APRIL 2016

A PUBLICATION OF PNNwww.PhysiciansNewsNetwork.com

O F F I C I A L P U B L I C AT I O N O F T H E L O S A N G E L E S C O U N T Y M E D I C A L A S S O C I AT I O N

C O N N E C T E D C A R E | T E L E H E A L T H • A P P S • D A T A S H A R I N G

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LACMA WELCOMES NEW CEO

Gustavo Friederichsen

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APRIL 2016 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 1

Volume 147 Issue 4

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LACMA Welcomes New CEO Gustavo Friederichsen

LACMA’s new CEO, Gustavo Friederichsen, vows to make LACMA relevant and valuable again. Starting with his 100-day action plan, Friederichsen outlines the steps that will provide the platform for LACMA’s new model.

FEATURE | CONNECTED CARE

6 Heed Those EHR Alerts

14 CONNECTED CARE: Telehealth | Interoperability | Apps

20 UC Health Commits to Improved Data Sharing

22 New Physician Report Card Offers Side-by-Side Comparisons of Cost, Quality Ratings

FROM YOUR ASSOCIATION

4 President’s Letter | Peter Richman, MD

24 United We Stand | At Work for You

20

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14

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lenges of managing a practice.

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Success.

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4 P H YS I C I A N M AG A Z I N E | APRIL 2016

OVER THE NEX T FEW MONTHS , I am going to use the prerogative of the presidency to discuss topics that I find interesting or thought-provoking.

In March I attended a forum at UCLA at which innovations in the field of medicine were discussed. One presenter spoke about genetic profiling for disease prediction. I am going to write about the lure of big data.

During my residency, paper chart reviews were time-consuming, especially in data collection. Computers aided only in the statistical analysis. As data storage devices improved, more data was accessible for analysis, but it was still entered manually into the computer.

At first this amount overwhelmed a single computer. The Internet tied multiple computers to-gether, allowing for parallel processing and decreasing analytic time. With computer processors now

doubling their speed every 24 months (Moore’s Law), large databases can be ana-lyzed in multiple ways by a single computer. With electronic medical records, data is being entered automatically.

With hospital and clinics sharing databases, vast amounts of information are being accumulated. This is a veritable treasure trove to be sliced and diced for statistical significance requiring large numerators. Trends may be observed, which then require more in-depth research. We will learn better ways of disease detec-tion and management.

The Human Genome Project was started in 1990 by the National Institutes of Health. Celera Genomics launched its effort in 1998 using some of the database from the government. Several individuals contributed their genetic material for the project. The first papers detailing the human genome were published in February 2001. The sequencing effort took 11 years by the government and three years by Celera. The first complete genome of a single individual was published in 2006.

The genome consists of 20,500 genes and 3.3 billion base pairs. It can now be sequenced in one week. Myriad Genetics sequenced BRCA1 in 1994 and BRCA2 in 1995. The company has been analyzing tens of thousands of breast cancers now for 22 years and has found multiple genetic defects within these genes re-sponsible for the propensity for breast and ovarian cancer. There are genetic varia-tions that are not at higher risk for cancer, and there are genetic variations which are indeterminate at this time. Genetic profiling for single gene determinants of disease will take tens of thousands of patients to build a data profile. For other dis-eases in which multiple gene defects are causal, even greater numbers of patients

will be needed. The complexity is mind-boggling, It will take a generation for medicine to accumulate the data to allow for full prediction of genetic risk. Once we have this data, we will be able to accu-rately assess an individual’s risk of genetically determined diseases or responses to certain disease states and treatments.

Currently, we have many risk-reducing strategies for patients. Cigarette smoking has been linked to lung, head and neck and esophageal cancers for decades,

and physicians have advocated for smoking cessation for decades. Although greatly decreased, peo-ple still smoke. Dietary risks of high fat, high cholesterol and high caloric intake are all well known. Morbid obesity has skyrocketed, as has type 2 diabetes. People exercise less now and physicians are beginning to note the risks of prolonged sitting. Alcohol in moderation is beneficial; we advocate against over-imbibing, yet we continue to see the devastating effects of drunken driving and alcohol-ism. We counsel against illicit drug use, but prescription drug misuse is epidemic. We instruct patients to avoid excess sun exposure, yet there are tanning salons all over Southern California. We know mar-riage is life prolonging for males, but divorce rates are high. Screening tests and procedures such as mammography and colonoscopy are life-saving but they are not universally performed.

Big data will eventually give us more evidence for our discussions with patients. However, it will still come down to the doctor-patient relationship to transmit that information in a manner that is un-derstandable and meaningful to our patients.

People have difficulty changing habits. Physicians will need to manage population health. Big data will not change that aspect of our profession.

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Big data will even-tually give us more

evidence for our discussions with pa-

tients. However, it will still come down

to the doctor-pa-tient relationship to transmit that infor-

mation in a manner that is understand-able and meaning-ful to our patients.

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Heed Those EHR AlertsBY JACQUELINE ROSS, PHD, RN, SENIOR CLINICAL ANALYST, DEPARTMENT OF PATIENT SAFETY AND RISK MANAGEMENT, AND SUSAN SHEPARD, MSN, RN, DIRECTOR, PATIENT SAFETY AND RISK MANAGEMENT EDUCATION

Patient harm caused at least in part by the use of electronic health records (EHRs)—or e iatrogenesis—emerged as a factor in a closed claims study conduct-ed by The Doctors Company. The study of 71 claims closed by The Doctors Company between 2007 and 2013 revealed that 65% involved EHR-related user is-sues, and 42% identified system technology design risk factors. Some claims included both user issues and system technology design risk factors.

The ECRI Institute (formerly Emergency Care Re-search Institute) recognized alarm hazards as the number one IT-related problem in 2015. Alarm haz-ards occur not only with physiologic monitoring sys-tems,1 but also with alarm-generating devices, such as EHRs. Unfortunately, human factors may prevent healthcare providers from responding appropriately or using the alarms that are readily available to them.

EHRs have multiple benefits—from improved patient outcomes and improved care coordination to practice efficiency and cost savings. However, in-appropriate use of or ignoring EHR alarms/alerts has been connected to patient harm. On the issue of over-alerting (systems generating too many alerts), Tejal K. Gandhi, MD, president and CEO of the National Patient Safety Foundation, noted “most studies have found that only 20% of alerts are actually accepted,” so an important alert could be missed. She added that studies have shown that reducing the number of alerts “by streamlining the ones that you decide to alert on, by tiering, to only interrupt for things that have a cer-

tain amount of significance, you can actually reduce the number of interruptions significantly.”2

E-health data come from external sources, such as websites or through health information exchanges (hospital charts, consultant reports, and laboratory and radiology reports). Doctors also have access to data through e-prescribing community medication histories—which can expose them to liability for po-tential interactions with drugs prescribed by other cli-nicians. For example: Dr. A renews a medication, and his e-prescribing program sends an alert advising him that the medication could interact with another medi-cation the patient is taking. He has not prescribed that drug, so his office staff will have to contact the patient to identify who has prescribed it, and then Dr. A will have to contact Dr. X to “negotiate” which drug will be discontinued or changed. If failure to take action results in patient injury from a drug-drug interaction, Dr. A may be liable.3

Drug-drug interaction lists are often so compre-hensive and generate alerts with such frequency that they can become disruptive and annoying. Doctors may develop “alert fatigue” and ignore, override, or disable them. However, if it can be shown that fol-lowing an alert would have prevented an adverse patient event, the physician may be found liable for failing to respond.4 Optimized, clinically meaningful drug-drug interaction lists that focus on a smaller set of interactions most frequently associated with harm or expert consensus lists may address this problem.

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8 P H YS I C I A N M AG A Z I N E | APRIL 2016

However, EHR vendors may resist eliminating the low-risk warnings, fear-ing that doing so could increase their liability.

The following two claims illustrate some of the issues surrounding alerts and human factors.

CLAIM ONE | An elderly female saw an otolaryngologist for ear/nose complaints. The physician intended to order Flonase nasal spray. The pa-tient filled the prescription and took it as directed. Ten days later, she went to the ER for dizziness. Two weeks after that, the pharmacy sent a refill to the physician at his request. It was for Flomax—a medication prescribed for enlarged prostate—which has a side effect of hypotension. When or-dering the prescription, the physician had typed “FLO” in the medication order screen. The EHR automatched Flomax, and the physician selected it without realizing the mistake. Flomax is not FDA-approved for females. There was no EHR Drug Alert available for gender. To prevent this type of mistake, the provider should have reviewed the prescription with the pa-tient and read what was ordered. By writing the indication for the medica-tion on the prescription, the pharmacist would have been alerted that the medication was not appropriate to the condition being treated.

CLAIM TWO | A dialysis patient was transferred to a skilled nursing facil-ity. There was an active hospital transfer order for Lovenox. A physician evaluated the patient on admission but made no comment about the Lo-venox order. During the first dialysis treatment, there was active bleeding at the fistula site. The anticoagulant heparin had not been given. The nurs-ing staff did not inform the physician of the bleeding. During the second dialysis treatment, there was uncontrolled bleeding from the fistula, and the patient exsanguinated and expired. Experts were critical that there was no EHR high-risk medication alert. Medication reconciliation might have prevented this error.

Alerts are a necessary safety mechanism when used, heeded, and con-figured appropriately for your practice. Check your alerts to make sure they provide adequate information and are not overly burdensome to your practice. ____________________

References1. ECRI Institute. Top 10 health technology hazards for 2015: a report from health devices. November 2014.

www.ecri.org/2015hazards. Accessed July 1, 2015.

2. Texas Medical Institute of Technology. Webinar transcript: Ambulatory patient safety issues—opportunities for improvement. http://www.safetyleaders.org/downloads/WebinarTranscript_August2013.pdf. August 15, 2013.

3. Troxel D. Electronic health record malpractice risks. The Doctors Company. Available at: http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/Electronic-Health-Record-Malpractice-Risks. Ac-cessed July 1, 2015.

4. Ibid.

5. Lacker C. Physiologic Alarm Management. Pennsylvania Patient Safety Advisory. 2011 Sep;8(3)105-8.

6. ECRI Institute. Top 10 health technology hazards for 2015: a report from health devices. November 2014. www.ecri.org/2015hazards. Accessed July 1, 2015.

7. Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. Prescribers’ interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human-computer interaction. Int J Med Inform. 2012 Apr;81(4):232-243.

Reprinted with permission. ©2016 The Doctors Company (www.thedoctors.com). This article originally appeared in The Doctor’s Advocate, fourth quarter 2015.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Strategies for Reducing Alert Hazards• Understand alarm fatigue. When care-

givers become overwhelmed, distract-ed, or desensitized to an alarm or an alert, determine the most important alarms, and work with your vendor to ensure that unnecessary alarms or alerts are not built into your system.5

• Determine if alerts are appropriately configured so that alert conditions are not missed or ignored.6

• Assess your EHR for frequent drug-drug interaction alerts, which have been shown to lead to alert fatigue that can cause the alerts to be disregarded, ignored, or disabled. Work with your EHR vendor to use key data elements to design EHR alerts for high-risk drug-to-drug interactions. The result will be more meaningful alerts that are less likely to be ignored or disabled, thus avoiding a possible error.

• Be aware that clicking through drug-to-drug therapeutic duplicates or drug/allergy alerts with little review can be interpreted to mean that the physician ignored the safety alerts.

• Read the alerts. EHRs record how much time is spent reviewing information. If the time is very brief and there is a negative patient outcome, the physi-cian could be perceived as sloppy or hurried.

• Don’t turn off alerts. If a hospital-em-ployed physician and hospital turn off alerts that could have avoided a patient problem, the hospital and physician may both be found liable.

• Always document why a clinical deci-sion support (CDS) prompt was overrid-den. CDS may conflict with a medical specialty’s clinical standards of care or practice guidelines or with the informa-tion in FDA-approved drug labels.7

StabilityPreferred Insurance prides itself on its stability, which includes maintaining some of the best andmost consistent pricing available for CMA members. And because of its Medical Provider Networkof credentialed medical professionals, claim costs can be closely monitored and managed whileproviding quality care to injured employees.

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SavingsCMA members qualify for an additional 5% discount*on top of Preferred Insurance’salready competitive rates. Preferred’s rates are set for long term consistency, and are managedby focusing on safety and injury prevention, fraud prevention and the control of medical costsfor your practice by getting employees back to work as soon as practical.

ServiceMercer’s team of insurance advisors is knowledgeable about the needs of physicians and is availableto walk you through the application process. Preferred’s claims examiners are experts in helpingmembers with an employee injury or illness claim. Plus Preferred’s payroll management and flexiblepayment plans help you manage your premiums in the way that works best for you and yourpractice’s cash-flow needs.

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1 0 P H YS I C I A N M AG A Z I N E | APRIL 2016

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LACMA’s new CEO, Gustavo Friederichsen, vows to make LACMA

relevant and valuable again. When Friederichsen met with LACMA’s

board of directors to unveil his vision for the organization, starting with

a targeted, goal-oriented action plan during his first 100 days in office,

they knew he’d bring welcomed change.

BY MARION WEBB

APRIL 2016 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 11

Peter Richman, MD, president of LACMA, expressed his delight about the board’s nomination of LACMA’s new leader.

“During the interview process, Mr. Friederichsen stood out by his communication skills, enthusiasm, business acumen and desire to grow LACMA by creating greater value for its physician members,” Dr. Rich-man said.

Friederichsen, a marketing and brand management expert who has held top senior management positions at major health organizations in-cluding Palomar Health and Sharp HealthCare, said he wants to leverage his skill sets and experience to grow LACMA into the go-to umbrella organization for all physicians in LA County.

“I am ecstatic and honored to be able to lead this organization,” Frie-derichsen told Physician Magazine. “I want to create a culture where we are all in this together and be relevant and create value.”

Starting with his 100-day action plan, here are the four steps that will provide the platform for LACMA’s new model:

1. STAFF MODEL | Friederichsen said he’s committed to creating a compelling, yet accountable work environment and that starts with examining the roles and responsibilities of each staff member. He wants to create a staff model that’s supportive to physicians and has a growth strat-egy. What’s new is that he plans to hold everyone – including him-self – accountable by relying on meaningful metrics to measure performance to meet the strategic goals of the organization. Trans-parency, trust and ongoing com-munication rank high on his list. Every staff member and board member will know what the goals are, he said, and he’ll report monthly to the board on whether goals have been met or not.

2. RESOURCE MODEL | He’ll also take a close look at existing com-munication channels, as well as the benefits and resources cur-rently in place, with the goal to make them more engaging, thoughtful and purposeful for all members.

3. BUDGET MODEL | Looking at how dollars are invested and whether they help support physi-cians in their practices and types of communications that attract new physicians and retain exist-

“I am ecstatic and honored to be able to lead this

organization. I want to cre-ate a culture where we are

all in this together and be relevant and create value.”

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12 P H YS I C I A N M AG A Z I N E | APRIL 2016

ing members is another prong of Friederichsen’s strategy. He plans to create an aggressive, inte-grated collaborative model that will attract physicians of all ethnicities and practice opportuni-ties and bring in organizations that want to partner with LACMA for the right reasons, which will result in value for all physicians.

4. COMMUNICATION MODEL | Truly listening to physicians and applying that feedback to cre-ate solutions takes center stage for Friederichsen and is key to LACMA’s successful growth. He stressed that he’ll meet personally with every physician who wants to have a conversation as well as key influencers in LA County and on the state level, and ensure that LACMA will have a voice in Sacramento. He also stressed the importance of a closer alliance with CMA. In his words, “We want to create a bridge for working together and be on the same wavelength and create alliances for physician practices.”

He also wants to put metrics in place to ensure the print and digital content is truly meaningful to doctors: “I will look at every channel we have to-day and calibrate it, improve what we have, and launch new forms of communication that are also more conducive to mobile devices.” There will be more of a dialogue, and new channels for doctors to communicate with other doctors and share best practices, he said.

Friederichsen said he considers his new role a “once-in-a-lifetime” opportunity and thanks the board and members for giving him the opportu-nity to lead the organization into the new decade.

Dr. Richman added that as the new CEO, Frie-derichsen will “advance physicians’ concerns and foster greater public health through coordinated communication with written, broadcast and digi-

tal media and advocate through LACPAC with the local representatives. His goal is for LACMA to become the umbrella organization within the county for physicians in all practice modes, and af-filiate with the ethnic medical societies and medical specialty societies.”

Steven Larson, MD, MPH, president of the statewide California Medical Association (CMA) stat-ed, “In a county as big as Los Angeles, where 27% of the state’s active licensed physicians reside, it is critical to have tested leaders in the right position, ready to serve the needs of those professionals. With Gustavo, LACMA has a tried-and-true CEO, and the physicians of LA have a bold new leader, hungry to make a difference in their profession.”

And while Friederichsen has already proven to bring a high level of energy to the job, he also appeals with his strong sense of humility.

Married, living in Westlake Village, and with a son in college, Friederichsen said he’s also pas-sionate about homeless issues, HIV and AIDS. “I do volunteer work to help those who are less fortunate and don’t have a voice,” he said. “I want to do something that’s purposeful and personal.”

He said as LACMA’s CEO, he is excited about applying his leadership skills to serve its physician members and grow the organization to new heights.

“I will meet personally with every physician who wants to have a conversation as well as key influencers in LA County and on the state level, and ensure that LACMA will have a voice in Sacramento.”TH

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CONNECTED CARET E L E H E A LT H | D A T A S H A R I N G | A P P S | I N T E R O P E R A B I L I T Y

Connected care is changing the equation among physi-cians, patients and hospitals as new technology, apps, ideas and opportunities are being introduced every day. Because telehealth is becoming an integral part of main-stream medicine, we provide an in-depth look at how phy-sicians can successfully implement a telehealth program, what efforts are under way to engage more consumers and healthcare professionals in using apps and new tech-nologies to create positive outcomes, and what are the latest reimbursement, legal and regulatory trends.

BY MARION WEBB

APRIL 2016 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 15

A survey pub-lished by the American Family Physician reports that while the ma-

jority of physicians see the many benefits of tele-health, few are currently using the technology.

Of the 1,557 family physicians who responded to the survey, conducted in 2014 by the Robert Graham Center for Policy Studies in Family Medi-cine and Primary Care, just 15% said they had used telehealth services in the last 12 months; yet, 78% said they believe telehealth improved access to care, while 68% said they believed it improved continuity of care.

The researchers said the findings confirm that family physicians see promise in the ability

of telehealth to improve access to primary care services. However, they believe it will not become widely adopted until health systems are reformed to address barriers.

Ed Simcox, U.S. healthcare practice leader for Logicalis Healthcare Solutions, an international IT solutions and managed services provider, said in a news release that even in instances when orga-nizations bought telehealth equipment, they of-ten end up not using it because they believe it doesn’t fit into their workflow and culture.

To successfully use telehealth, Simcox stressed, technology decisions must be made with a strategic approach to design and imple-mentation of such a program.

He offers the following nine steps to help healthcare CIOs take a successful approach:

1 Build an effective governance model: The governance model will support the planning, imple-mentation and ongoing activities necessary to begin and sustain the telehealth program. It will

also be used to resolve differences, prioritize activities and advance the well-being of the program with the values of the organization.

2 Create multidisciplinary telehealth teams: A telehealth team should include a coordinator who acts as the single point of contact, a clinical champion who helps define the workflow and signs

off on the clinical usability of the program, and an IT technical lead who oversees the technology as-pects of the program.

3 Assess outside opportunities: Start by identifying gaps in care that telehealth can meet, then determine the willingness of patients to embrace accessing care via telehealth.

4 Design a telehealth program: Start by doing a needs assessment by clinicians and patients and identify workflow and technical requirements, then see how technology can meet those needs.

5 Develop a business plan and financial model: To be viable, telehealth needs to contribute posi-tively to the bottom line of the healthcare system in various ways: direct revenue, quality of care

outcomes, revenue protection, productivity gains or access to growth opportunities. Alternatively, telehealth solutions might also focus on achieving charitable or community benefit goals for a non-profit healthcare system.

6 Create a project plan: A well-defined plan will address required tasks and milestones necessary to successfully establish the telehealth service or program in a timely manner. It is key to consider

the integration of the new processes into existing clinical workflows. The project should also define how the technical components of the telehealth solution will be integrated and tested with current systems such as registration, scheduling, clinical documentation and other modules of the EHR.

7 Develop internal and external marketing plans: Communication is key to the success of a tele-health program internally and externally. That means having the support of patients and in-house

staff and attracting younger doctors for whom robust connective care capabilities are a minimum requirement of employment.

8 Identify key metrics to measure outcomes: Some of these metrics may include frequency of use, impact on clinical outcomes, and clinician and patient satisfaction levels.

9 Design a training plan for clinicians and support staff: There is always a learning curve to every new service, and helping people is key to a smooth and quick transition.

IMPLEMENTING A TELEHEALTH

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While the 2014 survey by the Robert Graham Center found that only 9% of 3,769 surveyed readers had used a telehealth ser-

vice for a minor illness, experts foresee a grow-ing need and trend in that area and other areas as well.

The survey revealed that 90% of consumers who used telehealth ser-vices said the experience was the same or better than at a doctor’s office, while 45% of respon-dents said they were unaware these services even existed.

The challenge, many experts say, is to create more positive outcomes and engage more con-sumers in that experi-ence.

One of the best ways to do that is via mobile apps, which are already widely used by consum-ers to track information using health and wellness programs and to interact with other participants or a personal coach.

With the rapid growth and deployment of mo-bile apps and telemedi-cine to save costs while improving patient care and satisfaction, the National Law Review re-cently published an article that focused on tele-medicine’s continued growth and transforma-tion of healthcare delivery in 2016.

REIMBURSEMENT According to the article, written by Nathaniel M. Lacktman, a partner and healthcare lawyer with Foley & Lardner LLP and a Certified Compliance and Ethics Professional, both private and gov-ernment payers will continue to expand tele-medicine coverage as consumers gain experi-

ence with technology and demand access to telemedicine services.

Lacktman wrote that some health plans have already begun bolster-ing coverage for tele-medicine, viewing it as value-based care, and predicted that in 2016, Medicaid managed care organizations and Medi-care Advantage plans will follow that trend.

He said while re-imbursement was the primary obstacle to telemedicine imple-mentation, new laws requiring coverage of t e l e m e d i c i n e - b a s e d services have been im-plemented at the state level, and 2016 will be the year these laws drive implementation in those states.

MOMENTUM AT THE STATE LEVEL According to a study by the Center for Connect-ed Health Policy, dur-ing the 2015 legislative session, more than 200

pieces of telemedicine-related legislation were introduced in 42 states. Currently, 29 states and the District of Columbia have enacted laws re-quiring that health plans cover telemedicine services, Lacktman said.

CATERING TO CONSUMERS’

HEALTHY LIVING NEEDS

TELEMEDICINE TRENDS

Researchers at the University of Southern California’s Cen-

ter for Body Computing’s new Virtual Care Clinic (VCC), which named eight mHealth companies as “foundational partners,” are now aiming to extend Keck Medicine to anyone with a smartphone by harnessing technolo-gies and creative solutions devel-oped at the USC Institute of Creative Technologies in Playa Vista.

Leslie Saxon, MD, founder and executive director of the USC Center for Body Computing, said in a news release, “Because we have worked in collaboration with our VCC partners and medical experts, this healthcare model will empower patients, im-prove quality outcomes with more precision medicine analytics and di-agnosis, and enhance the physician-patient relationship by creating a con-textualized experience and seamless communication that puts the patient in the driver seat of their own health-care experience and outcomes.”

In February, the organization said that the VCC will initially offer access to its experts at the USC Eye Institute and the USC Institute of Urology. Ul-timately, all 1,500 faculty/physician experts, surgeons and researchers at Keck Medicine of USC will become involved in the VCC.

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Lacktman wrote that this year even more bills will be introduced to support coverage of telemedicine services.

The Centers for Medicare and Medicaid Services (CMS) is considering expansion of Medicare coverage for telemedicine, and a bill working its way through the U.S. House of Rep-resentatives would pay physicians for delivering telemedicine services to Medicare beneficiaries in any location.

Other news reported that CMS also pro-posed new rules to allow approved organiza-tions to confidentially share or sell analyses of Medicare and private sector claims data to pro-viders, employers and anyone else who can use that data to improve care.

According to CMS Acting Administrator Andy Slavitt, “Increasing access to analyses and data that include Medicare data will make it eas-ier for stakeholders throughout the healthcare system to make smarter and more informed healthcare decisions.”

This year, Lacktman wrote, more providers will also explore payment models beyond fee-for-service reimbursement including institution-to-institution contracts and greater willingness by patients to pay out-of-pocket for services.

UPTICK IN INTERNATIONAL ARRANGEMENTSThis year, Lacktman wrote, more U.S. hospitals and healthcare providers will also forge ties with overseas medical institutions, spreading U.S. healthcare expertise abroad. According to the American Telemedicine Association, more than 200 academic medical centers in the U.S. already offer video-based consulting in other parts of the world, adding that while most of these are pilot programs, this year will see a maturation and commercialization of these in-ternational arrangements.

GROWTH OF RETAIL CLINICS AND EMPLOYER ONSITE HEALTHCARE CENTERS

According to a recent study by Towers Wat-son, more than 35% of employers with onsite health facilities offer telemedicine services and another 12% plan to add these services in the

WHAT ARE THE GO-TO APPS OF 2016?Realizing the huge marketing opportunity, healthcare apps de-velopers everywhere are trying to gain traction and create the go-to app for physicians and their patients. The verdict is still out, but here are some of the leading apps, for both providers and patients, that are vying to rank among the go-to apps for 2016, according to a Becker’s Health IT editors’ review.

22OTTERS | Funded in part by Nuance Communication, Gam-gee’s 22otters patient outreach platform allows doctors to dictate instructions into the app and set alerts for patients. It allows for post-discharge follow-up by allowing providers to see when patients have completed certain tasks.

AMWELL | Ranked the most popular consumer telehealth app worldwide in 2014 by app analytics services company App Annie, AmWell is American Well’s answer for allowing clini-cians and patients to connect remotely featuring a virtual wait-ing room, e-prescribing, online documentation and payment collection. The platform is HIPAA-compliant and includes training, clinical guidelines and peer support for doctors, ac-cording to an article in Becker’s Hospital Review.

BETTERDOCTOR | This app aims to allow consumers to make better decisions about their care and encourages collabora-tion, allowing doctors to grow their practices by building an online presence and helping consumers locate doctors.

BLUESTAR | WellDoc’s FDA-cleared mobile app is the first type 2 diabetes therapy to be made available by prescription.

BURNOUT PROOF | Developed by Dike Drummond, “Happy MD,’ this app is physician-tested and contains numerous re-sources and tools to reduce physician burnout.

EPOCRATES | Ranked the No. 1 medical reference app among U.S. physicians in Manhattan Research’s Taking the Pulse study.

DOXIMITY | With more than 60% of U.S. physicians registered as members, the app’s vertical social network has surpassed AMA membership in just three years.

HEALTHTAP | Offering a mobile directory containing more than 1.3 million physicians, this app allows users to connect with clinicians anywhere via video or text consultations using a pay-as-you-go plan.

HUMAN DX | The Human Diagnosis Project, a San Francisco-based group. aims to map every health problem on the planet into a genomic database.

ICDEASY | ICDEasy allows doctors to input an ICD-9 code and have it spit out the corresponding ICD-10 code. The app costs $5.99 and integrates three types of code-creation-translation settings, making codes searchable by keyword and chapter in addition to the existing ICD-9 code.

For more information on apps and technologies, visit becker-shospitalreview.com.

1 8 P H YS I C I A N M AG A Z I N E | APRIL 2016

next two years.The study

showed that U.S. employers could save up to $6 bil-lion per year if em-ployees routinely engaged in remote consults instead of visiting emergency rooms, urgent care centers or the doctor’s office.

Other studies suggest that nearly 70% of employers will offer telemedicine services as an employee benefit in 2017. The growth of MDLIVE and Teladoc are examples of this grow-ing trend.

More consumers will also visit retail medi-cal clinics and pay out-of-pocket for services not covered under their insurance plans. CVS Health and Walgreens have publicly announced they plan to incorporate telemedicine-based services at their locations.

MORE ACOS USE TELEMEDICINE TO IMPROVE CARE AND CUT COSTSThis year, the rising number of accountable care organizations (ACOs) serving Medicare beneficiaries are ideally positioned to use tele-medicine. While CMS offers heavy cost-cutting incentives in the form of shared-savings pay, only 27% of ACOs achieved enough savings to qualify for these incentives last year; with only 20% of ACOs using telemedicine services, more will likely adopt telemedicine to hit the incentive payment metrics.

Last month, the U.S. De-partment of

Health and Human Services (HHS) Secretary Syl-via M. Burwell announced a major federal initia-tive that has gathered together industry leaders to advance data-sharing, consumer access to healthcare data, and interoperability.

The group of companies that provide 90%

of electronic health records used by U.S. hospitals, the nation’s five largest private healthcare systems, and more than a dozen lead-

ing professional associations and stakeholder groups have pledged to implement three core commitments that will improve the flow of health information to consumers and healthcare providers, according to an HSS news announce-ment released at the same time.

“We have to speak the same language, with federally recognized standards,” Burwell said in her keynote address at the HIMSS event held in March in Las Vegas. “We need to work together to unblock data. Doctors should share data with each other without high fees or restrictive legal arrangements.”

According to the announcement, the three commitments are:

CONSUMER ACCESSTo help consumers easily and securely access their electronic health information, direct it to any desired location, learn how their informa-tion can be shared and used, and be assured that this information will be effectively and safely used to benefit their health and that of their community. Many of the biggest health IT developers have committed to using standard-ized application programming interfaces and a single shared standard for communicating with one another, Health Level 7 – Fast Health Care Interoperability Resources (FHIR), so that user-friendly resources, like smartphone and tablet apps, can quickly be made market-ready and compatible with one another. These advances will make it easier for consumers to access their test results, track progress in their care, and communicate with their providers.

NO INFORMATION BLOCKINGTo help providers share individuals’ health infor-

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DATA-SHARING & INTEROPERABILITY

“WE NEED TO WORK TO-GETHER TO UNBLOCK

DATA. DOCTORS SHOULD SHARE DATA WITH EACH OTHER WITHOUT HIGH

FEES OR RESTRICTIVE LE-GAL ARRANGEMENTS.”

APRIL 2016 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 19

mation for care with other providers and their patients whenever permitted by law, and not block electronic health information (defined as knowingly and unreasonably interfering with information sharing). The report to Congress by the Office of the National Coordinator for Health IT (ONC) discussed the prevalence of in-formation blocking.

STANDARDSImplement federally recognized, national in-teroperability stan-dards, policies, guid-ance, and practices for electronic health information, and adopt best practices includ-ing those related to privacy and security. Many of these market leaders are embracing ONC’s Interoperability Standards Advisory — a coordinated catalog of existing and emerging standards and imple-mentation specifica-tions. This guidance is updated annually in order to keep pace with developments in the health IT industry. By identifying current best practices in standards, this advisory will assist healthcare providers to more easily collaborate with one another and share data across “in-teroperable” electronic health records.

“These commitments are a major step for-ward in our efforts to support a healthcare sys-tem that is better, smarter, and results in health-ier people,” Burwell said. “Technology isn’t just one leg of our strategy to build a better health-care system for our nation, it supports the entire effort. We are working to unlock healthcare data and information so that providers are better informed and patients and families can access their healthcare information, making them em-

powered, active participants in their own care.”Currently, electronic health information flows

only in pockets of the healthcare system, and business practices can inhibit data sharing. Even when electronic health information is shared, it can be underutilized and difficult to access due to hard-to-use technology or the use of different standards. The commitments by health IT devel-opers who provide electronic health records to the vast majority of the inpatient market, health-care systems who serve patients in 46 states, and

leading professional associations and stake-holder groups will help lead to a future where electronic health data is shared seamlessly and is easily accessible when and where it mat-ters most to providers and consumers. To see a full list of individual organizations that have made commitments and their pledges, visit www.healthit.gov/com-mitment.

“The future of the nation’s health delivery

system is one where electronic health informa-tion is unlocked and shared securely, yet seam-lessly, to put patients at the center of their own care,” said Karen B. DeSalvo, MD, MPH, MSc, national coordinator for health information technology. “The broad agreement by leaders in health and health IT across the nation brings us much closer to our vision for a truly learning, connected health system.”

In this changing healthcare environment, more healthcare professionals and organiza-tions will take full advantage of what connected care has to offer to increase patient and provid-er satisfaction and cut costs.

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The Precision Medicine Initiative Summit, hosted by President Barack Obama, brought to-gether patients, researchers and health leaders to discuss progress made during the one year since the launch of the initiative. A team from Cedars-Sinai and four UC San Francisco lead-ers and researchers were among those invited to participate in the Feb. 25 summit, which fea-tured a panel discussion with the president and included a closed-door roundtable discussion about the future of precision medicine.

UC Health joined dozens of healthcare pro-viders, universities, government agencies, tech start-ups and nonprofits in announcing specific new commitments to support the goals of the Precision Medicine Initiative. UC Health plans to give patients the tools to download their own health data from any of the five UC Health med-ical centers, and share the information with pro-viders for more effective personalized care and with researchers to accelerate the development of treatments and cures.

The commitment stated: “Today, many UC Health patients have access to basic ‘Blue But-ton’ technology offered through various patient portals in conjunction with electronic health re-cords systems. Starting in 2017, the more than 14 million UC Health patients will be able to use a more comprehensive ‘Blue and Gold But-ton’ to download their integrated clinical data

from across all participating UC sites, enabling them to make better choices about their health and contribute their own data for research.”

EMPOWERMENT FOR PATIENTS AND NEW TOOLS FOR RESEARCHERS

“UC Health is committed to advancing preci-sion medicine,” said John Stobo, MD, UC Health executive vice president. “We support the White House’s Precision Medicine Initiative and are working to harness our data to deliver the right treatment at the right time to the right person.”

UC Health was represented at the summit by Atul Butte, MD, PhD, executive director of clinical informatics for UC Health and leader of the California Initiative to Advance Precision Medicine; Keith Yamamoto, PhD, vice chancel-lor of Science Policy and Strategy at UCSF; Este-ban Burchard, MD, PhD, a member of Obama’s 15-person Precision Medicine Initiative Work-ing Group, which has advised Obama and the National Institutes of Health in the initiative’s first year; and Kathy Giacomini, PhD, a profes-sor of Bioengineering and Therapeutic Sciences in UCSF’s schools of Pharmacy and Medicine.

Basic science can be empowered by advanc-es in big data, said Dr. Butte, who also leads the UCSF Institute of Computational Health. “Preci-sion medicine sits at a crossroads where amaz-ing discoveries about our DNA join with our

UC Health Commits to Improved Data SharingUniversity of California Health, which is composed

of five academic health centers, including UCLA,

UC Irvine, and UC San Diego, committed to en-

abling patients to access and share their own health

data, joining more than 40 other organizations that

made various commitments to advance precision

medicine during a White House summit last month.

APRIL 2016 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 2 1

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long-term investments in personalized care and deploy-ment of electronic health records. When we really start to understand what is happening to our patients at a bio-logical level, and are able to computationally compare that to thousands or millions of other patients, we are go-ing to reach a more precise way to practice medicine.”

In his comments, Obama highlighted the importance of engaging patient populations directly in the course of their own care. “One of the promises of precision medi-cine is not just giving researchers and medical practitio-ners tools to help cure people,” he said, “it is also em-powering individuals to monitor and take a more active role in their own health.”

‘A VERY EXCITING DAY’Dr. Burchard, who also is professor of bioengineering

and therapeutics sciences, was appointed last year to the Precision Medicine Initiative Working Group to ensure that the new initiative reflects the strength of America’s diversity.

“The commitments announced today – to invest in recruiting and studying large populations of volunteers that build upon the rich diversity of the nation with re-spect to race/ethnicity, social and geographic variation

– will have tremendous benefits for the future of health,” Dr. Burchard said after the morning’s panel discussion. “One size does not fit all, and precision medicine thrives on diversity.”

“The president’s vision, from research and medical product approval through the ultimate goal of tailored healthcare for individuals, is impressive in its depth and breadth,” said Dr. Giacomini, who co-directs CERSI with Stanford collaborator Russ Altman, PhD. “It was a very exciting day!”

SECURITY AND THE PRECISION MEDICINE INITIATIVEIn late February, the White House released for public

comment the draft Data Security Policy Principles and Framework for the Precision Medicine Initiative. This document was developed through an interagency pro-cess and informed by a series of roundtables with secu-rity experts from private industry and academia and a review of existing data security resources. Recognizing that security requires a continuous set of evolving pro-cesses and controls to address both internal and external threats, this document is intended to provide a frame-work for customized data-security needs across the pre-cision medicine community.

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The result of a partnership between the nonprofit Integrated Healthcare Association (IHA) and the California Office of the Patient Advocate (OPA), the Medical Group Report Card is the largest statewide, multi-payer public report card to provide side-by-side comparisons of both quality and cost measures at the medical group level — where care is delivered.

The report card uses a 4-star rating system to com-pare each medical group’s performance on providing recommended clinical care, patient experience, and average annual payments for care from both health plans and patients — also known as total cost of care.

“Making side-by-side quality and cost information for medical groups available on such a large scale will help consumers make more informed choices and en-courage providers to compete on cost and quality,” said OPA Director Elizabeth Abbott. “Research shows that higher costs do not necessarily mean higher qual-ity care, and the report card shows that many medical groups provide high-quality care at a lower average

cost than other groups.”The cost data in the Medical Group Report Card

— labeled as “Rating of Average Payment by Patients & Health Plan for Care” — were collected through IHA’s Value Based Pay-for-Performance program, one of the nation’s largest advanced alternative-payment models designed to reward physician organizations that provide high-quality, affordable, patient-centered care.

However, Kaiser Health News reports a new study throws cold water on the popular idea that consumers can save themselves and the healthcare system loads of money if they become savvier shoppers for health-care services.

The analysis by the Health Care Cost Institute fo-cused on what consumers paid out of pocket where comparison shopping can result in lower costs.

The study found that less than 7% of total health-care spending in 2011 was paid by consumers for “shoppable” services, defined as those that could

PNN CONNECTED | MOST READ

New Physician Report Card Offers Comparisons of Cost, Quality RatingsConsumers and purchasers can now compare side-by-side

cost and quality ratings for more than 150 medical groups

caring for about 9 million commercially insured Californians.

be scheduled in advance and were among the most used and/or highest priced services; they then divided claims into categories such as outpatient/physician services and inpatient facility services, among others.

The study also found that less than half — 43% — of the $524.2 billion in total healthcare spending in 2011 was on services that could be considered shoppable, such as non-emergency hip and knee re-placements, colonoscopies, flu shots and blood tests. Consumers’ out-of-pocket spending on those services made up $37.7 billion.

Consumers’ out-of-pocket spending total includes what they pay in deductibles, copayments and coin-surance payments for healthcare services. Since co-payments are flat fees — $20 for a doctor visit, for example — they aren’t affected by price comparison shopping. A quarter of the money consumers spent out of pocket for shoppable services was on copay-ments in 2011.

The study found that deductibles accounted for

nearly half of the dollars spent by consumers on shop-pable services, while 27% was tied to co-insurance payments, the vast majority of which were for outpa-tient/physician services.

Deductibles and co-insurance, in which consum-ers pay a percentage of the bill, are highly variable, however, and present consumers’ best opportunity for shopping savings.

The onus should instead be on employers, insur-ers, providers and regulators to move the needle, said David Newman, executive director of the Health Care Cost Institute and co-author of the study. One promis-ing possibility is reference-based pricing, for exam-ple, where employers cap the amount that they’ll pay for healthcare services that vary widely in price, thus encouraging workers to make cost-effective choices.

“Overall, we come to the conclusion that the potential gains from the consumer price shopping aspect of price transparency are modest,” the ana-lysts wrote.

“Doctor, can I record our conversation today?”Have you ever heard that question from a patient or a pa-

tient’s family member? The issue of allowing patients to record their appointments requires balancing potential privacy and li-ability risks with the potential benefits of improved patient rec-ollection of instructions and treatment adherence.

It’s typically not the best course to allow patients to record the appointment. The recording devices could be disruptive and could be potentially intimidating to physicians and staff. In addition, these recordings—unlike the electronic health record—can be altered or manipulated to create an inaccurate portrayal of what actually occurred. These recordings can also easily be streamed or posted online, raising the issue of patient and staff privacy and HIPAA compliance. In addition, recording the visit may inhibit the flow of information between the doctor and patient. Patients may be less likely to be open about sensitive health issues because of the fear that the recording might be listened to by an outside party.

If a patient records a visit without the doctor’s permission, that can result in a loss of trust, which is the basis of a strong physician-patient relationship. Only about a dozen states na-tionwide prohibit electronic recordings done without the ex-plicit consent of all participants in the encounter. It is important to know the specific laws concerning recordings in the jurisdic-tion where you practice. Regardless, it is recommended that patients be advised unequivocally that digital recordings by handheld devices such as smartphones are prohibited on the

premises in order to protect the privacy of other patients and staff in compliance with federal and state privacy laws.

Post this notice clearly on your practice website, in the con-ditions of treatment signed by the patient at the outset of the relationship, and as office signage near the reception window. Suspected violations should be handled immediately. If this policy is violated, meet with the patient in a confidential set-ting to discuss the issue and reiterate the office policy. Depend-ing on the circumstances and the status of the patient’s current episode of care, advise the patient that further violations may result in termination of the physician-patient relationship.

If patients ask to record the visit, encourage them instead to take notes or to have a trusted family member or friend join them for the office visit to help take notes, remember informa-tion, and ask questions. Doctors can also encourage patients to be engaged in the conversation with “Ask Me 3,” a program that promotes clear communication through these three main questions:

1. What is my main problem?2. What do I need to do?3. Why is it important for me to do this?

Doctors should also ask patients to repeat back the informa-tion shared, and then correct any misunderstandings. _________Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

SMILE! THE DOCTOR IS ON CAMERA: The Pros and Cons of Recording Office Visits and ProceduresBY RICH CAHILL, VICE PRESIDENT AND ASSOCIATE GENERAL COUNSEL, THE DOCTORS COMPANY

2 4 P H YS I C I A N M AG A Z I N E | APRIL 2016

CMS ANNOUNCES SECOND CYCLE OF MEDICARE REVALIDATION

Since the passage of the Affordable Care Act (ACA), all Medicare providers and suppliers have been required to revalidate their Medicare enroll-ment information under new enrollment screening criteria in an effort to prevent fraud within the Medi-care system. Once a Medicare enrollment applica-tion is validated, the clock starts ticking on a five-year revalidation cycle. Now that five years have passed since the ACA’s revalidation requirement took ef-fect, the Centers for Medicare and Medicaid Services (CMS) is initiating a second cycle of revalidation re-quests.

According to CMS, Medicare Administrative Con-tractors (MAC) – Noridian in California – will contin-ue to send revalidation notices two or three months prior to each provider’s revalidation due date.

WHAT PROVIDERS NEED TO KNOW:• If you have multiple reassignments/billing struc-

tures, you must coordinate the revalidation ap-plication submission with each entity.

• MACs will send revalidation notices (either by email or mail) two or three months prior to the revalidation due date. When responding to reval-idation requests, be sure to revalidate your entire Medicare enrollment record, including all reas-signment and practice locations.

• If a revalidation application is received but in-complete, your MAC will contact you for the missing information. If the missing information is not received within 30 days of the request, the MAC will deactivate your billing privileges.

• If billing privileges are deactivated, a reactivation will result in the same Provider Transaction Access Number, but there will be an interruption in billing during the period of deactivation. This will result in a gap in the provider’s enrollment status with Medicare.

• If the revalidation application is approved, the provider will be revalidated and no further action is needed.

Providers can now look up an individual pro-vider or organization to find their revalidation date through CMS’ look-up tool. Those due for revalida-tion in the near future will display a revalidation due date. All other providers/suppliers will see “TBD” in the due date field.

For more information on the revalidation process, see MLN Matters #SE1605.

If you have questions about the revalidation pro-cess, click here or contact Noridian by calling (855) 609-9960.

2016 MATCH DAY Many California Medial StudentsReceive Out-of-State Residency Assignments

The 2016 Match Day, the annual rite of passage for future physicians, was the largest on record according to the National Resident Matching Program. Match Day is the system through which medical school students and graduates obtain residency positions in U.S. accredited training pro-grams.

2016 Match Day included a total of 42,370 registered applicants and filled 30,750 positions. Locally, that included 163 Keck School of Medi-cine fourth-year medical students and 165 from David Geffen School of Medicine at UCLA.

About 58% of the 2016 class from UCLA will be training in primary care, and 74% will become medical residents in California. There are 36 budding surgeons — about 22% of the class.

The number of United States medical school seniors grew by 221 to 18,668, and the number of available first-year positions rose to 27,860, which is 567 more than last year. Despite the high numbers of candidates matching with residency programs this year, many qualified California students must leave the state to study elsewhere due to a lack of funding for graduate medical train-ing, highlighting the need to pass Senate Bill 22.

“Each year, California is fortu-nate to have thousands of ambi-tious medical students apply for residencies across the state, eager to improve the health of their com-munities,” said Steven E. Larson, MD, MPH, president of the Cali-fornia Medical Association. “Many of these physicians-in-training will one day be the backbone of healthcare in our state. But sadly, some will be forced to head else-where, since current funding lev-els are not high enough to ensure enough residency spots in Califor-nia. The data tells us that if a medi-cal student is forced to leave the state to complete his or her training, it is more likely they will stay and practice out of state, despite our desperate need for more physicians, particularly in primary care.”

California has lost tens of millions of dollars in funding for primary care physician training. In 2016 alone, more than $40 million of funding for the training of California’s primary care physicians is expiring.

To help combat a physician shortage in the state and protect patients’ access to care, the state Legislature is currently considering SB 22, which would direct state funds to new and existing graduate medical education primary care physician residency positions and support training medical school faculty.

“Solving California’s dire physician shortage is critical to the health-care for all Californians,” said Sen. Richard Roth, author of SB 22. “I in-troduced Senate Bill 22 to fund additional medical residency positions throughout our state’s medically underserved areas, especially in Inland Southern California and the Central Valley. Studies have shown that if we train tomorrow’s doctors in the areas that need them most, they are more likely to continue serving those areas, helping alleviate critical physician shortages and ensuring equal access to healthcare.”

SB 22 has passed the Senate and is expected to be taken up by the Assembly Health Committee in June.

Many qualified Cali-

fornia students must

leave the state to

study elsewhere due

to a lack of funding

for graduate medical

training, highlight-

ing the need to pass

Senate Bill 22.

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