O

FF

IC

I AL M A G

A

ZI

NE

OF

F

IC

IAL MAG

AZ

IN

E

OCTOBER 2015

O

FF

IC

I AL M A G

A

ZI

NE

OF

F

IC

IAL MAG

AZ

IN

E

A PUBLICATION OF PNNwww.PhysiciansNewsNetwork.com

R E P O R T I N G O N T H E E C O N O M I C S O F H E A L T H C A R E D E L I V E R Y

P L U S : L A C O U N T Y D I S A S T E R H E A L T H C A R E V O L U N T E E R S

AppsFOR DOCTORS& PATIENTS

mHealth TOPBEST PRACTICES

All financing is subject to credit approval. Business refinance program is for practice-related debt only. Existing Wells Fargo Practice Finance debt and revolving credit are not eligible for consolidation.

2015 Wells Fargo Bank, N.A. All rights reserved. Wells Fargo Practice Finance is a division of Wells Fargo Bank, N.A. ECG-1436101 SBS60-0244

Financing for your practice and so much more

Wells Fargo Practice Finance

With more than 25 years of healthcare financing experience, Wells Fargo Practice Finance understands the business of running a practice and is here to help you achieve your practice goals.

Get up to 100% financing for a variety of business purposes: Practice start-up and acquisition

Equipment purchases or upgrades

Office expansion, remodel, and relocation

Practice debt refinancing

Working capital

Thinking about starting, acquiring, or expanding your practice? Lets talk: 1-800-377-7340 or wellsfargo.com/physicians

OCTOBER 2015 | 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 146 Issue 10

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright 2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine,801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Advertising rates and information sent upon request.

OC

TOBER 2015 | TABLE O

F CO

NTEN

TS

COVER STORY12 mHEALTH & APPS In this issue of Physician Magazine, we will help clarify some pressing mHealth issues, starting with the current regulatory framework and mHealth best practices. Well also take a look at the promise of using Apple software to help researchers track and study major diseases as well as how this information will ultimately benefit doctors. Youll find a top 10 list of medical apps you can use in your practice today and the top 10 health apps to prescribe to your patients.

6 Los Angeles County Disaster Healthcare Volunteers8 ICD-10: Key Changes for Primary Care18 mHealth & Telehealth Top 10

186

SUBSCRIPTIONSMembers of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

The Los Angeles County Medi-

cal Association is a profes-

sional association representing

physicians from every medical

specialty and practice setting

as well as medical students,

interns and residents. For more

than 100 years, LACMA has

been at the forefront of cur-

rent medicine, ensuring that its

members are represented in the

areas of public policy, govern-

ment relations and community

relations. Through its advocacy

efforts in both Los Angeles

County and with the statewide

California Medical Association,

your physician leaders and staff

strive toward a common goal

that you might spend more time

treating your patients and less

time worrying about the chal-

lenges of managing a practice.

LACMAs Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Director of Governance, at lisa@lacmanet.org or 213-226-0304.

EDITOR

DISPLAY AD SALES / DIRECTOR OF SALESCLASSIFIED AD SALES

EDITORIAL ADVISORY BOARD

PRESIDENT PRESIDENT-ELECT

TREASURER SECRETARY

IMMEDIATE PAST PRESIDENT

CMA TRUSTEEALTERNATE RESIDENT/FELLOW COUNCILOR

COUNCILOR SSGPF COUNCILOR DISTRICT 9

CMA TRUSTEE COUNCILOR

COUNCILOR DISTRICT 2COUNCILOR-AT-LARGE

ETHNIC PHYSICIANS COMMITTEE REPCOUNCILOR DISTRICT 1

COUNCILOR DISTRICT 17COUNCILOR DISTRICT 14

COUNCILOR USCCOUNCILOR DISTRICT 7 COUNCILOR DISTRICT 6

COUNCILOR-AT-LARGE COUNCILOR ALLIED PHYSICIANS

COUNCILOR-AT-LARGECOUNCILOR DISTRICT 3

COUNCILOR DISTRICT 10MEDICAL STUDENT COUNCILOR/USC

COUNCILOR SCPMG RESIDENT/FELLOW COUNCILORYOUNG PHYSICIAN COUNCILOR

COUNCILOR-AT-LARGECOUNCILOR SSGPF

ALT. MEDICAL STUDENT COUNCILOR/UCLACOUNCILOR-AT-LARGE

CHAIR OF LACMA DELEGATION

Sheri Carr 858.226.7647 | sheri@physiciansnewsnetwork.com

ADVERTISING SALES

Christina Correia 213.226.0325 | christinac@lacmanet.orgDari Pebdani 858.231.1231 | dpebdani@gmail.comDavid H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD

HEADQUARTERS

Physicians News NetworkLos Angeles County Medical Association801 S. Grand Avenue, Suite 425Los Angeles, CA 90017Tel 213.683.9900 | Fax 213.226.0350www.physiciansnewsnetwork.com

LACMA OFFICERS Peter Richman, MDVito Imbasciani, MDWilliam Averill, MDRichard Baker, MDPedram Salimpour, MD

LACMA BOARD OF DIRECTORS

David Aizuss, MDErik Berg, MDRobert Bitonte, MDStephanie Booth, MDJack Chou, MDTroy Elander, MDHilary Fausett, MDSamuel Fink, MDHector Flores, MDC. Freeman, MDSidney Gold, MDJinha Park, MDStephanie Hall, MDDavid Hopp, MDKambiz Kosari, MDSion Roy, MDPaul Liu, MDMaria Lymberis, MDPhilip Hill, MDNassim Moradi, MDVamsi AribindiAshish Parekh, MDJerry Abraham, MDPo-Yin Samuel Huang, MDMichael Sanchez, MDHeather Silverman, MDAnnie WangNhat Tran, MDFred Ziel, MD

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.

SafetyIn addition to mandatory CalOSHA information and videos on workplace safety, Preferreds teamof Risk Advisors are available for consultations when you need them. They also have a strong fraudprevention policy and as a California-based carrier, they know exactly what it takes to do businesssuccessfully in this State.

SavingsCMA members qualify for an additional 5% discount*on top of Preferred Insurancesalready competitive rates. Preferreds 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.

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

Call Mercer today at 800-842-3761 for a premium indication.CMACounty.Insurance.service@mercer.com or www.CountyCMAMemberInsurance.com.

See how CMA/LACMAs Workers Compensation team can help you save!

The CMA/LACMAs exclusive new Workers Compensation program can help

your practice save money!

Mercer Health & Benefits Insurance Services LLC CA Ins. Lic. #0G39709 Copyright 2015 Mercer LLC. All rights reserved. 71387 (10/15)777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 www.CountyCMAMemberInsurance.com CMACounty.Insurance.service@mercer.com

*Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

Underwritten by: Scan for info:Sponsored by:

MERCER Project 71387, LACMA, (10/15)

Full Size: 8.375 x 10.875 Bleed: 8.625 x 11.125Folds to: N/A Perf: N/AColors: 4cStock: N/APostage: N/AMisc: N/A

71387 LACMA Oct 2015 WC Ad:ADS 9/16/15 10:44 AM Page 1

4 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

I A M A NATIVE CALIFORNIAN , born and raised in the San Fernando Valley. Earthquakes are part of the Southern California lifestyle.

In school we trained for the inevitable earthquake (and the possible thermonuclear blast from a Soviet bomb) by ducking under our desks with our fingers interlocked behind our necks for protection. We all know of the San Andreas Fault. When a room shakes, we judge the size of the quake and turn on the TV to see the measurements from Caltech.

In 1971 the Sylmar quake hit, causing substantial damage. It measured 6.5 on the Richter scale. There were 64 deaths and 2,543 injuries. Olive View Hospital and the San Fernando

Valley Veterans Hospital partially collapsed, and Holy Cross Hospital was beyond repair. Olive View and Holy Cross were rebuilt to the up-dated earthquake standards. The Van Norman Dam adjacent to the 405 Freeway was damaged, and there was consternation for several days that a rupture would occur, killing tens of thousands and flood-ing the north-mid valley. I was in junior high school and rode my bike the length of Ventura Boulevard to survey the damage the day of the quake.

After I had completed my residency residency at Harbor-UCLA, I returned to the San Fernando Valley for employment with Facey Medical Group. My wife and I bought a house in Northridge in 1992. We spent 18 months doing renovations ourselves. Our son was born in January 1993. The Norhtridge earthquake hit in January 1994. It measured 6.9 on the Richter scale. Fifty-seven people lost their lives (many from the collapse of a single apartment building), and 8,700 were injured. There was extensive damage to freeway overpasses in the North Valley, Simi Valley and Santa Monica. Eleven hospitals were severely damaged.

As Angelenos, we need to prepare for the Big One. We need to prepare a family emergency plan. We should have an emergency kit, adequate food and water, tents and sleeping bags for temporary

shelter, and supplies to sustain the family for more than one week. When New Orleans was devastated by a known approaching hurricane, it took FEMA more than a week to mobilize assistance. New Orleans was a city of nearly 500,000 people. Los Angeles County has 10.6 million people.

We as physicians have a special obligation and need to prepare for this as well. There will be thousands of people with injuries seeking medical attention. Hospital patients may be displaced and sent to other facilities where they will need ongoing medical care. The medical community needs to prepare for this. The Los Angeles County Emergency Medical Services Agency has been planning and training for such an event. Volunteer physicians will be needed to provide emergency and urgent services, perhaps outside of their immedi-ate communities. At a time when there will be personal disruptions, business interruptions, perhaps loss of offices, etc., our knowledge and skills will be most needed. Many of us have volunteered our services in foreign countries, this will be aiding our fellow Angelenos.

PR

ES

IDE

NT

S L

ET

TE

R |

PE

TE

R R

ICH

MA

N,

MD

Success.

Protect Your Online Reputation With CAPs Free Physicians Action Guide!

Since 1977, the Cooperative of American Physicians

(CAP) has provided superior medical professional

liability coverage and valuable risk and practice

management programs to Californias finest

physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand

the realities of running a medical practice, and

are committed to supporting you with a range of

value-added programs and services. These include

a 24-hour adverse outcomes hotline, HR support,

EHR consultation, a group purchasing program,

and payment and reimbursement education and

support, to name a few.

Its what Californias finest physicians strive for. . .and what CAP can help you achieve.

The Physicians Online Reputation Action Guide can

help you build a strong and positive reputation.

Learn how to:

Encourage patients to post positive reviews.

Appropriately respond to negative reviews.

Optimize social media to establish your credibility.

Request your free electronic or hard copy today!

800-356-5672 | CAPphysicians.com/ReputationPro

6 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

To meet the increased need for healthcare personnel following di-sasters, Los Angeles County launched the Los Angeles County Disaster Healthcare Volunteer (DHV) program in 2007.

LA County DHV is a collaborative effort led by the Los Angeles Coun-ty Department of Health Services Emergency Medical Services Agency and Department of Public Health.

In addition to the Los Angeles County Surge Unit, there are two Medical Reserve Corps (MRC) units within the collaborative. They are MRC Los Angeles and Long Beach MRC.

Volunteers are given a choice of joining one of these units when they register. The DHV Surge Unit is the hospital ready team for volunteers who wish to be assigned primarily to hospitals and clinics to provide di-rect patient care following disasters. The MRC Units focus on responding

to public health emergencies (including dispensing medication at a Medical Point of Dispensing site to provide mass prophylaxis to the population) and pro-moting preparedness activities.

All of the Los Angeles County DHV Units are a part of a federally mandated effort to recruit and register healthcare volunteers in advance of the next disaster.

WE NEED YOUR HELP | Developing and implementing such a volunteer system in a county as large as Los Angeles presents many challenges. For example, in a large-scale anthrax attack, the county would need as many as 43,000 volunteers to support mass medica-tion dispensing efforts and about 4,000 medical vol-unteers for the surge-capacity staffing at area hospitals.

Although the Los Angeles County Medical Asso-

ciation (LACMA) has thousands of members here in LA County, it would be difficult to mobilize a group that size to respond rapidly without pre-registration.

As recent disasters demonstrate, healthcare provid-ers are eager, willing and able to volunteer in an emer-gency. We need you to meet the extraordinary de-mands of a large-scale emergency or natural disaster. Hospitals and other healthcare providers will depend on the services that volunteer physicians can provide.

The goal of the new and exciting collaborative ef-fort between LA County and LACMA is to:

Pre-identify and register local physicians; stream-line their identification at disaster sites; and pre-val-idate their practice and licensure, credentials and training.

It is understood that the first duty of physicians is to their own hospitals, clinics and private practice settings. If asked to deploy, each individual physician may accept, decline or ask to be rescheduled.

Registering as a LA County Disaster Healthcare Volunteer will not detract in any way from your obli-gation to your own facility.

REGISTER TO BECOME A DISASTER HEALTHCARE VOLUN-TEER TODAY! | The process is simple and free. Go to www.lacountydhv.org and select the Unit that you would like to register in. Volunteers who would like to sign up for the LA County Surge Unit can go di-rectly to the LA County Surge Unit website at www.JoinSurgeTeam.org and click on Sign-up Now. Cre-ate a username and password. Complete the applica-tion. Done! You will receive a follow-up e-mail from the DHV registration system.

LACMA members who have questions regarding: LA County Surge Unit: Dr. Millicent Wilson, LA

County EMS Agency at (562) 347-1609 or milwil-son@dhs.lacounty.gov

MRC Los Angeles: Jee Kim (213) 637-3636 or Jee-Kim@ph.lacounty.gov

Long Beach MRC: Veronica Ornelas (562) 570-4273 or Veronica.Ornelas@longbeach.gov

LOS ANGELES COUNTY Disaster Healthcare VolunteersBY MILLICENT WILSON, MD; SANDRA SHIELDS, LMFT, LPCC, CTS; AND JEE KIM, EDD, MPH

VOLUNTEERS NEEDED INCLUDE: Physicians of all Specialties - Emergency Medicine - Pediatrics - Internal Medicine - Family Practice - General Surgeons - Orthopedic Surgeons - Pediatric Surgeons - Ophthalmologists - ENT Specialists - Dentists & Oral Surgeons - Radiologists - Infectious Disease Specialists All other medical, health and

mental health professionals

WE KNOW THAT a major disaster will hit Los Angeles County.

The question is not if, but when. We need your helpwhen

help is needed the most. The events of September 11 and Hur-

ricanes Sandy and Katrina point to the need for organized sys-

tems to recruit and mobilize qualified medical professionals.

A

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

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

I M P R O V E P A T I E N T A C C E S S A F T E R H O U R S P R E S C R I B E S A F E L Y A F T E R H O U R S H A V E A B E T T E R Q U A L I T Y O F L I F E A U T O M A T I C A L L Y K E E P R E C O R D S O F A L L P A T I E N T A F T E R H O U R S

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

F E W S E C O N D S H I P A A C O M P L I A N T I N T E G R A T E S W I T H A L L E M R S T H E U L T I M A T E P A T I E N T S E L F - S C H E D U L E R T H E U L T I M A T E C A L L C E N T E R R E L A C E M E N T

844-722-5536 3 4 4 5 P a c i f i c C o a s t H w y

S u i t e 2 0 0 T o r r a n c e , C A 9 0 5 0 5

w w w . s p h i n x m e d t e c h . c o m w w w . c a l l m y d o c . c o m

w w w . s c h e d u l e m y p a t i e n t . c o m

SC

Schedule My Patient

Call My Doc

SPHINX MEDICAL TECHNOLOGIES PRESENTS ITS TWO LATEST DEVELOPMENTS

CALL US NOW AT 844-722-5536

FOR A FREE SETUP, FOR THE FIRST 100

CALLERS!

NEW

8 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

Key Changes for Primary CareBY MARY JEAN SAGE, PRESIDENT, THE SAGE ASSOCIATES; EXPERT CONSULTANT FOR THE COOPERATIVE OF AMERICAN PHYSICIANS, INC.

T R A N S I T I O N I N G successfully to the

new ICD-10-CM code set will be particu-

larly important for primary care physicians.

ICD-10-CM will allow primary care special-

ists to more accurately depict chronic con-

ditions as well as other commonly report-

ed diagnoses. Physicians will need to be

more specific in their documentation than

they likely have been in the past. Because

there will be a greater number of code

choices in ICD-10-CM, physicians should

have to choose an unspecified code less

often. The greater specificity in diagnostic

coding should help improve disease man-

agement and reporting overall. Practices

should examine their top diagnoses and

compare how those codes will change

once ICD-10-CM goes into effect Oc-

tober 1, 2015. Here are some diagnoses

to which primary care providers should

pay close attention. This is certainly not an

all-encompassing list, but is an example

of some of the common diagnoses often

reported by the PCP.

DIABETES | Diabetes (codes E08 E13) has greatly expanded in ICD-10-CM. Physicians must document whether the diabetes is Type 1, Type 2, drug- or chemical-induced, or due to an underlying condition. They must document the specific underlying condition, the specific drug or toxin, as well as the use of any insulin. ICD-10-CM requires very specific details regarding any complications or manifestation of the diabetes. For exam-ple, code E08.341 denotes diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema.

HYPERTENSION | ICD-10-CM code I10 denotes essential (primary) hy-pertension. There are separate codes for hypertension involving vessels of the brain (codes I60 I69) and hypertension involving vessels of the eye (code H35.0). ICD-10-CM also includes codes for hypertensive heart disease with or without heart failure (code I11), and hypertensive chronic kidney disease (code I12). It is important to note that physicians must document the stage of the chronic kidney disease as well. Additionally, there are codes for hypertensive heart and chronic kidney disease (code I13), and secondary hypertension (code I15).

ASTHMA | Asthma (code J45) is another diagnosis that was expanded in ICD-10-CM. Physicians must document whether the asthma is:

- Mild intermittent - Mild persistent- Moderate persistent - Severe persistent- Other and unspecified asthma (in ICD-9-CM, it is classified by type)The physician must also specify whether the asthma is uncomplicat-

ed, with acute exacerbation, or with status asthmaticus. ICD-10 instructs the physician to identify tobacco exposure as an additional code when reporting asthma. Those choices are:

- Exposure to environmental tobacco smoke (Z77.22)- Exposure to tobacco smoke in the perinatal period (P96.81)- History of tobacco use (Z87.31)- Occupational exposure to environmental tobacco smoke (Z57.31)

- Tobacco dependence (F17.-)- Tobacco use (Z72.0)

HEADACHE | ICD-10-CM includes a variety of new codes for report-ing headaches. For example, when a patient presents with a migraine (code G43), physicians must specify whether its common, hemiplegic, persistent, chronic, ophthalmologic, abdominal or menstrual. Cluster headaches and other trigeminal autonomic cephalalgias (code G44.0) are grouped into episodic, chronic, episodic paroxysmal hemicranias, chronic paroxysmal hemicranias, and short-lasting unilateral neuralgi-form headache with conjunctival injection and tearing. There are also codes for vascular headaches (G44.1), tension-type headaches (G44.2), post-traumatic headaches (G44.3), drug-induced headaches (G44.4), as well as a variety of other headache syndromes. Many of the codes in the

IC

D-1

0

| K

EY

CH

AN

GE

S F

OR

PR

IMA

RY

CA

RE

OCTOBER 2015 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 9

headache section also require the following docu-mentation:

- With or without aura - Intractable vs. not intractable- With or without status migrainosus

EAR INFECTIONS | ICD-10-CM includes various codes to denote specific forms of a middle ear infection. These codes are grouped in H65-H67 and distinguish between these forms of otitis media:

- Serous - Allergic- Mucoid -Nonsuppurative- Suppurative - Tu b o t y m p a n i c suppurative

- Atticoantral suppurativePhysicians must also document the following for

many of the codes in this section:

- Acute vs. chronic- Laterality (left vs. right vs. bilateral)- Any associated perforated tympanic mem-braneTobacco exposure should be identified

as a second diagnosis, using an additional code when an ear infection is reported.

DEPRESSION | According to the Centers for Disease Control and Prevention, an estimat-ed one in 10 adults reports depression. De-pression codes have been greatly expanded in ICD-10-CM. When a patient presents with major depression (codes F32 F33), physi-cians must consider and document the fol-lowing:

- Single episode vs. recurrent- Mild, moderate, or severe- With or without psychotic features- In partial or full remission

OTHER CODES | Chapter 21 of ICD-10-CM includes an array of codes related to factors that influence health status and contact with health services. For example, primary care physicians may be interested in codes Z55 Z65, which pertain to health hazards related to socioeconomic and psychosocial circum-stances. Codes in the Z68 category denote specific data related to body mass index (BMI). These should be reported additionally when reporting obesity (Code E66) and the BMI is known. Codes in the Z72 category denote problems related to lifestyle (e.g., tobacco use, lack of exercise, and high-risk

sexual behavior).This chapter also includes codes for preventive

care, such as Z01.3 (encounter for examination of blood pressure), Z01.4 (encounter for gynecological exam), and more. Many of the codes for reporting well-visits require a selection between with abnormal findings or without abnormal findings. When ab-normal findings are present, a second code is required to identify the abnormal findings.

Converting to ICD-10-CM may be a challenging transition for many practices. However, its likely that physicians will recognize its benefits over time. ICD-10-CM is certainly more complex than its predeces-sor, but in this changing world of healthcare econom-ics, its increased specificity should prove beneficial to you and your practice.

Mary Jean Sage is president and founder of The Sage Associates and expert consultant in billing and coding for the Cooperative of American Physicians, Inc. (CAP). CAP offers a range of products and services, including medical professional liability protection and risk management services, in the healthcare field. The Sage Associates is a leading multispecialty provider of healthcare management services. www.CAPphysicians.com.

Assisting physicians with legal issues for over three decades.

Fenton Law Group, LLP1990 South Bundy DriveSuite 777Los Angeles, CA 90025 310.444.5244

www.fentonlawgroup.com

M E D I C A L B O A R D H O S P I T A L S T A F F F R A U D / A B U S E M E D I - C A L / M E D I C A R EMEDICAL PRACTICE PURCHASES, SALES AND MERGERS

The brand physicians trust

Key Changes for Primary CareBY MARY JEAN SAGE, PRESIDENT, THE SAGE ASSOCIATES; EXPERT CONSULTANT FOR THE COOPERATIVE OF AMERICAN PHYSICIANS, INC.

KE

Y C

HA

NG

ES

FO

R P

RIM

AR

Y C

AR

E | IC

D-1

0

Did you know that your LACMA/CMA Membership

pays for itself?

Los Angeles CountyMedical Association

PRIMA MEDICAL WASTELACMA has negotiated exclusive pricing for its members that saves them 25% on their existing medical waste bill guaran-teed for three years. Additional benefits include complemen-tary waste analysis, OSHA trainings, and more!www.lacmanet.org/MedicalWaste

25%GUARANTEED SAVINGS

CMAS CENTER FOR ECONOMIC SERVICESAre you getting your fair share? The CES team successfully intervenes with payors on behalf of members. This is service alone is worth the price of your membership! Find out how you can recoup thousands in unpaid claims today!www.lacmanet.org/Reimbursementassistance

$10MOVER $10 MILLION

RECOUPED

MEDLINE INDUSTRIESThrough an exclusive partnership with Medline, LACMA saves members a guaranteed minimum of 10% on their medical sup-plies and equipment. On average, members are saving 15-27%. Find out how one member saved $31,000 for his practice!www.lacmanet.org/Medline

10%GUARANTEED SAVINGS

LACMAS JOB BOARD & CAREER CENTERLACMA makes it easy to search for a career opportunity suited to your interests. Looking to expand your office or hospital staff? Recruit physicians and qualified staff with a click of a button.www.careers.lacmanet.org

JOBSUNLIMITED ACCESS TO JOB POSTINGS

Your LACMA/CMA Membership at work

Learn more at www.lacmanet.org/Membership

LACMA_MemberBenefits_FlyerAd_2015.indd 2 4/17/15 11:34 AM

Did you know that your LACMA/CMA Membership

pays for itself? Maximize your benefits & take advantage of these MEMBER - EXCLUSIVE Savings Programs today:CME RESOURCE CENTER | WWW.LACMANET.ORG/CME CMA/IMQ CME Tracking & Credentialing Online CME Courses LACMA CME-Accredited Live Events CME Presenter Training

LEGAL RESOURCE CENTER | WWW.LACMANET.ORG/LEGALRESOURCES LA County Bar Association Lawyer Referral & Consultation Program Contract Analyses & Health Plan Resources

PROFESSIONAL DEVELOPMENT CENTER | WWW.LACMANET.ORG/

PROFESSIONALDEVELOPMENT Leadership & Management Development Leadership Placement on Boards & Commissions LACMAs Job Board & Career Center Media Training

JURY DUTY CONCIERGE | WWW.LACMANET.ORG/JURYDUTY SMS Updates Simplified Online-Processing of Requests Change your court location and/or reporting date with ease

EXCLUSIVE SAVINGS PROGRAMS | WWW.LACMANET.ORG/PARTNERS 25% Guaranteed Savings on your Medical Waste 10% Guaranteed Savings on your Medical Supplies

To learn more about your new LACMA & CMA benefits,

visit www.lacmanet.org/Membership

LACMA_MemberBenefits_FlyerAd_2015.indd 3 4/17/15 11:34 AM

mH

EALT

H |

is an

abbr

eviat

ion

for m

obile

hea

lth, a

term

use

d fo

r the

pra

ctice

of m

edi-

cine

and

publ

ic he

alth

supp

orte

d by

mob

ile d

evice

s. m

Healt

h ap

plica

tions

inclu

de

the

use

of m

obile

dev

ices i

n co

llect

ing

com

mun

ity a

nd cl

inica

l hea

lth d

ata,

deliv

ery

of

heal

thca

re in

form

atio

n to

pra

ctiti

one

rs, r

esea

rche

rs, a

nd p

atie

nts,

rea

l-tim

e m

oni

-to

ring

of p

atie

nt vi

tal s

igns

, and

dire

ct p

rovis

ion

of ca

re vi

a mob

ile te

lem

edici

ne.

mHealthBEST PRACTICESApps

FOR DOCTORS& PATIENTS

TOP

BY MARION WEBB

With more and more Americans expressing in-

terest in monitoring their health using mobile de-

vices, and with doctors acceptance and usage of

these technologies on the rise, the way to incor-

porate them into physician practices raises many

questions and concerns. In this issue of Physician

Magazine, we will help clarify some of these issues,

starting with the current regulatory framework and

mHealth best practices. Well also take a look at the

promise of using Apple software to help research-

ers track and study major diseases as well as how

this information will ultimately benefit doctors.

Youll find a top 10 list of medical apps you can use

in your practice today and the top 10 health apps

to prescribe to your patients.

mH

EA

LTH

& A

PP

S | F

EA

TU

RE

According to an online study

of 2,024 Americans by Research

Now, 56% of Americans want

their doctors to monitor their

health using connected health

devices and both consumers

and doctors believe that mo-

bile health apps are beneficial

to quality of life. Of 1,000 mo-

bile health users surveyed, 60%

said they use apps to monitor

workouts and activity, and 53%

use apps to get motivated to

exercise. Using apps to moni-

tor calorie intake and weight

loss ranked third and fourth.

Among the 500 surveyed

healthcare professionals, the

majority, or 86%, believed that

using mobile health apps will

increase their knowledge of

their patients medical condi-

tions, and 76% said it will help

them manage patients with

chronic diseases. Sixty-one

percent said they believed they

could use apps to help those at

high risk for developing health

issues, and 55% believed they

could use them to help healthy

people stay healthy.

Regulatory Framework | There is no denying that the world of mobile health, or mHealth, is continually changing, due in large part to rapid ad-vances made by the innovative industry. This, in turn, has brought challenges to regulating the industry in terms of ensuring proper consumer access and patient safety.

FDA | Recent moves by the U.S. Food and Drug Administration (FDA) to provide more transparency regarding compliance with governing laws have been welcome news to the mHealth industry, which requested the transpar-ency.

As it stands today, consumer apps such as those that track fitness or pro-vide reminders for doctors visits and/or drug dosing schedules or save and display particular medical records are not regulated by the FDA, according to an article written by attorneys at Wiley Rein LLP.

The agency also does not regulate mobile apps sold in the Apple iTunes Store or Google Play.

Remaining under FDA oversight, as stated in the FDAs final guidance, are mobile apps that are medical devices and whose functionality could pose a risk to patients safety if the mobile app were to not function as intended.

Apps that clearly fall under FDA oversight and require clearance, the at-torneys noted, comprise those that connect to a medical device to control it or are used for active patient monitoring or medical data analysis; transform mobile platforms into regulated devices by using attachments or functional-ities similar to those found in regulated devices; or perform patient-specific analysis, diagnosis, or treatment recommendations.

The attorneys pointed out that confusion still exists for those inventing apps that include both characteristics of a medical device and an app that doesnt fall under the FDAs regulatory framework.

FCC | Ambiguity also still exists when it comes to questions pertaining to privacy protection such as who monitors sensitive health data and where it gets stored, which are issues regulated by the Federal Communications Com-mission (FCC).

The FCC and FDA entered into a Memorandum of Understanding to col-laborate with each other within the areas of their respective agencies.

The attorneys further noted that the FCCs recent action to change the regulatory classification of broadband to be more highly regulated in the same manner as safeguarding consumer data by telephone companies by directing broadband providers to employ effective privacy protections in line with their privacy policies, may unintentionally be muddying the waters.

Although the new rules imposed through broadband reclassification ap-ply only to broadband providers, a petition has already been filed by Con-sumer Watchdog to apply the new rules to edge providers like Google and Facebook to give the FCC authority to force those companies to honor con-sumers do not track preferences, the attorneys wrote.

While it remains to be seen what action the FCC will take, the request would extend new privacy rules to all edge providers, including mHealth apps.

FTC | Finally, the Federal Trade Commission (FTC) also collaborates with the FDA and FCC to protect consumers from unfair and deceptive acts or prac-tices as well as false or misleading claims, the attorneys wrote.

When it comes to mHealth, they said, the FTC has already been active in enforcing against mobile health app marketers that have not met those requirements.

14 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

The attorneys noted that while all three agen-cies seem to have adopted the idea of fostering regulatory flexibility, they also have reserved dis-cretion given that mHealth appears highly innova-tive and complex.

Best Practices for Physicians | With the technol-ogy rapidly evolving, it may be difficult to figure out which mobile health solutions are right for you and your practice.

Here are some ways that doctors have success-fully implemented mobile and portal technologies into their practices as well as what things to con-sider when doing so, according to Physicians Prac-tice, a practice management website, and other experts.

1. PATIENT PORTALS | Patient portals are a great way to streamline patient visits and help patients come to appointments more informed. A good way to approach this is to send patients a message prior to their visit to fill out paperwork and bring it to the visit.

2. MOBILE APPS | Mobile apps can be a great way to monitor patients health, and more doctors are open to prescribing them. According to Manhat-tan Research data, the conversation is more likely to take place if a doctor is part of an ACO. Some 90% of doctors who own a wearable device or use health apps themselves had discussions with patients about wearable devices. For the top con-sumer apps, see the sidebar of this story.

3. TEXT MESSAGES | More doctors also find that text messages are a great, effective and cost-effective way to remind patients of appointments. Accord-ing to a Cochrane Collaboration review, Text mes-sage reminders improved the rate of attendance at healthcare appointments compared with no re-minders . . . and postal reminders.

4. ACTIVITY TRACKERS | When it comes to tracking activity and health information that can be shared by providers, the question is, do doctors want and need all that information to help them make a bet-ter diagnosis or provide better care?

F

EA

TU

RE

|

mH

EA

LTH

& A

PP

S

FAST GROWTH EXPECTED IN MEDICAL APPS MARKET | The medical apps market is estimated at $489 million in 2015. While thats not huge compared to the total app market, the mhealth apps market was a mere $85 million five years ago. And medical apps are

expected to be a fast growing area and one with loyal customers. The finding was made in Kalorama Informations recent report

mHealth Markets Worldwide. The report indicates that estimated ownership trends among healthcare workers are a driver in

mHealth sales. Over five years ago, around 25% of practicing physicians in the U.S. used a PDA or smartphone for professional and

other uses. This increased to approximately 35% to 40% in 2008. By 2010, more than 50% of physicians used smartphones or PDAs on

a regular basis for everyday treatment activity. Today upwards of 70% of physicians and medical workers use mobile medical apps on a

regular basis. And when they use apps, they tend to pay more, with medical apps averaging $9. The report indicates growth for medical

apps is estimated at 41.9% compounded annually over the past five years, while the growth for all apps combined is at 38.1%. Apples

iOS platform is the highest performing among its competitors with about 55% of the medial app market in terms of dollars for 2015.

Sales for medical apps for Apple smartphones, tablets and similar equipment can be estimated at $268.8 million for the year. Apple

has experienced increasing competition from its main competitor Android (Google) and newer competition from the Windows

platform in recent years. The result has been a slowly eroding market share. However, the growing use of the iPad in health func-

tions is keeping Apple at the top of the list.

OCTOBER 2015 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 15

FAST GROWTH EXPECTED IN MEDICAL APPS MARKET | The medical apps market is estimated at $489 million in 2015. While thats not huge compared to the total app market, the mhealth apps market was a mere $85 million five years ago. And medical apps are

expected to be a fast growing area and one with loyal customers. The finding was made in Kalorama Informations recent report

mHealth Markets Worldwide. The report indicates that estimated ownership trends among healthcare workers are a driver in

mHealth sales. Over five years ago, around 25% of practicing physicians in the U.S. used a PDA or smartphone for professional and

other uses. This increased to approximately 35% to 40% in 2008. By 2010, more than 50% of physicians used smartphones or PDAs on

a regular basis for everyday treatment activity. Today upwards of 70% of physicians and medical workers use mobile medical apps on a

regular basis. And when they use apps, they tend to pay more, with medical apps averaging $9. The report indicates growth for medical

apps is estimated at 41.9% compounded annually over the past five years, while the growth for all apps combined is at 38.1%. Apples

iOS platform is the highest performing among its competitors with about 55% of the medial app market in terms of dollars for 2015.

Sales for medical apps for Apple smartphones, tablets and similar equipment can be estimated at $268.8 million for the year. Apple

has experienced increasing competition from its main competitor Android (Google) and newer competition from the Windows

platform in recent years. The result has been a slowly eroding market share. However, the growing use of the iPad in health func-

tions is keeping Apple at the top of the list.

EPOCRATES | remains the gold standard for medical apps to look up drug information and interac-tions, find providers for consults and referrals and quickly calculate measurements such as BMI.

UP TO DATE | chock-full of medical info that gives answers to clinical questions when needed. App is free. Subscription is $499 a year per physician.

DOXIMITY | social network for doctors. App and membership in the network are free.

READ BY QXMD | centralizes medical literature and journals in magazine format. App is free. Some PubMed and other journals require subscription or creden-tials.

NEJM THIS WEEK | access articles, images of medical conditions, lis-ten to video and audio of articles. Free.

SKYSCAPE | decision-support tool with drug information, a medical calculator, evidence-based clini-cal information and summaries of journal articles.

ISABEL | database of more than 6,000 disease presentations and symptoms with the ability to re-fine by age, gender and travel his-tory. App requires online access. Monthly subscription is $10.99, or annually $119.99.

MEDSCAPE | a unit of WebMD that offers prescribing and safety information for drugs, procedure videos, a medical calculator and continuing medical education (CME) information.

KIDSPEAK | free app geared toward pediatricians, family physicians and emergency medi-cine physicians; explains disease pathology to parents and kids in an easy-to-understand manner.

PROGNOSIS PSYCHIATRY | a collec-tion of case-based presentations on patients with psychiatric complaints.

TOP 10 MEDICAL APPS FOR DOCTORS

1. Weight Watchers Mobile

2. My Fitness Pal and Run Keeper

3. White Noise Lite

4. Instant Heart Rate and Glu-cose Buddy

5. Pocket First Aid & CPR (Jive Media)

6. Calorie Counter and Diet Tracker (MyFitnesPal.com)

7. Spot a Stroke Fast by the American Heart Association

8. Drugs.com

9. Health Tap

10. The American Red Cross

The following health apps, rated by thousands of physicians in a HealthTap survey based on ease of use, effective-ness, medical accuracy, validity and soundness for patient prescriptions, as well as other physician recommenda-tions, made the top 10 list:

TOP 10 HEALTH APPS FOR CONSUMERS

Apple ResearchKit Software | Among the most recent technological advances that research sci-entists are considering in mobile technology is the ResearchKit software introduced by Apple this March with five apps to investigate Parkinsons dis-ease, asthma, heart disease, diabetes and breast cancer.

A sixth app was reportedly released in June to collect information for a long-term study on gays and lesbians by the University of California, San Francisco.

This is how it works: Any iPhone user who wants to participate in a study can simply download the app and fill out a questionnaire to determine eli-gibility and establish a baseline for comparisons. Users learn about the study before giving consent. The idea is that scientists at research institutions can use the preliminary data from participants to gain a better understanding of major diseases. To protect privacy, Apple will not see any data.

To date, more than 75,000 people have en-rolled in the health studies, which use specialized iPhone apps built with software Apple created to turn the smartphone into a research tool. Once

REPORT | Sm

artpho

ne users now

have mo

re than 165,000 app

s available to help them

stay healthy or monitor a m

edical condi-tion, but just three dozen account for nearly half of all down-loads, the IM

S Institute for Healthcare Informatics reports.

THE

INTE

RNET

OF

THIN

GS (I

oT)

| re

fers

to a

ny o

bjec

t or d

evice

that

con

-ne

cts

to th

e In

tern

et to

aut

omat

ically

sen

d an

d/or

rece

ive d

ata,

in-

cludi

ng m

edica

l dev

ices,

such

as

wire

less

hea

rt m

onito

rs o

r ins

ulin

d

isp

ense

rs; w

eara

ble

s, s

uch

as fi

tnes

s d

evic

es; a

nd o

ffice

eq

uip

men

t, su

ch a

s pr

inte

rs. I

oT d

evice

s co

nnec

t thr

ough

com

pute

r ne

twor

ks

to e

xcha

nge

data

with

the

oper

ator

, bus

ines

ses,

man

ufac

ture

rs a

nd

othe

r con

nect

ed d

evice

s, m

ainly

with

out r

equi

ring

hum

an in

tera

ctio

n.

FBI Issues Cyber Alert for IoT and Medical Devices As more businesses and homeowners use web-connected devices to enhance company efficiency or lifestyle conveniences, their

connection to the Internet also increases the target space for malicious cyber actors. Similar to other computing devices, like comput-ers or smartphones, IoT devices also pose security risks to consumers. The FBI is warning companies and the general public to be aware of IoT vulnerabilities cybercriminals could exploit, and offers some tips on mitigating those cyber threats.

The FBI specifically calls out the potential vulnerabilities of IoT devices that can lead to the theft of personal information and inten-tional tampering with devices to cause harm, according to a Health Data Management article on the subject. In particular, the agency warns that unprotected medical devices used in home healthcare, such as those used to collect and transmit personal monitoring data or time-dispense medicines, are a ripe target for cybercriminals, especially devices capable of long-range connectivity.

THE FBI PROVIDED A LIST OF RECOMMENDATIONS TO BETTER SAFEGUARD IOT DEVICES: Isolate IoT devices on their own protected networks.

Disable UPnP on routers.

Consider whether IoT devices are ideal for their intended purpose.

Purchase IoT devices from manufacturers with a track record of providing secure devices.

When available, update IoT devices with security patches.

Consumers should be aware of the capabilities of the devices and appliances installed in their homes and businesses. If a device comes with a default password or an open Wi-Fi connection, consumers should change the password and allow it to operate only on a home network with a secured Wi-Fi router.

Use current best practices when connecting IoT devices to wireless networks, and when connecting remotely to an IoT device.

Patients should be informed about the capabilities of any medical devices prescribed for at-home use. If the device is capable of remote operation or transmission of data, it could be a target for a malicious actor.

Ensure all default passwords are changed to strong passwords. Do not use the default password deter-mined by the device manufacturer. Many default passwords can be easily located on the Internet. Do not use common words and simple phrases or passwords containing easily obtainable personal information, such as important dates or names of children or pets. If the device does not allow the capability to change the access password, ensure the device providing wireless Internet service has a strong password and uses strong encryption.

enrolled, iPhone users use the app to submit data on a daily basis by answering survey questions or using the iPhone built-in sensors to measure their symptoms.

For instance, the Parkinsons mPower app uses the iPhone sensors to measure and track patients symptoms from tremor, balance and gait, and also asks participants to provide information before and after they take medications every day. The goals are to cull insights into the variables of Par-kinsons, find better ways to track the progression of the disease and improve the quality of life for those living with the disease.

Another app, the MyHeart Counts app, collects data about physical activity and cardiac risk factors for Stanford scientists studying the prevention and treatment of heart disease.

There are two major elements to the study, said Michael McConnell, MD, professor of cardio-vascular medicine and principal investigator for the MyHeart Counts study, in a press release. One

is collecting data as broadly as possible on physi-cal activity, fitness and cardiovascular risk factors, which provides important feedback to the partici-pants and helpful research data for our study. The second is studying ways to help people enhance activity and fitness, and decrease their chance of heart disease.

Dr. McConnell also said that while there has been an explosion in the marketing of wearable devices to record and report information about behaviors, physical activity or sleep patterns to improve health, there is limited scientific data to show theyre effective. Stanford wants to study which types of behavior-modification methods ac-tually succeed. The scientists hope that the results will ultimately also help physicians.

Preventive medicine hasnt worked by having doctors make to-do lists for their patients, then seeing them every six months later and hoping they did everything on the list, he said.

OCTOBER 2015 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 17

If you are involved in an incident which could result in criminal

charges or malpractice allegations, do NOT wait until you receive

that dreaded letter from your professional licensing board. Make

an appointment for a free confidential consultation with our law

firm. Whether you have received a notice of disciplinary action

from the California Medical Board, Nursing board or any other

licensing board regulating the conduct

of medical professionals, we

are very well experienced in

defending such cases from

their inception when the

initial letter is received to an

adjudication or trial in front

of an administrative law judge.

A SUCCESSFUL DEFENSE IS AN AGGRESSIVE DEFENSE

MyCriminalDefense.com

CALL TODAY FOR A FREE CONFIDENTIAL CONSULTATIONATTORNEY STEPHEN R. BRODSKY, SENIOR PARTNER213-703-1015 | 433 N. CAMDEN AVE., STE. 960 BEVERLY HILLS, CA 90210

1 8 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

1. INVESTMENT ACTIVITY | mHealth (and its cousin Telehealth) represents the most rapidly growing sec-tor in the healthcare industry. Excitement about this growth is reflected in the concurrent growth in inter-est in telehealth technologies in the venture capital market. Telehealth provider group Teladoc held an IPO this year with favorable results. Private equity and venture capital continue to invest in telehealth and digital health innovation, as the number of incubators and accelerators grows.

U.S. employers spend approximately $620 bil-lion annually on healthcare benefits, and investors recognize the role that technology plays in reducing costs. According to Rock Health, a start-up incuba-tor, funding for digital healthcare technology compa-nies exceeded $4.1 billion in 2014 (125% year over year growth) with over 295 deals closed and an aver-age deal size of $14.1 million. The first six months of 2015 already yielded over $2.1 billion in funding, with no signs of slowing down. As telehealth and mHealth use increases within the healthcare industry, it will continue to generate interest within the invest-ment community.

2. CROSS-BORDER LICENSURE | With a virtual health platform, the geographic restrictions of brick and mortar clinical practices begin to lose their meaning. Telehealth providers can seamlessly offer services across state and national borders; but they need to be cognizant of the fact that they are generally subject to the state and/or national laws of the places where their patients are located. Moreover, in the heavily regulated healthcare industry, business models and contractual arrangements that work in one state will not necessarily work in other states. There are spe-cific exceptions and some business strategies and models that have been built on those exceptions, but the majority of direct to patient arrangements, for example, will require the physician to be licensed in the state where the patient is located at the time of the consult.

2015 saw notable efforts to streamline and sim-plify physician licensing across state lines. Perhaps the most important example gaining traction is the Federation of State Medical Boards Physician Li-censure Compact. Under the Compact, participat-ing state medical boards would retain their licensing

The mHealth & Telehealth T O P 1 0 F O R 2 0 1 5

M H E A LT H A N D T E L E H E A LT H continue to be an innovative alternative to traditional brick-and-

mortar medicine. The number of providers offering telehealth services is rapidly increasing, and

states are enacting laws requiring health plans to cover telehealth services and mHealth technol-

ogy at a brisk pace. Listed below are the key issues that providers of telehealth services should

keep in mind as they navigate the changing landscape.

BY NATHANIEL M. LACKTMAN | FOLEY & LARDNER LLP | WWW.HEALTHCARELAWTODAY.COM

mH

EA

LTH

& T

EL

EH

EA

LTH

|

TO

P 1

0 O

F 2

01

5

OCTOBER 2015 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 19 2015 NORCAL Mutual Insurance Company. * Based on 2014 data.

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

GUIDEGUARDADVOCATE

MEDICAL PROFESSIONAL LIABILITY INSURANCE CALIFORNIA PHYSICIANS DESERVE

Your Guide: Awarding more than 35,000 CME certificates in 2014*

Your Guard: Resolving 89%* of claims without indemnity payments

Your Advocate: Largest contributor to the No On 46 coalition

Our heart beats in California ... and has for almost 4 decades. Talk to an Agent/Broker today about NORCAL Mutual. 844.4NORCAL | CA.NORCALMUTUAL.COM

2 0 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

and disciplinary authority, but would agree to share information and processes essential to the licensing and regulation of physicians who practice across state borders. The Compact would function like the Nurse Licensure Compact currently in operation in approxi-mately 24 states. The Physician Licensure Compact has received significant support, and at least 10 states have completed the process necessary to bring it to adoption once it becomes effective.

3. EXPANSION OF TELEHEALTH COMMERCIAL INSUR-ANCE COVERAGE | Nationwide, states have begun to enact laws requiring commercial health plans to cover medical services provided via telehealth to the same extent they cover medical services provided in-person. These laws are intended to promote in-novation and care deliv-ery in the private sector by encouraging health-care providers and plans to invest in and use the powerful telehealth technologies available in the marketplace. Cur-rently, 29 states plus the District of Columbia have enacted commer-cial payment statutes, and similar bills are in development (or pro-cess) in several states.

Many hospitals and healthcare providers already offer telehealth services, and patients have been able to access virtual care as part of these healthcare delivery mod-els. But these laws are expected to drive the commer-cial insurance market to expand telehealth coverage, allowing telehealth to be enjoyed by more patients across the country. Successes in these 29 states will signal the promise of telehealth coverage and pay-ment parity as the remaining 21 states consider their own legislation.

4. NEW PAYMENT APPROACHES | mHealth and tele-health technologies are particularly suited to alter-native payment methodologies because they allow providers to better manage risk. Under a traditional fee-for-service (FFS) payment model, the payor bears almost all of the risk because providers get paid each time they perform a service. A provider has little in-centive to manage the patients health and the associ-

ated costs of care. Indeed, compensating a provider on a FFS basis incentivizes the provider to perform more services for more patients, as that is the only way for the provider to generate more revenue.

Under capitated, shared savings, or hybrid alter-native payment models, the risk associated with over-used and high cost services is borne by the provider, who is responsible for managing the health of his/her/its patient population (hence the trending term population health management). To manage risk, the provider is best served by practicing the new old-fashioned way: increased communication with patients, meaningful information exchange, periodic monitoring, and fostering a strong doctor/provider-patient relationship. Telehealth is a powerful tool

to accomplish this be-cause it reduces barri-ers to accessing care, increases the conve-nience and likelihood a patient will communi-cate with the doctor, of-fers inexpensive remote patient monitoring tools to give the pro-vider a stream of health information, draws on data mining, brings the doctor to the patient, and leverages special-ist physician expertise. The increased patient touches plus mean-ingful health informa-tion exchange allow providers to better as-sess and treat patients

health on a long-term horizon. These are just a few ways telehealth technology allows providers to man-age risk far better than traditional bricks and mortar practices. In that sense, telehealth is the innovation of blending high-tech tools with old-fashioned doctor-patient relationships.

5 CHRONIC CARE MANAGEMENT | Effective January 1, 2015, telehealth-based Chronic Care Management (CCM) is a new service covered by Medicare. It is perfectly suited for telehealth, as CCM may be pro-vided via remote care services. CCM is another way providers can harness telehealth technology to lever-age staffing, improve patient care, increase doctor-patient contact, decrease inpatient length of stay, and ultimately reduce overall patient costs. The CCM bill-ing code (CPT 99490) pays providers on a monthly capitated (per patient per month) basis. Hospitals and

To manage risk,

the provider

is best served

by practicing

the new old-

fashioned way:

increased com-

munication with

patients, mean-

ingful informa-

tion exchange,

periodic monitor-

ing, and fostering

a strong doctor/

provider-patient

relationship.

mH

EA

LTH

& T

EL

EH

EA

LTH

|

TO

P 1

0 O

F 2

01

5

OCTOBER 2015 | 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

physicians using telehealth to develop patient population health and care coordination services are taking a serious look at CCM billing, as are third party companies experienced in chronic care services and now looking to offer contracted CCM services on a telehealth platform.

6. INTERNATIONAL TELEMEDICINE ARRANGEMENTS | U.S. com-panies continue to look abroad for mHealth and telehealth op-portunities, particularly in China. They are exploring both institu-tional arrangements and direct-to-patient service offerings such as Internet-based medical consultations and online second opinions. China is anxious to promote and grow telemedicine, but U.S. com-panies must be sensitive to the differences on how government authorities in China define and regulate these offerings.

The opportunities for growth in telemedicine services in Chinas healthcare system are evident. U.S. businesses undertaking proj-ects or contemplating Internet-based healthcare-sector opportuni-ties in China should take steps to assess the legality and compli-ance issues associated with these projects. Taking steps now to develop proper international arrangements can position providers to best harness these growth opportunities.

7. MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT | Tele-health was one of the beneficiaries of changes introduced by the

so-called doc fix bill, formally titled the Medicare Access and CHIP Reauthorization Act (H.R. 2). The legislation was passed by Congress on April 15, 2015, and signed into law on April 16, 2015. It introduced sweeping changes to the reimbursement methodolo-gies and financing of healthcare in the United States, including a notable shift away from the traditional fee-for-service model, a shift towards Accountable Care Organizations and risk-based payment, and a focus on quality and population health.

In the Act, telehealth and remote patient monitoring are ex-pressly recognized as, and included in the definition of, Clini-cal Practice Improvement Activities along with care coordination, population health management, and monitoring of health condi-tions. Moreover, new Alternative Payment Models may include payment for telehealth services, even if the services are not oth-erwise covered by the traditional Medicare program. The Act re-quires the Government Accountability Office to conduct a study on telehealth and the Medicare program, and a second study on remote patient monitoring and the Medicare program, publishing both reports no later than April 2017.

8. TELEHEALTH APPS AND HIPAA | With the 2014 and 2015 changes in FDAs guidance on mHealth apps and medical devices, many tele-health app developers appear to be focusing their regulatory atten-tion primarily on whether (or not) their app is a medical device. Less attention appears to be focused on the applicability to their

TO

P 1

0 O

F 2

01

5 | m

HE

ALT

H &

TE

LE

HE

ALT

H

AEMCEMBACEMBCC

Contact us today and apply for Fall 2015!Health Care Executive MBA ProgramKdalton@uci.edu 949.824.0561

merage.uci.edu/go/HCEMBA

Lead the change in health care. Be a part of the solution.Advance your career with the Health Care Executive MBA program:

Classes meet one weekend per month for just 21 months

Week-long experiential residential on Federal Policy in Health Care in Washington D.C.

Learn from the same world-renowned faculty who teach in our top-ranked Executive MBA program

Up to 30 CME units may be earned

Partial merit-based scholarships available for qualied candidates

Dr. Michael Miyamoto, HCEMBA 12Cardiologist and CMO, uncleCare

Health Care Executive MBA

2 2 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

mH

EA

LTH

& T

EL

EH

EA

LTH

|

TO

P 1

0 O

F 2

01

5

products of privacy and security rules, which are not limited to the rules promulgated pursuant to the Health Insurance Portability and Accountability Act (HIPAA).

In reality, an app developer frequently is not a Covered Entity subject to HIPAA rules, and in many apps, the developer is not a Business Associate either. The specifics depend on the nature and function of the app itself. But simply because an app collects identi-fiable, health-related data, it does not mean that the app is subject to HIPAA. Similarly, a wearable health app used by a consumer is not necessarily subject to HIPAA, nor is a med-ication-adherence app for patient self-use. But that does not end the story, and ad-dressing privacy and security issues should definitely be on the to do list of any telehealth app devel-opers business plan.

For example, these apps may be subject to Federal Trade Commission oversight and its un-fair acts power. In addition, state law may apply, particu-larly if the developer intends the app to be used in multiple states across the country. Many states have enacted their own state law privacy and security statutes, and they frequently ap-ply to a much broader scope of activities than HIPAA. An app developer can easily be subject to state privacy and security laws, even if it is not a Covered Entity or Business Associate and not subject to HIPAA rules.

9. PHYSICIAN EMPLOYMENT MODELS AND THE UBER-IZATION OF HEALTHCARE SERVICES | Many telehealth companies, particularly those with multi-state foot-prints, have embraced the uber concept of an on-de-mand service economy. Some utilize an independent contractor model to develop one or more networks of physician providers, and thereby ensure that the com-pany has access to the services of licensed physicians in each of the states in which the company plans to of-fer services. An independent contractor model (using 1099 contractors) can help keep overhead costs rela-tively low because contractor status helps the compa-ny avoid taking on some of the financial and reporting obligations of a W-2/employment model enterprise.

An independent contractor model also offers flexibil-ity and scalability when the company wants to begin providing services in new states with initially lower patient encounter volumes.

The June 2015 OIG Fraud Alert on Physician Com-pensation Arrangements served as a reminder that physician contracts must comply with fraud and abuse laws, and that independent contractor arrangements do not enjoy the same flexibility as bona fide employ-ment arrangements under the Employment Safe Har-bor to the Anti-Kickback Statute. But another question

that has begun to arise for companies using an independent contractor, on-de-mand service model is whether regulators will start to claim that those contractors are really employees.

Teladocs S-1 fil-ing issued in con-nection with its IPO describes how the telemedicine compa-ny uses an indepen-dent contractor mod-el with its healthcare providers. Teladoc asserted the arrange-ment is a valid inde-pendent contractor relationship, but not-ed as a risk area that

tax or other regulatory authorities may in the future challenge our characterization of these relationships. Telehealth companies can look to IRS Revenue Ruling 87-41, 1987-1 CB 296, where the IRS enumerates 20 factors used to determine whether a worker is properly characterized as an independent contractor or an em-ployee. These factors provide a general framework for examining both types of relationships. If a regulator or court were to determine that a companys independent contractors were actually employees, the costs to the company would be significant. The company would be required to withhold income taxes, to withhold and pay Social Security, Medicare and similar taxes, and pay unemployment and other related payroll taxes (to say nothing of unpaid past taxes and penalties). Com-panies should take the time to carefully craft their in-dependent contractor agreements under the IRS guid-ance, particularly if they plan to roll out contracts on a widespread basis for an on-demand telehealth model.

10. REMOTE PRESCRIBING | While virtual consults,

An independent

contractor model

also offers flexibil-

ity and scalability

when the compa-

ny wants to begin

providing services

in new states with

initially lower

patient encounter

volumes.

OCTOBER 2015 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 2 3

diagnoses, and treatment recommendations are gaining widespread acceptance, remote prescribing remains an area of concern for state medical boards, and a number of states require an in-person examination of the patient prior to issuing a prescription. When it comes to DEA controlled substances, however, the issue is becoming red hot as 2015 saw one of the first instances of a DEA action against a physician (located in Dallas) for remote prescribing in an otherwise clinically-acceptable telepsy-chiatry arrangement. At the same time, the Fifth Circuit Court of Appeals is examining the Fourth Amendment implications and appropriateness of the DEAs use of ad-ministrative subpoenas of medical records as a means to investigate physicians for criminal prescribing violations, despite never obtaining a search warrant. A DEA victory in that case might allow it to use administrative subpoenas to examine the medical records of telemedicine prescrib-ers to determine whether or not the prescriber complied with the federal Ryan Haight Act.

Federally, remote prescribing of controlled substanc-es is governed by the Ryan Haight Act. The Act and its implementing regulations require a physician to conduct at least one in-person medical evaluation of the patient before prescribing any controlled substances remotely.

Once the prescribing practitioner has conducted an in-person exam, the regulations do not set an expiration pe-riod or a minimum requirement for subsequent annual re-examinations. Several states expressly permit remote prescribing of controlled substances, but the federal Act preempts state law. The Act contains certain exceptions for telemedicine practice, but none of the exceptions (drafted in 2008 before telehealths recent rapid evolution and refinement) cover the direct-to-patient virtual care model widely used in telemedicine, most notably tele-psychiatry, where medical management of mental health is accepted and utilized.

The Act includes a process for a telemedicine special registration that, despite being enacted seven years ago, the DEA has not made available for prescribers. Change may be afoot, as congressional committees have instruct-ed the DEA to open this special registration process and make it available to telehealth prescribers. In spring 2015, the DEA announced it will issue a proposed rule to enable a telemedicine special registration. This is a key devel-opment for telemedicine prescribers to monitor in 2015. Note, though, telemedicine prescribers should continue to also be mindful of prescribing requirements under ap-plicable state laws.

OrganicAcidsWorkshopLos Angeles

December 5, 2015

Clarion Anaheim Hotel

Early Bird Price

Ends: November 8, 2015

$199Regular Price

$259

The Organic Acids Test (OAT) from The Great Plains Laboratory is a diagnostic tool that every healthcare practioner should know about. Whether you are a general practitioner, family practitioner, internist, neurologist, pediatrician, mental health specialist, or nutritionist, the information available from the OAT can be applied to any practice situation.

Register now atwww.ORGANICACIDWORKSHOP.com

TO

P 1

0 O

F 2

01

5 | m

HE

ALT

H &

TE

LE

HE

ALT

H

2 4 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

AS

SO

CIA

TIO

N H

AP

PE

NIN

GS

| L

AC

MA

NE

WS

CEOs LETTER

W I T H A S L A T E O F E L E C T I O N S on the ballot this fall, LACMA is encouraging its members to also take a closer look at some of Californias local healthcare issues running hot this season.

For one, the California Department of Public Health Office of Health Equity recently released its five-year strategic plan to heal health disparities called The Portrait of Promise: The California Statewide Plan to Promote Health and Mental Health Equity. This plan seeks to provide equal opportunities for mental health and well-being.

The plan calls for better data collection and analysis to identify and respond to inequities, strategic communication to build awareness and enlist support to fight against inequities, and through infrastructure development, empower residents and their institutions to act effectively. To learn more about the plan, please visit cdph.ca.gov/programs online.

This month, the California Medical Association (CMA) House of Delegates will hold its annual meeting to debate and act on resolutions and reports dealing with myriad medical practice, public health and CMA governance issues. The event will take place from 8 a.m. to 5 p.m. on Oct. 16-18 at the Disneyland Hotel, 1150 Magic Way in Anaheim.

For physicians who would like to get involved in Physician Health Committees, the three-hour workshop from 9:30 a.m. to 12:30 p.m. on Oct. 31 at the LAC/USC Medical Center, 2051 Marengo St., Los Angeles, is a great way to network and learn from fellow physicians.

Another workshop titled Professionalism Program for Physicians, presented by CMAs Institute of Medical Quality, addresses the legal and ethical issues of practic-ing medicine in California and introduces participants to available resources to ad-dress present and future problems. The program will take place from on Nov. 7 and Nov. 8 at the Hilton Garden Inn, 2100 E. Mariposa Ave., El Segundo. Physicians, den-tists, physician assistants and dental assistants are invited to attend. Register today.

This program encourages interactive learning and is limited to only 12 participants. Finally, if you havent registered for LACMAs biggest event of the year, the Los Angeles

Healthcare Awards, it is not too late. LACMA is once again looking forward to recognizing, through its Patient Care Foundation,

outstanding individuals and institutions for their unwavering commitment to increasing access to quality healthcare in Los Angeles County through leadership, innovation, education and service.

Register today, or if you are unable to attend, please make a donation to the Marshall Morgan Scholarship Fund at lahealthcareawards.org.

We are proud to announce that Richard Baker, MD was selected to receive the 2015 Ethnic Physician Leadership Award sponsored by the CMA Foundation during a luncheon held on Sept. 19 at the Riverside Convention Center.

Stay tuned, as this promises to be an interesting election season and an equally exciting time of opportunities for LACMA physicians.

Regards,

Rocky DelgadilloChief Executive Officer

OCTOBER 2015 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 2 5

Sphinx Medical Technologies, Inc. has created two new products geared towards solving a doctors daily obsta-cles, in addition to increasing practice revenue, improving a physicians quality of life, facilitating patient access to healthcare, increasing patient satisfaction, and decreasing physician overhead and office staff stress and expense: CallMyDoc and ScheduleMyPatient.

CallMyDoc is a smartphone app that provides re-liable and secure technology to replace any doctors answering service. CallMyDoc is designed to provide patients the ability to contact their doctor and and the flex-ibility for the physician to respond from their smartphone. It allows doctors to easily bill by sending automated claim documentation for the call, creates an automated record in the patient chart and can send e-prescriptions to any pharmacy in the United States. The app allows a physician to view patient medications, allergies, labs and history all which appear on the doctors smartphone screen.

The second product - ScheduleMyPatient is a calen-daring system, which allows a patient to make their own appointments. Once a patient uses the system, the ap-pointment is instantly booked and appears on the prac-tice electronic schedule for staff and physician viewing. Patients chose any appointment from a variety of types as authorized by the doctor and any day without the need for staff involve-ment. The patient receives a confirmation email and text message for their upcoming appoint-ment instantly and one day before the appoint-ment time. ScheduleMyPatient can be linked to any websites, emails or reminders. Schedule-MyPatient is designed to work on all electronic devices.

Both CallMyDoc and ScheduleMyPatient are HIPPA Compliant.

USE CASE EXAMPLE: SOLIMAN CARE FAMILY PRACTICE CENTER | Both CallMyDoc and ScheduleMyPa-tient are in full use at Soliman Care Family Practice Center - a very busy, family practice in Torrance, California. A few days after installing the CallMyDoc app, Dr. Soliman was attend-ing a concert. Midway through the event her smartphone vibrated and she saw it was a call from a patient. Although she could have lis-tened to the voicemail message, the app also transcribed the message. The patient was hav-ing a medical event. Instantly, Dr. Soliman was able to review the patient message, return a message to the patient, review the last progress note, check patient allergies and write two e-prescriptions, which were immediately sent to the patients pharmacy. The patient was also automatically notified that the prescriptions were sent. The situation was fully resolved in a

few moments and without the need to leave her seat! But, if the patient needed an emergency room, Dr. Soliman could just as easily contacted the ER and sent instructions and orders from the same smartphone using CallMyDoc again, without leaving the arena.

With ScheduleMyPatient, Dr. Solimans patients only enter their date of birth and the first three letters of their name. ScheduleMyPatient then permits the patient to schedule an appointment in few seconds for the next available or future date. In addition, because of its design simplicity of the scheduler software, all patients from the ages of 20 to 80 are booking their own appointments. Each month at her practice sees more and more patients using the scheduler to make new appointments. To date, not one complaint has been received from either patients or office staff

Since installing ScheduleMyPatient, Dr. Soliman is now booking an extra five to eight patients a day, seven days a week. This includes increasing patient appointments for her physician assistants, which adds more revenue to the overall practice.

SPONSORED CONTENT

SPHINX MEDICAL TECHNOLOGIES

PLEASE JOIN US FOR OUR 7th ANNUAL COPD CONFERENCE.

www.breathela.org

2015

54

AMA PRA Category 1 Credits and 2.25 prescribed credits by the American Academy of Family Physicians.

Time: 8am to 12:30pmLocation: The Mark

9320 W. Pico Blvd. Los Angeles, CA 90035

Theme: Advancing the diagnosis and management of COPD with a

focus on COPD exacerbations.

REGISTRATIONDETAILS ONLINE:

http://tinyurl.com/blacopd

2 6 P H YS I C I A N M AG A Z I N E | OCTOBER 2015

JOB

BO

AR

D |

CL

AS

SIF

IED

S

TO PLACE A CLASSIFIED AD VISIT WWW.PHYSICIANSNEWSNETWORK.COM OR CONTACT DARI PEBDANI AT DPEBDANI@GMAIL.COM OR 858-231-1231.

LOCUM TENENS AVAILABLE

FAMILY MEDICAL AND INTERNAL MEDICINE IN VISTA AND RIVERSIDE

Located in Vista, California, Vista Community Clinic is a private, nonprofit outpatient community clinic located in North San Diego County serving people who expe-rience social, cultural or economic barriers to health care in a com-prehensive, high quality setting.

POSITION: Full-time, Part-time and Per Diem Family Medicine Physicians and Internal Medicine Physicians.

RESPONSIBILITIES: Provides outpatient care to clinic patients and ensures quality assurance. Malpractice coverage is provided by Clinic.

REQUIREMENTS: California li-cense, DEA license, CPR certifica-tion and board certified in fam-ily medicine. Bilingual English/Spanish preferred.

CONTACT US: Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacom-munityclinic.org or fax resume to 760 414 3702.EEO/AA/M/F/Vet/ Disabled

RADIOLOGISTBoard certified. Have own malpractice insurance. Available for part-time posi-tion or film reading. Call 310-477-4257.

OPPORTUNITY WANTED

OFFICE SPACE - LEASE/SHARE

CONSULTING & SERVICES

Practice Appraisal & SalesPartnership Buy-In / Buy OutSupporting Southern California

Physicians Since 1983Call for a Courtesy Consultation

818-693-7055

Shorr Healthcare Consulting

Consultants to Healthcare Providers

avishorr@gmail.com

OPENINGSPHYSICIANS

PhysiciansNewsNetwork.com

ONLINE. IN PRINT. ONE PRICE.

REACH THOUSANDS OF SOUTHERN CALIFORNIA PHYSICIANS

Place Your Ad Today!

OFFICE SPACE CULVER CITYMedical space available for optometrist and physical therapy. Excellent Loca-tion, Well Maintained, Free Patient Parking, Labcorp located within Facility, Easy access to 405. CONTACT : ALLAN MORRISON,MD OR RITA KUMAR, MD (310) 559-4411

TRACY ZWEIG ASSOCIATES, INC.

Physicians Nurse Practitioners Physician Assistants

LOCUM TENENSPERMANENT PLACEMENT

800-919-9141 805-641-9141FAX: 805-641-9143

email: tzweig@tracyzweig.comwww.tracyzweig.com

MEDICAL OFFICE CLOSING Numerous like-new, little used exam tables with stirrups and electricity. Ophthalmoscopes, otoscopes, blood pressure cuffs on rolling stands. Metal filing shelving. Desks. Chairs and more. Call: 310-383-7373

MEDICAL OFFICE FOR LEASE SURGERY CENTER ON PREMISES9884 South Santa Monica Blvd, Beverly Hills, CA, 90212 (310) 276-5856

MEDICAL EQUIPMENT FOR SALE

OCTOBER 2015 | W W W. P H YS I C I A N S N E W S N E T WO R K .COM 2 7

CL

AS

SIF

IED

S | JO

B B

OA

RD

ADVERTISER INDEX

Breathe LA ........................................................................................................................25

Cooperative of American Physicians ....................................................................................5

The Doctors Company ..................................................................................................... C4

Fenton Law Group ..............................................................................................................9

Great Plains Laboratory .....................................................................................................23

Mercer ................................................................................................................................3

MyCriminalDefense.com ..................................................................................................17

NORCAL ...........................................................................................................................19

Office Ally ....................................................................................................................... C3

Sphinx Medical Technologies ..............................................................................................7

UC Irvine ..........................................................................................................................21

Wells Fargo ...................................................................................................................... C2

TO PLACE A CLASSIFIED AD VISIT WWW.PHYSICIANSNEWSNETWORK.COM OR CONTACT DARI PEBDANI AT DPEBDANI@GMAIL.COM OR 858-231-1231.

PM Marketplace

Full or part-time positions

Competitive Pay Add revenue to your

current practice

Flexible schedule, complete autonomy

No Call

Surgeons Needed for Expanding Nationwide Surgical Practice

PLEASE CONTACT US FOR MORE INFORMATION:Phone: 1-877-878-3289 Fax: 1-877-817-3227

or email CV to: Jobs@AdvantageWoundCare.org www.AdvantageWoundCare.org

TRACY ZWEIG ASSOCIATES, INC.

Physicians Nurse Practitioners Physician Assistants

LOCUM TENENSPERMANENT PLACEMENT

800-919-9141 805-641-9141FAX: 805-641-9143

email: tzweig@tracyzweig.comwww.tracyzweig.com

WE WOULD LIKE TO THANK OUR SPONSORS AND ADVERTISERS AND ENCOURAGE OUR VALUED READERS TO SUPPORT THEIR BUSINESSES

Los Angeles County Medical Association Alliance

Were the Home for Los Angeles Countys Physicians, Medical Students and Spouses/Partners...

The Family of Medicine in our Great Los Angeles County

www.lacmaalliance.com

Physician Family Activities

Join Us for This and More!

Community Health Projects

Support for our Future Physicians

Social Activities

www.facebook.com/lacmaalliance

As the nations largest physician-owned

medical malpractice insurer, we have an

unparalleled understanding of liability

claims against plastic surgeons. This

gives us a significant advantage in the

courtroom. It also accounts for our

ability to anticipate emerging trends and

provide innovative patient safety tools

to help physicians reduce risk. When

your reputation and livelihood are on

the line, only one medical malp