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American College of Physicians: Internal Medicine — Doctors for Adults ®

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Daily 4-23-10

Internal Medicine 2010 News reports breaking news and events live each day from Internal Medicine 2010 and the American College of Physicians.

Highlights

  • E-mail boosts communication, patient satisfaction
  • Ethical issues of concierge medicine countered by huge physician interest

EHR use

  • Precourse offers advice on EHR ‘meaningful use’
  • EHRs critical to effective reporting of quality measures, says ACP

For attendees

  • Geriatrics update offers fixes to common problems
  • Infectious diseases update veers off the beaten path
  • What makes a good neighbor? PCMH and subspecialty practices
  • Allergy and immunology session canceled

Highlights

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E-mail boosts communication, patient satisfaction

E-mail has the speed of a bullet, the power of a locomotive and the half-life of plastic, noted John R. Maese, FACP, during a session Thursday on using e-mail in practice.

"You can't take back what you wrote, and an e-mail lives forever," said Dr. Maese, a practicing internist in Staten Island, N.Y. "Choose your words carefully."

Physicians should decide from the start how they intend to use e-mail in their practices, as well as who in the office will be allowed to read the e-mails, what the response time will be, and how e-mails are handled during vacations, holidays, weekends and at night.

Once these questions are answered, the office manual should be rewritten (or written, as the case may be) to reflect the policy. Staff and patients should be apprised of the policy specifications.

E-mail allows physicians to provide patients with a written record so they aren't phoning the office; this can lower phone costs and cut down on phone tag, he said. It also allows clinicians to give orders for home care, and to more completely instruct on matters like diet.

"It is really a good tool for chronic management—like asking patients, 'Did you eat that doughnut today'?" Dr. Maese said.

A handy rule of thumb for deciding when to e-mail or not e-mail patients: If you can't say it in two to three lines, you should call the patient or have him or her come in instead.

"You can't write, 'Cancer. See ya.'," Dr. Maese said. "It shouldn't be used for bad, sensitive or complex information."

E-mail also shouldn't be used for emergencies, and with new patients whose receptiveness to the medium is unknown, he added. As with a fax, every e-mail should include a disclaimer. Standard messages that are frequently sent to patients should be reviewed by an attorney before they become a regular part of the practice, he said.

It's important to make sure one's office e-mail system is secure. When it is, all messages will be encrypted so that they can only be read by the intended user, Dr. Maese added.

Patients will initially need instructions to set up encrypted email capability. Once they are registered, they will need to type in their e-mail addresses and passwords whenever they receive messages from the office, he said.

If a physician's office sends a secure e-mail to a patient with a Web-based account like Gmail, the message will remain secure as long as the patient uses the "reply" button. It will not be secure if he or she starts a new e-mail thread, however, he noted.

It is the physician's responsibility to ensure all communication from his or her office is secure. If, for example, a patient starts a conversation through an unsecured account, the office must put that question in an encrypted format when it is sent back.

E-mail is billable to some insurers, including Cigna, Aetna and Wellpoint; the CPT code is 99444. Reimbursements run about $30 to $60, depending on the insurer, he said.

A good resource for helping practices set up e-mail is ACP's Center for Practice Improvement and Innovation (CPII), Dr. Maese added. Attendees can also stop by the CPII booth at the ACP Resource Center in the Exhibit Hall to learn more.

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Ethical issues of concierge medicine countered by huge physician interest

It wasn’t precisely the debate it was billed as. The hundred or so attendees at Thursday morning’s session “Concierge Medicine: The Debate Continues” appeared almost unanimously in favor of the alternative practice model that both speakers follow.

Panelist Jon Yardney, ACP Member, did disagree with the term, however. “I don’t view myself as anybody’s concierge,” he said, joking that he doesn’t do dinner reservations. But like co-panelist Matthew J. Killion, FACP, he does have patients who pay annually for his services and in exchange receive benefits such as same-day scheduling and direct, round-the-clock access to a physician (i.e., they have his cell phone number).

During the session, which was sponsored by ACP’s Council of Young Physicians and chaired by Council chair-elect Ryan D. Mire, FACP, the two physicians discussed the motivations behind their transitions from traditional private practice to a model in which patients pay a retainer for access.

Dr. Killion’s practice is actually a “hybrid” concierge model, in which some of his patients are covered just by insurance and others pay for concierge service. It was his patients who first gave him the idea. “Patients actually started to ask me about a retainer model,” he said. The idea fit the schedule he wanted to work as a father of two young children who enjoys being able to drop off and pick up his kids at school. “Whereas I was seeing 20 to 25 patients and doing hospital consults, at this point I see about 12 patients a day and still do consults because I like it,” he said. “It’s really about a lifestyle choice.”

Dr. Yardney was driven to concierge (or retainer) practice by a lifestyle that he had found to be untenable. As patients in his small traditional practice aged, they required more of his time while documentation ate up a lot of his day. “If something didn’t change, I was going to walk away,” he said.

Both doctors began taking some of their patients on retainer several years ago and are pleased with the results. “It’s been a way to renew all the fun and the interest that I originally had in primary care,” said Dr. Yardney. “There’s time to listen to stories, tell a joke or two.”

Attendees, who were mostly either in concierge practice or considering entering the field, were eager to hear the physicians’ stories and elicit advice. Questioners raised a few of the common concerns about concierge medicine, such as the legality of taking payment from both patients and third-party payers. The rules vary according to location and insurer, the speakers answered. One prospective concierge doc, a recent residency grad, was warned that the model typically requires starting off a career in a traditional outpatient practice, unless you’re taking over for a retiring physician.

The speakers also addressed the issue of whether concierge physicians—who typically provide annual physicals as a part of their contract—use scans and tests excessively. “I bristle at the suggestion that retainer medicine means you overtest,” said Dr. Yardney, describing the value of his annual physicals. “If it does nothing more, it deepens the relationship.”

The session attendees also discussed the relationship between ACP and concierge physicians, with some audience members calling for support for the model from the College. Dr. Mire noted that although two resolutions on the topic have been brought before the Board of Governors, the College’s only official statement on the issue has been a warning that physicians who engage in the practice “risk compromising their professional obligation to care for the poor.”

“Some argue that it’s an elitist style of practice,” noted Dr. Mire. One questioner asked Dr. Killion how his non-concierge patients feel about the fact that other patients have 24/7 access to him through his cell phone. The others have access, too, he responded. “They can reach me through my answering service.”

The session’s final questioner summed up some of the concerns but also the appeal of the practice model. “I thought it was like skimming the cream and I don’t want any part of it. On the other hand, when you see how crippled you are in general internal medicine, you have to say there must be some other way to do it.”

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EHR use

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Precourse offers advice on EHR ‘meaningful use’

Wednesday’s precourse on performance measurement in the patient-centered medical home (PCMH) included a section offering advice on managing new rules for meaningful use of electronic health records (EHRs).

“We’re looking to give members the best information so they can accomplish a couple of goals at the same time,” said presenter Lea Anne Gardner, RN, PhD, senior associate for clinical programs and quality of care for ACP.

Stage 1 of the EHR meaningful use incentive program, part of the 2009 American Reinvestment and Recovery Act, begins in 2011. Participation is voluntary but will have penalties for those who do not participate by 2015. ACP has a Web page of frequently asked questions on the EHR meaningful use program online.

The EHR meaningful use incentive program involves EHR measure data and clinical data. The EHR measure data include 25 measures, eight of which are “yes/no” measures and 17 that require numerator and denominator information. The clinical data include the following clinical core measures: tobacco screening, blood pressure measurement, and two measures on drugs to be avoided in the elderly.

In addition, participating clinicians must select a specialty measure group to report. The final set of specialty measures will be available in late spring, but based on the current proposed rule, ACP is recommending that internists choose oncology (six measures), neurology (five measures) or cardiology (10 measures). The specialty measures are open to all clinicians, Dr. Gardner said. For example, a clinician doesn’t have to be a cardiologist to report on cardiology measures.

“We focused on these areas as opposed to the primary care measure set because the latter included 29 measures, ranging from pediatric measures and immunizations all the way up to Medicare patients,” Dr. Gardner said. “It was a wide range of different conditions.” The three specialty areas ACP is recommending are more manageable, she noted, especially since clinicians must commit to the choice: Whatever area is selected for the first payment year will be required for reporting in the second payment year.

Becoming a PCMH and participating in the EHR meaningful use incentive program are different things, Dr. Gardner emphasized, but ACP is focusing on areas where the two overlap.

“We’re trying to give physicians and their practices a way of reporting measures while functioning as a PCMH and still keep current with other demands that are going to come their way,” she said.

The precourse was videotaped and will be available as part of the ACP Medical Home Builder offering, which can be found online.

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EHRs critical to effective reporting of quality measures, says ACP

Increasing the use of quality measurement as part of electronic health record (EHR) systems is critical to achieving meaningful use of health information technology, the American College of Physicians reported in a paper released Thursday.


Joseph W. Stubbs, FACP, ACP President (right), and Michael S. Barr, FACP, MBA, ACP Vice President of Practice Advocacy and Improvement, discuss EHR meaningful use and health care improvement.



“EHR-Based Quality Measurement and Reporting—Critical for Meaningful Use and Health Care Improvement” says that using EHRs as the basis for quality measurement systems would allow for a more complete reflection of care processes and patient outcomes. Ultimately, this would result in a more clinically useful set of quality data.

“Physician practices face significant financial and workflow barriers to EHR adoption,” said Joseph W. Stubbs, FACP, ACP’s president. “With the promise that could come from better quality measurement, it is critical that we provide physicians with the support necessary to acquire these systems.”

In order to take full advantage of the benefits EHRs could offer for quality measurement and reporting procedures, ACP believes that:

  • The primary purpose of EHR-based quality measurement and reporting should be to facilitate higher-quality, cost-effective health care.
  • In order for an EHR-based quality measurement and reporting program to engage all health care stakeholders, it must use clinically relevant measures and be accurate and trusted by a full range of stakeholders, particularly patients, physicians, and other health care providers.
  • Data to support EHR-based quality measurement and reporting should rely upon information routinely collected during the course of providing clinical care, including relevant data supplied by patients.
  • EHR-based quality measurement should begin with the goal of facilitating the real-time collection of data that support the effective use of point-of-care clinical decision support algorithms.
  • EHR-based quality measurement and reporting must not increase administrative work and/or impose uncompensated financial costs upon physicians and other health care providers, health care organizations, or patients.
  • Data elements that comprise quality measure data sets should be defined in a standard way to enable health IT developers to implement them effectively.

ACP supports the commitment of the HIT Standards Committee, the National Quality Forum (NQF), the NQF Health Information Technology Expert Panel (HITEP), Health Information Technology Standards Panel (HITSP), and others to develop unified standards for structured, codified data elements, calculation logic, measure structure, and reporting structure for quality measures. The development of these standards requires concerted and consistent input from all health care stakeholders.

“Physicians using EHRs for effective quality measurement face significant implementation barriers. The challenge to making this happen is ensuring that EHRs are capable of reporting clinical outcomes and measures, and that physician offices have the necessary financial and workforce resources,” concluded Dr. Stubbs. “However, the benefits that improved quality measurement could have for patient care would be tremendous.”

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For attendees

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Geriatrics update offers fixes to common problems

“My back hurts.” “I can’t sleep.” “I fell down.” On a typical morning, an internist with geriatric patients can expect to hear some—if not all—of these complaints. This Friday morning, attendees at the Update in Geriatrics session can learn the latest answers to these typical problems of older patients at 7-8 a.m. in the North Auditorium.

William J. Hall, MACP, will discuss new research on conditions common in geriatric practice, including osteoporosis, syncope, insomnia, memory loss and chronic pain. As director of the Center for Healthy Aging at the University of Rochester School of Medicine, Dr. Hall is familiar with the issues facing geriatrics physicians and patients.

“There are very few older adults who won’t complain of some degree of pain,” he said. During the session, he’ll review some potential responses to the pain problem. “There are a lot more rational ideas of pain management, usually using a combination of simple therapies for pain control, that are associated with much more functional ability.”

He’ll offer some simple, or at least non-narcotic, solutions to the second biggest issue on the agenda, too. “Next to pain, insomnia is probably one of the most common geriatric problems. There is a great deal to be learned about patterns of medication use and also methods of dealing with people who seem to have chronic insomnia that don’t involve drugs at all—using various cognitive behavioral therapies,” he said.

Then there are the geriatric patients with, in some sense, the opposite problem—loss of consciousness, or syncope. “I’m going to talk a little about what’s new in the diagnosis and management of syncope,” said Dr. Hall. “Information coming through suggests that a very thorough clinical evaluation is often the key to figuring out whether there’s a treatable cause for syncope. By paying attention to that, we might be able to avoid a great deal of testing, particularly very expensive imaging testing.”

Preventive care can also avoid expense and treatment, and Dr. Hall will cover some of the latest findings in that arena. “Every year one of the vitamins becomes the vitamin of the year. You have to be very careful about this, but vitamin D is emerging as one of the most underutilized, very simple therapies that we have available,” he said. He’ll discuss research showing associations between low vitamin D levels and a number of geriatric conditions, and advise physicians on treatment of their vitamin D-deficient patients.

Geriatric patients can fulfill some of their need for vitamin D if they go outdoors to follow recommendations for continued physical activity, which Dr. Hall will discuss. “Not only does [exercise] improve physical function in older people but it unequivocally has an effect on brain function, preventing memory loss.” On the subject of memory loss, he’ll look at the use of monoclonal antibodies for Alzheimer’s disease.

Dr. Hall will also discuss a new group of patients who are beginning to present with geriatric problems. “People with HIV are living longer, so that about half of all people with HIV in the U.S. are over the age of 50,” he said. “The problem is that either HIV or the drugs that we use to treat HIV are causing people to age prematurely.”

If you’re concerned about covering that many topics in an hour, you’re not the only one. “I probably won’t cover all of them,” acknowledged Dr. Hall. “The muse wakes me as I get closer to the time.”

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Infectious diseases update veers off the beaten path

It's no surprise that H1N1 influenza will be one of the main topics of this year's Update in Infectious Diseases session at 2:15-3:45 p.m. in the North Auditorium. More unexpected, however, will be the tale of how one physician changed national rabies policy in Canada.

"(Rabies is) not a hot topic in the field, but it's a fun story to tell," said presenter John G. Bartlett, MACP, chief of the division of infectious diseases at Johns Hopkins University in Baltimore.

John G. Bartlett, MACP Indeed, Dr. Bartlett's session aims not only to cover the most important and widely discussed issues from the previous year, but to highlight a few offbeat yet relevant subjects physicians may have missed. In both cases, attendees will get the inside scoop. Dr. Bartlett called the authors of each paper "to see what they really think," he said.

For H1N1 influenza, Dr. Bartlett will discuss what's been learned as a result of the epidemic; the need for a universal influenza vaccine; and whether—and which—surgical masks are effective against the virus.

"One (mask) is cheap and comfortable; the other is expensive and in short supply and not comfortable, and yet nobody seems able to make a good recommendation for which one to use. This affects every doctor, of course," he said.

He'll also review the latest scientific and clinical developments for Clostridium difficile (C. diff) and Methicillin-resistant Staphylococcus aureus (MRSA). For MRSA, he'll review current screening recommendations, and some interesting science on resistance and virulence mechanisms. For C. diff, he'll summarize a recent paper (N Engl J Med. 2010;362 (3):197-205) on the successful use of monoclonal antibodies to reduce infection recurrence, "a non-antibiotic way to treat an antibiotic disease," and discuss whether and when this might lead to a vaccine.

Dr. Bartlett will also offer perspective on The Lancet's retraction in February of Dr. Andrew Wakefield's 1998 paper on the MMR vaccine and autism (The Lancet. 2010;375 (9713):445). "This was an interesting experience; it's amazing the amount of controversy and impact that was generated from a study with just 12 patients," he said. "To this day, one in four parents is still worried about vaccines."

Two important developments regarding HIV/AIDS are on the agenda. One is an upcoming initiative in Washington, D.C. to test and treat every single resident to try to reduce or eliminate the virus in the city, which has the highest AIDS rate (5%) in the U.S. Another is the updated Department of Health and Human Services guidelines on treating HIV-positive patients, whose broad revisions generated widespread controversy.

More offbeat topics include a review of a 200-page monograph from Europe about antibiotic resistance and the reasons drug companies don’t make antibiotics anymore. "The paper was put together in a fine way, and it had legs. It resulted in a global effort to address the problem of resistance and drug development," Dr. Bartlett said.

And then there is the odd, fascinating tale of how a single physician changed Canada's policy on what should be done with patients who awaken to discover a bat in the bedroom.

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What makes a good neighbor? PCMH and subspecialty practices

This panel will address the interface between the patient-centered medical home (PCMH) model and subspecialty practices at 4:30-5:30 p.m. in Room 717. It will introduce the concept of the PCMH-Neighbor (PCMH-N), which refers to a specialty/subspecialty practice that engages in processes to facilitate integration and coordination of services. It also will outline a set of principles for the development of service agreements, or “compacts,” that provide a practical means for improved communication regarding referrals, information flow and responsibility designation between PCMH and PCMH-N practices.

The content offered in this session resulted from over two years of deliberations of a PCMH workgroup composed of subspecialty representatives from the College’s Council of Subspecialty Societies. Stephan Kamholz, MACP, the moderator, is a pulmonologist and the current chair of the council. Other speakers include the following:

Carol Greenlee, FACP, an endocrinologist from Colorado, will describe the process of the workgroup and introduce the PCMH-N concept and the set of service agreement principles developed by the workgroup.

Mai Pham, MD, MPH, a physician on the staff of the Center for the Study of Health System Change, will provide early information on a Commonwealth Fund grant project she is leading surveying various efforts throughout the country to implement these practice service agreement arrangements. She will also address the relationship between the PCMH-N concept, service agreements and recent interest in the Accountable Care Organization structure.

Sue Bornstein, FACP, an internal medicine physician and executive director of the Texas Medical Home Initiative, will convey the early experiences of this project, which features the implementation and evaluation of service agreements between the participating PCMH practices and their specialty/subspecialty neighbors.

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Allergy and immunology session canceled

Saturday's Update in Allergy and Immunology (UD 014) has been canceled. The session was scheduled to be held 7-8 a.m. in the North Auditorium.

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