the thriving practice
40	 AAO-HNS Bulletin ||||||||||||||| July 2007
For the first time in nearly a decade, AAO-HNS, the A...
the thriving practice
AAO-HNS Bulletin ||||||||||||||| July 2007	 41
At Annual Meeting: Quality,
Patient Safety, and Pay-f...
the thriving practice
art of codes
QWhat is Intraoperative Neurophysiology Testing (Nerve
Monitoring), and can I bill for ...
the thriving practice
AAO-HNS Bulletin ||||||||||||||| July 2007	 43
the thriving practice
he Health Insurance Portabili...
the thriving practice
44	 AAO-HNS Bulletin ||||||||||||||| July 2007
Economic practice of medicine
The economic realties i...
the thriving practice
AAO-HNS Bulletin ||||||||||||||| July 2007	 45
When I meet with physicians, to review their financia...
the thriving practice
AAO-HNS Bulletin ||||||||||||||| July 2007	 47
Cheryl C. Fatzinger, CMA, MBA
Practice Administrator
the thriving practice
48	 AAO-HNS Bulletin ||||||||||||||| July 2007
communication and to be sure that
individual is autho...
the thriving practice
communications. The consent form
should list the appropriate use and limi-
tation of online communic...
the thriving practice
50	 AAO-HNS Bulletin ||||||||||||||| July 2007
How Can I
Implement a
Change in My
by Rahul...
the thriving practice
AAO-HNS Bulletin ||||||||||||||| July 2007	 51
performed in the office. Once you have
an area or ran...
Upcoming SlideShare
Loading in...5

AAO-HNS and AMA Conducting Physician Practice Information Survey


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

AAO-HNS and AMA Conducting Physician Practice Information Survey

  1. 1. the thriving practice 40 AAO-HNS Bulletin ||||||||||||||| July 2007 For the first time in nearly a decade, AAO-HNS, the American Medical Association (AMA), and more than 70 other medical specialty societies, have worked together to coordinate a comprehensive multi-specialty survey of America’s physician practices during 2007. The purpose of the Physician Practice Information (PPI) survey is to collect up-to-date information on physician practice characteristics in order to positively influ- ence national decision makers while further developing and refining AMA and AAO-HNS policy. Thousands of practices will be surveyed from virtually all physician specialties to ensure accurate and fair representation for all physicians and their patients. The unique aspect of the project is that it explores both the clinical and business side of medical practice. The reason for this is that it is important for the nation’s policy makers to learn what is truly involved in running a practice that can provide patients with expert care, but is able to do so in a sustainable way. A complete understanding of the landscape and the requirements for today’s care is critical. The data obtained will be an im- portant source of information for the AMA and the AAO-HNS. It will represent practice concerns to national policy makers that will lead to policy initiatives that not only help in the short-term, but will allow future generations of doctors to continue providing superior care to their patients. The Gallup Organization has been retained to conduct the PPI survey among a representative sample of practices in each of the participating specialties. The Physician Practice Information survey is an important and necessary vehicle for positive change. Please watch for this survey in the coming weeks and do your part in completing it in a thorough and accurate manner, if randomly selected to represent our specialty. AAO-HNS and AMA Conducting Physician Practice Information Survey American Academy of Otolaryngology–Head and Neck Surgery Foundation Working for the Best Ear, Nose, and Throat Care One Prince Street | Alexandria, VA 22314-3357 | 1-703-836-4444 | Fax: 1-703-684-4288
  2. 2. the thriving practice AAO-HNS Bulletin ||||||||||||||| July 2007 41 At Annual Meeting: Quality, Patient Safety, and Pay-for- Performance A s you plan your course selections for this year’s annual meeting in Washington, DC, consider a concentration in quality, patient safety, and pay-for-performance (P4P). A number of sessions will help you learn about these hot issues and give you an opportunity to interact with representatives of hospitals, health plans, and payers who are actively engaged in quality improvement and P4P. Start with “Successful Practice in the Era of Value-based Purchasing” (Monday, September 17, 10:30 am to 12:00 noon). This year’s BOG mini seminar will educate otolaryngologists about the current status and consequences of the value-based purchasing model; discuss practice management applications of quality improvement, including data collection and utili- zation, reimbursement, and socioeconomic impact; discuss phy- sicians’ concerns regarding the appropriateness of measures used by CMS and other third-party carriers; and review the steps the Academy is taking to ensure physician involvement in the development of otolaryngology guidelines and measures. In the afternoon, two instructional courses will be of interest. First, “Techniques of Evidence-Based Medicine in Otolaryngol- ogy” (Monday, September 17, 1:45 pm to 2:45 pm) demonstrates several EBM websites and techniques and tools as means to teach participants the fundamentals of working with current medi- cal evidence and applying it to clinical and academic practices. Second, “Successful Practice: P4P Using Information Technology” (Monday, September 17, 1:45 pm to 4:00 pm) will discuss how appropriate use of health information technology, algorithms, and guidelines will help documentation and support successful engagement with pay-for-performance programs. On Tuesday morning, check out the miniseminar sponsored by the Patient Safety and Quality Improvement Committee, “Bulletproofing Your Practice for the Quality Invasion” (Tues- day, September 18, 9:30 am to 10:30am). This miniseminar will give you practical examples of how to identify, imple- ment, change, and measure quality improvement initiatives in individual practices. The course will show the importance of a systems-based approach and of targeting “low-hanging fruit” for initial safety initiatives. The goal for participants will be to leave this miniseminar with the basic tools to initiate measures to enhance patient safety and quality in your own practice. Then be sure to stop in and hear the oral scientific presenta- tion, “Implementation of Advanced Clinical Access: Lessons Learned” (Tuesday, September 18, 11:24 am to 11:34 am). Advanced clinical access models have been highly successful in enabling physicians to see more patients, more efficiently, with higher patient and physician satisfaction, but they have only recently begun to be used by surgical specialty clinics. This ses- sion will describe the outcomes of implementing an advanced clinical access model in a five-person otolaryngology practice within a larger multispecialty group. On Wednesday, there is an instructional course called “Data, Electronic Medical Records and Pay-for-performance” (Wednesday, September 19, 1:15 pm to 2:15 pm). Data and payment are being used in today’s market to influence physi- cian and patient choices. The course is designed to provide you with practical information on what to look for in current data systems and what to move toward to prepare for coming trends. The only way to face change is to plan. The physician will be taught to use practice-based data to plan for the provi- sion of quality care. These sessions on patient safety, quality improvement, and pay-for-performance will be complemented by many other sessions on electronic health records, practice management, and health policy. They are at the heart of the Academy’s mis- sion to work for “the best ear, nose, and throat care” and will provide valuable insight into the rapidly changing healthcare marketplace. Your Academy’s Quality Improvement staff looks forward to seeing you at this year’s annual meeting. Day Time Title Monday, September 17 10:30 am to 12:00 noon “Successful Practice in the Era of Value-based Purchasing” Monday, September 17 1:45 pm to 2:45 pm “Techniques of Evidence-Based Medicine in Otolaryngology” Monday, September 17 1:45 pm to 4:00 pm “Successful Practice: P4P Using Information Technology” Tuesday, September 18 9:30 am to 10:30am “Bulletproofing Your Practice for the Quality Invasion” Tuesday, September 18 11:24 am to 11:34 am “Implementation of Advanced Clinical Access: Lessons Learned” B
  3. 3. the thriving practice art of codes QWhat is Intraoperative Neurophysiology Testing (Nerve Monitoring), and can I bill for it? A This “add-on” code, CPT 95920 Intraoperative Neurophysi- ology testing, per hour (list separately in addition to code for primary procedure), frequently called “nerve monitoring,” is utilized by physicians when performing nerve monitoring during complex surgical procedures involving cranial nerves. The surgeon, another physician (e.g., neurologist or physiatrist), or an electrodiagnostic technologist prepares the patient prior to surgery by attaching fine wires and electrodes on designated areas, such as the face or neck (in the case of facial nerve moni- toring). In a case of recurrent nerve monitoring, the electrodes are integrated into the endotracheal tube. These electrodes are connected to electrodiagnostic equipment that monitors specific nerves either through automated monitoring (e.g., an audible alarm) or by clinician interpretation of the monitoring device’s output. The surgeon is alerted when the nerve is being affected by the procedure. CPT does not limit the billing of CPT codes to any particular specialty. Therefore, otolaryngologists may bill intraoperative neurophysiology testing, using code 95920 if this represents their physician work during the reporting period. However, per CPT coding guidelines, that CPT code cannot be reported by the sur- geon and/or assistant surgeon. In addition, CPT code 95920 is The Art of Otolaryngology Coding (revised May 2007) not billable as a stand-alone code and is modifier –51 (multiple procedures) exempt. This code must be billed with the appropri- ate CPT code identifying the monitoring study being performed. For example, in the case of facial nerve monitoring during parotidectomy, the coder would link CPT code 95920 to the EMG CPT code 95867 Needle electromyography; cranial nerve sup- plied muscle(s), unilateral, not to the CPT code for the parotid surgery. A full listing of these codes can be found in the CPT book’s “Intraoperative Neurophysiology” section, in a paren- thetical statement under the description of CPT 95920. This code is reported per hour and at least 30 minutes of monitoring must be performed to report the code. If the clinician performs only the interpretation and does not own the equipment, modifier -26 (professional component) must be appended to the code used for the study performed. The provider performing the monitor- ing must both report the intraoperative findings and record his or her precise level of involvement in this process to obtain reimbursement. It is best to use CPT terminology in the dictation whenever possible. The individual doing the monitoring should have credentials to interpret the tests and, in most cases, must be practicing in another specialty to be reimbursed. In addition, many carri- ers do not consider monitoring with an automated device to be reimbursable using these codes—they consider it integral to the surgery. It is important to know how the carriers with whom you are contracted accept reporting of monitoring and their specific reimbursement policies. Ultimately, it is the surgeon’s judgment as to whether and how monitoring is performed. For more information, contact the coding hotline at 1-800-584-7773. A number of members have inquired about the correct usage of CPT codes 31233 Nasal/sinus endoscopy, diag- nostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture), and 31235 Nasal/sinus endoscopy, diag- nostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium). Some who perform endoscopic exams after the postoperative global period to view the interior of maxillary or sphenoid sinuses through existing surgically cre- ated patent sinusostomies are reporting 31233 or 31235 (or perhaps both). For these situations, it is the Academy’s position that only 31231 Nasal/sinus endoscopy, diagnostic, unilateral or bilat- eral (separate procedure) should be reported. CPT codes 31233 and 31235 require a puncture or trocar cannulation prior to placing the scope into the sinus. The procedure represented by CPT 31231 is inherently bilateral; the other two codes (31233 and 31235) are unilateral. The use of 31233 or 31235 to report diagnostic sinus endoscopy performed via an existing and patent opening into the maxillary or sphenoid sinus represents incorrect CPT coding. CPT for ENT: Reporting Nasal/Sinus Endoscopy with CPT Codes 31233, 31235 42 AAO-HNS Bulletin ||||||||||||||| July 2007 B B
  4. 4. the thriving practice AAO-HNS Bulletin ||||||||||||||| July 2007 43 the thriving practice T he Health Insurance Portability and Accountability Act (HIPAA) of 1996 required issuance of a unique national provider identi- fier (NPI) to each physician, supplier, and other provider of healthcare who conducts HIPAA standard electronic transactions. CMS began to issue NPIs on May 23, 2005. On April 24, 2007, the Centers for Medicare and Medicaid (CMS) released a contingency plan for the implementation of the NPI. Here are the basics you’ll need to know for correct implementation of the NPI: On April 2, 2007, the Department of Health and Human Services (HHS) stated that covered entities (including health plans and covered health provid- ers) acting in good faith toward compli- ance, may establish contingency plans to facilitate the compliance of their trad- ing partners. For an unspecified time beyond May 23, 2007, Medicare FFS will allow continued use of legacy numbers such as UPIN numbers, PIN numbers, NSC numbers, or OSCAR numbers on transactions as well as accept transac- tions that contain only an NPI, and transactions with both legacy numbers and NPIs. Further guidance from CMS will specify the length of the contin- gency period. In May 2007, Medicare FFS evaluated claims submissions with NPIs. CMS anticipates that an upcoming analysis will demonstrate that a sufficient num- ber of submitted claims from billing, pay-to, and rendering providers will contain an NPI. When that happens, Medicare will begin rejecting claims that do not contain the primary provider’s NPI. Those providers will be notified of the rejections. A rejection does not mean that you will not be paid for the claim; it only indicates that you left out needed information on the claim and it needs to be corrected and resubmitted. In checking for NPIs, Medicare classi- fies billing, pay-to, and rendering pro- viders as primary providers who must be identified by NPIs, or their claims will be rejected. All other providers (including refer- ring, ordering, supervising, facility, care plan oversight, purchase service, attend- ing, operating, and “other” providers) are classified as secondary providers, and legacy numbers will be accepted for these providers until May 23, 2008. If an NPI is present on the claim for the secondary provider, it will only be checked to assure it is a valid NPI. Claim rejections could start as soon as July 1, 2007. If, however, there are not sufficient claims containing NPIs in the May analysis, Medicare FFS will reassess the compliance rate in June 2007 and will determine whether to begin rejecting claims in August 2007. After May 23, 2008, legacy numbers will not be permitted on any inbound (e.g., claim submissions, status inquiries, etc.) or outbound (e.g., remittance advice, EOBs, etc.) transactions. CMS has also considered the National Council of Prescrip- tion Drug Programs (NCPDP) claims. These types of claims allow the provider to report only one identifier; there- fore, NCPDP claims can contain either the NPI or the legacy number, but not both, until May 23, 2008. If the claim is submitted with an NPI, the NPI will be sent on the associated X12835 remittance advice; otherwise the legacy number will be sent on the associated X12835. If a claim is submitted with an NPI, the associated X12837 Coordina- tion of Benefits (COB) transactions will be sent with both the NPI and legacy numbers; oth- erwise only the legacy number will be sent. By May 23, 2008, the X12 270/271 eligibility inquiry/response supported by CMS via the Extranet and Internet must contain the NPI. This pertains to all claims, not just NCPDP claims. For additional information pertaining to the contingency plan or information related to the NPI, please go to: www. If you have additional questions, please feel free to contact the Academy’s reim- bursement analyst at 1-703-299-1128 or via email, Medicare Fee-For-Service (FFS) National Provider Identifier (NPI) Implementation Contingency Plan B
  5. 5. the thriving practice 44 AAO-HNS Bulletin ||||||||||||||| July 2007 Economic practice of medicine The economic realties in which a private physician practice operates are of increasing concern. Physicians are potentially facing substantial reductions in Medicare reimbursements over the next five years and will realize similar cuts from commercial insurers whose fee schedules are also based on some percentage of Medicare. While fore- casted revenue reductions are quickly approaching, many ongoing monthly practice expenses continue to rise. Most office leases contain annual rent escalators. Employee salary and benefit costs increase every year and many physicians are still embroiled in the national insurance crisis, with dramati- cally increasing premium costs. You do not need a Harvard MBA to understand what happens to physician compensa- tion when faced with rising costs and decreasing reimbursements. However, all is not lost. Many otolar- yngology practices continue to thrive and are enjoying annual double-digit increases in physician compensation. This success is due in large part to the implementation of a comprehensive productivity benchmarking program. Benchmarking to improve your practice As defined, benchmarking is an improvement tool whereby a company measures its perfor- mance or process against other best practices, determines how those best prac- tices were achieved, and uses the informa- tion to improve its own performance. A successful benchmarking program will: 1. Increase collegial competitiveness among physicians in a practice; 2. Improve financial performance of the practice; 3. Provide data from which to make deci- sions; and 4. Promote physician awareness and encourage change in a physician’s behavior and practice pattern. Key performance indicators Data available from a computer- ized patient management system is too diverse to provide a quick overview of your practice. For a benchmarking pro- gram to be useful in improving perfor- mance, careful attention must be paid to the selection of concise, well-defined comparative benchmarks known as key performance indicators (KPIs). For data to be useful and actionable, selected KPIs must be specific and measurable regu- larly with consistent data sets. Most otolaryngologists are unaware of how their personal productivity, col- lections, and overhead compare with their peers nationally. Thankfully, the Association of Otolaryngology Admin- istrators (AOA) annual benchmarking survey provides a nationally recognized comprehensive resource for financial and productivity measurements of ENT practices. For the physicians in my practice, I have developed a set of KPIs that evalu- ate physician productivity/ancillary service utilization, overhead, and the management of the accounts receivable. Success in these three key areas directly impacts the financial performance of each individual physician and the entire group practice as well. Increas- ing physician productivity and collec- tions via strong management of the accounts receivable, combined with the aggressive control of expenses, leads to increased physician compensation. Specific measurements Listed below is an actual monthly benchmarking report for one of the physicians in my practice. It details indi- vidual productivity as compared with the group and the AOA national otolar- yngologist average. All figures provided are accurate and can be used as a tool to evaluate physician productivity in your own practice. Key Performance Indicators Doctor Average Practice Average AOA Survey Average Physician Productivity # Patients Seen/Month 451 330 273 # Audiology Procedures per Patient Seen 0.64 0.65 0.64 # Office Procedures per Patient Seen 0.74 0.72 0.24 Expense Management Overhead 44.2% 44.2% 52.5% Accounts Receivable Management $124,600 $108,000 $64,326 Days of Service Outstanding (DSO) 30.8 31.2 43.9 Gross Collection % 75% 72% 49% Implementing a Productivity Benchmarking Program How to diagnose and improve the financial health of your practice
  6. 6. the thriving practice AAO-HNS Bulletin ||||||||||||||| July 2007 45 When I meet with physicians, to review their financials, I provide them with a one-page graphical summary of the above KPIs to help them better understand and analyze their own individual productivity. In the case of the physician profiled above, from a clinical perspective, he is treating more patients than his peers in the group and at the national level. His frequency of ordering diagnostic audiology tests on his patient population is com- parable to both the group and national benchmark, but his utilization of office procedures is substantially higher than the national average. It must be realized that physician productiv- ity numbers and AOA survey averages may also be influenced by the basis of clinical interest or a physician’s subspecialty. From an expense perspective, his overhead costs are lower than both indexes and his monthly collections and gross col- lection percentage far outpace the national average. Finally, his days of service outstanding (which represent the number of days that the practice takes to collect revenue on billed charges) are significantly lower than the national otolaryngology aver- age, meaning his receipts are collected sooner by the practice than most other practices. Benchmarking conclusions The sole objective of benchmarking is to improve and promote patient care by ensuring that patients are provided access to the appropriate diagnostic tools in a timely manner. The availability of ancillary services should not preclude a change in standard and acceptable physician practice patterns but, rather, should foster better use of evidence-based medical guidelines. However, to ensure this likelihood, one should have an active and routine compliance program to help prevent any unnecessary procedure utilization. Benchmarking productivity illuminates aspects of a medi- cal group that are often ignored by practicing physicians whose main focus is on direct patient care activities. How- ever, a strong clinical physician needs a strong financial prac- tice to continue providing high-quality patient care. Because we are facing a 40 percent reduction in Medicare payments over the next decade, change is coming and only the most efficient practices will survive. It is important as a specialty that we quickly identify and quantify these efficiencies through continued comprehensive benchmarking initiatives on a national level. Todd Blum, MHA, MBA is the Chief Executive Officer of Ear, Nose, and Throat Associates of South Florida, PA. To contact Mr. Blum, please e-mail him at B American Academy of Otolaryngology– Head and Neck Surgery Working for the Best Ear, Nose, and Throat Care One Prince Street | Alexandria, VA 22314-3357 1-703-836-4444 | Fax: 1-703-684-4288 Otolaryngology- Head and Neck Surgery See the July 2007 issue, including: • Safety and outcomes of balloon catheter sinusotomy: Multi-center 24-week analysis in 115 patients Bolger, et al • The impact of a cation channel blocker (furosemide) on pseudomonas aeruginosa PAO1 biofilm architecture Cross, et al • Sinonasal surfactant protein A1, A2, and D is elevated in cystic fibrosis: A preliminary report Woodworth, et al Website:
  7. 7. the thriving practice AAO-HNS Bulletin ||||||||||||||| July 2007 47 Cheryl C. Fatzinger, CMA, MBA Practice Administrator Piedmont Ear, Nose, Throat Associates Winston-Salem, NC W hen trying to increase the “bottom line” or net profit- ability of the medical practice, physicians often focus on the expense portion of the income statement. This is very important, of course, but there is a second variable in the profitabil- ity equation, and too many times it is taken for granted. Physicians expect if they put the charges on the books, the revenues will be there. If I bill it, it will come. Unfortunately, this assumption could lead to the demise of an other- wise productive and profitable practice. Below are a few suggestions to make sure you’re getting every precious dollar you deserve. The process starts as soon as the patient checks in. Make sure those co-pays and deductibles are collected before the patient gets to the exam room. This money is most difficult to collect once the patient leaves the office, and it can be a substantial amount of the contracted allowable insurance pay- ment. Unlike groceries, once the patient has received your services, you can’t take it back for nonpayment. Are you leaving money on the table? Do you have systems in place to make sure all your surgeries are posted for payment? Are you billing for all the ser- vices you performed during the patient visit? Just because Medicare says you can’t bill for an EM code along with a procedure such as wax removal, doesn’t mean your private payers won’t allow it. Make sure you check all the boxes on the encounter form that pertain to services performed during the visit. Ask your clinical assistant to review it before the patient checks out. Modifiers may need to be appended to certain CPT codes, but these can be added by your check- out or insurance personnel. Now that you’ve billed for your ser- vices, are you sure the claim got paid? Are you tracking your denied claims rate? If it’s above 10 percent, you need to find out why your claims are being denied. Is your receptionist confirming the patient’s demographic information, including current insurance informa- tion, when the patient checks in? The main reason for denials is incorrect demographic information. Something as simple as entering one incorrect number in a birth date will cause a claim to be denied. Front-office staff not only have to be personable and friendly, but also detail oriented. As the old saying goes, garbage in, garbage out, but this garbage can cost you a lot of money. On average, a denied claim will take an additional six weeks for payment. If a claim is denied, who’s correcting it before refiling? Working a claim does not mean refiling the same claim with- out first correcting the reason for the denial. This sounds silly, but it happens in far too many practices. Your insur- ance contracts stipulate the amount of time you have to file a clean claim. If the time is exceeded, you can kiss the money goodbye and know that you just added to the insurance company’s net profitability. Now if that doesn’t make you angry, nothing will! Make sure you employ insurance and billing personnel who take pride in their work and aren’t just collecting a paycheck. So, how do you know if your insurance and billing personnel are doing their job? You need to track your accounts receivable (AR) stats monthly. Your practice management system can print a report that ages the practice AR (current, 31–60 days, 61–90 days, over 90 days). For a better represen- tation of your AR aging, make sure the clock starts ticking as soon as the charge is posted—not when the claim is first filed. Also track your gross and net collection rates. Your gross collec- tion rate (revenue divided by charges) is simply an internal benchmark because charges will vary from prac- tice to practice. If after a few months of tracking you see a 5 percent or more variation, something has changed and the reason for the variation should be investigated. Net collection rate (revenue divided by charges minus write-offs) measures the percentage of “allow- able” charges you are collecting. Red flags should be raised if this drops much below 95 percent. Another indicator to track, although my least favorite because it can be affected by many variables beyond the staff’s control, is average days in AR defined as your total AR divided by average daily charge (total gross charges divided by 365). There are more AR statistics that can be monitored, but this will get you started. Now that you have your AR stats, benchmark them against national averages to see how well your practice is doing. The Association of Otolaryn- gology Administrators (AOA) published its first benchmark survey in 2006. It includes all the above-mentioned benchmarks plus a multitude of addi- tional practice management statistical averages. Once you have benchmarked your practice against national aver- ages, up the ante and benchmark against “better practices.” The Medi- cal Group Management Association publishes “better practice” standards. In addition to the benchmark surveys, the AOA will be publishing an accounts receivable policy and procedure manual that will be available for pur- chase at the AOA national conference in September. Courses are offered every year at the AOA national conference to help your practice administrator manage the “top line.” Encourage your practice administrator to join the AOA and attend the national conference. For more information about the AOA, go to Believe it or not, I know of a practice that lost $400,000 in revenues last year as a result of taking its eye off the “top line.” Don’t let this happen to you! Who’s Watching the Top Line? B
  8. 8. the thriving practice 48 AAO-HNS Bulletin ||||||||||||||| July 2007 communication and to be sure that individual is authorized to receive it so that patient privacy and confidential- ity are never compromised. That is why you should establish a written patient authentication protocol for all practice personnel and ensure that all staff mem- bers understand and follow it. Another important guideline is to maintain a written record of each patient who is authenticated for online communication. Make sure the record includes the patient’s name, the authen- tication date, the name of the staff member authenticating the patient, and the method your office used to authenti- cate the patient. Prevent unauthorized computer access Your office should have a system in place to guard against unauthorized access to computers by using automatic log-out and password protection. Obtain informed consent Be sure your patient signs an informed consent form before you initiate online The Doctors Company T he use of online communication and consultation between doctors and patients is becoming more common in everyday physician practice. The unique concerns and risks inher- ent in this form of communication have prompted the development of the “eRisk Guidelines for Online Communication.” “Medicine is increasingly using the Internet for communications and there is growing pressure from health plans, employers, and government to use both personal health records (PHRs) and elec- tronic medical records,” says David B. Troxel, MD, medical director of The Doc- tors Company. In light of these develop- ments, it is important for physicians to know how to avoid potential risks when using online patient communications. The guidelines were initially created in 2000 by the eRisk Working Group for Healthcare, a volunteer consortium including professional liability carriers, medical societies, and state licensing boards. Released late last year, the 2006 revision represents the third update. “In the latest update we alert doctors to potential licensure problems with online communications,” Dr. Troxel explains. For example, if something goes awry as a result of an online consultation that a physician has with an out-of-state patient, there is a potential that the doc- tor could be accused of practicing medi- cine without a license if he or she doesn’t have a license in the patient’s state. In addition, a new PHR section rep- resents a substantial new guidance for physicians. One of the most important provisions is that physicians must make is that patients are responsible for what appears in their personal health record. “For example, if a new blood test result is automatically added to the record by a laboratory, the patient must inform the doctor of that addition,” he warns. Because the technology of online com- munications introduces special concerns and risks, it’s important to understand the latest major provisions. Here are some of the main points: Maintain patient confidentiality. Physicians are responsible for tak- ing reasonable steps to protect patient privacy and guard against unauthorized access to and/or use of patient infor- mation. This responsibility extends to the use of network services, which are expected to have an appropriate level of privacy and security as required under the Health Insurance Portability and Accountability Act (HIPAA). To maintain confidentiality, conduct online communications with patients over a secure network that contains encryption technology. Standard email services don’t meet HIPAA requirements. When sending standard, nonsecure emails to patients, add a disclosure to the bottom stating that “this email is not secure, and is not for use by patients or for healthcare purposes in general.” It is also important to take reasonable steps to authenticate the identity of the individuals receiving your electronic How Physicians Can Identify and Reduce eRisk
  9. 9. the thriving practice communications. The consent form should list the appropriate use and limi- tation of online communications. You will also want to develop specific written guidelines and protocols for online communications with patients, such as avoiding emergency use, height- ened consideration of use for highly sensitive medical topics, and setting expectations for response times. Take the time to document these guidelines in your practice’s policy manual, patient terms of service, disclosures, and the medical record, when appropriate. Limit online communication to existing patients Online communication of any kind is best suited for patients previously seen and evaluated in an office setting. Ini- tiating a physician-patient relationship online may increase liability exposure. Understand licensing jurisdiction Online interactions with patients are subject to state licensure require- ments. Pathologists, radiologists, and other clinicians interpreting specimens, slides, or images sent through interstate commerce for a primary diagnosis that becomes part of the patient’s medical record should have a license to prac- tice medicine in the state in which the patient presents the diagnosis, or where the specimen is taken or image is made. Intraspecialty consultation, however, does not require in-state licensure, as long as the consultation is requested by a physician licensed within the state and referenced in a report he or she issues. Inform patients about sensitive subject matter Always advise patients of the risks that information the patient considers sensitive may inadvertently be accessed by someone not authorized to see it. You can list examples for patients of conditions that should be handled in an office setting, such as mental health, substance abuse, reproductive history, sexually transmitted diseases, drug and alcohol problems, and HIV status. Some states may prohibit electronic transfer of specific classes of information, regard- less of patient consent. Be sure you know what the law requires in your state. Understand your responsibility regarding online patient education Physicians are responsible for informa- tion made available to patients online. Be sure the information provided to patients through a PHR, automated patient education programs, care man- agement, and other online services come either directly from you or from a recog- nized, credible, authoritative source. Warn against electronic communication regarding emergency topics... ...such as chest pain, shortness of breath, and high fever. Discourage the use of online communication to address medical emergencies. Ask your patients instead to call the office or go to an emer- gency department. To avoid potential problems, use a disclaimer on web pages and emails reminding patients that emergency subject matter is not appro- priate for electronic communication. Document communication in the medical record You should keep a permanent record of online communications with patients, whether that record is paper or elec- tronic. Accurate and thorough documen- tation is an effective risk-management tool. Remember that email and online information, including PHRs and con- sultations, are not erased from the hard drive when deleted and are potentially discoverable in litigation. You are responsible for the information available to patients on your practice’s website Any medical information you provide on your website should come either directly from you or from a recognized credible source. Tread carefully when it comes to commercial information. Websites and online communications dealing with advertising, promotions, or marketing may raise patient expectations and increase your liability. This is espe- cially true when cosmetic procedures, off- label drug use, and non–FDA-approved procedures are promoted. “If something goes wrong, an aggressive public pros- ecutor may make claims about implied warranties,” Dr. Troxel warns. The guidelines recommend posting a disclaimer page between your practice’s website and links to any third-party site, advising patients and others that they are leaving your practice’s site and that you don’t assume responsibility for the content or privacy of the linked site. Properly manage fee-based consultations The eRisk working group also provides physicians with guidance on how to handle fee-based online communica- tions. There are also potential risks when patients are referred to online pharmacies, because some employ “cyberdocs” who dispense drugs and medical devices without a valid doctor’s order, and others may be involved in the illegal importation of prescription drugs. The National Association of Boards of Pharmacy has a Verified Internet Phar- macy Practices Sites (VIPPS) program ( asp). Pharmacies in compliance with their standards show the VIPPS seal of approval on their home pages. Following these guidelines and stay- ing up to date with the latest version can help physicians avoid potential electronic liability minefields. Says Dr. Troxel: “Physicians should become famil- iar with the liability risks inherent in online communications, since the failure to follow them increases their liability exposure.” For more on the eRisk Guide- lines, go to AAO-HNS Bulletin ||||||||||||||| july 2007 49 B
  10. 10. the thriving practice 50 AAO-HNS Bulletin ||||||||||||||| July 2007 How Can I Implement a Change in My Practice? by Rahul K. Shah, MD, Children’s National Medical Center, Washington, D.C. O ccasionally we are approached by individuals such as the Academy member above who effected change in his hospital without imple- menting drastic changes. More often, however, we are approached by col- leagues who complain about obstacles to safety and efficiency in their practices and their lack of knowledge of how to bring about change. Some of the blame lies in the literature, which is replete with examples and suggestions of com- plex interventions that, at first read, are intimidating and perhaps impractical to implement in our practices. The article cited below, “Quality and Safety in a Complex World: Why Systems Science Matters to Otolaryngologists,”1 although scientific in nature, has tremendous practical application and offers guidance on how to make changes in your own practice. In it, the authors advocate strate- gies that involve 1) standardization to improve functioning of repetitive processes, and 2) using a rapid feedback loop (i.e., shortened cycle time) to gauge the impact of your intervention. For example, an Academy member patient safety and hospital compliance. The cost-benefit analysis is quite easy in this scenario, because the cost of a Joint Commission violation for problems with a verbal order not being signed properly far outweighs the cost of distributing the stamps. On an individual practice level, there are a few strategies to help you determine if your practice is safe. Ask your patients and support staff if they feel there are areas in the practice that can be ame- liorated. Almost certainly, someone will mention items such as lengthy delays in receiving pathology reports/lab results, poor communication between patients and support staff, difficulty with schedul- ing, or concerns about procedures being was troubled when he noted that there had been an inadvertent misadminis- tration of allergy sera in his practice, leading to an adverse outcome for the patient. The member did not embark upon a large research study or meta- analysis to investi- gate the success of different methods of solving this problem. Rather, he simply made a rule that the patients’ names and their sera would be double-checked and clearly shown to them prior to injection. This simple intervention imme- diately changed his practice environ- ment. He continues to evaluate his allergy practice to ensure that this practice is working. He has informally asked many patients for feedback and they now report feeling that the pro- cess is much safer. This is an excellent example of standardization improving the function of a repetitive process. In another example, an academic medical center audited their in-patient admissions and noted that residents were making dosing errors for commonly prescribed medications. The residents were convened and the dosing of these few medications was reviewed; each resident was given a small keychain calculator that they could use to properly dose the medications. The cost of the intervention was less than ten dollars per resident. Though the benefits cannot pre- cisely be quantified, avoiding even one adverse event from a medication error makes this simple intervention worth the time and effort. The rapid feedback to the residents with a proposed solution enabled this strategy to succeed. One institution noted that resident signatures were often illegible and sup- port staff would have difficulty reaching the appropriate physician when needed. This hospital distributed ink stamps to residents with their full names and pager numbers. The effect of this small change was far-reaching and improved “ ” Our institution was audited and deficiencies in our universal protocol were noted. As we wanted to be a safer and more compliant institution, physicians were recruited to assist in changing our forms. I was shocked at how simple it was to make small, incremental changes to achieve a compliant universal protocol. -Academy member Tips for making changes in your practice:1,2 1. Start small and achieve early victories. Identify a small proj- ect that you believe can be conquered. 2. Obtain buy-in. Make sure the change that you desire is also sought by those whom the change will affect (administra- tive/ancillary staff in your office, or pertinent hospital staff). 3. Once you implement a change, rapidly and repetitively review the system that was changed. 4. Be prepared for unanticipated consequences. Fragile systems (as many of us believe medicine is at present) can at times be per- turbed by changes that appear benign. 5. Ask for guidance. The AAO-HNS has superb resources to assist us in improving quality and safety in our practices. Ask your local phy- sician colleagues about what they have done that has been success- ful. Their practice milieu is prob- ably similar to yours.
  11. 11. the thriving practice AAO-HNS Bulletin ||||||||||||||| July 2007 51 performed in the office. Once you have an area or range of areas where your practice can benefit from some interven- tions, the next step is to pick one and plan an intervention. This should be a small-scale effort that will not require extensive time or cost to implement. After the change you selected has been implemented, frequently and infor- mally review the effect of the change to ensure that it has the intended conse- quences. A review can include meeting in the hallway to informally discuss the results of the intervention. A shortened cycle time will allow you to improve the function of the system. For example, if your intervention created a new barrier to workflow, you are much better off to recognize this sooner rather than later. In summary, identify areas for improvement, ask for opinions of all of those involved, implement change, and monitor for the effect. There is a simple, common pathway for implementing change, PDCA (Plan-Do-Check-Act). The Plan phase consists of identifying an area that is amenable to quality improvement; the Do phase involves developing the metrics to measure the problem and implementing the small- scale intervention; the Check phase is where the data is reviewed and ana- lyzed; and, in the Act phase, the success- ful interventions from the prior part of the cycle are implemented throughout the system and the success of the inter- vention is celebrated. We have seen that there is no lack of knowledge about implementing process changes, but, rather, a lack of confi- dence in one’s ability to affect micro- changes, or concern that microchanges will not significantly affect overall quality and safety. Many physicians are shocked at how easy and rewarding it can be to implement practice changes to enhance patient safety and qual- ity for their individual practices and institutions. References: 1. Roberson DW, Kentala E, Healy GB. Quality and safety in a complex world: Why systems science matters to Otolaryngologists. Laryngoscope. 2004. 114:1810–1814. 2. Core curriculum for medical quality man- agement. American College of Medical Quality (ACMQ). Jones and Bartlett Publishers, MA; 2005. We encourage members to write us with any quality or safety topic of interest and we will try to research and discuss the issue. Member’s names are published only after they have been contacted directly by Acad- emy staff and have given consent to the use of their name. Please email the Academy at to engage us in a patient safety and quality discus- sion that is pertinent to your practice. Keep them in the know with our informative patient leaflets Full of up-to-date, peer physician-reviewed information conveniently packaged in a user-friendly format. Content includes: • A description of the ailments • Usage tips • Prevention • Symptoms • Treatment Order these titles today: Allergies and Hay Fever PLEAF 4763150 You and Your Stuffy Nose PLEAF 4763160 Antihistamines, Decongestants, and Cold Remedies PLEAF 4763170 Sore Throats PLEAF 4763660 $96 Nonmembers (per 100) only $48for AAO-HNS Members (per 100) *Price does not include shipping and handling GiveYour Patients A Defense Against Allergy Season American Academy of Otolaryngology—Head and Neck Surgery Working for the Best Ear, Nose, and Throat Care One Prince Street | Alexandria, VA 22314-3357 | 1-703-836-4444 | Fax: 1-703-684-4288 B