texas family physician, fall 2015

TEXAS FAMILY PHYSICIANVOL. 66 NO. 4 2015

Presorted StandardU.S. Postage

PAID Austin, TXPermit No. 1450

HELLOOPERATOR

With Growing Patient Demand And Booming Venture Capital

Investment, Telehealth Is The Next Big Thing

PLUS:Are You Sure You’re Billing Properly For Services Your NPs And PAs Provide?

10 Top Apps To Boost Your Efficiency And Help Your Patients

Hard Knocks: Sports-Related Concussion In The Young Athlete

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4 TEXAS FAMILY PHYSICIAN FALL 2015

INSI

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16 Telemedicine: A disruptive revolutionPatients value access and convenience above all else and telemedicine might be the best way they can get it.

By Jonathan Nelson

19 Got any questions about telehealth rules?Check out this set of FAQs from the Texas Medical Board.

20 Value-based telemedicineAll parties involved—patients, providers, and payers—must be

aligned correctly to make high-quality telemedicine a possibility. By Blake McKinney, MD

22 The mHealth perspectiveMobile tech plus primary care is the recipe for delivering high-

quality population health. By W.C. Thornbury, MD

24 Top 10 apps for daily practiceUse your smartphone to help your patients and boost your

efficiency with these recommendations from an Ohio FP. By Evan Howe, MD, MPH, PhD

8 FROM YOUR PRESIDENT It’s time for family physicians to step up to the plate.

10 AAFP NEWSMedicaid waivers fund advanced primary care at Texas med school

12 NEWS ALERT Are you correctly billing for services provided by NPs and PAs? Sources say insurance audits are on the rise.

13 MEMBER NEWSTAFP introduces new Family Medicine Leadership Experience | Resident member wins AAFP award | Lubbock member appointed to TMA Foundation Board

27 PUBLIC HEALTHSports-related concussion in the young athlete: Who plays? Who sits?

30 TAFP PERSPECTIVEThe joy of being a preceptor in the Texas Statewide Preceptor-ship Program

CONTROL

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LETTERS


The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or [email protected].

OFFICERS

president Dale Ragle, MD

president-elect Ajay Gupta, MD

vice president Janet Hurley, MD

treasurer Tricia Elliott, MD

immediate past president Clare Hawkins, MD, MSc

EDITORIAL STAFF

managing editor Jonathan L. Nelson

associate editor Samantha White

chief executive officer and executive vice president Tom Banning

chief operating officer Kathy McCarthy, CAE

advertising sales associate Michael Conwell

CONTRIBUTING EDITORS

Adrian N. Billings, MD, PhD, FAAFPWalter L. Calmbach, MD, MPH

Evan Howe, MD, MPH, PhDMark Hutchens, MD

Michael LaffBlake McKinney, MDW.C. Thornbury, MD

SUBSCRIPTIONSTo subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technol-ogy Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year.

Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not neces-sarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and adver-tising deemed inappropriate. Publica tion of an adver-tisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas.

LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727.

© 2015 Texas Academy of Family Physicians

POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.

i read with interest the commentary of Dr. Vincent Mandola in the summer 2015 issue of TEXAS FAMILY PHYSICIAN (First do no harm? A reflection on pain and inter-vention at the end of life. No. 66, Vol. 3). His experience is diametrically opposite mine, both in my own clinical practice experience and in my personal family experience.

Firstly, I began clinical practice in Texas in the mid-1980s. In the early 1990s I took care of an occasional terminally ill patient of mine in the home before hospice was a widely known word and we were able to set up IV morphine even back then for control-ling pain. We were able to set up patient-controlled dosing at the time also.

It is certainly possible that Texas regu-lations have changed in the decade since I left clinical practice, but I am shocked to read that a hospice physician in the case of a terminally ill patient would be wanting to reduce medication in order to investigate symptoms. For what possible reason? People choose hospice because they want no more intervention other than to be kept comfort-able. Quality of remaining life is paramount. Dr. Mandola’s experience is certainly not consistent with my clinical experience. In fact, the first patient for whom I cared in the home by seat-of-the-pants hospice was one of my clinical patients during my residency in South Carolina. IV morphine was also available then; the patient was kept com-fortable for the month he lived before lung cancer won the war.

More recently, my mother was terminal secondary to metastatic breast cancer. She lived in Florida so we were involved with Marion County hospice. I had the privi-lege of spending the last five to six weeks of mom’s life with her, helping my sisters to care for her and being there to witness hos-pice care firsthand as a family member who happened to have medical training rather than as the physician.

Mom was kept comfortable at all times; she was never denied medication that was needed, whether for pain or anything else, and the hospice people were marvelous in keeping us informed at every step. In fact, hospice was more aggressive with treatment

recommendations than I originally thought necessary, but keeping my eyes and ears open and mouth shut soon showed me they knew what they were doing, and did it well. Medications that were ordered were deliv-ered to the house that same afternoon. Visits always focused on comfort of bodily func-tions and pain. Mom died peacefully, and as far as we could tell, pain free.

Subsequently, in the past few months, I was introduced to the book “Being Mortal.” It lead me to read “The Miracle of Hospice” and “Living at the End of Life.” I wish I had known of and had read these books prior to or while taking care of mom. Many of our questions and concerns during the process would have become neither had I been aware of the information contained in the books. I believe they should be required reading of every family medicine resident. “The Miracle of Hospice” could have been written about the process of caring for my mother, it was that consistent with our experience.

One has to wonder just what kind of hos-pice operation was taking care of Dr. Man-dola’s mother. It is so foreign to my experi-ence, both as a practicing physician and as the son of a dying mother cared for by hos-pice, that one wonders if it were truly hos-pice. I truly feel for Dr. Mandola and hope that his experience will help him immeasur-ably as he begins his professional career. I hope, as a retired Texas senior citizen, that this is not the standard for what Texas medi-cine calls hospice and palliative care. Quality of life is, or at least should be, the premier goal of hospice. Period.

Respectfully,

John Fieler, MD, FAAFP Conroe, Texas

Hospice care and family medicine

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PRESIDENT’S COLUMN

this will be my final letter to you as TAFP president. It has been an honor and privilege to serve you and our outstanding organization.

This is an exciting and challenging time for family medicine. Health care reform and the sustainable growth rate repeal are expanding the rolls of the insured and will transition us from a volume-based payment system to a quality-based system over the next several years. Some analysts are con-cerned that increasing the number of insured may strain our health care system in the absence of increasing the physician work-force. While increasing the insurance rolls will generally increase access to care in the younger population, the resultant strain on our health care system could make it more difficult for certain vulnerable populations, such as elderly patients already on Medicare, to access the health system. This effect could be magnified in our state, which has about a 20 percent uninsured rate, unfortunately the highest in the nation.

However, I believe that fragmentation of our health care system contributes to access problems as much as the possibility of not having enough physicians. Fragmentation involves patients seeing multiple physicians and using multiple imaging centers, labs, and hospitals. Not all patients with congestive heart failure need to see a cardiologist; not all patients with COPD need to see a pulmon-ologist. Not all patients with both conditions need to see both specialists. Specialization and subspecialization has led much of our popu-lation to believe “the more specialized, the better.” I’m sure most of us have been asked about a referral to a dermatologist for grade I or II acne. As family physicians we need to be diligent in educating our patients about the breadth and depth of our specialty. This should be done not in a spirit of limiting per-sonal choice, but to show them the benefits of one physician caring for the whole person.

We must remind our patients with mul-tiple comorbidities that they can often be cared for by one competent and well-trained family physician as well as or better than by multiple specialists. We are certainly a more cost-effective option. To do this it is impor-tant that we all practice to the full extent of

our training. This will become important as we move from a payment system based on volume and procedures to one that rewards quality disease management and population health. There are probably not enough family physicians in Texas to provide this level of care to everyone if all of our state’s uninsured were to suddenly gain coverage. However, I believe that increasing our ranks with just a few more well-trained family physicians who practice to the full extent of their training would go far in relieving the physician shortage.

Because of our reputation of putting the patient first, we are well-respected among most policymakers and payers. As a patient-centered and community-centered specialty, family medicine is in a unique position to step up to the plate and help shepherd our health care system through these changes. The thought of this energizes and excites me. However, for us to be a part of the solution in this way, there must be more of us. We must advocate for more family medicine training to policymak-ers and create a bigger pipeline of family physi-cians. If there are not enough of us to meet the needs in the future, patients and access to care will suffer. I encourage each of you to develop a relationship with your state representative, state senator, and congressional representa-tive. Communicate to them the value of family medicine, our patient-centered approach, and remind them of the need to increase our ranks in the future to fulfill the health care needs of our state and nation.

For those of you who are less active in our organization, I encourage you to become more involved. Attend your local chapter meetings. I would also encourage you to attend the annual and interim state meet-ings. Almost all committees and commis-sions are open for attendance. If you would like to join a committee or commission, contact TAFP headquarters and our staff can help you gain appointment.

Family medicine is at a crossroads. We must continue to distinguish ourselves with a sustained focus on the welfare of our patients, providing quality evidence-based care, and positioning ourselves to be a part of the solution. If we do this, we have a bright future ahead.

Time to step up to the plateBy Dale Ragle, MDTAFP President

C. Frank Webber Lectureship & Interim SessionApril 15-16, 2016Omni Austin Hotel at Southpark Austin, Texas

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Annual Session and Primary Care SummitNov. 4-6, 2016Nov. 2-3: Business meetings and preconference workshops

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About New Products, Changes & Sales • Donations to TAFP With Every Purchase!

Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV.

Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management.

The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine.

Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered.

Contact Cindy Berenson or Jeff Winokur at (800) 741-2044

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one medical school in texas was able to fund advanced primary care initiatives and increase the number of family medicine res-idency positions without waiting for policy changes in Congress or the state legislature.

Instead of relying on increased federal funding for graduate medical education, which has been capped since 1997, or state expansion of Medicaid, which Texas rejected, the University of Texas Health Science Center at San Antonio is using Medicaid waivers to fund both endeavors.

Part of the Social Security Act, the 1115 Medicaid waiver program supports innova-tive approaches to expanding access to care for low-income patients. It can be used to expand Medicaid eligibility for individuals, as well as to fund services that Medicaid typically does not cover and new service delivery systems that improve care, increase efficiency, and reduce costs. UTHSCSA obtained three waivers to hire health care professionals for population health and increase the number of family medicine resi-dents from 13 to 15 annually, a change that is expected to be approved by summer 2016.

The health center used one waiver to hire two nurse care managers—one dedicated entirely to patients with diabetes—as well as three medical assistants for population health management and a health coach. Another waiver helped the health center hire additional faculty and pay the salaries of residents in the family medicine program. A third waiver covers the recruitment of 13 community health workers who will address residency clinic patient needs such as home visits, community resources, medication, transportation, and language services.

“When you are transforming the residency program, it is about more than just increas-ing the number of residents,” said Carlos Jaén, MD, PhD, professor and chair of family and community medicine at UTHSCSA.

“You are getting more resources to practice community health or hiring RN care man-agers who monitor ER visits and hospital discharges to optimize transitions of care.”

Funding from the waivers will last five years, gradually rising from $1 million

to $1.7 million, and Jaén hopes that with additional funding from local partners, the health center can extend the initiatives to seven years.

Jaén said the waivers enable the medi-cal school to accelerate its transition to a comprehensive care model. The next step is persuading insurers to increase payment for greater coordination.

“Now that we have something in place, we can have a discussion with payers to demonstrate that we need to find ways to get paid differently,” he said. “When you are making the transition, it’s difficult to have a dialogue with insurers if you don’t have anything to show for it.”

Finding financial support for family resi-dencies is vital given the cap on graduate medical education imposed by the 1997 Bal-anced Budget Act and the limited expansion of family residency slots at university health centers. Although the overall number of first-year residencies in Texas increased steadily between 2000 and 2012, the number of family residencies during that time declined from 247 to 211. Since 2002, three family medicine residency programs have closed in the state, according to TAFP.

Elsewhere in Texas, UTHSCSA is using another waiver to fund a new family medicine residency at Doctors Hospital at Renaissance in Edinburg—an area with a high concentration of low-income residents

—and to help restructure one that was in jeopardy at McAllen Medical Center.

“A few years ago, the trend was that we were closing family medicine programs,” Jaén said. “We’re moving in the opposite direction now, which is exciting to see.”

Jaén said the tide is turning in efforts to recruit medical students into family medi-cine residencies.

“We live in an academic health center that is still focused on specialist care,” he said. “We’re starting to see hopeful signs, particularly among older medical students who are learning to appreciate the totality of experience of whole-person care.”

Source: AAFP News, Aug. 24, 2015. © American Academy of Family Physicians.

Medicaid waivers fund advanced primary care at Texas medical school

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if you employ nurse practitioners or physician assistants, you should make sure you’re complying with each payer’s protocols when billing for services provided by nonphysicians. TAFP has recently heard from members who thought they were billing properly but have found themselves under investigation by payers. If these practices are found to be out of compliance, they may owe payers substantial refunds.

Many payers pay reduced fees for services provided by NPs and PAs but the rules and billing procedures doctors should follow when filing claims differ from payer to payer. For instance, Blue Cross Blue Shield of Texas pays 15 percent less for services provided by NPs or PAs than they would for services provided by the supervising physi-cian. The insurer requires that practices include a “Modifier SA” when filing claims to indicate that a service was performed by an NP or a PA.

Other payers do not require the modifier and instead require other forms of notification. If a practice has not been following those protocols and has been receiving full payment for services as though they were provided by a physician, the practice could be required to refund the insurer for the overpayment.

“There are so many different complexities to this that it has every single primary care doctor confused,” says Bradley Reiner of Reiner Consulting and Associates, TAFP’s practice management consultant. He believes many physicians may not be aware of these requirements and may be at risk if audited. “It is absolutely critical that any physician who is considering hiring a PA or NP or who has an existing physician extender review their contracts with insurers and the provider policy and procedure manuals for each of their payers to make sure they know how these services are supposed to be billed.”

Here is a list of billing procedures insurers might require when filing claims for services provided by NPs and PAs, but we are fairly certain this is not a complete list. Physicians should check their

NEWS ALERT

contracts and the provider policy and procedures manuals for each of their payers to make sure they are following the correct protocols.

• Some payers require practices to bill under the physician’s name using the modifier SA for services provided by NPs or PAs.

• For Medicaid, The Texas Medicaid and Healthcare Partnership requires practices to use modifier U7 for services provided by PAs, and to use modifier SA for services provided by NPs. The Texas Medicaid Providers Procedure Manual also allows NPs and PAs to be credentialed, and Reiner suggests physicians check with their Medicaid managed care plans to make sure they are following the proper procedures.

• Some payers will credential NPs or PAs. They may require practices to bill under Unique Physician Identification Number or the National Provider Identifier of the NP or PA who provided the service.

• Payers may require practices to bill under the physician’s name but include on the claim the UPIN or NPI of the NP or PA who provided the service.

• Some payers follow Medicare’s “incident to” guidelines, whereby if an NP or PA provides a service to a physician’s established patient while that supervising physician is on the premises, the physician may bill for the service as though he or she personally provided it.

• Some payers may not pay at a different rate for services provided by an NP or PA, so the practice can bill under the physician’s name as though he or she personally provided the service.

Reiner says these protocols are not new and have likely been on the books for each insurer for some time. “I think this is coming up now because there are more and more primary care physicians hiring physician extenders and with that comes understanding how to bill for those services properly. A lot of physician don’t understand that and so we’re beginning to see payers looking at this a little more care-fully because, hey, it’s an opportunity to get a little money back.”

Doctors report insurers are auditing billing procedures for services provided by NPs, PAsPhysicians should examine insurer contracts, provider policy and procedure manuals to ensure compliance

By Jonathan Nelson

www.tafp.org 13

FMLE 2016 Schedule at a GlanceDates for June, August, and November will be announced soon, but they will most likely take place on weekends.

April 15, 2016 | Team Leadership and Interpersonal Skills

The inaugural group session will be held along with TAFP’s C. Frank Webber Lectureship and Interim Session. Participants will discuss the importance of personality types in teams, how to lead change, negotiation, and motivational skills. They will embark upon a yearlong project, the result of which will be presented at the program’s conclusion.

June 2016 | Advocacy & Influence

Participants will gather in Austin to learn about leadership in advocacy.

• Understanding policy issues, state and national, that affect health care and family medicine.

• Role playing scenarios: How to have successful meetings with legislators and how to give per-suasive testimony to a legislative committee.

August 2016 | Communications and Organizational Leadership

After spending the day training in Austin, the group will join TAFP’s Board of Directors for dinner.

• Public speaking and media training.

• Running a meeting, governance, and organized medicine.

• Presentation skills.

November 2016 | Sharing Your Knowledge and Graduation

The group will graduate from the program at TAFP’s Annual Session and Primary Care Summit in Dallas. Participants will be asked to present their projects during the FMLE final session.

PROGRAM GUIDELINES

• Applicants must be active

TAFP members and should be

new physicians, mid-career

physicians, or residents.

• A maximum of 30 members

will be selected to participate

in the program.

PROGRAM STRUCTURE

Over the course of one year,

participants in the Family Medi-

cine Leadership Experience will

attend four in-person sessions

lasting one to two days and

presented in a variety of formats

including didactic lectures, small

group discussions, and interac-

tive learning exercises.

Participants must attend all four

sessions to graduate from the

program, but the curriculum will

repeat annually, so a participant

could pause and resume the

program if he or she were to

have difficulty making all four

events in one year.

FEES AND EXPENSES

There is no tuition fee, but

scholars are required to pay

their travel expenses and some

housing expenses. TAFP provides

meals and program materials

during training.

APPLICATION AND SELECTION

Download the application at

www.tafp.org/membership/FMLE or request an application

by email: [email protected].

The application asks for a brief

description of your leadership

and management experience as

well as a statement describing

why you would like to pursue

advanced leadership training.

The TAFP Leadership Develop-

ment Committee will review all

applications to compose the

FMLE class of 2016.

Applicants will receive notifica-

tion no later than Jan. 15, 2016.

SUBMIT YOUR APPLICATION BY DEC. 15, 2015.

Email: [email protected]

Fax: (512) 329-8237

Mail: TAFP, 12012 Technology

Blvd. Ste. 200, Austin, TX 78727

STILL HAVE QUESTIONS?

Contact Kathy McCarthy

at [email protected] or

(512) 329-8666 ext. 114.

Introducing the Texas Academy of Family Physicians’

Family Medicine Leadership Experience

In today’s rapidly changing environment, health care enterprises need leaders who can anticipate what’s coming next, make solid decisions in the face of ambiguity, and deploy their talent effectively. At TAFP, we believe these leaders should be well-trained family physicians capable of articulating a compelling vision for the future and of winning the trust and support needed to carry out this vision.

Welcome to the Family Medicine Leadership Experience, TAFP’s yearlong leadership development program designed to equip family doctors with the skills they need to lead their physician groups, health care systems, aca-demic institutions, community organizations, and professional societies.

Through interactive learning sessions, didactic lectures, case presenta-tions, multimedia presentations, and small-group breakouts, the Family Medicine Leadership Experience will provide expert training in:

✗ strategic planning ✗ public speaking ✗ persuasive communication

✗ negotiation and conflict resolution ✗ winning media engagements

Are you ready to gain the skills you need to take the next step in your career? Join the Family Medicine Leadership Experience.

Applications are due by Dec. 15, 2015.


SEEKING RURAL PRIMARY CARE PHYSICIAN

Lavaca Medical Center in Hallettsville, Texas, is seeking a physician for its rural health clinic. Applicants should be experienced in either

family practice or internal medicine, either MD or DO, experienced or recent graduates, and must be licensed to practice in Texas. The clinic is located at 1400 North Texana, Hallettsville, Texas 77964. Interested

providers should call (361) 798-3671 ext. 1207 or visit www.lavacamedcen.com.

adv e r t i s ement

SEEKING PRIMARY CARE PHYSICIANSJoin the Coastal Health & Wellness Healthcare Team! Excellent

federally-qualified primary care clinics on the coast in Galveston County seeking PRIMARY CARE PHYSICIANS to join our clinician team serving residents of all ages. Family practice training and certification preferred. Excellent work hours and benefits. SALARY NEGOTIABLE!

Applications and additional information may be found at http://www.gchd.org/hr/job.htm or by contacting

HR at [email protected] or (409) 938-2260.

adv e r t i s ement

Resident member wins AAFP award

tafp resident member Nish Shah, MD, received the 2015 AAFP Award for Excellence

in Graduate Medical Education for his hard work as a resident and commitment to the specialty of family medicine.

“My involvement with TAFP has been such a gratifying experience,” Shah says, “and has absolutely enriched my residency

by allowing me to reflect on the political and social advocacy aspect of family medicine, and I cannot wait to further my experi-ences with TAFP in the years to come. I urge all residents who want the opportunity to get involved with TAFP to do so.”

Shah is currently the chair of TAFP’s Section on Resident Physicians and has previously served as a delegate representing TAFP at AAFP’s National Congress of Family Medicine Residents. He is a third-year

resident at the Houston Methodist San Jacinto Family Medicine Residency program in Baytown and received his medical degree from Baylor College of Medicine in Houston.

Lubbock member appointed to TMA Foundation Board

tafp member Eldon Stevens Robinson, MD, was recently appointed to the Finance Committee for the Texas Medical Associ-ation Foundation Board of Trustees, which oversees the Foundation’s investments and assists the executive director regarding gifts. Robinson will serve on the Board for a three-year term. He has a BBA in marketing, and said that he is excited to add his expertise in the subject to an “already excellent board.”

Robinson received his medical degree from the Texas Tech University Health Sciences Center School of Medicine and currently practices in Lubbock. He is also an active member of the Lubbock-Crosby-Garza County Medical Society and currently chairs TMA’s Committee on Rural Health.

Nish Shah, MD

MEMBER NEWS

Supported in part by a grant from the American Academy of Family Physicians Foundation.

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today’s patients prize access to care above all else. They want their care when and where they choose, and the more of that care they pay for out of their own pockets, the more demanding they become.

In a recent webinar on trends and projections for health care delivery, athenahealth executive vice president and COO Ed Park said consumerism among patients is driving disruption in how, when, and from whom patients seek care.

“If you ask patients what they care about in this day and age where everything is moving at hyper velocity, patients care most about access and convenience, even more so than service and affordability. Those certainly come into play but access is the domi-nant factor that explains why a patient will go to a certain location, particularly for primary care services.”

In an Advisory Board study published last year on the rise of consumerism in health care, patients consistently rated access and convenience higher than quality, affordability, and other attributes when deciding on a primary care physician. Of the practice characteristics respondents reported they cared most about, six out of 10 were tied to access. What statement received the most votes? “I can walk in without an appointment and I’m guaranteed to be seen within 30 minutes.”

That is the defining characteristic of a retail health clinic. Is it any wonder the numbers of retail clinics, urgent care centers, and free-standing emergency centers are booming? Well-funded venture capital and investment firms are pouring money into these delivery models, but Park thinks this is just the beginning.

“What we see is that retail urgent care is just the first salvo. The next salvo coming along is telehealth, which is coming of age.”

TELEMEDICINE:The evolution of consumer-driven care

By Jonathan Nelson

www.tafp.org 17


The new generation of telehealth platforms is rapidly increasing in sophistication, with many offering instant high-definition video consultation. Companies like Doctor on Demand, American Well, meVisit, CirrusMD, and Teledoc—which went public this past summer—are

rolling out marketing campaigns and negotiating partnerships fueled by significant private and venture capital investment. According to Ken Research, the telehealth market generated $9.6 billion in rev-enue in 2013, up 60 percent from the previous year, and the market is expected to generate annual revenue of $38.5 billion by 2018.

As patients get more comfortable receiving acute care services through telehealth interactions, the complexity of those visits is certain to increase. Couple these advancements with a burgeoning market for inte-grated personal health apps for smartphones and tablets like EKG moni-tors, blood pressure tracking, and more, and it’s a short hop to imagine the use of telemedicine to manage conditions like chronic diabetes.

“To see CVS partner with American Well, Doctor on Demand, and Teledoc tells you something,” Park said. “This is a market reaction, a capitalist reaction to real demand. … Developing an intentional strat-egy for how to meet these patients as consumers—patients as shop-pers—where they are will be crucial.”

TAFP CEO Tom Banning agrees. How family physicians in Texas can incorporate telemedicine and compete in a consumer-driven market is top of mind for the Academy. “There are tremendous dis-ruptive, competitive forces coming to the fore that doctors are going to have to deal with,” he says. “Physicians have an opportunity right now to start looking at this technology, how to implement it, put it into their office, how to engage their patients in using it before some very well-heeled entities come in and compete against those doctors.”

If implemented and utilized correctly, telemedicine could be a powerful tool to help physicians improve the quality of care they give patients while increasing their efficiency. Many patient visits in the exam room could be handled remotely via telehealth or mobile tech-nology, saving resources and time for the patient and the doctor.

“Think about the inefficiencies and the cost of having a patient with a chronic problem who has to come into the office repeatedly for treatment, and what if that patient is fragile? Coming to a doctor’s office is not always easy,” Banning says.

As the health care industry moves away from fee-for-service toward value-based payment, telemedicine holds big potential for expanding access to after-hours care and keeping patients out of high-cost set-tings, which can be a huge help in achieving shared savings goals and other efficiency measures.

On the other hand, the speed of telemedicine’s growth and adop-tion constitutes a threat to physicians’ status quo. “When you look at where retail health is moving and the commoditization of health care services, there is a lot of interest from hospital systems, from private companies to move into the primary care sphere and essentially carve up services that I would argue should be maintained by the patient’s primary care doctor.”

Banning predicts as patients use more telemedicine and realize the benefit of not having to leave their home or office to go to a doc-tor’s office or even a retail health clinic, telehealth could render retail health obsolete. “How physicians get ahead of this trend is going to be critical going forward.”

TAFP is committed to helping family physicians realize the oppor-tunities telemedicine offers. First, the Academy is working with health plans to ensure that physicians who want to provide telehealth ser-vices are compensated appropriately for doing so.

“There is no less cognitive skill used whether the patient is in your office or you’re treating them over a mobile or telehealth device,” Ban-ning says. “The liability still exists.”

Secondly, TAFP will continue to ensure that patient safety is first and foremost, whether care is delivered in person in a clinic setting or via the use of telehealth technology. “Patient safety must be the cornerstone,” Banning says. Within that boundary, the Academy will work with the Texas Medical Board and other regulatory agencies to make sure physicians have the flexibility to determine what each patient needs, whether he or she can be treated using telehealth or whether the patient should come into the office.

“I think the real challenge is that the technology is growing at such a rapid rate that the regulations, the laws, and the reimbursement are having trouble keeping pace. But as of now the medical board has written very thoughtful rules that emphasize patient care and the importance of continuity.”

Lastly, TAFP will monitor the telehealth market and seek to evalu-ate vendors and technologies to help family physicians make confi-dent decisions when implementing telehealth products and services.

For years the concept of telemedicine was stuck in a mire of regu-lation and technical impracticality, relegated to the list of potential solutions for delivering care to poor folks in far flung rural areas. With the rise of consumerism in health care, those days are over. Patients want instant access and they’re willing to pay for it. For them, tele-medicine offers the greatest convenience. Physicians will have to find ways to embrace this disruptive technology to engage their patients in a new virtual paradigm.

“To see CVS partner with American Well, Doctor on Demand, and Teledoc tells you something. This is a market reaction, a capitalist reaction to real demand. … Developing an intentional strategy for how to meet these patients as consumers—patients as shoppers—where they are will be crucial.”

— Ed Park, COO of athenahealth

www.tafp.org 19

■ What is telemedicine?

In Texas, telemedicine involves a health care

provider’s medical care delivered to patients

physically located at sites other than where the

provider is located, with the use of technology

that allows the provider to communicate with

and see and hear the patients in real time.

■ Who may treat a patient in Texas using telemedicine?

A physician, physician assistant, or advanced

practice nurse who is supervised by and has

delegated authority from a physician may

treat a patient using telemedicine. Such a

provider is referred to under the rules as a

distant site provider. All distant site providers

must be licensed to practice in Texas.

■ What requirements must be met in order for a distant site provider to provide medical care via telemedicine?

To provide medical care via telemedicine, a

distant site provider must in all cases establish

a physician-patient relationship, which at a

minimum includes:

• establishing that the person requesting the

treatment is in fact who the person claims

to be;

• establishing a diagnosis through the use

of acceptable medical practices, including

documenting and performing patient his-

tory, mental status examination, appropri-

ate diagnostic and laboratory testing, and

for medical care other than mental health

services, a physical examination;

• discussing with the patient the diagnosis

and the evidence for it, the risks and ben-

efits of various treatment options; and

• ensuring the availability of the distant site

provider or coverage of the patient for

appropriate follow-up care.

In addition, the care must be provided at

an appropriate location and—unless an

exception applies—include the presence of

qualified staff, also referred to as patient site

presenters, to assist in the evaluation of the

patient. Treatment and consultation recom-

mendations made via telemedicine are held

to the same standards of acceptable medical

practices as those made in the traditional in-

person clinical settings.

■ Where may telemedicine care be provided?

If a patient is being seen for the very first time

by a distant site provider, or is presenting with

a new condition, telemedicine may only be

used at a location that has qualified staff pres-

ent and sufficient technology and medical

equipment to allow the distant site provider

to conduct an adequate physical evaluation.

Such a location is referred to under the board

rules as an established medical site.

If not at an established medical site, a distant

site provider will be permitted to provide

medical care using telemedicine, contingent

upon the following requirements being met:

• Follow-up care for an established patient’s

previously diagnosed condition. The pro-

vider will be allowed to provide telemedi-

cine care to a patient at a site other than

an established medical site, contingent

upon the provider having previously diag-

nosed the condition either through an in-

person evaluation (meaning, while at the

same physical location as the patient) or

an evaluation conducted at an established

medical site.

• Referral by a physician who completed

a proper evaluation. The provider will be

allowed to provide telemedicine care to a

patient at a site other than an established

medical site, contingent upon the patient

having received an evaluation either in-

person or at an established medical site by

another physician who referred the patient

to the provider for additional care.

• Established patient with new condition

advised to seek appropriate follow-up

care. The provider will be allowed to pro-

vide telemedicine care for an established

patient’s new condition at a site other than

an established medical site, if the distant

site provider advises the patient to see a

physician (either at an established medical

site or in-person) within 72 hours if the

symptoms do not resolve, and provides no

additional care for such symptoms if the

patient is not seen by such a physician.

■ What are some examples of places that meet the definition of an “established medical site?”

In order for a location to qualify as an estab-

lished medical site, the key criteria are the

availability and presence of:

• qualified staff, also referred to as patient

site presenters, who are health care pro-

fessionals licensed or certified in Texas,

such as a nurse, emergency medical

technician, or pharmacist;

• sufficient technology and medical equip-

ment to allow for an adequate physical

evaluation, as appropriate for the patient’s

presenting complaint; and

• sufficient size to accommodate patient

privacy and to enable the presentation of

the patient to the provider.

Contingent upon the locations meeting the

above criteria, they could include a nurse’s

station in a public or private school, volunteer

fire department, emergency medical services

station, oil rig, mental health and mental

retardation centers, community centers,

pharmacy, or even a patient’s home.

In the case of a patient’s home, the rules fur-

ther specify that a patient site presenter must

use sufficient communication and remote

medical diagnostic technology to allow the

provider to carry out an adequate physical

examination appropriate for the patient’s pre-

senting condition while seeing and hearing

the patient in real time.

■ Who may act as a patient site presenter?

A person that is licensed or certified in Texas

to perform health care services or a qualified

mental health professional-community ser-

vices may act as a patient site presenter. The

patient site presenter may be delegated only

tasks and activities within the scope of his

or her licensure or certification. Patient site

presenters assist in the interaction between

the patient and the provider, who is located

at a distant site. If only mental health services

are being provided to the patient, a patient

site presenter may not be required unless the

patient poses a danger to himself or others.

■ Are patient site presenters always required to be present during patient visits, in order for a physician to treat a patient via telemedicine?

No. It will depend on the nature of the ser-

vices provided and conditions being treated.

If the only services being provided relate

to mental health services (not including

behavioral health emergencies), or to follow

up on evaluation or treatment of a previously

diagnosed condition, it is at the discretion of

the distant site provider whether the presence

of a patient site presenter is necessary.

Telemedicine Q&A from the Texas Medical BoardFor a complete set of rules and FAQs regarding telemedicine in Texas, go to www.tmb.state.tx.us/page/laws-gc-faqs-telemedicine.


■ Does a distant site provider have to see a patient in person prior to providing treat-ment using telemedicine?

No. What is required is that either the pro-

vider conduct a face-to-face evaluation via

telemedicine at an established medical site

(see discussion above for basic requirements

related to an established medical site) prior

to providing such ongoing care, or provide

treatment for a patient referred by another

physician who completed a face-to-face

evaluation via telemedicine at an established

medical site.

■ What is the difference between a face-to-face and an in-person evaluation?

A face-to-face evaluation is defined under the

rules as including an evaluation performed

by a distant site provider for a patient who is

located at a different location qualifying as an

established medical site.

An in-person evaluation is one that is con-

ducted by the provider for a patient located in

the same physical location as the provider.

■ May a distant site provider make an initial diagnosis for a new patient via telemedi-cine at the patient’s home?

Yes, on the condition that the provider

establish a defined physician-patient relation-

ship, utilize the presence of a patient site

presenter during the interaction (except for

mental health services not including behav-

ioral health emergencies), and ensure that the

patient site presenter has sufficient com-

munication and remote medical diagnostic

technology to allow the distant site provider

to carry out an adequate physical examina-

tion appropriate for the patient’s present-

ing condition while seeing and hearing the

patient in real time.

■ May telemedicine services be used to treat chronic pain with scheduled drugs?

No.

■ For mental health services to be provided via telemedicine, must a distant site pro-vider conduct a physical examination?

No. For mental health services to be pro-

vided, a distant site provider must, however,

conduct a face-to-face visit and ensure that

a defined physician-patient relationship is

established, which includes documenting

and performing patient history, mental status

examination, and appropriate diagnostic and

laboratory testing.

TMB Telemedicine Q&A Continued

Fast forward to next year. An eMarketer report estimates 2 billion people will have smartphones across the world in 2016. Industries are being transformed radically by the widespread uptake of these devices. Health care will be no different and will continue to move toward more virtual care enabled by smartphones. As the example above demonstrates, it makes sense for both care and economics. Virtual care and telemedicine worldwide is expected to be a $34 billion market by 2020 according to a Morder Intelligence report, with the U.S. accounting for 40 percent of that, nearing $15 billion in the next five years. Several early stage telemedicine companies have raised many millions of dollars in the last several months.

Payment reforms are driving the market toward value-based care and will only accelerate the use of telemedicine via smartphone. Many new forms of payment for medical services are emerging that are not tied to the legacy fee-for-service reim-

bursement model. Patients are paying more out of pocket and therefore have increasingly aligned interests with payers to reduce costs while achieving better overall health. These changes are, in turn, driving the empowered health care con-sumers’ demand for a better experience and convenience.

Estimates are consistent that more than half of all clinic, urgent care, and ER visits “could be handled safely and effec-tively over the phone or video,” according to the American Medical Association and the Wellness Council of America. A recent JAMA study found no difference in qual-ity between in-person and telemedicine visits for minor conditions. Physicians and payers are both looking for ways to adapt to these new realities.

In this new context, the old ways of treating many ailments in an expensive facility across town or even across the neighborhood no longer fit with modern consumer expectations. If a patient can

VALUE-BASED TELEMEDICINE

By Blake McKinney, MD

when a family member was a new mom, she called me con-cerned about her 7-day-old baby’s breathing. I almost sent them to the ER. Then she asked me if we could FaceTime. What I saw was a warm, pink, dry baby looking around, look-ing quite well to me. I was able to tell that she had no labored breathing, no retractions, or nasal flaring. She just had a little stuffy nose. I had been answering questions, treating minor ailments, and triaging the acutely ill for several years via text, but it was in that moment that I knew the iPhone and other smartphone devices would fundamentally and forever change the way physicians can deliver our services.

www.tafp.org 21

In this new context, the old ways of treating many ailments in an expensive facility across town or even across the neighborhood no longer fit with modern consumer expectations. If a patient can visit with a physician by phone, video, or secure text in the middle of the night or during working hours at little or no cost for the individual, in-person visits in many circumstances may become unnecessary.

visit with a physician by phone, video, or secure text in the middle of the night or during working hours at little or no cost for the individual, in-person visits in many circumstances may become unnecessary. In-person care can be a drain on resources and productivity, with substantial oppor-tunity costs associated with missed work or school.

To get to high quality telemedicine, it will take more than just a doctor on a phone. To help align patients, providers, and payers toward achieving telemedicine that works for each, the following are necessary for get-ting value-based telemedicine right.

1. Close the loop, continue the story.It’s often been said, recently by The Com-

monwealth Fund, all health care is local. Ironically, the same is true for telehealth.

Providers in value-based systems want to ensure their patients get the care they need in a way that takes care of urgent issues but also ensures that physicians can communi-cate with primary care and hospital services when needed. It isn’t as simple as an isolated video chat, text message, or phone call: it requires working remote physician access into an entire continuum of traditional care; supplementing and integrating virtual with in-person visits and closing the loop.

Telemedicine shouldn’t create yet another silo of data and care. Each patient is a story, but treating a patient out of network turns a chapter in a story into an isolated event, in a separate book, kept in another library. It can become very difficult to enable true patient engagement and behavior change when epi-sodes of care all too easily disappear from a longitudinal record.

2. Don’t add a co-pay to telemedicine services.

Adding a co-pay or other fee-for-service component creates a cost barrier for the patient to use the service and therefore doesn’t meet the litmus test of the triple aim. Co-pays disincentivize individuals from using the service (and possibly receiving needed care) and create perverse incentives for providers to try to accumulate more indi-vidual calls rather than providing treatment in the most effective and efficient way pos-sible. Payers and risk-bearing providers are learning that it makes more sense to pro-vide a free service to their members. When more than half of in-person visits to the ER and urgent care are unnecessary and virtual care provides equal results, the value-based approach is the more sensible one.

3. Make it convenient, available anywhere via text and video.

Direct access to a physician can be valu-able anywhere, anytime and in an unpredict-able fashion. The telemedicine of yesterday was built on closed-circuit TVs, video tele-conferencing technology, and hub-and-spoke network architecture. However, today’s tele-medicine is based upon technology that most Americans carry in their pockets. We spend a lot of time on our phones and on our com-puters, asking questions and holding con-versations. As many doctors currently text, call, and video chat with their own friends and family when a medical issue arises, often conferring great value, so should doctors be able to care for large populations, supported by the right technology and business models.

4. Help doctors work the way they want to work, the “quadruple aim.”

Physician dissatisfaction is rampant. What many doctors acknowledge as a work-force-wide collective depression results in large part from how physicians today spend the majority of their time: entering documentation into bulky electronic health record systems designed primarily to maxi-mize fee-for-service billing rather than clini-cal utility or doctor-patient engagement. According to Dr. Bob Wachter, a UCSF physi-cian and the author of “The Digital Doctor,” a large part of physician dissatisfaction stems from the time they spend interfacing with EHRs and their billing apparatus, often called “administrative overhead.” What this really means is that physicians have to spend more time figuring out how they are going to get paid and entering data to justify why they

should be paid than actually listening and interacting with patients. Physicians hate it, and patients feel irrelevant. By making the interaction with technology a byproduct of a conversation that is self-documenting within the technology platform, physicians can get back to working the way they want to work. If we then structure physician com-pensation around value-based payments and measure success against outcomes, we can reward physicians for delivering the type of high-quality, customer-centric care that most doctors got into medicine to provide in the first place.

Because physician burnout endangers the triple aim, the Annals of Family Medi-cine suggests it be expanded to the quadruple aim by including physician satisfaction. Data capture around a clinical encounter doesn’t have to be a chore. Value-based care with the right technology allows for the capture of real interactions the way they happen in nature, so to speak, without the need for artificial billing codes. It enables us to return to one of the oldest and most intimate forms of human interaction – the doctor-patient encounter.

Moving to a new health care model based on value requires more than just repackaging old technology systems. It requires enabling the ways people are already communicating, and the right telehealth solution reinforces new business models that create the right financial incentives and physician/patient workflows to align the interests of all participants.

Blake McKinney, MD, is chief medical officer and co-founder of CirrusMD.

This story first appeared on The Health Care Blog.

Health care’s necessity for cost-control and consumer demand

for access will inexorably drive a portion of health care delivery

online. Recent advances in mobile technology have enabled

telehealth to become efficient—and, for the first time, practical

for family physicians to implement.1

Online health care delivery is undergoing rapid change. In the

past, care has been directed by technology into two divergent

paths: Store-and-forward (e-visits) or live telemedicine (secure

video). Store-and-forward is convenient and efficient for the

physician to use; secure video provides an emotional comfort

and the visual nuance face-to-face interaction affords.

There is an emerging generation of technology, mTelehealth,

which leverages the capabilities of the mobile platform, like

smartphones and tablets, and marries them to e-visits and video.

mTelehealth distributes mobility and the system’s computational

power to both patient and provider. This close combination

yields synergistic advantages that allow the physician to direct

the virtual care encounter rather than the technology dictating

the direction of the physician. Health professionals may now

address online care in the same manner as they do in-office

care, determining how much and what type of information and

communication are most appropriate for an encounter.

Efficiency is premium. A family physician with a well-estab-

lished relationship with his or her patient understands how

much information will contribute to an efficient online care

encounter. The clinic, be it in-office or virtual, presents a vari-

ety of clinical complexities. Physicians invest differing amounts

of intellectual capital in the gentle care and disposition of each

case. It is illogical and inefficient to restrict clinicians in their

approach to care, though past technology has conspired to

do so. What is clinically important to the physician is that the

appropriate amount of information be collected and docu-

mented to safely and efficiently provide care. The practicalities

of practice management demand it.

mTelehealth links primary care to the virtual clinic. mTele-

health’s mobility allows care requests to follow the provider.

Further, its store-and-forward capability affords the clinician

flexibility in his or her response. The technology can render

care up to 300 percent more efficiently than older generations

of telemedicine—in as little as four minutes for a fully docu-

mented encounter.2 Thus, this new generation of telehealth

yields an ability to incorporate virtual medicine seamlessly

during a hectic office or after hours. This efficiency is the

catalyst that overcomes important previous impediments of

first-generation technology, finally making it practical for the

family physician and the medical home.

mTelehealth links the virtual clinic to chronic disease. Family

physicians are in a unique position to leverage their patient

relationships with the cost-savings of the virtual platform. Their

capability to render continuity of care via mTelehealth offers

the mechanism to expand the palate from the treatment of

minor acute care to the management of chronic disease care,

which accounts for 75 percent of the health dollar.3 Over time, upwards of 40 percent of office-based encounters may well be amendable to the virtual clinic. Thus, family medicine can influence and substantively change the nation’s delivery of out-patient care.

mTelehealth links chronic disease to population health. More consequential is mTelehealth’s ability to drive population health. Hospitals presently retain the majority of health provid-ers and will leverage their capacity to work efficiently with patients, families, caregivers, and colleagues inexpensively online to provide an extended suite of services. Primary care enables virtual follow-up during transitional care, thus reduced readmissions. Increased access allows for chronic diseases to be addressed before unnecessary time, travel, or higher level care is required. Assisted-living, skilled, and long-term care facility adaptation may reduce transportation costs and ED misuse. It provides a vehicle to implement CMS’s chronic care management initiative addressing needs online before a costly intervention. Most importantly, it opens access to brick-and-mortar facilities that don’t have a provider for patients requiring face-to-face care.

mTelehealth is evolving as a new generation of delivery tech-nology offering clinicians the ability to provide online care practically. Its breadth of influence will place family physicians in the position to support the patient-centered medical home, impact population health, and bend the cost curve of the nation’s escalating health care system. It has the means to help end medical homelessness.

Time and talent will be required to embed this new delivery model between patients and their providers. However, such investment will open the door to increased provider productiv-ity, lower per-capita cost of care, and an improved consumer experience—the tenets of the triple aim. Family physicians and their leadership should respect the developing megatrend that mTelehealth will bring to the profession and implement a global mHealth strategy moving forward.

REFERENCES

1 Kaibara P. Should You Treat Patients Virtually? Fam Pract Manag. 2015 Jul-Aug;22(4):16-20.

2 Thornbury W. How Mobility Within the Medical Home Can Positively Disrupt Healthcare. Journal KAFP. 2013 Summer; 79;20-23.

3 Thornbury W, Thornbury S. mHealth in Chronic Disease Management: Case Study of a Mobile-to-Mobile Delivery Model. Global Telemedicine and eHealth Updates-Knowl-edge Resources. 2014 Apr(7):649-653.

Dr. Thornbury is a family physician in private practice and medical director of Medical Associates of Southern Kentucky in Glasgow, Kentucky. He is the founder of a mHealth technology company, meVisit Technologies.

Mobilizing online care to deliver population healthmTelehealth + primary care = population health

By W.C. Thornbury, MD

www.tafp.org 23

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I learned in my medical education that while it was impor-tant to know the answers, it was more important to know where to find the answers that I didn’t know. This once meant exploring shelves of notable tomes. The portability of information has opened up new avenues for accessing the information that I need in order to get through my day.

Using my phone as an information portal to assist my work in my family medicine clinic has become part of my daily routine. Most patients appreciate the use of the technology to assist in decision making. There is a skill to using technology as a teammate alongside the patient-physician dyad rather than as an intermediary or, even worse, a barricade to prevent genuine interaction. I have learned to suggest to the patient that these apps enhance the treatment plan, not substitute for my judgment.

Here are 10 of my favorite apps I use on a regular basis in my daily practice, mostly on my mobile phone.

TOPAPPSTOPAPPS

in myin myDAILYPRACTICEDAILYPRACTICE

By Evan Howe, MD, MPH, PhDBy Evan Howe, MD, MPH, PhD

Dr. Howe practices family medicine in his hometown of Jefferson, Ohio.

This story originally appeared in the summer 2015 issue of The Ohio Family Physician and is reproduced with permission from the Ohio Academy of Family Physicians.

Epocrates➜ Free app with subscription upgrade for iOS and Android

This is a well-known service with both web-based and app-based

access points. I find it most helpful for checking medication dos-

ages and drug interaction. There are disease-based monographs

with bullet point information that identify priorities for diagnostic

testing and clarify treatment alternatives. Other features include

searchable databases of ICD-10 and CPT codes, and an antibiotic

selection aid with information on local drug-resistance patterns.

BiliCalc➜ $1.99 for iOS and $0.99 for Android

For those of us providing inpatient newborn care, this app makes

quick work of calculating risk stratification and phototherapy

threshold. It provides guidelines for next bilirubin check and a list

of neurotoxicity risk factors. The app simply asks for information

on birth time or age in hours, lab time, and bilirubin level, and

calculates the next steps for you. This definitely beats the time I

used to spend trying to find a bilirubin chart and plot these out on

a graph where the boxes were too small to be certain that I was

just below the curve.

Calculate by QxMD➜ Free for iOS and Android

This is another mega app that contains far more information than

I typically need. However, it is a very efficient repository of the

calculations I need in a typical day such as CHADS2, CURB-65,

TIMI, APACHE, FENa, Bishop score, Ottawa knee and ankle rules,

Epworth sleepiness scale, corticosteroid equivalence, and peak

flow prediction, among others. The peak flow calculator tops my

list for office management. Calculators are organized within the

app in categorical or alphabetical order.

www.tafp.org 25

E/M Coder➜ Free with $39.99 upgrade for full version; iOS only

This app is a bit pricey for its function, but it has focused the time

I spend documenting my encounters. It includes E/M calculators

for all of the contexts in which family physicians provide care—

office, hospital, nursing home, house calls, emergency depart-

ment, and rest home. The user inputs the number of elements in

each category, and the app provides tips on requirements to meet

the next level of documentation in each of the history, exam, and

medical decision-making components. This helps me identify

where adding a bit of information (already collected, but often

overlooked) can help me become eligible for reimbursement

for care I am already providing. The app’s summary report also

provides information on the associated relative value unit for each

code, and reminds me whether I should code an encounter as a

two of three or three of three.

ASCCP➜ $9.99 for iOS and Android

Interpretation of Pap and colposcopy results was another area

where I felt buried in stacks of papers and algorithms as I figured

out which table came next in my evaluation. This app takes age,

HPV status, pregnancy status, and Pap results into account when

identifying where on the algorithm your patient lies. It even pro-

vides the opportunity to input colposcopy results and follow-up

co-testing results. I use this app in a number of settings. When I

receive the Pap or pathology reports, it is often handy to calculate

quickly the next follow-up. I have also found it to be quite helpful

during new patient encounters when I need to review recommen-

dations with patients in real time during the visit.

Shots ➜ Free for iOS and Android; by the Society of Teachers of Family Medicine

This is a great app for keeping the up-to-date immunization

schedules at your fingertips. It provides pediatric and adult

immunization schedules, information on integrating combination

vaccines into your schedule, plus helpful tips on the epidemiol-

ogy, administration, and contraindications of each vaccine. As with

most of the information relevant to the other apps listed above,

there are paper charts that do this work, but this digital portal

makes the same information ubiquitous.

ABFM Exam Prep➜ Free for iOS and Android

This app helped me maximize my spare time waiting in line

somewhere or before drifting off to sleep this past summer as I

prepared for my board exam (passed!). It continues to be useful

to keep me sharp and focused with exam-type questions that

highlight some of those areas where I need to touch up. The app

generates short, 10-question quizzes and enables a quick review

of the reasoning for any incorrect answers.

American Academy of Family Physicians➜ Free for iOS and Android

This is another multifunctional app that I’m sure each person

uses differently. This mobile access point for your AAFP account

includes links to job searches, residency and fellowship directories,

meeting calendar, links to familydoctor.org, and the Family Prac-

tice Management journal. I mostly use this app for the legislative

tracker with its easy link to send my representatives and senators

an email stating my support for issues critical to family medicine

and the AAFP.

Agency for Healthcare Research and Quality ePSS➜ Free for iOS and Android

This app provides a mobile platform for accessing all of the AHRQ

guidelines on current screening tests. While I might have the

colonoscopy guidelines on the tip of my tongue (how many times

a day do I have to run through that?), I don’t necessarily remem-

ber the frequency of other services. Additionally, the app provides

the clinical reasoning behind the guidelines and recommended

screening modalities. The app can generate a list of recommenda-

tions after inputting information on the age, sex, pregnancy status,

tobacco use status, and sexual activity status. Within each recom-

mendation are relevant tools and applicable risk calculators. This

is another great app to use alongside patients to include them in

shared decision making over health maintenance schedules.

ASCVD Risk➜ Free for iOS and Android

This calculator contains all of the updated 2013 American Col-

lege of Cardiology/American Heart Association recommenda-

tions including the 10-year risk estimator. This output serves as a

teaching tool with patients to help them understand the impact

of changing modifiable aspects of their risk profile. For example,

when patients return to my office for discussion of lipid results, I

use this calculator to explain the modifiable and non-modifiable

risk factors for cardiovascular disease. It is easy to toggle through

the independent risk factors to show the potential impact of quit-

ting smoking or controlling blood pressure.


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www.tafp.org 27

By Walter L. Calmbach, MD, MPH Department of Family and Community Medicine, UT Health Science Center at San Antonio

Mark Hutchens, MD Texas Sports and Family Medicine, Austin

BACKGROUND: Concussions are a common injury among athletes, with an estimated 300,000 sports-related con-cussions occurring annually in the U.S.1 However, as many as 50 percent of the concussions may go unreported.2 Recent studies have shown that young athletes are more susceptible to concussions than older athletes, and due to the ongoing neurocog-nitive development that occurs throughout adolescence, concussions can have severe acute and long-term complications in young athletes.1 These findings have serious impli-cations because participation in high school athletics has increased for years, with more than half of all high school students, over 3.1 million girls and 4.2 million boys, participat-ing in sports during the 2009-10 school year.

HIGHER RISK FOR YOUNG ATHLETES: Worryingly, children seem to be more vulnerable to the effects of brain injury than adults. After concussion, there are specific changes at the cellular level resulting in a “metabolic mismatch:” increased glucose utilization and reduced cerebral blood flow.3,4 Physicians must be aware of the ath-lete’s increased vulnerability to injury during the recovery period, which typically takes seven to 14 days.5

BOYS AND GIRLS: It is important for primary care physicians to be aware that while overall, boys have a higher concussion rate than girls, for some sports (e.g., soccer and basketball) girls actually have a slightly higher concussion rate than boys.6

CONCUSSION–A FUNCTIONAL DISTURBANCE: After a blow to the head or helmet, the athlete commonly experi-ences the rapid onset of usually short-lived neurological impairment. These include a range of clinical symptoms that may or may not involve loss of consciousness (see Table 1). The symptoms could be very subtle, such as lack of focused concentration or balance disturbance. Typically, these symptoms resolve spontaneously. It is important to rec-ognize that these acute clinical symptoms reflect a functional disturbance rather than structural injury. Because of this, neuroim-aging studies are typically normal.

INDIVIDUALIZED MANAGEMENT: Recently, recommendations on treating athletes have undergone a major paradigm shift, with a new focus on individualizing management after sports-related concus-

sion. In the past there was an overreliance on published guidelines, which were not uniform, lacked prospective validation, and over-emphasized loss of consciousness as a marker of severity. However, published guidelines remain useful as a starting point when evaluating athletes.7 Importantly, outdated guidelines once allowed for same-day return-to-play, but the new consensus is that there is no same-day return-to-play for an athlete with a concussion.

We now recognize the broad individual variation in presentation and recovery after concussion. Therefore, current recommen-dations focus on individualized manage-ment based on the athlete’s signs and symp-toms, guided by routine use of standardized assessment tools. Some of these common assessment tools include the Standard-ized Assessment of Concussion, the Sport Concussion Assessment Tool 3rd Edition, the Balance Error Scoring System, and vari-ous computerized neurocognitive testing systems.4,8 The SAC is a simple paper-and-pencil scoring tool that assesses orientation, immediate recall, common neurological symptoms, concentration (both numbers and months), and delayed recall. The athlete receives a total score that guides diagnosis, management, and return-to-play decisions. You can find the SCAT3 form at http://bjsm.bmj.com/content/47/5/259.full.pdf.

NEUROCOGNITIVE TESTING: Computer-ized neurocognitive testing systems measure concussion-related symptoms, verbal and visual memory, processing speed, and reac-tion time. They can objectively evaluate post-injury status, and track recovery for safe return-to-play, especially if baseline testing is present. Neurocognitive testing is useful as one component of the evalu-ation, but should not be used in isolation to manage athletes or make return-to-play decisions. It can be helpful in the overall management along with past medical his-tory (e.g., history of previous concussion), presence of comorbid conditions (e.g., anxiety, depression, and learning disability), presence or persistence of post-concussion symptoms, and physical examination.

PHYSICAL AND COGNITIVE REST: Ath-letes with concussions benefit from a brief period of physical and cognitive rest imme-diately after the injury to allow symptoms to abate.6 The rest period varies for each individual. In the immediate post-injury period, athletes should avoid activities that

PUBLIC HEALTH

Sports-related concussion in the young athlete: Who plays? Who sits?


PHYSICAL

Headache

Nausea

Vomiting

Balance problems

Visual problems

Fatigue

Sensitivity to light

Sensitivity to noise

Dazed

Stunned

COGNITIVE

Feeling mentally “foggy”

Feeling slowed down

Difficulty concentrating

Difficulty remembering

Forgetful of recent information

Confused about recent events

Answers questions slowly

Repeats questions

EMOTIONAL

Irritability

Sadness

More emotional

Nervousness

SLEEP

Drowsiness

Sleeping more than usual

Sleeping less than usual

Difficulty falling asleep

Table 1. Signs and symptoms of concussion4

Repeated vomiting

Severe or progressively worsening headache

Seizure activity

Unsteady gait

Slurred speech

Weakness or numbness in the extremities

Signs of basilar skull fracture

Altered mental status

Glasgow coma scale < 15

Severe headache

Seizures

Focal neurological findings

Repeated emesis

Significant drowsiness/difficulty awakening

Slurred speech

Poor orientation to person/place/time

Neck pain

Significant irritability

Hx LOC > 30 seconds

Table 2. Indications for transport to an emergency facility4

Table 3. Indications for neuroimaging4

Table 4. Return to schoolwork progression6

Physical rest Encourage healthy sleep, additional sleep may be needed, no activities that result in sustained increased heart rate or breaking a sweat or severe symptom exacerbation

Light activity associated with everyday Walkinglife avoiding triggering severe symptoms

Light aerobic exercise Brisk walking, light jogging to increase heart rate without triggering severe symptom exacerbation

Sport-specific aerobic exercise Noncontact skating, dribbling, or running drills as tolerated

Advance to complex noncontact sport-specific training drills and add resistance training as tolerated

After medical clearance Full contact practice

Normal game play

Table 5. Return to play progression6

Cognitive rest No school/work, homework, texting, video games, computer work

Relative rest Reintroduce short periods (5–15 minutes) of aforementioned activities that do not trigger severe symptom exacerbation

Homework/work at home Longer periods of cognitive activity (20–30 minutes) to build stamina, avoiding triggering severe symptoms

Return to school/work Partial-day school/work with accommodations after tolerating 1–2 cumulative hours of homework at home

Ramp up to full day With accommodations for full work load, limited make up work

Full return to schoolwork Full day, full work load, fully caught up with makeup load

www.tafp.org 29

exacerbate concussion symptoms. It is also essential the athlete avoid any contact or collision activities that increase the risk for a repeat head injury during this vulner-able acute post-injury period. After a brief period of physical and cognitive rest, during which symptoms usually decrease, athletes can gradually resume routine cognitive and physical tasks, while being careful to avoid activities that cause an increase or return of symptoms [see Tables 4 and 5].

PREDICTORS OF PROLONGED RECOVERY: Several factors have been sug-gested as predictors of prolonged recovery after concussion, including younger age, female gender, history of multiple concus-sions, and learning disability.6 Other neuro-cognitive impairments, including slowed reac-tion time and impaired visual memory, have also been shown to be predictive of prolonged recovery.Ibid Finally, posttraumatic migraine has been associated with a more severe and protracted recovery after concussion.

UNIVERSITY INTERSCHOLASTIC LEAGUE: Due to changes to the Texas Education Commission mandated by the 82nd Texas Legislature, the University Interscholastic League now requires a concussion man-agement team at each UIL-aligned school district. One key task of the concussion management team is to design a return-to-play protocol that describes in detail the steps athletes must follow before they are allowed to resume full athletic competi-tion. The UIL also requires a concussion acknowledgement form to be signed by the student and parent or guardian, as well as a concussion management protocol return-to-play form to be signed by a school official and the parent or guardian. The UIL site also provides a link to concussion manage-ment recommendations published by the National Federation of State High School Associations, found at www.uiltexas.org/health/concussions.

SUMMARY: Sports-related concussion is common, with more than 300,000 occur-ring each year in the U.S. Family physicians must be aware of the special circumstances of young athletes, who are at greater risk of injury, and tend to recover more slowly than adults. When possible, preseason baseline cognitive assessment is recom-mended, whether with the paper-and-pencil Standardized Assessment of Concussion or computerized neurocognitive testing

systems. When managing an athlete with a sports-related concussion, the physician should follow a structured follow-up and return-to-play protocol. Finally, as primary care physicians we have a special responsi-bility to protect young athletes: “When in doubt, sit them out.”

CONCLUSION: Family physicians should take every concussion seriously. The con-cussed athlete has a decreased ability to process new information, and the degree of impairment is proportional to the severity of the injury. Moreover, symptoms worsen with repeated injury (the so-called cumula-tive concussion). Thus, no head injury is “minor;” all need prompt evaluation before returning to play.

REFERENCES1. Marar M, McIlvain NM, Sarah K. Fields

SK, Comstock RD. Epidemiology of concussions among United States high school athletes across 20 sports. Am J Sports Med 2012; 40(4): 747-755.

2. Harman KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, Kutcher JS, Pana A, Putukian M, Roberts WO. The American Medical Society for Sports Medicine position statement: con-cussion in sport. Br J Sports Med 2013; 47(1):1 15-26.

3. Scorza KA, Raleigh MF, O’Connor FG. Current concepts in concussion: evalu-ation and management. Am Fam Phys 2012; 85(2): 123-132.

4. Halstead ME, Walter KD. Clinical report – sport-related concussion in children and adolescents. Pediatrics 2010; 126(3) 597-616.

5. Lovell MR, Fazio V. Concussion manage-ment in the child and adolescent athlete. Curr Sports Med Rep 2008; 7(1): 12-15.

6. Master CL, Balcer L, Collins M. Concus-sion. Ann Intern Med 2014; 160(3):ITC2, 1-16.

7. Practice Guidelines: Evaluation and management of concussion in athletes: recommendations from the AAN. Am Fam Physician 2014; 89(7): 585-587.

8. McCrory P, et al. Consensus statement on concussion in sport: the 4th Inter-national Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47:5 250-258.

Online Resources

“Sport-Related Concussion in Children and Adolescents.” Mark E. Halstead,

Kevin D. Walter and The Council on

Sports Medicine and Fitness

http://pediatrics.aappublications.org/content/126/3/597.full

AAFP’s American Family Physician

www.aafp.org/afp/viewRelatedDocu-mentsByMesh.htm?meshId=D001924

FamilyDoctor.org

http://familydoctor.org/familydoctor/en/diseases-conditions/concussion.html

American Academy of Pediatrics HealthyChildren.org

www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/Concussions.aspx

American Academy of Neurology Concussion Management guidelines

www.neurology.org/con-tent/80/24/2250.full

Centers for Disease Control and Prevention Heads-Up program

www.cdc.gov/headsup

Sport Concussion Assessment Tool, 3rd Edition

http://bjsm.bmj.com/content/47/5/259.full.pdf

University Interscholastic League

www.uiltexas.org/health/concussions

National Federation of State High School Associations Suggested Guide-lines for Management of Concussion in Sports

www.uiltexas.org/files/health/2013_Sug-gested_Guidelines_for_Management_of_Concussion_in_Sports.pdf

Neurocognitive testing: Immediate Post-Concussion Assessment and Cognitive Testing

www.impacttest.com


why do i precept medical students? Luckily, I ask myself this ques-tion less and less frequently because I enjoy having these junior col-leagues with me, especially at 2 a.m. while delivering babies. How-ever, I recently explored this question with some reflection on my past seven years of precepting around 100 medical students and 20 resident physicians in my practice.

Unequivocally, the answer to the preceding question is that I precept medical students because my patients receive better care if I have a medical student working with me. It does not matter how fresh a medical student is into clinical training, two sets of eyes and two sets of brains examining and thinking about a patient’s problem are better than my own brain by itself. I have had preclini-cal students consider and make diagnoses that I have not been able to. Even if the students don’t make the correct diagnosis and they hear zebra hoofbeats instead of horse hoofbeats, this mental task causes me to consider a broader and more thorough differential diagnosis with their valuable input. I consider it an honor and privilege to be entrusted by medical schools with these young student physicians.

I also precept medical students because of the Hippocratic Oath. When I took the Hippocratic Oath as a medical student I held it as one that is binding and sacred to my role as a physician to society to include “treat the sick to the best of one’s ability, preserve patient privacy, teach the secrets of medicine to the next generation.”

I firmly believe I am a better physician because of my role as a medical student preceptor. Medical students challenge me on a daily basis for academic answers to their questions. I am comfortable in my own skin enough to know I do not have all the answers, and when I don’t, that’s when the medical student is assigned homework and we review that lesson and answer the next day.

My patients by in large enjoy the medical students’ enthusi-asm, attention, and extra time they spend with the patients. My practice is accustomed enough to me hosting medical students that my patients and staff miss them when we do not have one rotating with our practice. I miss the students as well when they are not present.

Also, I have found that I am more efficient when working with a medical student alongside me. Additionally, my day is more inter-esting and fun with medical students around.

I initially began hosting medical students when I was in solo private practice because I was lonely and missed the camaraderie of medical school and residency. The selfish side of me wanted to find a future partner to share hospital call with. My community and I have been blessed to have three former trainees return to practice in the Big Bend with me. Medical students are a great investment and we should invest our time and energies in them.

I want to open the door for medical students to rotate with me in a federally qualified health center in one of the most medically underserved areas of Texas, which has limited health care resources. This demonstrates to them the full potential of a family physician who practices full spec-trum family medicine, from cradle to grave, including house calls. My hope for them is that they work with a physician who loves his or her job and practice, and they see how important and vital a family physician is to their patients and community. For many of these students, this rotation will be their only exposure to this kind of domestic mis-sionary medicine and my hope is that all of them will become family physicians.

However, they all will not enter family medicine nor even primary care. Perhaps, these future physicians will have a healthier respect for the challenges underserved patients and their primary care physicians have if they ultimately become a specialist physician. Maybe, later in their career, if they are practicing at a larger tertiary care hospital as a specialist and they get that 2 a.m. tele-phone call for help from me or someone like me, they will remember their rural, under-served family medicine experience and have a better understanding of the challenges of family medicine.

Please volunteer to precept medical students. It does not matter whether you practice in Pampa or Plano, in direct primary care or in a federally qualified health center, or whether you include hospital medicine or obstetrics in your practice, you are needed as a mentor to these student physicians. Once you have precepted medical students in your practice, the rewards are tremendous and my hope is that you feel as I do, incomplete, without a young enthusiastic and brilliant medical student shadowing you.

Thank you for all you do for our profession.

Billings is the director of the Texas Statewide Family Medicine Preceptorship Program.

Why I precept medical studentsBy Adrian N. Billings, MD, PhD, FAAFP

I want to open the door for medical

students to rotate with me in a federally qualified health center

in one of the most medically underserved areas of Texas, which

has limited health care resources. This

demonstrates to them the full potential of a family physician who

practices full spectrum family medicine,

from cradle to grave, including house calls.

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