than Have a plan outdated contact information and criticize. And criticisms tend When information posted about a incomplete biographical and education- to be about environmental physician or a practice is clearly false, al history, but will likely give doctors factors rather than actual there are actions that can be taken. the opportunity to edit their own pro- health care or physician- Many websites have policies against files. Take advantage of this; bolster the patient interaction. posting defamatory or false statements. information that is presented and high- Physicians concerned Contact the site administrator to ask light positive aspects. about dealing with unflatter- about its policy and request removal of ing and unedited online comments can Create and manage your online the comment. Try to approach and take proactive measures. It may be presence remain cordial in your communications cliché, but the best defense for an Create your own online presence with them. Most experts agree that online reputation scrub is a good through a practice website, blog, suing over negative online posts should offense. Facebook page or Twitter account. The be a last resort. If you are considering Know thyself more active a practice is on a site like employing a reputation management Or at least know what is being said Twitter, the more likely it will jump to firm, be sure to pick one that demon- about you online. Google yourself and the top of any search someone might strates understanding of a physician’s learn about what information you need do on the practice's name. Practices can business, has a relationship with a rep- to consider managing about your online use the sites to solicit positive feedback. utable attorney, and is familiar with First Amendment and copyright laws. reputation. Experts recommend con- Drum up positive reviews ducting monthly or more frequent Encourage your patients to go SOURCES searches to help you stay ahead of a online and provide comments and rat- Dolan, Pamela Lewis. “5 ways to manage your online reputation.” American Medical News. Sept. 12, 2011. potential problem. Additionally, you ings at specific ratings sites that you http://www.ama- assn.org/amednews/2011/09/12/bisa0912.htm can set up online alerts, such as the trust, or control, such as your office - “How to use online patient comments to your Google and Yahoo alerts feature that Facebook page. You might have your advantage.” American Medical News. July 26, 2010. http://www.ama-assn.org/amednews/2010/07/ allow you to register keywords such as office staff tell patients about the sites, 26/bica0726.htm physicians’ or practices names, then hang signs in the waiting room, and This article was originally published in send an e-mail with a link to any new hand out fliers at the check-out desk. AzMedicine, Vol. 23, No.1, and is reprinted mention of those keywords. Be sure to Some website management resources with the permission of the Arizona Medical include all reasonable variations of your automatically email post-appointment Association. l
Page 7 Nebraska Medicine | Fall 2012 Hyper-connected Digital Doc: True Confessions of “Geek-man” by Richard J. Baltaro, MD, PhD favorite apps are for prescription med- withover one thousand “friends”! and John C. Baltaro ications, for medical calculations (e.g. I share interesting articles on medicine, Omaha BMI or anion gap), another for choles- international events, and humor; but I terol guidelines and risks, and yet t a typical Metro Omaha another for eponyms. I sometimes use a Medical Society Board Meeting, New England Journal of Medicine app. I haveA with me a smart phone connect- My personal life is enriched daily by ed with one service provider, a tablet free apps for news, both U.S. and computer, an old fashioned flip-phone European. Years ago, I used to get up at connected with a different service 5 or 6 a.m. to speak by telephone with provider and a pager. I definitely consid- European relatives. It was noon or 1 er myself a hyper-connected physician. p.m. for them. When the internet first Richard J. Baltaro, MD, John C. Baltaro On more than one occasion I have became widely available I started con- PhD helped my fellow physicians connect to necting with a slow dial-up and-I would refuse any game requests. About a year the internet using wireless passwords or wait while European newspaper pages ago I started a LinkedIn profile. I find by troubleshooting other basic issues. would load up at 3200 bauds. At the the conversation threads time consum- Some marvel at my technological time, I was so happy just to access them. ing and do not participate. Although I expertise, which always surprises me. It was the latest technology! Now I have have never considered using Facebook My smart phone and tablet are used apps in Spanish, French, Italian and or LinkedIn at work, I am currently primarily to keep my calendar, to alert German, usually newspapers. Many suffering from a serious daily Facebook me to appointments with patients and apps that used to be free are now requir- addiction/fascination. My daily “fix” meetings, and last, (but certainly not ing payment and/or passwords. I am fre- usually occurs in the evening or early least,) to connect to the Internet for quently forgetting one of the hundreds morning, which is a serious strain on access to the library of the World Wide of passwords I have on an app. When my wife’s patience. In moments when it Web. When I am connected to the the app is no longer easy to use or when is particularly bad she has labeled me resources of this vast and nebulous I have forgotten or lack a password I am “Geek-man.” She’s one to complain! library, I have more knowledge at my unlikely to use that app. She works in epilepsy and gets updates disposal than the Library of Alexandria, Until three years ago, I had success- from Medscape and Epilepsy.com multi- the British Museum and the fully resisted all temptations to use ple times a day. She posts about epilepsy Smithsonian all put together. I am fre- social media. But when I saw the con- news on Twitter and her dedicated quently researching diseases, laboratory nections being made by my son, my Facebook page, EpilepsyAce. tests, drugs, government rules and regu- wife, my son-in-law and my almost-MD Due to my increasing use of multi- lations, the geography of Nebraska, not daughter I took the plunge. Once I real- functioning devices, I have eliminated to mention my state legislators’ websites. ized that I could easily converse daily the daily wearing of a wristwatch, as I have several free medical apps on with my relatives across the U.S., every device I carry tells time. I only my smart phone. The medical students Europe, Canada and Latin America, I have my wristwatch when I travel, and residents are good at alerting me started a Facebook page and began to because it is not required to be turned to technological advances in these connect with friends from my past (high off on airplanes. I would like to get rid resources; and through trial and error, school, college, medical school), as well of my old fashion flip-phone, but (due I have learned whose recommendations as old coworkers and neighbors. to the vagaries of different carriers) it is are most likely to be useful. (I have In less than a year I had connected connected in places where my smart downloaded apps that I never use.) My (continued on Page 13) Page 8 Nebraska Medicine | Fall 2012 Physicians and Facebook: Implications of Social Media Usage in the Health Care Industry (continued) b. If physicians interact with patients on Act (“ARRA”) HITECH Act established ed ethical and legal issues. As the recent- the Internet, physicians must main- more rigorous regulations for protecting ly released AMA policy on social media tain appropriate boundaries of the patient data, enacted new federal patient recommends, physicians should under- physician-patient relationship in breach notification requirements, and stand the potential consequences of their accordance with professional ethical increased civil and criminal penalties for social media activities and should apply guidelines, just as they would in any HIPAA violations. the same precautions to their social other context. While there is little case law covering media presence as they do c. To maintain appropriate professional health care employees’ use of social in other contexts. By following these boundaries, physicians should consid- media, in 2009 the Minnesota Court of guidelines and acting cautiously and er separating personal and profession- Appeals addressed the issue in Yath v. professionally while interacting through al content online.7 Fairview Clinics, N.P., where a patient social media, physicians can reap the brought an invasion of privacy action benefits of these online communication II. Possible Ethical and Legal against her healthcare provider and two tools without exposing themselves to Consequences of Using Social of its employees.9 In Yath, an employee ethical and legal risks. Media in the Medical Field of the clinic where the patient received Inappropriate use of social media medical care disclosed information from * The author wishes to thank law student within medical practices can raise ethical Katherine Kelley for her assistance in the the patient’s medical records to another issues under the AMA’s Code of Medical research and preparation of this article. employee, who then told others. Later, a Ethics. Under the Code of Medical Ethics, MySpace page was created disclosing the 1 Nicolas P. Terry, Fear of Facebook: Private Ordering of providers have a duty of confidentiality, Social Media Risks Incurred by Healthcare Providers, patient’s confidential medical informa- 90 Neb. L. Rev. 704, 705 (2011-2012) (citing Ed and that duty is breached by a disclosure Bennett, Hospital Social Network List, Found in Cache, tion. Considering whether posting the http://ebennett.org/hsnl/ (last updated Oct. 9, 2011)). to a third party, without patient consent patient’s medical information on the 2 David Gevertz, Esq. & Gina Greenwood, Esq., Crafting or court order, of private information an Effective Social Media Policy for Healthcare MySpace page constituted a “publica- Employees, 22 Health Law. 28, 28 (2009-2010). that the provider has learned within the 3 Terry, Fear of Facebook: Private Ordering of Social 8 tion,” the court found in the patient’s Media Risks Incurred by Healthcare Providers, 90 Neb. physician-patient relationship. The ease L. Rev. at 737 (citing Gabriel T. Bosslet et al., The favor and held “the publicity element of of using social media and unauthorized Patient-Doctor Relationship and Online Social an invasion-of-privacy claim is satisfied Networks: Results of a National Survey, 26 J. Gen. access to online communication tools Internal Med. 1168, 1171 (2011)). when private information is posted on a 4 Nicolas P. Terry, Physicians and Patients Who “Friend” increase the risk of unauthorized disclo- or “Tweet”: Constructing a Legal Framework for Social publicly accessible Internet website.”10 Networking In a Highly Regulated Domain, 43 Ind. L. sures of confidential information. Rev. 285, 332-33 (citing Eric E. Shore, Giving Advice Although this holding does not bind on Social Networking Sites, 85 Med. Econ. 18 (2008), Providers should take note of the AMA’s available at 2008 WLNR 25457729)). Nebraska courts, it does suggest Code of Medical Ethics and its applica- 5 Id. at 333. Nebraska physicians and other medical 6 Council on Ethical and Judicial Affairs, CEJA Report tion to all settings. 8-I-10: Professionalism in the Use of Social Media, 1 employees could be held liable for unau- The use of social media in the (2011). thorized disclosure of patient informa- 7 AMA Policy: Professionalism in the Use of Social medical field also raises potential legal Media, Am. Med. Ass’n, http://www.ama- tion on social media sites. Thus, physi- assn.org/ama/pub/meeting/professionalism-social- liability including possible violations of media.shtml (last visited 7/25/2012). cians must be aware of the potential the Health Insurance Portability and 8 Patient Confidentiality, American Medical Association impact of their social media communi- (last visited 7/26/2012), http://www.ama- Accountability Act (“HIPAA”), which assn.org/ama/pub/physician-resources/legal- cations and govern their conduct topics/patient-physician-relationship-topics/patient- requires the protection of individually- confidentiality.page. accordingly. 9 Yath v. Fairview Clinics, N.P., 767 N.W.2d 34 (Minn. identifiable patient health information Ct. App. 2009). pursuant to HIPPA’s privacy and securi- III. Conclusion 10 Id. at 43. l ty standards, as well as claims for inva- The increased use of social media sion of privacy. Additionally, the 2009 raises concerns about its effect on the American Recovery and Reinvestment physician-patient relationship and relat-
Page 9 Nebraska Medicine | Fall 2012 Social (Media) Security: Navigating the Pitfalls & Promises of the Modern Internet (continued) has become as necessary as washing Twitter—a “micro blogging” site that e40253. doi:10.1371/journal.pone.0040253 your hands before each patient interac- allows users to craft their thoughts into Newcomb, Tim. "Brain Surgery, Live on Twitter." Time. 9 5 2012:
Page 10 Nebraska Medicine | Fall 2012
Using an iPad in Practice (continued)
makes this possible. I find it much phone calls to the office. In addition, to be an electronic book reader, perform easier and less time consuming to find there are apps available that allow you online banking, provide current weather the information I need digitally than to scan/copy lab results and other and radar information, track flights and the “old-fashioned” way of looking in a reports so that these reports can be check flight status, book hotel rooms, book. The best part of these apps is that easily emailed or faxed to patients view local TV news stations and numer- they automatically update as the new and/or consultants. Newer iPads are ous other functions. The possibilities information is put forth. The demands equipped with high resolution cameras really are endless with what one can do on our time, as physicians, are great and that can be used to document medical with this device. this is an easy way to become more findings and shared through email with I have focused on the iPad but efficient while obtaining the most a consulting colleague. One can even almost all the apps discussed are current medical information. use an iPad for excellent video confer- available for both Apple (iPad) and I routinely use the iPad to commu- encing in the right setting. Android-based tablets. In addition, nicate with patients through email. I I have provided a very brief overview most of the apps are free to use. find it much faster to check email on of how I use the iPad in my practice Hopefully, based on the information I the iPad as opposed to using a desktop of medicine. The iPad has even more have provided, you will soon discover computer as the iPad is an “instant on” uses outside of medicine to enhance the benefits of iPad technology in your type device. I feel this allows me to productivity in your personal life. Every own medical practice. l more efficiently communicate patients day new apps are being developed for and decreases the number of daily the device. There are apps that allow it
Page 11 Nebraska Medicine | Fall 2012
Medical Blogging in your Practice (continued) get your reader interested quickly and try decide what two or three major points Bottom Line to keep their attention. Writing personal you want to make and then start. Do not Paragraph headers that announce the history about yourself or relate a patient try to impart too much information. subject of the paragraph and bullet points story that is interesting and relevant to Readers will likely read only part of the are very conducive to imparting informa- the topic you are discussing. This can be article so try to make your major points tion in an article. The use of bullets can a very good “hook” for starting the arti- early and then expand on those points in also be very helpful to get the essential cle. Another “hook” that I use is to relate the latter part of the article. Just like you information to your patient. Remember: new information about a research study I learned in high school writing, tell them • Keep it simple and short have just read or a news item that has what you are going to tell them, tell • No more than two or three essential just been covered by some major media. them and then tell them what you told messages This will usually get them interested in them. • Let your personality show in the article. what you have to say. As you start, This will keep them interested. l
Digital Technology (continued)
Subsequent hospital care code requirements 99231 99232 99233 records). Two points are generated when I independently visualize an History of present illness elements 1-3 1-3 >4 image, tracing or specimen. Two points Personal, family, and social history elements - -- are also generated for certain activities Review of systems elements - 1 2-9 involving discussion: reviewing and Examination elements 1 2-4 5-7 summarizing old records; obtaining history from someone other than the Medical decision making Straightforward Moderate High or Low Complexity Complexity Complexity patient; or discussion of the case with another health care provider. If I’m not sure what code to bill, I used to determine the complexity of The risk of complications and can take a look at the table. How many medical decision making. The other morbidity is determined from a table elements do I have in the history of the two are the extent of data reviewed of risk that is part of the AMA’s CPT present illness? Do I have 1-3 elements? and the risk of complications and code book. This table is widely avail- Or 4? How many elements do I have in morbidity. able. Most of my patients are at least the review of systems? None? One? Or My score sheet does have a list of moderate risk because I’m involved in at least two? What about my examina- items to consider in classifying the prescription drug management. tion? One, two to four, or five to seven? extent of data reviewed. It’s a point There’s more to my scoresheet. After Those issues are relatively straightfor- system. Some items that I document are all, it just about fills up two sides of ward. To determine the complexity of able to generate one point each. They letter-size paper with Arial Narrow in a medical decision making, I need to turn are: clinical lab tests (reviewing or 6-point font. Yet I’ve found that infec- to another part of the score sheet. ordering them); radiology (reviewing or tious diseases fellows who want to get That other part of the score sheet is ordering); medicine tests such as paid for the work they do—to be the one that I described above. It’s the echocardiograms (also reviewing or frank—can pick it up quickly. one where I list and classify the diag- ordering); discussion of test results with If you’d like to learn more about noses and treatments considered at the performing physician; and a decision to my scorecard contact me at visit. The diagnoses and treatments, obtain history from a source other than [email protected]. l however, are only one of three issues the patient (or a decision to obtain old Page 12 Nebraska Medicine | Fall 2012 Hyper-connected Digital Doc: True Confessions of “Geek-man” (continued)
phone’s reception is poor. application and related protocol or with phones such as iPhone or Android into I am overwhelmed by email, and smart phones with sensors. medical devices for monitoring blood have email fatigue. Let me restate that, I Telemedicine has already begun to do sugar or blood pressure. The smart am literally drowning in e-mail. this. The Nebraska Telehealth Network phones can even function as scopes, Everyday, I must delete close to one has had the capacity to link rural resi- using the built-in cameras to view the thousand emails (more time consuming dents with specialists in Omaha for over eyes, ears, throats and more. There are than I want to admit). I have two email 40 years. Neurologists located in Omaha early adopters and later adopters. Some accounts for work, one for the medical are talking with and examining patients really progressive digital doctors, who school and the other for VA hospital across the state, saving patients hundreds recognized early on the opportunities work. At home I have two private of miles of travel, hours of car time, for better care and prevention, have emails, and I am not counting the time away from work or school, not to jumped right in. The information revo- LinkedIn or Facebook messages and mention hotel and meal costs for the lution is growing the economic, social notifications. trip. Emergency rooms can link up with and technological role of information. Soon we doctors will be “wirelessly specialists or even with the patients’ Physicians have the “RAM” and “hard connected” with our patients and with families in remote areas of our state. drive” capacity to profit from these other physicians, either through video Already, some companies are devel- changes and when they do, it will calling (video telephone) software oping apps that are turning smart benefit our patients. l
The NMA is now on Facebook!
Please like our page!
Page 13 Nebraska Medicine | Fall 2012
“As physicians, we have so many unknowns coming our way...
One thing I am certain about is my malpractice protection.”
Medicine is feeling the effects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to an atmosphere of uncertainty and lack of control.
What we do control as physicians: our choice of a liability partner.
I selected ProAssurance because they stand behind my good medicine and understand my business decisions. In spite of the maelstrom of change, I am protected, respected, and heard.
I believe in fair treatment— and I get it.
Professional Liability Insurance & Risk Management Services ProAssurance Group is rated A (Excellent) by A.M. Best. ProAssurance.com å ..
Page 14 Nebraska Medicine | Fall 2012 You’re always there for them.
We’re always here for you.
We have defended and supported the individual needs of health professionals for more than 30 years. And nobody is more personally committed to protecting you from the risks you face every day.
To learn more about our medical professional liability insurance coverage, call 888-397-3034 or visit MMICGroup.com.
Page 15 Nebraska Medicine | Fall 2012
Page 16 Nebraska Medicine | Fall 2012 Healthcare Reform
by Ross Polking in it.” Certainly not a great confi- elevated taxation of investment income Provided by the Foster Group dence-builder. Nevertheless, the 2,700 and an increased Medicare contribution page document is a daunting read, even to Social Security by the “wealthy” “ urprised, but not shocked,” was for those responsible for its creation and (those with individual income over the assessment from a high pro- passage. A Google search of “healthcare $200,000 or joint income over file,S well-respected individual within the reform” returns over 100 million $250,000), annual fees on insurance Nebraska medical community. His entries; information and opinions are providers, formerly uninsured individu- words to me referenced the 5-4 ruling limitless. The need for some type of als now paying premiums, as well as an from the Supreme Court upholding the reform of our healthcare system is array of other taxes, fees and penalties. majority of the Patient Protection and something most Americans agree on. Virtually no one is left untouched by Affordable Care Act (PPACA). The What should be done, and how, quick- the changes on the horizon. Because of surprise was the deciding vote cast by ly devolves into seemingly infinite alter- the number of physicians and medical- conservative, Bush-43-appointee and natives. Some notable features of the related organizations we serve, we are Chief Justice, John Roberts. Virtually PPACA: often asked what steps one should take no one had tabbed Roberts, who re- • Individual and/or group mandate to in response. Our best answer today: characterized the “penalty” for not pur- obtain insurance coverage, “Don’t over-react.” The unknowns in chasing individual insurance a “tax” the provisions of the law are significant, • Establishment of health insurance instead, as the swing vote. The consti- and the extent to which the PPACA exchanges to facilitate purchasing and tutionality of the PPACA was, and will actually be implemented is yet to benchmarking, remains, in question to many. Twenty- be determined. Much depends on the • Expansion of Medicaid eligibility, eight states and numerous organizations balance of power resulting from the have since filed actions challenging • Requirements on insurance providers November elections. Stay informed implementation of the law. to increase dependent eligibility, - and be aware of how you could be Healthcare reform has been a polar- reduce pre-existing condition restric- impacted, based on your stage of life, izing issue for years. We are poised to tions, and eliminate lifetime limits. goals you may have and financial stand- see the most sweeping changes since The January 1, 2014 deadline by ing – particularly if you fall into the Medicare and Medicaid were imple- which these provisions must be in place previous definition of “wealthy.” mented in the mid-1960’s. The details is rapidly approaching. Continue planning for the future and complexities are overwhelming, How will it be funded? A fantastic which, interestingly, has always been calling to mind Speaker Nancy Pelosi’s question, considering the poor financial filled with uncertainty and potential infamous statement, “We have to pass condition of Medicare and Medicaid pitfalls. And more than ever, stay the bill so that you can find out what is currently. Revenue is expected from diversified. l
Page 17 Nebraska Medicine | Fall 2012
Foster Group is proud to partner with Nebraska Medical Association as a Platinum Sponsor
The Foster Group Team
Delivering planning services including fee-only portfolio management, retirement planning, estate & charitable giving strategies, risk management & education funding. West Des Moines For more information or to schedule a private consultation, Quad Cities
please contact our office at 800.798.1012 or visit our website Phone 800 798.1012 at www.fostergrp.com
Foster Group’s (the advisor) marketing material should (1) not be construed by any existing or prospective client as a guarantee that they will experience a certain level of results if they engage or continue to engage the advisor’s services; (2) it should not be construed as a current or past endorsement of the advisor by any of its clients; and (3) lists or rankings published by magazines and other sources are generally based exclusively on information prepared and submitted by the recognized advisor. Foster Group has entered into a sponsorship agreement with the Nebraska Medical Association (NMA) under which it pays an annual fee. NMA is also an advisory client of Foster Group.
Page 18