02.2015 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care www.aad.org Dermatologists profile the specialty’s data needs 20 + 04 Coding 09 Research 11 Legal Issues 18 Practice Management 41 Academy News Dermatology-Specific Amplified. Turn up the volume. Move through your exams faster and through your day more efficiently. Designed with three things in mind – speed, convenience, and adaptability – EMA DermatologyTM has been developed for you and the way you work, on the go and according to your dermatology workflow. Tap and touch and you’re done. Learn more | www.modmed.com/dermatology Visit us | American Academy of Dermatology’s 2015 Annual Meeting | Booth 5216 w w w. m o d m e d . c o m | 5 6 1 . 8 8 0 . 2 9 9 8 Dermatology-Specific Multiplied. Specialty-specific. Multiple Solutions. More Value. Modernizing Medicine gives you more than a leading dermatologyspecific electronic medical records (EMR) system. When you use EMA Dermatology™, you can get even more specialty-specific choices for better results. Multiply your efficiencies and get more value with dermatology billing, inventory management and group purchasing savings. Learn more | www.modmed.com/dermatology-services w w w. m o d m e d . c o m | 5 6 1 . 8 8 0 . 2 9 9 8 in this issue from the editor DEAR READERS, February is known for its quaint story about a groundhog. W e all know the plot, especially here in the north. The presence or absence of his shadow is supposed to predict information about the remaining duration of the winter. Punxsutawney, Pennsylvania is the location of today’s famed groundhog named Phil with forecasting talent, although it is a tradition that began in the ancient world. And for those of us in the colder parts of the U.S. who are often anxious to see the cold, snowy days come to an end, this in essence predicts what will be in store for the rest of the winter season. I’ve been struck in Philadelphia that the groundhog almost always sees his shadow, and disappointingly the winter soldiers on. I suspect though that it is the rare person who doesn’t take note of the data point. This brings me to the piece in Derm World that I’d like to highlight — about data, and the Academy’s plan to create a dermatology data platform. This proposed platform will answer questions that appeal to the scientist in each of us. Following in the path of some of the other specialty societies, the leaders of our Academy have realized that it is imperative that we collect and own data. While insurance companies have their own data stores, their agendas and missions vary significantly from ours and therefore we need to own our own. The hope, of course, is that it will assist us in providing proof of the value of our services, something that will become increasingly necessary. Some derms have expressed the concern that it will be used against us, but Dr. Oliver Wisco reassures us when he tells us that “we have to get out of the mindset that data is about grading.” It has the potential to guide us whether we think it will or not. Dr. Teisberg aptly notes that “What you measure will be what improves, so measure what really matters to the patient.” Understanding what patients think of the outcome of our treatments will teach us how to make them better. It is exciting to think that the Academy will be aiding us in this way. Read our piece, and see if you agree. Speaking of data, you will also want to take a look at the Answers in Practice piece on the penalties coming out of CMS. One percent here and 2 percent there — boy, after a while these penalties certainly add up! We thought that standing back and taking a look at the overall picture might be useful to many. With only 30 percent of derms complying with meaningful use, Rachna Chaudhari from the AAD tells us that it is not too late to reconsider and take steps to comply with the federal programs. Otherwise you might begin to feel like that guy in the Groundhog Day movie, stuck in the time warp of the day. With additional penalties taken each year caring for the 65+ crowd may get more and more challenging. Hope that the numbers inspire a few of you. Well, I know what I will do if the groundhog sees his shadow on that day that is halfway between solstice and equinox…stream Groundhog Day and enjoy the laughs! That will brighten things up. Hope you do the same! Enjoy your reading. VOL. 25 NO. 2 | FEBRUARY 2015 PRESIDENT Brett Coldiron, MD EXECUTIVE DIRECTOR Elaine Weiss, JD PUBLISHER Lara Lowery EDITOR Katie Domanowski MANAGING EDITOR Richard Nelson, MS ASSISTANT MANAGING EDITOR Victoria Houghton, MPA DESIGN MANAGER Ed Wantuch EDITORIAL DESIGNER Theresa Oloier DESIGN TEAM Nicole Torling ADVERTISING SPECIALIST Carrie Parratt PHYSICIAN EDITOR Abby Van Voorhees, MD PHYSICIAN REVIEWER Barbara Mathes, MD CONTRIBUTING WRITERS Diane Donofrio Angelucci Rachna Chaudhari Terri D’Arrigo Susan Jackson Clifford Lober, MD, JD Alexander Miller, MD Victoria Pasko Morris Stemp, MBA Beverly Wachtel EDITORIAL ADVISORS Lakshi Aldredge, MSN, ANP-BC Annie Chiu, MD Jeffrey Dover, MD Rosalie Elenitsas, MD John Harris, MD, PhD Chad Hivnor, MD Sylvia Hsu, MD Risa Jampel, MD Michel McDonald, MD Christen Mowad, MD Robert Sidbury, MD Oliver Wisco, DO Printed in U.S.A. Copyright © 2015 by the American Academy of Dermatology Association 930 E. Woodfield Rd. Schaumburg, IL 60173-4729 Phone: (847) 330-0230 Fax: (847) 330-0050 MISSION STATEMENT: Dermatology World is published monthly by the American Academy of Dermatology Association. Through insightful analysis of the trends that affect them, it provides members with a trusted, inside source for balanced news and information about managing their practice, understanding legislative and regulatory issues, and incorporating clinical and research developments into patient care. Dermatology World® (ISSN 10602445) is published monthly by the American Academy of Dermatology and AAD Association, 930 E. Woodfield Rd., Schaumburg, IL 60173-4729. Subscription price $48.00 per year included in AAD membership dues. Non-member annual subscription price $108.00 US or $120.00 international. Periodicals Postage Paid at Schaumburg, IL and additional mailing offices. POSTMASTER: Send address changes to Dermatology World®, American Academy of Dermatology Association, P.O. Box 4014, Schaumburg, IL 60168-4014. ADVERTISING: For display advertising information contact Bridget Blaney at (773) 259-2825 or [email protected]. 2 DERMATOLOGY WORLD // February 2015 ABBY S. VAN VOORHEES, MD, PHYSICIAN EDITOR www.aad.org/dw 02.2015 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care features www.aad.org depts 02 FROM THE EDITOR 04 CRACKING THE CODE Flap, or not? “How do we switch from a strategy around volume to one 20 of value?” 06 ROUNDS Medical license portability. 09 ACTA ERUDITORUM Can better access to dermatologists improve melanoma prognosis? 11 COVER STORY LEGALLY SPEAKING Dermatologists profile the specialty’s data needs Do you have a duty to warn a third party? DEMONSTRATING QUALITY BY VICTORIA HOUGHTON 28 ITCHING FOR RELIEF Dermatologists take aim at pruritus BY DIANE DONOFRIO ANGELUCCI 34 BUILDING AN OFFICE CULTURE THAT WORKS Physician-practice manager partnership is key BY TERRI D’ARRIGO 14 TECHNICALLY SPEAKING How to choose tech solutions to maximize productivity and improve patient care. 18 ANSWERS IN PRACTICE Keeping track of all those penalties. 40 FROM THE PRESIDENT 41 ACADEMY UPDATE 2014 AM&P Excel Bronze Award, Design Excellence 2011, 2012, 2013, and 2014 Graphic Design USA Award – Cover/Feature Design. 2014 Graphic Design USA American Web Design Award Advisory Board resolutions sought, more. 44 FACTS AT YOUR FINGERTIPS 2013 HOW InHOWse Design Award – Cover/Feature Design 2011 Ozzie Silver Award, Best Redesign: Association/Non-profit. 2014 Eddie Honorable Mention, Association/ Non-profit video Modest increase would keep AAD’s dues lower than many similar organizations. DERMATOLOGY WORLD // February 2015 3 cracking the code BY ALEXANDER MILLER, MD Flap, or not? ALEXANDER MILLER, MD, addresses important coding and documentation questions each month in Cracking the Code. Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT® Advisory Committee. You repair a large surgical defect with bilateral M-plasties. Do you bill for an adjacent tissue rearrangement (flap)? Adjacent tissue transfer or rearrangement (flap) codes are defined in the CPT as including Z-plasty, W-plasty, V-Y plasty, rotation flap, random island flap, and advancement flap. An M-plasty does not rearrange any tissue or move any tissue about. It results from a redirection of the lines of closure from a straight linear pattern to essentially two backcuts formed at the distal incision end(s) to shorten the closure length. The excised tissue edges are then approximated side-to-side. Nothing is advanced or transposed, and the apex of the M-plasty where it intersects the central line of closure is not advanced or repositioned. It remains in place. Consequently, in an M-plasty, unlike that in a Z-plasty or W-plasty, there is no tissue transfer/advancement or rearrangement. In conclusion, an M-plasty does not qualify for the adjacent tissue transfer/rearrangement CPT code series 14000 - 14061. In the above example one would bill for the appropriate level of complexity of linear reconstruction, most commonly with an intermediate (layered) or complex (extensive undermining) repair code. For the purpose of optimizing tissue alignment and cosmetic appeal one may excise standing cones of skin adjacent to a central surgical defect in an opposing offset fashion, undermine the edges, and suture the site shut. This type of closure results in a curvilinear or S-plasty pattern. Although such a repair generates a wiggly pattern, it is a variation on a straight linear closure, as there is no true advancement or rearrangement of tissue, regardless of the degree of undermining done to facilitate tissue motion. This repair qualifies only for intermediate or complex repair CPT coding. In arrangements where CPT coding is determined by anyone other than the service provider (such as by in-office billers, facility billers, or outside coders) the biller must be presented with appropriate supporting chart data in order to generate CPT codes that reflect the work done. Similarly, in situations where the electronic health record prompts code selection, the chart input must be optimized for logical code choices. Thus, for flap repairs the recorded data must satisfy the flap definition requirements, and should specify the 4 DERMATOLOGY WORLD // February 2015 location and the area of the defect plus that of the raised flap. Diagrammatic and photographic illustrations of a surgery can help justify both the appropriateness and legitimacy of what was done. This can prove useful in chart audit situations. Tracking insurer reimbursement patterns and any chart documentation requests may reveal an individual insurer’s peculiar requirements, such as for justifications in the patient record for why a flap was chosen over a linear repair. Integrating such data into the patient record may help to prevent payment rejections and the expenses of appeals and delays in payment. A quirky consequence of electronic billing is that some insurers will subsequently request a surgical report when Mohs surgery is done with a reconstruction. When expecting such a consequence, proactively paper billing on a CMS-1500 form with an attached surgical report will streamline reimbursement. Example 1: A patient presents to you with an upper lip vertically banded scar that pulls up on the vermilion margin. You do a narrow fusiform excision of the scar and then depress the still somewhat elevated lip margin with a Z-plasty. You bill for the 1.2 cm excision with CPT 11442 and for the flap repair with CPT 14060. Answer: Incorrect. Only the Z-plasty flap repair is billable, as the adjacent tissue rearrangement codes include the primary excision. (CPT Assistant, July 2008, p. 5). Example 2: In the process of repairing an ear lobule rim defect linearly you do a Z-plasty across the lobule’s edge in order to reconstitute the rim’s convexity and to avoid notching. You bill CPT 14060. Answer: Correct. As an adjacent tissue rearrangement was done as part of the repair, one is justified in billing for the appropriately done Z-plasty. www.aad.org/dw coding tips Example 3: You broadly undermine the cheek adjacent to a large defect, advance the edges, and excise the resulting standing cones, generating a curvilinear closure line conforming to the skin tension lines. The insurer audits your chart and adjusts your billing from an adjacent tissue rearrangement code to a complex repair. Answer: Correct. The chart record shows that broad undermining and a linear repair were done. The CPT specifically states: “Undermining alone of adjacent tissues to achieve closure, without additional incisions, does not constitute adjacent tissue transfer, see complex repair codes 13100-13160.” The additional incisions needed to excise standing cones of tissue do not generate adjacent tissue transfer or rearrangement. Example 4: Following an excision of a basal cell carcinoma on the arm you close the 2.7 cm-wide surgical defect with an intradermal pursestring suture. As you undermined broadly beyond the defect’s edges in order to mobilize tissue you bill CPT 11603 for the malignant excision and CPT 13121 for the complex repair. Although the tissue edges are concentrically advanced centrally, the procedure does meet the definition of a flap closure. Answer: Correct. Since extensive undermining was necessary to mobilize the wound edges, both an excision and a complex repair code are appropriate. If a purse-string suture were done with minimal to no undermining, only a malignant excision code, CPT 11603, would be applicable. The February 2007 CPT Assistant defines a simple excision as, “…includes simple (non-layered) closure when performed.” A typical purse-string closure consists of a single, continuous cutaneous suture layer. Example 5: Following a Mohs surgical excision of a squamous cell carcinoma located on the dorsal hand you reduce the 1.7 cm diameter defect with a purse-string closure and then further approximate the skin edges with several vertical interrupted nylon stitches. You bill for the Mohs surgery and CPT 12041 for the layered (intermediate) repair. Answer: Incorrect. Intermediate repair requires deeper layered closure of subcutaneous tissue and superficial (non-muscle) fascia in addition to epidermal-dermal skin closure. In the above example both suturing techniques approximate the same epidermaldermal skin layers, such that only the simple repair criterion, CPT 12001, is met despite the use of two distinct suturing modalities. Similarly, if one repairs a non-undermined defect with a combination of horizontal mattress and simple interrupted exteriorized sutures, only a simple repair definition is fulfilled. dw No XS needed if codes aren’t mutually exclusive THE NEW XE, XS, XP, AND XU MODIFIERS that CMS began using this year to supplement modifier 59 will change a lot of things for dermatologists. They will not, however, change the list of Correct Coding Initiative edits that govern the use of modifiers. In our November 2014 Cracking the Code, we presented an example of XS modifier use that would have been correct…if the two biopsies being billed were on the mutually exclusive list. As they were not, no XS modifier is necessary. The corrected example appears below. The full article, with the correction, is available at www.aad.org/dw/ monthly/2014/november/the-59-modifier-modified. Example 3: You destroy multiple penile condyloma acuminata with liquid nitrogen and biopsy an unrelated cheek lesion suspicious for basal cell carcinoma on a Medicare patient. You bill CPT 54056 for the destruction of condylomas and 11100-XS for the cheek biopsy. Answer: Incorrect: These two codes are not mutually exclusive by CCI edits, and they both can be billed together without any modifier. In a slightly different circumstance, a lip biopsy and a cheek biopsy at the same visit, use of the XS modifier would be required: CPT 40490 for the lip biopsy and 11000-XS for a cheek biopsy. The difference: 40490 and 11100 are on the mutually exclusive list and a modifier is required to indicate that they represent two separate services. dw DERMATOLOGY WORLD // February 2015 5 rounds news in brief Federation of State Medical Boards addresses medical license portability STATE NEWS ROUNDUP A s a result of the Affordable Care Act, the demand for health care has increased. In order to provide care to an increased patient population, many physicians are looking to expand their practices across state lines. Current state licensing requirements can make this complicated. But many states are expected to address medical license portability this year. To provide a model framework for license portability, the Federation of State Medical Boards (FSMB) developed an Interstate Medical Licensure Compact in September 2014 which — if adopted by state legislatures — would allow for expedited licensure to physicians interested in practicing in multiple states, without requiring changes to the states’ laws that govern the practice of medicine, or the state medical boards’ regulatory authority. Additionally, the Compact stipulates that the practice of medicine occurs where the patient is located at the time of the physician-patient encounter. Therefore, the physician would be required to be under the state medical board jurisdiction where the patient is located. State medical boards that participate in the Compact would retain the authority to impose an adverse action against a license to practice medicine in that state issued to a physician through the procedures in the Compact. Participation in the Compact would be on a voluntary basis for both physicians and state boards of medicine. The American Academy of Dermatology Association (AADA) supports the Compact and will be working with state medical societies and state dermatologic societies to pass legislation in 2015 that would implement it. For more information, or to find out how your state can get involved, email Victoria Pasko at [email protected]. STATE ACCESS TO INNOVATIVE MEDICINE COALITION TACKLES PRESCRIPTION DRUG COSTS The AADA has joined the State Access to Innovative Medicine (SAIM) coalition — a group of patient advocacy organizations, physician groups, and industry members dedicated to decreasing barriers to patient access to prescription medications. The coalition’s advocacy efforts will focus on legislation that caps out-of-pocket prescription medication costs and limits the use of step therapy and drug tiering. Other members of the coalition include the Leukemia and Lymphoma Society, National Psoriasis Foundation, Lupus Foundation, Arthritis Foundation, Coalition of State Rheumatology Organizations, Celgene, Genentech, and Pfizer. The SAIM coalition will collaborate when possible on advocacy efforts and will serve as a resource to the AADA as it pursues this issue at the state and federal level. – VICTORIA PASKO dw 6 DERMATOLOGY WORLD // February 2015 www.aad.org/dw NEW FOR THE TREATMENT OF COMEDONAL AND INFLAMMATORY ACNE For more information, please visit www.OnextonGel.com INDICATION ONEXTON (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/3.75% is indicated for the topical treatment of acne vulgaris in patients 12 years of age or older. IMPORTANT SAFETY INFORMATION • ONEXTON Gel is contraindicated in patients with a known hypersensitivity to clindamycin, benzoyl peroxide, any component of the formulation or lincomycin. • ONEXTON Gel is contraindicated in patients with a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis. • Diarrhea, bloody diarrhea, and colitis (including pseudomembranous colitis) have been reported with the use of topical or systemic clindamycin. ONEXTON Gel should be discontinued if significant diarrhea occurs. • Orally and parenterally administered clindamycin has been associated with severe colitis, which may result in death. • Anaphylaxis, as well as other allergic • • • • reactions leading to hospitalizations, has been reported in postmarketing use of products containing clindamycin/benzoyl peroxide. If a patient develops symptoms of an allergic reaction such as swelling and shortness of breath, they should be instructed to discontinue use and contact a physician immediately. The most common local adverse reactions experienced by patients in clinical trials were burning sensation, contact dermatitis, pruritus and rash. All occurred in <0.5% of patients. ONEXTON Gel should not be used in combination with erythromycin-containing products because of its clindamycin component. Patients should be advised to avoid contact with the eyes or mucous membranes. Patients should avoid exposure to natural sunlight and avoid artificial sunlight (tanning beds or UVA/B treatment) while using ONEXTON Gel. Please see Brief Summary of Prescribing Information on the following page. Except as otherwise indicated, all product names, slogans, and other marks are trademarks of the Valeant family of companies. © 2014 Valeant Pharmaceuticals North America LLC. DM/ONX/14/0026 BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION Neuromuscular Blocking Agents This Brief Summary does not include all the information needed to use ONEXTON Gel safely and effectively. See full prescribing information for ONEXTON Gel. Clindamycin has been shown to have neuromuscular blocking properties that may enhance the action of other neuromuscular blocking agents. ONEXTON Gel should be used with caution in patients receiving such agents. ONEXTON™ (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/3.75%, for topical use Initial U.S. Approval: 2000 CONTRAINDICATIONS Hypersensitivity ONEXTON Gel is contraindicated in those individuals who have shown hypersensitivity to clindamycin, benzoyl peroxide, any components of the formulation, or lincomycin. Anaphylaxis, as well as allergic reactions leading to hospitalization, has been reported in postmarketing use with ONEXTON Gel [see Adverse Reactions] WARNINGS AND PRECAUTIONS Colitis/Enteritis Systemic absorption of clindamycin has been demonstrated following topical use of clindamycin. Diarrhea, bloody diarrhea, and colitis (including pseudomembranous colitis) have been reported with the use of topical and systemic clindamycin. If significant diarrhea occurs, ONEXTON Gel should be discontinued. Severe colitis has occurred following oral and parenteral administration of clindamycin with an onset of up to several weeks following cessation of therapy. Antiperistaltic agents such as opiates and diphenoxylate with atropine may prolong and/or worsen severe colitis. Severe colitis may result in death. Studies indicate toxin(s) produced by Clostridia is one primary cause of antibiotic-associated colitis. The colitis is usually characterized by severe persistent diarrhea and severe abdominal cramps and may be associated with the passage of blood and mucus. Stool cultures for Clostridium difficile and stool assay for C. difficile toxin may be helpful diagnostically. Ultraviolet Light and Environmental Exposure Minimize sun exposure (including use of tanning beds or sun lamps) following drug application [see Nonclinical Toxicology]. ADVERSE REACTIONS The following adverse reaction is described in more detail in the Warnings and Precautions section of the label: Colitis [see Warnings and Precautions]. Table 1: Local Skin Reactions - Percent of Subjects with Symptoms Present. Results from the Phase 3 Trial of ONEXTON Gel 1.2%/3.75% (N = 243) Before Treatment (Baseline) Maximum During Treatment End of Treatment (Week 12) Mild Mod.* Severe Mild Mod.* Severe Mild Mod.* Severe Erythema 20 6 0 28 5 <1 15 2 0 Scaling 10 1 0 19 3 0 10 <1 0 Itching 14 3 <1 15 3 0 7 2 0 Burning 5 <1 <1 7 1 <1 3 <1 0 Stinging 5 <1 0 7 0 <1 3 0 <1 *Mod. = Moderate Postmarketing Experience Because postmarketing adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Anaphylaxis, as well as allergic reactions leading to hospitalizations, has been reported in postmarketing use of products containing clindamycin phosphate/benzoyl peroxide. DRUG INTERACTIONS Erythromycin Avoid using ONEXTON Gel in combination with topical or oral erythromycincontaining products due to its clindamycin component. In vitro studies have shown antagonism between erythromycin and clindamycin. The clinical significance of this in vitro antagonism is not known. Concomitant Topical Medications Concomitant topical acne therapy should be used with caution since a possible cumulative irritancy effect may occur, especially with the use of peeling, desquamating, or abrasive agents. If irritancy or dermatitis occurs, reduce frequency of application or temporarily interrupt treatment and resume once the irritation subsides. Treatment should be discontinued if the irritation persists. Nursing Mothers It is not known whether clindamycin is excreted in human milk after topical application of ONEXTON Gel. However, orally and parenterally administered clindamycin has been reported to appear in breast milk. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to use ONEXTON Gel while nursing, taking into account the importance of the drug to the mother. Pediatric Use Safety and effectiveness of ONEXTON Gel in pediatric patients under the age of 12 have not been evaluated. Geriatric Use Clinical trials of ONEXTON Gel did not include sufficient numbers of subjects aged 65 and older to determine whether they respond differently from younger subjects. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity, mutagenicity and impairment of fertility testing of ONEXTON Gel have not been performed. Benzoyl peroxide has been shown to be a tumor promoter and progression agent in a number of animal studies. Benzoyl peroxide in acetone at doses of 5 and 10 mg administered topically twice per week for 20 weeks induced skin tumors in transgenic Tg.AC mice. The clinical significance of this is unknown. Carcinogenicity studies have been conducted with a gel formulation containing 1% clindamycin and 5% benzoyl peroxide. In a 2-year dermal carcinogenicity study in mice, treatment with the gel formulation at doses of 900, 2700, and 15000 mg/kg/day (1.8, 5.4, and 30 times amount of clindamycin and 2.4, 7.2, and 40 times amount of benzoyl peroxide in the highest recommended adult human dose of 2.5 g ONEXTON Gel based on mg/m2, respectively) did not cause any increase in tumors. However, topical treatment with a different gel formulation containing 1% clindamycin and 5% benzoyl peroxide at doses of 100, 500, and 2000 mg/kg/day caused a dose-dependent increase in the incidence of keratoacanthoma at the treated skin site of male rats in a 2-year dermal carcinogenicity study in rats. In an oral (gavage) carcinogenicity study in rats, treatment with the gel formulation at doses of 300, 900 and 3000 mg/kg/day (1.2, 3.6, and 12 times amount of clindamycin and 1.6, 4.8, and 16 times amount of benzoyl peroxide in the highest recommended adult human dose of 2.5 g ONEXTON Gel based on mg/ m2, respectively) for up to 97 weeks did not cause any increase in tumors. In a 52-week dermal photocarcinogenicity study in hairless mice, (40 weeks of treatment followed by 12 weeks of observation), the median time to onset of skin tumor formation decreased and the number of tumors per mouse increased relative to controls following chronic concurrent topical administration of the higher concentration benzoyl peroxide formulation (5000 and 10000 mg/kg/day, 5 days/week) and exposure to ultraviolet radiation. Clindamycin phosphate was not genotoxic in the human lymphocyte chromosome aberration assay. Benzoyl peroxide has been found to cause DNA strand breaks in a variety of mammalian cell types, to be mutagenic in S. typhimurium tests by some but not all investigators, and to cause sister chromatid exchanges in Chinese hamster ovary cells. Fertility studies have not been performed with ONEXTON Gel or benzoyl peroxide, but fertility and mating ability have been studied with clindamycin. Fertility studies in rats treated orally with up to 300 mg/kg/day of clindamycin (approximately 120 times the amount of clindamycin in the highest recommended adult human dose of 2.5 g ONEXTON Gel, based on mg/m2) revealed no effects on fertility or mating ability. PATIENT COUNSELING INFORMATION See FDA-approved patient labeling (Patient Information). Distributed by: Valeant Pharmaceuticals North America LLC, Bridgewater, NJ 08807 Manufactured by: Contract Pharmaceuticals Limited Mississauga, Ontario, Canada L5N 6L6 U.S. Patents 5,733,886 and 8,288,434 Issued 11/2014 9389300 DM/ONX/14/0031(1) S:9.75” Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates observed in the clinical trials of another drug and may not reflect the rates observed in clinical practice. These adverse reactions occurred in less than 0.5% of subjects treated with ONEXTON Gel: burning sensation (0.4%); contact dermatitis (0.4%); pruritus (0.4%); and rash (0.4%). During the clinical trial, subjects were assessed for local cutaneous signs and symptoms of erythema, scaling, itching, burning and stinging. Most local skin reactions either were the same as baseline or increased and peaked around week 4 and were near or improved from baseline levels by week 12. The percentage of subjects that had symptoms present before treatment (at baseline), during treatment, and the percent with symptoms present at week 12 are shown in Table 1. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women treated with ONEXTON Gel. ONEXTON Gel should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Animal reproductive/developmental toxicity studies have not been conducted with ONEXTON Gel or benzoyl peroxide. Developmental toxicity studies of clindamycin performed in rats and mice using oral doses of up to 600 mg/kg/day (240 and 120 times amount of clindamycin in the highest recommended adult human dose based on mg/m2, respectively) or subcutaneous doses of up to 200 mg/kg/day (80 and 40 times the amount of clindamycin in the highest recommended adult human dose based on mg/m2, respectively) revealed no evidence of teratogenicity. research in practice Can better access to dermatologists improve melanoma prognosis? IN THIS MONTH’S ACTA ERUDITORUM COLUMN, Physician Editor Abby S. Van Voorhees, MD, talks with Dr. David Moreno-Ramirez about his recent Journal of the American Academy of Dermatology article, “The role of accessibility policies and other determinants of health care provision in the initial prognosis of malignant melanoma: A cross-sectional study.” acta eruditorum Q&A DR. VAN VOORHEES: Dermatologists around the world have been involved in trying to identify those with melanomas as early as possible. Your study looks at the benefits of these efforts in Spain. Tell us what you have discovered. DR. MORENO-RAMIREZ: The TEDIMEL project has shown that interventions aimed at improving melanoma patients’ ability to access dermatology units have the greatest impact on the early diagnosis of malignant melanoma. Those primary care centers with direct referrals have shown a greater frequency of early diagnosis of malignant melanoma (Tis-T1). In our region, several policies aimed at this goal have been implemented over the last decade. TEDIMEL has shown us how these policies have contributed to changing the trends in melanoma diagnosis in just 10 years. In 2004, the regional government launched a “15-day rule” for skin cancer patients. This obliged skin cancer and melanoma units to enable direct and fast referral systems to achieve the goal of a diagnosis within 15 days. That effort explained the significant change in early diagnoses after 2004, as observed in TEDIMEL. DR. VAN VOORHEES: What kinds of trends did you find? Were there an increasing number of cases of melanoma identified? If so, by how much? Were there changes in the mean age at which patients were diagnosed? Was there the expected male/ female ratio? Was there a shift in the percentage of cases that were diagnosed at a later stage? DERMATOLOGY WORLD // February 2015 9 acta eruditorum continued DR. MORENO-RAMIREZ: Over the study period, the total number of melanoma cases increased by 78 percent. Luckily, this change was mainly due to the increase in the diagnosis of in situ and T1 malignant melanomas. The increasing frequency of thin malignant melanoma had been noticed in recent years in our melanoma clinics, and it has been confirmed by the TEDIMEL study. In terms of age, an increased incidence of melanoma in younger subsets has been suggested. However, during the study period, TEDIMEL failed to show a significant change in the frequency of malignant melanoma in those aged zero to 29 years. A slight increase was observed, between 5 percent and 12 percent, but it did not reach statistical significance. By contrast, a significantly higher frequency of malignant melanoma was observed in women (54 percent vs 46 percent); however, this was balanced by the greater likelihood of early diagnosed malignant melanoma that was observed in women. DR. VAN VOORHEES: Were there other differences between sites that were important? What impact on the prognosis did these approaches have and how significant were they? DR. MORENO-RAMIREZ: Actually, the only relevant difference between the participating centers was the availability of well-established, fasttrack referral systems between 10 DERMATOLOGY WORLD // February 2015 research in practice primary care and melanoma clinics. It was this availability that led these centers to have a greater likelihood of identifying melanoma in its earlier stages, that is, at a noninvasive or a very thinly invasive stage (T1). These fast-track referral systems involved any procedure or intervention that allowed patients with suspected melanoma to have a specialized consultation within two weeks. And what we consider even more remarkable is that this change was achieved in various ways, from immediate letter referrals with no previous appointment to teledermatology-based screenings of suspicious lesions at the primary care center. So, I would stress that the type of intervention launched was not as important as the final results achieved: the shortening of delays to see a dermatologist. Other indicators of health care provision that might be major determinants of health outcomes, such as the ratio of dermatologists per capita, the complexity of the hospital, among others, failed to show any direct role in the early diagnosis of malignant melanoma. However, these variables might have served as confounding factors, or might simply not be as powerful. group found relevant results in a rather short period of time from an epidemiological point of view, the impact of health care interventions in terms of final outcomes such as survival need much longer study periods. Nonetheless, in the meantime the results obtained through TEDIMEL can be considered a good starting point for policy makers. DR. VAN VOORHEES: If there is one thing that you feel should be learned from this paper to facilitate the care of those with melanoma what would it be? DR. MORENO-RAMIREZ: The easier access is to a dermatologist, the better the prognosis is for malignant melanoma. It sounds basic and even simple, but it necessarily involves dermatologists and policy makers working together. This has been the experience at our region for the last decade. dw DR. MORENO-RAMIREZ is clinical director of the dermatology unit at Hospital Universitario Virgen Macarena in Seville, Spain. His article appeared in the September 2014 issue of the Journal of the American Academy of Dermatology. J Am Acad Dermatol 2014;71(3):507-515.doi: http://dx.doi.org/10.1016/j.jaad.2014.04.049. DR. VAN VOORHEES: What were the limitations of this study? DR. MORENO-RAMIREZ: The main limitation is its retrospective nature, and probably the lack of a survival analysis. However, although our www.aad.org/dw legally speaking legal issues BY CLIFFORD WARREN LOBER, MD, JD Do you have a duty to warn a third party? EVERY MONTH, DERMATOLOGY WORLD covers legal issues in “Legally Speaking.” Clifford Warren Lober, MD, JD, presents legal dilemmas in dermatology every other month. He is a dermatologist in practice in Florida and a partner in the law firm Lober, Brown, and Lober. I t’s a beautiful winter day when Bryan’s receptionist bursts into his office. She tells him that Sandy, one of his dermatology clients, is on the phone with an urgent problem. Bryan picks up the phone and begins the conversation. Bryan: Sandy, how are you? It’s been a while since we spoke. Sandy: Bryan, I have a real problem. I just finished removing a skin cancer from one of my patients. During the procedure, she told me that she was aware that her husband was “fooling around” and that she has “had enough.” She swore that the next time he does it she is going to kill him with the gun kept in her bedroom nightstand. She was absolutely livid when she told me this and I truly believe that she will do so. Should I warn her husband? Do I need to report this to the police? What should I do? I have never been in this position before. Bryan: The issue here is whether you can or must violate the patient’s confidentiality, which is inherent and expected in the doctor-patient relationship, to protect her husband. One of the few times state laws make an exception to the duty of confidentiality is when there is a credible threat of violence against another person. States and even localities within states vary in whether, and if so to whom, they permit you to disclose this information. When it is permitted, however, there must be a clearly identifiable intended victim and an imminent, credible expectation that the patient is capable of and truly intends to commit the violent act. In this case the patient has clearly identified the circumstances under which she will shoot her husband and has the means and intent to do so. DERMATOLOGY WORLD // February 2015 11 legally speaking continued Sandy: You said there are differences in whether I can or need to disclose this information. What do you mean? Bryan: Some jurisdictions impose a duty to warn the potential victim. This duty permits you to contact the intended victim and tell them of the foreseeable danger. The duty to warn may be mandatory, meaning that you must warn the intended victim, or merely permissive, in which case you have the option of warning the intended victim. The duty to warn always necessitates violating the patient’s confidentiality. Other jurisdictions impose a different requirement, called the duty to protect, which allows or requires that you take action to protect the intended victim, such as notifying the police. Like the duty to inform, the duty to protect may be either mandatory or simply permissive. Sometimes it may be possible to take action to protect an intended victim without breaching the patient’s confidentiality, such as by committing a patient with a psychiatric issue to a mental health facility. Sandy: Do all states have a duty to inform or a duty to protect? How do I know which applies to me? Bryan: No! Surprisingly, some states and jurisdictions have neither a duty to warn nor a duty to protect third parties. They give you no protection if you violate the patient’s confidentiality. Therefore, I have to check the laws in our jurisdiction before telling you how to proceed. There is another wrinkle, however. 12 DERMATOLOGY WORLD // February 2015 legal issues KEY POINTS: 1 State and local jurisdictions vary in whether they permit or require you to warn a potential victim of foreseeable violence. 2 There must be a clearly identifiable victim and an imminent, credible expectation that the patient is capable of and truly intends to commit violence. 3 Some jurisdictions impose a duty to warn potential victims. This may be permissive or mandatory, thus allowing or requiring you to contact and notify the intended victim. 4 Other states and jurisdictions have a duty to protect, which is either permissive or mandatory, permitting or mandating that you take affirmative steps to protect the third party. 5 If the duty to warn or protect the intended victim in your jurisdiction is limited by statute to mental health and/or social workers, it may offer no protection to dermatologists. Sandy: What’s that? Bryan: The laws that permit health care personnel to breach a patient’s confidentiality to protect a third party are frequently limited in scope to mental health professionals, such as psychiatrists or psychologists, and/or social workers. If the laws are strictly limited to those professionals, they may offer no protection to you as a dermatologist. law and get back to you as quickly as possible. Sandy: Okay, Bryan. I will wait to hear from you. Thank you again for your help. If you have any suggestions for topics to be discussed in this column, please email them to me at [email protected]. See the February 2013 issue of Dermatology World for disclaimers. Sandy: What about my ethical duty to protect the patient’s husband? I really think he is in danger. Bryan: I am certain that you feel morally obligated to act. Nevertheless, if neither our state nor local jurisdiction recognizes a duty to inform or protect the patient’s husband, the patient may take legal action against you if you violate her confidentiality. I will check the relevant state and local www.aad.org/dw about g in th g in rd a w re Th e m o s t gist is : lo to a rm e d a g in be ply) (check all that ap e rtise to mak medical expe y m g in Us ¨ e a differenc s' faces y on patient ¨ Seeing the jo ents t new treatm ¨ Learning abou in cancer nts about sk tie pa g in at c ¨ Edu tter about ople feel be pe ng pi el H ¨ ance their appear y for patients to pa or f s th on m ¨ Waiting e and care my expertis ___ ______________ ¨ ____________ If waiting for patients to pay didn't make your list, CareCredit can make an immediate difference. When a patient pays with the CareCredit health, wellness and beauty credit card you get paid in just 2 business days - with no responsibility if the patient delays or defaults.† This immediately helps make payment more rewarding: Reduce accounts receivable Improve cash flow Free your team from the time and stress of billing and collections Helps remove cost as a barrier – can be used for deductibles, co-pays, skin care products, and other fees not covered by insurance Preferred Provider To get started at no cost today, call 866-247-3049 † Subject to representations and warranties in the CareCredit Acceptance Agreement for Participating Professionals. www.carecredit.com DERMW2015CA technically speaking BY MORRIS W. STEMP, CPA, MBA, CPHIMS, AND BEVERLY WACHTEL How to choose tech solutions to maximize productivity and improve patient care EVERY OTHER MONTH, DERMATOLOGY WORLD covers technology issues in “Technically Speaking.” This month’s author, Morris W. Stemp, is the CEO of Stemp Systems Group, a Health IT solutions provider in New York City. Wachtel is the marketing manager at Stemp Systems. Stemp earned the designation of Certified Professional in Health care Information and Management Systems (CPHIMS) in 2010, joining an elite group of only 1,500 professionals worldwide to earn this certification. M edical practices don’t have computers and diagnostic equipment in the office because the doctors and staff love technology. They have this technology because it is required to take care of patients, run the office more efficiently, and get paid faster. There are many technologies and options available. Choosing the optimal solution can enhance the lives of the doctors and staff, and create an enjoyable patient experience. Choosing the wrong solution can be very frustrating, inefficient, and costly. Even more costly is the time and money to move from the wrong solution to the right solution (a task unfortunately performed at some point by almost 50 percent of EHR users). So how do you choose? The most central technology at any medical practice is the EHR including the practice management (PM) module. As you probably already know, a good part of a physician’s and staff’s work day revolves around using this technology, and using an EHR changes a practice’s entire workflow. You’ll find more information about choosing a dermatology-specific EHR, and technology which integrates with it, in the sidebar. CHOOSING THE RIGHT TECH SOLUTION Given all the complexity and options, how do you choose the right tech solutions? While there are many choices to address some needs, you’ll find that there are very few choices for others. While cost will always be a consideration, a system that is easier to use will lead to greater productivity and be less costly over time. THE STEPS OF THE PROCESS 1 Understand your needs It may seem obvious, but before you even consider a technology solution, you need to understand and document the problem you are trying to solve. Frequently, our clients know they have an issue but have difficulty articulating and documenting the details and nuances of the issue. This documentation is critical to convey your needs to possible solutions vendors and to evaluate the degree to which the solutions meet your needs. 2 Create an evaluation team The staff members who eventually use the solution are the best group to be involved in both documenting the need and evaluating the solutions. You’ll also have more cooperation from the staff in implementing the chosen solution if they have input into making the decision. 3 Learn the options Researching the available technology options that might meet your needs is the next step. Searching the 14 DERMATOLOGY WORLD // February 2015 www.aad.org/dw tech tips Internet, contacting vendors, attending dermatology and health IT conferences, as well as speaking with colleagues and with IT consultants, will expand your awareness of all the options and reveal a range of pricing. Gaining this awareness will also lead to further refinement of your needs. 4 Set a budget Now that you have an idea of the possibilities and range of costs, you can set your budget and refine your choices to those that fit within your budget. Be sure to consider not only the cost of the software and hardware alone, but also the cost of implementation, training, maintenance, and support. Do you have the funds available or will you consider financing the solution? If the purchase cost is substantial, you should discuss the income tax issues regarding purchasing and financing the equipment with your accountant. 5 Write a request for proposal When choosing an expensive technology solution such as an EHR, prepare a request for proposal (RFP) for each vendor you are seriously considering. This document tells the vendor about your practice and your priorities in choosing a solution. By submitting an RFP with blanks for the vendor to fill in answers, you will be able to do a side-by-side comparison of solutions from different vendors. The RFP should include the following information. Your practice information – size, location, computer hardware and network information and any product you currently use for the same purpose. Your practice’s goals for functionality – prioritized Request for vendor information – history, number of employees (for sales/ support/research and development, and management), financial statements, product history, list of current dermatology users of that product that are similar in size to your practice Request for product information – how it performs your prioritized functions, other functions it performs, software versions and release dates Hardware and network requirements to use their product Maintenance and support provided and related costs Training provided (included and for additional cost) Details of a proposed implementation plan Integration and interface capabilities Proposed costs and payment schedule Warranties Sample contract 6 Select vendors to consider Compare the RFPs and select the vendors of a few products you would seriously consider. If choosing an EHR, consider vendors that have EHR systems that are specific to dermatology, integrate with the other products you want to use, and have favorable ratings. 7 Schedule a demonstration Invite the vendors to come to your office to demonstrate functionality and workflow of the technology. (Some technologies have online demos, but it is preferable to have in-person demos for a system as pervasive as an EHR or PM system.) When vetting an EHR, look at the layout of the screens. Does the design of the screens make the steps to document a dermatology visit intuitive? Does the EHR have the option to draw on the screen (with your finger or stylus)? Does the design enable you to easily input data, construct queries, and create reports so that the EHR will be more useful than a paper record? How many clicks does it take for each visit? Extra clicks take more time, so make sure the next steps flow and the screens are easily accessible. Is the EHR easy to use on a laptop, tablet, or smartphone? Provide the vendor with scenarios to find out if the product meets those needs or can be customized. Ask the vendor about integration with other systems. Which practice management software integrates with their EHR? Is the EHR part of a suite which includes the PM system? Be sure to let staff participate in vendor demos to see if the EHR meets their needs as well, since they will be using different functions of the software. Everyone who will be using the system should have input, including clerks, medical assistants, nurses, and doctors. There needs to be buy-in from the whole team to ensure that implementation of the EHR will be successful. Ask about training and support for the product. If you are replacing your EHR, ask about moving the data into the new system, or creating an interface to allow you to access data from your old system. Upon moving to a new system, it’s important to consider what you are going to do with your old system and if you still need access to it. If the old system is a cloud-hosted system, maybe you can negotiate a lower rate since you will no longer be actively using it? If the old software is running on some old server, do you expect that server to be stable until you no longer need access to your old software? It may be possible to move the old system into a hosted environment where the system can be kept alive so you can access it. 8 Check references Check with other physician users and ask each the same questions about the solutions you’re considering. Compare their practice with your own. Inquire about their usage, the training and support they’ve received, the hardware that was required, how the product was implemented, and their satisfaction rating. Also check references with IT consultants. Then do the same type of side-by-side comparison of the responses. You might even consider asking the vendor for references to practices that were using their system but are no longer using it. Speak with those practices to find out why they switched away from the system you’re considering. 9 Visit other practices that use the solution you’re considering If you don’t know of other dermatology practices the same size as yours that are using the solutions you’re considering, visit the practices recommended by the vendor. Recognize that the vendor will only choose practices that are happy with their product, but it will give you the opportunity to see the product being used in an office environment. Pair a doctor from your office with a doctor who uses the product, and pair a practice manager with a practice manager, to observe DERMATOLOGY WORLD // February 2015 15 technically speaking continued the workflow. Watch how the product is used and ask questions about how the technology functions. Ask about their experience working with the vendor including the training, updates, and support provided. This is especially important in choosing an EHR since the EHR is a game-changer for your practice. Be sure to take notes. 10 Rank the vendors One of the most difficult aspects of evaluating possible solutions is determining which solution does the best job of meeting your needs. Rank the vendors using the results of the product demo and references, based on how they meet your goals and priorities. Consider not only functionality and cost, but also the implementation, training, sup- port, how the product is maintained, and the long-term viability of the vendor. If the solution you are considering has a lot of features to compare, it is a good idea to develop an evaluation matrix. For the columns list the goals you want to meet by using technology, and for the rows list the names of the technology solutions. You’ll find more criteria as you do your research, and then you can ask the vendors whether (and how) their product meets those needs. 11 Select a solution Compare your notes from the office visits to your notes from the demos and the RFPs. Select the best, and the second best, solution for your needs. If you are not happy dealing with your first choice when negotiating your contract, you’ll be ready to proceed with your second choice. 12 Negotiate a contract Your contract is just as important as the technology you choose. Most EHR vendors offer standardized contracts with some negotiable terms, but some will not negotiate terms. It is a good idea to consult an experienced attorney for help with contract negotiations. The Office of the National Coordinator for Health Information Technology has a guide that explains key contract terminology and how it may impact a physician’s practice. We strongly recommend that you read it. Ask for a trial period and escape clause. Also, review the terms of the training: find TECHNOLOGY DESIGNED FOR DERMATOLOGY EHR AND PRACTICE MANAGEMENT The electronic health record is an electronic version of the patient chart, including the medical history, demographics, progress notes, problems and medications. The practice management portion of the EHR manages appointment scheduling, secure messaging, reporting, document management, and billing. Some of the features which make an EHR specific to the practice of dermatology include: • Dermatology and cosmetic surgery specific templates (such as acne, psoriasis, lesions, rosacea, and cancer screenings) • Dermatology workflow management • Dermatology-specific procedure and diagnosis codes • Dermatology-specific clinical decision support • Graphics of each area of the body on which to identify the location of and draw the dermatologic condition • Ability to store before and after photos of patients • Ability to draw directly on photos to demonstrate location of treatment using touch-screen or digital pen 16 DERMATOLOGY WORLD // February 2015 With so many EHR choices, it will be helpful to follow a very comprehensive selection process like the one described in the main article. You’ll want to make sure you’re happy with the EHR that you’re using before you start focusing on add-ons and integrated technologies. Make sure that the EHR you choose can be configured to access your local Health Information Exchange to comply with the HIE requirements of meaningful use. In addition, make sure that the solution will enable you to transition smoothly to ICD-10. DERMATOLOGY SOLUTIONS THAT INTEGRATE WITH EHR There are many technology options that integrate with EHR systems. Data only has to be updated in one application and the changes are automatically made in the integrated systems. Integration benefits the practice by increasing efficiency and reducing errors due to manual entry of data. Patient Portal One of the requirements of meaningful use is patient engagement. Engaging patients with secure communication through a patient portal can also save your practice time. The portal enables patients to schedule and view appointments, receive communications from your office, and access portions of the patient’s medical record. Most EHR systems offer a cloud-hosted patient portal. There are also nonproduct specific portals which may integrate with your EHR such as Omedix, InteliChart, and Updox. Dictation Many physicians like to use dictation services to document their notes instead of typing and clicking through their EHR. Dragon Medical by Nuance is the top selling transcription software for health care. Many EHR systems integrate with Dragon for documentation of notes and even for navigating around the system. E-prescribing E-prescribing is built into most EHRs. For physicians not using an EHR, standalone options are available through Surescripts, MDToolbox, DrFirst’s Rcopia, and the National ePrescribing Patient Safety Initiative. Surescripts is an e-prescribing network which covers more than 90 percent of U.S. pharmacies. (MPR discontinued its ePrescribing service effective August 2014. Refills can be transferred to another e-prescribing service). www.aad.org/dw tech tips out how much training is included in the price and how much it costs for additional training later. SKIPPING SOME STEPS It is clear that some of these steps are not necessary for every technology solution you purchase. If you are the only one using the technology, you don’t need to create an evaluation team to choose it. There may only be one reputable vendor for the solution you want, so the RFP may not be relevant. You may simply decide to use the same technology your favorite colleague uses or that you were exposed to in medical school. Clinical decision support Clinical decision support (CDS) is interactive software used at point of care that works with the clinician’s knowledge to assist in diagnosis and analysis of patient specific data. It is built into most EHR systems. A standalone version for dermatology, available on desktop, smartphones, and tablets, is VisualDx. Laboratory platforms Instead of receiving your lab and pathology results by fax and having to manually file them in the patient charts, you can save time by having the results transmitted electronically from the lab and attached to the patient record in the EHR. All of the major medical laboratories set up integrations with EHRs, including Quest, Labcorp, Sunrise, and Shiel. Photo storage Storing and accessing photos is essential for dermatology. Options were discussed in the October 2012 Technically Speaking column; see www.aad.org/dw/ monthly/2012/october/dermatologistshave-options-for-storing-and-accessingphotos-in-their-records. Informed consent Integrating informed consent into your technology process helps to limit your liability. This was discussed in the ASSESSING THE SOLUTIONS YOU’RE CONSIDERING If you’ve prepared a matrix to compare products, you’ll find it is relatively easy to see which solutions have which features. Evaluate which features are most important to you, and eliminate the products that don’t have those features. Then, as you do your side-by-side comparison, decide which remaining features are more important to you and move the products that have those features to the top of the list. GETTING THE MOST OUT OF YOUR IT When you choose a technology solution, you want to make sure that the technology helps you improve productivity. To get the most out of your IT, you will want to October 2014 issue; see www.aad.org/ dw/monthly/2014/october/informedconsent-how-technology-can-improvethe-process. HIPAA-compliant communication There are many HIPAA-compliant methods of communication that you can use to collaborate on patient care such as text-like applications, encrypted email, and e-fax. Options can be found in the June 2014 issue; see www.aad.org/dw/monthly/2014/ june/hipaa-compliant-ways-tocommunicate-with-other-doctors. Cloud storage Sometimes it is helpful to work on documents with patient information outside of the office, or in collaboration with another provider who is not in the same location as you. Using a HIPAAcompliant cloud-storage solution will enable this process, as discussed in the February 2014 issue; see www.aad. org/dw/monthly/2014/february/usingthe-cloud-for-data-storage. Smartphone apps Your smartphone can be used in many ways to improve productivity in your dermatology office. If you do use smartphone apps for clinical care, ensure that your mobile phone is password encrypted and download a remote wipe app such as Find My iPhone. make sure that the technology solutions work together and that you know how to use them. So it boils down to integrations and training. If the product integrates with your EHR, the information gathered and produced by that technology will move directly into the patient records in the EHR, eliminating the need for data entry, which saves time and improves accuracy. With more training, you’ll know how to use more of the features of the product and the most efficient way to use it. Both will lead to improved productivity, accomplishing your goals of taking care of patients, running the office more efficiently, and ultimately, getting paid faster. dw There are skin scanner solutions that turn your smartphone into a dermatoscope, like the DermLite and the Handyscope, and imaging apps that associate patient metadata with the image like the tKDerm Touch. (See the October 2012 issue at www.aad.org/dw/ monthly/2012/october/dermatologistshave-options-for-storing-andaccessing-photos-in-their-records.) If you’re looking for easy access to information, there are also apps you can use on your smartphone or computer to access online materials, like Medscape for research and Epocrates for drug reference. Many of the hundreds of dermatology smartphone apps are designed for patients. If you decide to use them, check the ratings; most are not rated well. One that we like that is patient centered is ZocDoc. Potential patients, who download ZocDoc for free, use it to look up doctors in the area who take their insurance, and book appointments. Physicians pay a flat fee of $300 per month for a listing and the app syncs with the PM scheduling system. The cool thing about it is that the app tracks cancellations, enabling patients to book appointments in those slots. DERMATOLOGY WORLD // February 2015 17 answers in practice BY RACHNA CHAUDHARI Keeping track of all those penalties EACH MONTH, DERMATOLOGY WORLD tackles issues “in practice” for dermatologists. This month Rachna Chaudhari, the Academy’s practice management manager, offers tips on an area she commonly receives questions about from members. D ermatologists are well aware that they face penalties from the Centers for Medicare and Medicaid Services (CMS) if they do not comply with various quality reporting programs including meaningful use (MU), the Physician Quality Reporting System (PQRS), and the value-based modifier (VBM). However, due to the confusing regulatory language surrounding these programs, many dermatologists are not aware that these penalties are cumulative and add up to much larger percentages than they originally thought. In fact, the Medical Group Management Association (MGMA) recently released results from its Physician Practice Assessment: Medicare Quality Reporting Programs survey that showed over 70 percent of physician practices rated Medicare’s quality reporting requirements as “very” or “extremely” complex. Additionally, more than 83 percent of respondents believed the current Medicare quality reporting programs did not enhance quality of patient care; the vast majority of respondents, and probably most physicians, would support streamlining all of these programs into one quality reporting program that would standardize reporting. In order to fully comprehend how much of your Medicare Part B revenue is at stake with these quality reporting programs, you need to know how each program is administered and reported. Each program is outlined in the summary below. MEANINGFUL USE The MU program was created by Congress in 2009 to encourage physicians to adopt electronic health records (EHRs). MU requires that physicians complete a series of measures to show that they are utilizing their certified EHR in a quality manner, such as performing electronic prescribing, documenting medications in the electronic chart, and implementing a patient portal. All of the measures and guidelines are outlined on the AAD website at www.aad.org/meaningfuluse. Physicians who choose to not report in this program will face a 1 percent penalty in 2015. If you did not participate in the program between 2011-2014, you should check your Explanation of Benefits (EOB) statement to see the 1 percent penalty. Additionally, if you did 18 DERMATOLOGY WORLD // February 2015 www.aad.org/dw management insights not participate in the electronic prescribing program through CMS in 2012 or 2013, you will see an additional 1 percent penalty on your EOB. The e-prescribing penalty will end after 2015 while the MU penalty will increase by one percentage point every year to a maximum of 5 percent. PQRS PQRS was created by Congress in 2006 to foster quality measurement amongst medical providers. The program, which initially offered bonus payments to those who participated, now requires providers to report on a series of quality measures to avoid penalties on their Medicare Part B revenue. If you did not report in the PQRS program in 2013, you should review your current EOB to see if you are receiving a 1.5 percent penalty. (You probably are.) The penalty increases to 2 percent in 2016 and continues at 2 percent for every subsequent year. Each year of reporting to PQRS serves to avoid the penalty two years in the future. (New providers are assessed on a shorter timeline.) Dermatologists have several specialty-specific quality measures to report on including measures related to melanoma, psoriasis, and biopsies. For more information on measure specifications and reporting guidelines, see www. aad.org/qrs. VALUE-BASED MODIFIER The value-based modifier (VBM) was created through the Affordable Care Act (ACA) to begin value-based payments to providers for Medicare services. It will either raise or lower Medicare provider reimbursement based on their cost compared to other providers in the same geographic area and quality data from the PQRS program; nonparticipants in PQRS will automatically see VBM-based payment reductions. The program begins in 2016 for group practices with 10 or more eligible providers and will affect their pay by up to 2 percent that year. Practices with less than 10 providers or solo practitioners will be subject to the value-based modifier beginning in 2017. PENALTY SUMMARY For 1-9 provider practice Year EHR PQRS VBM Total 2015 1% 1.5% 0% 2.5% 2016 2% 2% 0% 4% 2017 3% 2% 2% 7% 2018 4%* 2% TBD** 6% + VBM 2019 5%* 2% TBD** 7% + VBM *EHR penalty will rise to 5% if less than 75% of all Medicare providers are participating in meaningful use by 2017. **Scheduled to be announced in final rule for 2016 Medicare fee schedule. For 10+ provider practice Year EHR PQRS VBM Total 2015 1% 1.5% 0% 2.5% 2016 2% 2% 2% 6% 2017 3% 2% Up to 4% Up to 9% 2018 4%* 2% TBD** 6% + VBM 2019 5%* 2% TBD** 7% + VBM *EHR penalty will rise to 5% if less than 75% of all Medicare providers are participating in meaningful use by 2017. **Scheduled to be announced in final rule for 2016 Medicare fee schedule. If you are part of a group practice of 10 or more providers, you would have had to participate in either the PQRS Group Practice Reporting Option (GPRO) or had at least 50 percent of your individual providers in the practice participate in PQRS in 2014 to avoid the 2 percent penalty in 2016. If your group practice successfully participated in PQRS in 2014 and you are deemed a high quality/low cost provider, you could obtain an incentive up to 2 percent of your Medicare Part B allowed charges in 2016. To determine if your practice meets these criteria, CMS will release a Quality and Resource Use Report (QRUR) in Summer of 2015 that will detail quality and cost performance data. You can view your QRUR from 2014 by logging in at https://portal.cms.gov/wps/portal/ unauthportal/home/. In 2015, you would have to continue participating in PQRS, however your group practice could still face a penalty of up to 4 percent in 2017 if you are deemed a low quality/high cost provider through the QRUR. If you are a solo practitioner or part of a group practice with less than 10 providers, you must report in the PQRS program in 2015 to avoid the value-based modifier penalty of 2 percent in 2017. You could also obtain an incentive of up to 2 percent if you are deemed a high quality/low cost provider through your QRUR report; however solo practitioners and group practices of less than 10 providers will be subject to greater penalties in 2018 even if they continue to participate in PQRS but are found to be low quality/high cost providers through QRUR. For more information on how the VBM is calculated, visit www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ PhysicianFeedbackProgram/ValueBasedPaymentModifier.html. dw DERMATOLOGY WORLD // February 2015 19 Dermatologists profile the specialty’s data needs 20 DERMATOLOGYWORLD WORLD////February February2015 2015 20 DERMATOLOGY www.aad.org/dw www.aad.org/dw BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR D ermatology patients are keenly aware of the unique value of the specialty’s care. According to a 2001 study in the Archives of Dermatology, patients have confidence in their primary care physician to care for their skin disease. However, they have more confidence in the care provided by their dermatologist (Arch Dermatol. 2001 Jan;137(1):25-9). Yet as health care evolves from a volumebased, fee-for-service model, physicians are being asked to prove their worth beyond anecdotal evidence. Given this new environment, experts are beginning to think that data collection is no longer a luxury, but a necessity. “People are starting to understand the imperative of having a strategy around value,” said Elizabeth O. Teisberg, PhD — author and professor at the >> DERMATOLOGY WORLD // February 2015 21 Dartmouth Center for Health Care Delivery Science — at a recent forum on demonstrating value in health care. “So how do we switch from a strategy around volume to one of value?” To Dr. Teisberg and many in dermatology, the answer to that question lies in the development of data registries that measure patient outcomes and physician performance. “Dermatology is a specialty that few people truly understand,” said Oliver Wisco, DO, a member of the Academy’s Ad Hoc Task Force on Data Collection Platform and Registries. “I see a data collection system as a way to define our role as specialists.” However, as a specialty that collectively treats up to 3,000 skin diseases, the continued process of determining data collection priorities will prove daunting. “We need to decide what to collect and what requires standardization,” Dr. Wisco said. “The development of a standardized way to grade a disease — or the features that lead to a certain grading system — needs to occur within the different subspecialty groups within our specialty.” The Ad Hoc Task Force on Data Collection Platform and Registries has been charged with investigating the data collection options for members, recommending action toward platform development, and advising on functionality to best serve dermatologists’ data needs. So far, the task force has gleaned some clarity on what the specialty’s specific data needs are, and where the Academy could potentially start when building out this platform, which has been named DataDerm™. HONING IN ON DISEASE To many, a natural first step in developing a data registry would be to focus on care for specific diseases. “As a specialty, skin cancer is one of the crucial areas of what we do that we have to own — I think we have the most comprehensive training to best care for skin cancer patients,” Dr. Wisco said. “Defining what we do and why we do it well, and what we should improve upon, is where we should start first.” Joel Gelfand, MD, MSCE, a member of the Academy’s Research Agenda Committee, agrees and believes that some of the most common dermatologic diseases — psoriasis, eczema, and acne — are the logical places to start. At the University of Pennsylvania, Dr. Gelfand developed the Dermatology Clinical Effectiveness Research Network (DCERN), the first U.S.-based independent dermatology registry, to review data on more than 1,800 patients across the country with moderate to severe psoriasis to benchmark his patients’ 22 DERMATOLOGY WORLD // February 2015 treatment outcomes. The registry was initiated through an NIH “Challenge Grant” targeting an Institute of Medicine priority to determine the comparative effectiveness of treatments for moderate to severe psoriasis. “DCERN data allows us to determine achievable goals for psoriasis patients, be they physician-reported, such as percent of patients being clear or almost clear, or patient-reported, such as percent of patients having minimal quality of life impairment based on the Dermatology Life Quality Index survey. Say, for example, the national average of being clear or almost clear on drug ‘X’ is about 50 percent. If in my practice it’s 30 percent, I might think something is wrong,” Dr. Gelfand said. Dr. Gelfand measures how thick, scaly, and red his patients’ plaques are, logging and following up on these data points over time. “I can show patients how they’re doing over time and we can make treatment decisions based on this objective data. The goal would be to help people identify what the norms of good control are so we could all have quality improvement.” According to James Cavan, president and chief operating officer of Corrona, LLC, which collects data across several disease areas, the breadth and depth of the collected data points will vary depending on the nature of the disease and the treatments. CORRONA was founded in 2000 to advance medical research and improve the quality of patient care by observing the effects of biologic agents in the treatment of rheumatoid arthritis, psoriatic arthritis, and spondyloarthritis, and is also launching a Psoriasis Registry in collaboration with the National Psoriasis Foundation. CORRONA has collected thousands of data points from multiple private and academic sites on over 42,000 rheumatic disease patients. After the data are analyzed by independent academicians and statisticians, employed by medical centers or universities, CORRONA will provide the aggregated tables and data to subscribers — both industry and research facilities — with general observations about the effects of a particular biologic agent on these patients. CREATING PATIENT VALUE While focusing on disease and treatment outcomes could be a first step in developing a registry, experts argue that gathering information on disease treatments is only a fraction of what a data collection system could do. “This will not be a registry in terms of just thinking about it as a disease-specific registry,” said James Taylor, www.aad.org/dw S C E N V I R O N M E N T A L Many specialty groups and disease-based organizations have dipped their toes into the data registry realm in recent years. While the conditions and data points may differ, the goal of each registry represents a shared desire to improve care. N Organization American College of Cardiology American Consortium of Academy of Rheumatology Ophthalmology Researchers of North America, Inc. Dermatology Clinical Effectiveness Research Network American College of Rheumatology Crohn’s and Colitis Foundation of America American Academy of Dermatology Name of registry NCDR™ (National Cardiovascular Data Registry) – Includes six hospital-based registries and one outpatient registry. IRIS™ Registry (Intelligent Research in Sight) CORRONA™ (Consortium of Rheumatology Researchers of North America, Inc.) Dermatology Clinical Effectiveness Research Network RISE (Rheumatology Informatics System for Effectiveness Registry) CCFA Partners Current: AAD Quality Reporting System (QRS) Established 1998 2014 2000 2009 Currently in beta-testing mode – expected completion fall 2015. Started as a pilot in 2010 2011 (QRS) Goal(s) Promote practice innovations and achieve clinical excellence. 1.Improve the quality of eye care. 2.Support pay-forperformance reporting. 3.Support MOC. 4.Provide infrastructure for clinical research. Utilize observational research of patients with rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, and psoriasis when they have meaningful exposure to biologic agents. Perform scientifically sound clinical research critical to advancing the care of dermatologic disorders. Help physicians make treatment decisions and improve the quality of care for moderate to severe psoriasis patients. Assist members in practice improvement, local population management, and participation in national quality programs. Improve the quality of life for patients living with inflammatory bowel disease (IBD) through research and education. QRS facilitates member and approved members’ non-physician clinicians to participate in CMS PQRS. User(s) ACC hospitals AAO members and physicians Physicians at CORRONAapproved sites. DCERN members ACR members Patients with Crohn’s Disease and ulcerative colitis. AAD members and approved members’ non-physician clinicians By the numbers Used by 2,400 hospitals and 1,000 outpatient providers and includes 18 million patient records. Collected more than 110,000 patient years of data representing about 42,000 patients. Data on over 1800 patients with moderate to severe psoriasis collected. 11 published studies in JAMA Dermatology and JAAD. Currently in beta-testing mode with 50 practices; have collected 300,000 patient encounters. 13,000 patients enrolled; have produced about 25 abstracts and 12 papers. Has recorded data on more than 396,000 patient encounters. 98 percent of users who submit data via QRS successfully qualify for CMS incentives. As of September 2014: 5,000 physicians registered; includes 10 million patient encounters from 3.85 million unique patients. Future: DataDerm™ DERMATOLOGY WORLD // February 2015 23 MD, co-chair of the Ad Hoc Task Force on Data Collection Platform and Registries. “The Academy envisions an expanded data platform that will collect electronic data from members nationwide for external reporting requirements, specialty advocacy, maintenance of certification, quality improvement, and related programs. The whole purpose is to have good outcomes and outstanding patient care. The patient is at the center of this.” By collecting patient-reported outcomes, physicians will be able to improve the value of the care from the patient’s perspective. Dr. Gelfand can think of a number of patients who he thought were doing well based on the outcomes data he was collecting. However, “I’ve had people whose qualityof-life scores were really not good,” Dr. Gelfand said. Those results prompted Dr. Gelfand to discuss changing therapies with the patient. “The more data The Martini Klinik attributes its ability to develop flexible and innovative therapies to several key factors. The clinic maintains that its surgeons have years of expertise in the field of prostate cancer and as such, that cumulative experience and knowledge can lead to high-quality care and innovative therapy development. Additionally, because the clinic is located at the University Medical Center Hamburg-Eppendorf, the clinic’s physicians and its patients benefit from the readily available expertise of other specialists throughout the hospital. This “network competence” includes not only the regular use of pathologists and oncologists to help develop necessary follow-up treatments, but psychologists to provide follow-up support to the patients as well. On average, one year after prostate surgery, roughly 75 percent of German patients report erectile dysfunction (ED). However, as a result of this specialized and comprehensive The more data we have to make good treatment care, at Martini only 34.7 percent of decisions the better off our patients will be. patients experience ED. On average, incontinence after one year of surgery is we have to make good treatment decisions the better 43.3 percent; at Martini it’s 6.5 percent. “Physicians off our patients will be.” have to get at what really matters for the patient with While the prospect of evaluating each patient’s a specific disease, beyond survival,” Dr. Teisberg quality-of-life may seem like an overwhelming said. “What you measure will be what improves, so endeavor, Dr. Teisberg maintains that for specific measure what really matters to the patient.” patient populations, the breadth of these data REFINING CARE points may prove thinner than one thinks. “Value By identifying both disease-based and patientis created at the level of the individual patient defined outcomes, physicians may find that they are but structured around common conditions,” Dr. Teisberg said. “Think about organizing solutions for altering their clinical care. “If I want to understand how my practice is doing in general, I need to figure segments of patients with similar needs.” According out how I am doing in making people’s quality of to Dr. Teisberg, at the Prostate Cancer Clinic at the life improve,” Dr. Gelfand said. “For the patients Martini Klinik in Germany, physicians capture not who aren’t doing well, how can I serve them better?” only survival rates, but also functional outcomes However, individual benchmarking may make some that the patients are most worried about: impotence uneasy. “We have to get out of the mindset that and incontinence. Because patients have defined data is about grading. Data is not about grading,” these needs as highly important, surgeons at the Dr. Wisco said. “Data is about understanding your Martini Klinik make it a priority to ensure that patient population and how to improve the care that the neurovascular area for continence and erectile they receive.” Additionally, according to Dr. Wisco, function remains intact during surgery. After the the value of data collection is not just to prove that surgery, staff at Martini collects data around these the specialty does its job well. “This is a system patient-defined outcomes one week, three months, that we can use to show the rest of the medical and every year after the treatment so physicians community that we are striving for better care, can evaluate their care and tweak treatments better access, and better patient outcomes.” accordingly. 24 DERMATOLOGY WORLD // February 2015 www.aad.org/dw Benchmarking care was one of the primary reasons that the American Academy of Ophthalmology (AAO) developed the IRIS™ registry (Intelligent Research in Sight). According to Michael Chiang, MD, chair of the AAO’s Medical Information Technology Committee, there are several goals with IRIS, but the number-one benefit of this platform is to improve the quality of eye care. IRIS was developed in 2012 and launched in March 2014. Since then, IRIS has registered 5,000 AAO physicians who have logged 3.85 million unique patients and 10 million patient visits in the system. “In terms of quality improvements, I think ophthalmologists just want to do a good job taking care of patients,” Dr. Chiang said. “The premise of the registry is that by providing a mechanism to do that, ophthalmologists can individually benchmark how they’re doing and identify what they’re doing well and how they can be better.” STREAMLINING REPORTING REQUIREMENTS In addition to improving the quality of the physician’s care and the value of that care to patients, Dr. Taylor said that DataDerm will continue to support members regarding the reporting requirements already in place. Specifically, Dr. Taylor believes that information gathered for DataDerm will be used for MOC selfassessment and quality improvement activities. “MOC is not going to go away so we need to come up with further ways for members to evaluate their own practices and then meet the requirements for MOC,” Dr. Taylor said. Additionally, physicians are now required to report quality measures through the Centers for Medicare and Medicaid Services’ (CMS) Medicare Physician Quality Reporting System (PQRS), or face a payment reduction. While physicians who reported quality measures in 2014 were eligible for an incentive payment of 0.5 percent of their total Medicare Part B allowed charges, physicians who haven’t reported will endure a 2 percent payment reduction, assessed in 2016. According to Dr. Taylor, having more measures to report that are developed by the Academy should make it easier for physicians to avoid future payment reductions, and a centralized data registry could help in the development of these measures. “CMS expanded the number of measures that we’re required to report from three to nine and we don’t have nine dermatology-specific measures,” Dr. Taylor said. According to Brent Moody, MD, a member of the AAD Health Care Finance Committee, CMS and a number of other programs are looking to the specialties to determine what their quality measures should be. “They are admitting that they cannot be the arbiter who determines quality practices for a particular specialty,” Dr. Moody said. “They invited the provider community to come up with meaningful measures for those providers and that type of practice.” ADVOCATING FOR THE SPECIALTY’S WORTH In addition to reporting demands, dermatology is facing unprecedented challenges to cut costs from the legislative, regulatory, and private payer arenas. Given these pressures, physicians are finding it more difficult to retain fair value for the services they provide. Experts argue that data is paramount in showcasing value with key policymakers, because data drives many of the decisions being made about health care today. Without these data, the value of the specialty may be determined elsewhere. “We are in a situation where the data is already out there and it’s being analyzed and acted upon, but the quality of that data right now is poor,” Dr. Moody said. Howard Rogers, MD, another member of the AAD Health Care Finance Committee, explains. “Insurance companies don’t have their own data regarding either the quality or cost-effectiveness of physicians. So in lieu of setting up in-house data, most insurers have gone to third-party private corporations that provide them with data.” According to Dr. Rogers, these third parties analyze the cost of claims data within individual episodes of care. The physician who was paid the most during that episode becomes the party deemed responsible for that episode. As a result, that physician is assigned a cost or quality index which ranks the physician with their peers. “The episodes of care are not well-differentiated in terms of severity and there are no good measures at this point on severity. A small superficial skin cancer in the leg will be compared to a large one on the nose, which may require more resources,” Dr. Rogers said. “In terms of outcomes, there’s no ability for the insurance companies or the people providing the episode of care to decide what the outcome was — whether the skin cancer was cured, there was a good cosmetic result, or the patient had significant side effects or complications from the surgery. All of these measures provided to the insurance companies are based solely on cost.” As a result, Dr. Rogers argues that a central dermatology data platform could provide the missing pieces in payers’ value equations. “The DERMATOLOGY WORLD // February 2015 25 data could tell us a lot about the severity of our patients and tell us how well we do in terms of diagnosing patients. It’s going to really indicate why certain patients are more severe. If we’re saying that dermatologists are the experts in skin disease and that we’re getting better outcomes, we’ll need to prove that. The only way to prove that is to have the data.” now a revenue stream for the College. That allows us to support advocacy and other programs.” However, perhaps a more daunting obstacle lies with the feasibility of collecting these data. “One of the challenges going forward is to handle this electronically with minimal effort on the part of the members to report their data,” Dr. Taylor said. “The idea would be that we would collect data directly from electronic records so there would be DATA COLLECTION CHALLENGES little direct involvement required on the part of the While there may be no shortage of physicians physicians. The challenge would be dealing with the who believe that a concerted data collection effort EHR vendors in terms of pushing or pulling data could help the specialty demonstrate its value, from the electronic records and interfacing with our many remain concerned about the administrative registry vendor to get the data.” and financial burdens that an undertaking of this Dr. Brindis reiterates that one of the most magnitude could have on physicians and their important considerations when developing a practices. To help pay for the development of a data successful data registry is ensuring that the registry and practice management tools and for administrative load on physicians does not interfere with work flow. “With the Pinnacle registry, we developed a tool Data drives many of the decisions that is agnostic to all EHR software being made about health care today. vendors and literally pulls data out of the patients’ encounter and populates the other advocacy activities, the Academy’s Board of data fields. You don’t have to have a staff person Directors is asking members to approve a one-time separately enter data in a Web-based database; the $50 dues increase starting in 2016, followed by a data are auto-populated from the encounter.” Once cost-of-living increase to sustain and maintain these the ACC collects and collates these data — roughly efforts in 2017 and beyond, which the Board of 60 to 80 data points for any given measure — the Directors can forgo if deemed unnecessary (see p. physician will then receive a report on how they 44). The cost-of-living increase will be taken from a fared compared to their peers on that particular national index, which has averaged 2.5 percent over measure. the past 10 years. Regardless of these challenges and concerns According to Ralph Brindis, MD, former about the burden of a data registry, many in president of the American College of Cardiology dermatology believe that physicians can no longer (ACC) and current board member of the ACC’s sit idle while others make decisions about the future National Cardiovascular Data Registry (NCDR™), of the profession and its patients. “If you think the initial investment up front may be a difficult you’re great, how do you know you’re great? If we pill to swallow. However, the value of the data will say that we’re the best at doing what we do, how do far exceed the costs. NCDR started in 1998 and has we know?” Dr. Wisco said. “We’re in an era of health since developed six hospital-based registries and one care where we simply can’t use anecdotal evidence. physician registry, called Pinnacle. “It started out as We have to be more specific in what we do. We have a $1 million investment for the College and people to have data collection systems because it’s crucial to were concerned that it was going to be a waste of our patients and there are limited funds for what we money and wasn’t going to be successful. It was do. But ultimately it’s really what’s right.” dw actually nicknamed ‘the black hole,’” Dr. Brindis recalls. Since then, the NCDR registries have grown into a $35 million a year enterprise for ACC through outsourced contracts with research centers. “It’s 26 DERMATOLOGY WORLD // February 2015 www.aad.org/dw Registration and Housing is open! Join us in San Francisco and experience an array of dermatologic educational sessions like no other! • Sharpen your skills with over 360 sessions covering the latest in dermatology • Enjoy full access to the high-energy exhibit floor as hundreds of exhibitors showcase the latest products and services • Network with colleagues from across the globe and build valuable professional relationships • Discover new and innovative research at the electronic poster exhibits And while in San Francisco, check out: • The Golden Gate Bridge – experience the views of San Francisco’s most famous landmark • Cable Cars – take a ride on the world’s last manually operated cable car system • Pier 39 – home to more than 100 shops and restaurants, an aquarium, and the famous sea lions • Museums – from Modern Art to Walt Disney, explore all the different museums that San Francisco has to offer Discounted rate expires February 11 at 12 p.m. (CT)! Advance registration closes March 11 at 12 p.m. (CT) Visit www.aad.org/AM15 for more information! Dermatologists take aim at pruritus 28 DERMATOLOGY WORLD // February 2015 www.aad.org/dw BY DIANE DONOFRIO ANGELUCCI, CONTRIBUTING WRITER P ruritus has emerged as a leading research target since the 2012 American Academy of Dermatology (AAD) Research Agenda Consensus Conference. Gathering thought leaders in dermatology and representatives from specialty societies, patient advocacy groups, regulatory agencies, and insurance companies, the meeting focused on identifying areas of research that need to be addressed within dermatology, said Henry Lim, MD, who is chair of the Research Agenda Committee and the C.S. Livingood Chair and chairman of the department of dermatology at Henry Ford Hospital in Detroit. Although the AAD is not a funding agency, its activities can help move these initiatives forward, he said. “At that meeting it became very apparent that there was a wide gap in understanding about pruritus and definitely a lack of treatments to address chronic conditions,” said Julie Block, chief executive officer of the National Eczema Association, who was president of the Coalition of Skin Diseases at that time. >> DERMATOLOGY WORLD // February 2015 29 Pruritus is a common symptom among dermatology patients. “It’s one of the biggest problems that patients have,” said Ethan Lerner, MD, PhD, associate professor of dermatology at Massachusetts General Hospital. Patients may have an inflammatory skin disease such as psoriasis or eczema or systemic conditions such as kidney or liver disease. “Those don’t necessarily come to the attention of the dermatologist unless they’re referred by someone else because they don’t really have spots on their skin for the most part,” Dr. Lerner continued. Although dermatologists’ knowledge of itch has been limited, along with their ability to help affected patients, that situation is changing. “I think that nowadays we are more capable and understanding what is behind itch, so we can help our patients,” said Gil Yosipovitch, MD, professor and chair of the department of dermatology at Temple University in Philadelphia; director of the Temple Itch Center; and author of Living With Itch: A Patient’s Guide. EXAMINING ITCH Pruritus can significantly impair patients’ quality of life, leading to sleep disturbances, mental health issues, and other difficulties (see sidebar). Furthermore, the incidence of pruritus increases with age. Kini and colleagues reported in Archives of Dermatology in 2011 (147:1153-1156) that chronic itch affects patients’ quality of life similarly to chronic pain, based on a study of 73 patients with chronic pruritus and 138 patients with chronic pain. “Many dermatologic conditions have itch as a central symptom, if not being the most debilitating symptom in that context,” said Brian Kim, MD, MTR, assistant professor of medicine in the division of dermatology at Washington University School of Medicine in St. Louis and its Center for the Study of Itch. “A good example would be eczema or atopic dermatitis, but… there’s also a number of people who have itch with no clear cause and this is actually quite frequent.” Previously, experts believed that that the same pathways that mediate pain might also mediate itch and, therefore, blocking all neural pathways might alleviate itch. “I think the most explosive move forward has been in the last several years with the identification of itch-specific receptors on sensory neurons,” Dr. Kim said. Such discoveries have provided evidence that itch is a distinct pathway from pain — not just a mild form of pain, he said. MEASURING ITCH One challenge in investigating itch is the lack of specific assessment tools. “We have multiple scales 30 DERMATOLOGY WORLD // February 2015 that have been used by various investigators, but there is no standardized measurement that everybody can agree upon that can be utilized in clinical studies and in presenting data to the FDA,” Dr. Lim said. The AAD Pruritus Workgroup is developing a standardized measurement that can be validated, Dr. Lim said. If accepted by the FDA, it could be used by the pharmaceutical industry when developing medications, he said. The Temple Itch Center uses a numeric visual analog similar to the pain analog commonly used, where patients are asked about the severity of itch on a scale of 0 to 10. “Patients can say, ‘I have horrible itch,’ but you want to get some kind of quantitative assessment,” said Dr. Yosipovitch, who founded the multispecialty International Forum for the Study of Itch in 2005 to promote better understanding of itch. He has also found the visual analog scale helpful when using electronic health records. A 2012 prospective study published in Acta Dermato-Venereologica reported that a visual analog scale, numerical rating scale, and verbal rating scale were highly reliable (92:502–507). Although some studies have investigated pruritus by assessing the number of scratch marks, people can have severe itch without scratch marks, Dr. Yosipovitch said. TREATING PRURITUS Because there are many types of itch, no single treatment fits all cases. “I think that if you don’t have any treatments in your armamentarium that are universally effective, you tend to shy away from managing it,” Dr. Kim said. In addition, the broad nature of the condition makes it difficult to address. “It’s hard for us as clinicians to even understand what itch really is. If you contrast that to, say, psoriasis, where we see it, we can biopsy it, the pathologist will confirm the diagnosis, and now we have treatments for psoriasis that are quite targeted,” Dr. Kim said. “There are some specific targets that we look into. First of all, most of the itch in chronic itch is not mediated by histamine, which was the classical prototype,” Dr. Yosipovitch said. “Antihistamines are the most commonly used medications because these are the only ones approved by the FDA.” However, the effects of antihistamines are limited. Topical treatments target skin receptors, such as the transient receptor potential (TRP) ion channels or TRPVI and TRPA1 associated with the itch of eczema, Dr. Yosipovitch said. He reported on treatments for chronic pruritus with Jeffrey Bernhard, MD, in the April 25, 2013, issue of the New England Journal of www.aad.org/dw Medicine (368:1625-1634). Topical menthol or cooling may help reduce itch through other TRP channels. For itch with dry skin, the upper layers of stratum corneum are damaged; this may be relieved by certain moisturizers, he said. Compounds such as capsaicin and a combination of lidocaine and prilocaine with amitriptyline and ketamine target the ion channels, Dr. Yosipovitch said. Additional topical agents such as strontium and pramoxine numb the nerve fibers and reduce itch. “Most of them work on these ion channels,” Dr. Yosipovitch said. In addition, dermatologists also turn to systemic medications to treat the neural system. “The common pathway of all itches is transfer of nerve fibers to the spinal cord and up to the brain,” Dr. Yosipovitch said. “The concept of reducing itch by mechanisms of drugs that work on the neural system is extremely important.” However, dermatologists may be less comfortable prescribing drugs that affect the neural system because they usually don’t deal with the neural system, Dr. Yosipovitch said. In cases of central sensitization, patients may develop a chronic itch that no longer is simply in ITCH’S IMPACT Patients with severe pruritus often endure constant itching that significantly impairs their quality of life. “Just imagine if you had mosquito bites or poison ivy covering a large portion of your body 24/7 and there was no end in sight to the itching,” said Julie Block, chief executive officer of the National Eczema Association. “The prospect of that is completely unimaginable, but that’s life for the more severe eczema patients,” she said. “Sleep deprivation is probably one of the greatest overall impacts of itch. What follows from that are depression, anxiety, low self-esteem, relationship issues, and isolation.” “I would say that the majority of chronic itch patients will tell you that in the evening and at night the itches intensify,” said Gil Yosipovitch, MD, professor and chair of the department of dermatology at Temple University in Philadelphia; director of the Temple Itch Center; and author of Living With Itch: A Patient’s Guide. “It causes significant impairment of quality of life, and it’s a vicious circle,” Dr. Yosipovitch said. “The more you lack sleep, the more you’re itchy. You’re more depressed. It has an effect on mood. It has an effect on self-esteem.” In extreme cases, he said, the effects can lead to suicide. Furthermore, Block explained, severe itch in children leads to sleep deprivation and impacts the entire family. Loss of sleep leads to social and academic problems for the child and challenges for parents and siblings who also have lost sleep and are anxious and worried about the affected child. Despite patients’ struggles, some physicians may not even ask them about the itch, Block said. “One, because there is no standardized tool to assess it, and two, because there are limited therapies to address it,” she said. Patients may go to great lengths to find a clinician who can provide relief of itch. “I’ve treated a lot of other conditions in the past, but half my patients are coming from hours away, driving from six hours away, flying in from the coast and I’m in St. Louis,” said Brian Kim, MD, MTR, assistant professor of medicine in the division of dermatology at Washington University School of Medicine in St. Louis and its Center for the Study of Itch. “I think that’s very striking.” Block is thrilled that the American Academy of Dermatology has prioritized this area of research. “We have a lot of catching up to do — there’s a gap in understanding, research, and treatments,” she said. “At last count, there were 22 drugs in development listed on clinicaltrials.gov for atopic dermatitis,” Block said. “Just a few short years ago that listing was practically blank. There are a couple of compounds on the list specifically targeting itch. We are entering a new decade for eczema care — we have a lot of hope!” DERMATOLOGY WORLD // February 2015 31 the skin, Dr. Lerner said. “So the neural networks or nervous system is trained to think, correctly or incorrectly, that there’s an itch, and when that happens, putting something on the skin isn’t going to help so much,” he continued. For example, chronic conditions like notalgia paresthetica and brachioradial pruritus have neuropathic origins. In chronic itch patients, hypersensitization phenomenon is common. Nerves react even to nonitchy stimuli, in which case some dermatologists may use medications that target the neural system. “Some of these drugs, such as gabapentin or pregabalin, are given for neuropathic pain and hypersensitization of pain, and they have the same effect for itch,” Dr. Yosipovitch said. In addition, Dr. Yosipovitch and his colleagues also use mirtazapine, a neuroepinephrine and selective serotonin inhibitor, which he discussed with Tejesh Patel, MD, in Expert Opinion on Pharmacotherapy (2010;11:1673-1682). “It reduces itch, not specifically, but it reduces that sensitization, and it enables the patients to sleep better and have less itch at night,” he said. “Sometimes the combination of it with gabapentin and pregabalin is even better.” Mu-opioid antagonists may reduce chronic itch in some cases, but results have not been consistent in uremic patients. However, nalfurafine hydrochloride, a kappa-opioid agonist, was approved in Japan but is not available in the U.S. It is given to patients with uremic pruritus who are receiving hemodialysis. Dr. Yosipovitch has prescribed butorphanol, a mu-opioid antagonist and kappa-opioid agonist, in an inhaled form for intractable itch. He and Aerlyn Dawn, MD, reported on this in the Journal of the American Academy of Dermatology in 2006 (54:527-531). However, this is another drug type that dermatologists are not accustomed to prescribing. In addition, researchers are exploring the use of botulinum toxin for pruritus, injecting it locally, Dr. Lerner said. In treating severe pruritus, clinicians often tell patients not to scratch, but this is a powerful compulsion in patients with itch. In addition, researchers have found that scratching an itch targets brain areas associated with reward, Dr. Yosipovitch said. If researchers could mimic the same brain response with future medications, they may be able to reduce itch, he said. included some speakers who are not dermatologists because there is a lot of research and there are a lot of activities that are going on outside of dermatology in research on pruritus,” he said. (This year’s session will take place Saturday, March 21 from 2 to 5 p.m. in room 2014 of the Moscone Center.) Researchers continue to focus on treatments that will target the specific pathways associated with itch. “There’s so much understanding now about the pathways involved in itch, and some of that learned from work that’s done in the pain field, that I’m truly optimistic that we will have targeted therapies,” Dr. Lerner said. “We have a very interdisciplinary program, and what we’re finding now is that when we do combine all of our skill sets and our techniques and our technologies, we’re able to do things that we never really thought of before,” Dr. Kim said. “I think we’ve had the tools to do this for a while now,” Dr. Kim said. “It’s just that people have not really looked at itch as a distinct discipline, disease, and if you don’t conceptualize it that way, it’s really difficult to tackle the problem.” Although treatments for conditions such as eczema and psoriasis block the inflammation, it is not known whether symptoms improve because the drugs broadly inhibit the inflammation or the itch itself. “That has yet to be determined, but I think in some respect we could see some things in the next five years,” Dr. Kim said. “I think other areas are going to take longer because it’s such an uncharted frontier in terms of research.” Despite these efforts, however, it is unlikely that researchers will develop a universal treatment to relieve pruritus. “Not all itch is equal,” Dr. Yosipovitch said. “Chronic pain could be from a lot of causes and the same with chronic itch.” Financial disclosures: Dr. Yosipovitch is a member of the scientific advisory boards of Creabilis, Cosmoderm, Trevi Therapeutics, Tigeract, and the National Eczema Association. He served as a consultant for Eli Lilly, Celgene, and Allergen. His research has been funded by GSK Stiefel, LEO Foundation, and the National Institutes of Health. Dr. Lerner is supported in part by a research grant from LEO Pharma. Dr. Lim and Dr. Kim have no financial interests related to their comments. dw FUTURE PERSPECTIVES Recognizing the importance of addressing pruritus, the AAD now presents a session on the condition during its Annual Meeting, Dr. Lim said. “We have 32 DERMATOLOGY WORLD // February 2015 www.aad.org/dw INTRODUCING AAD’s 2015 WEBINAR ALL-ACCESS PASS! Provide your staff with a year’s worth of practice management training The new Webinar All-Access Pass provides the ability to participate in all of the 2015 live webinars, and the flexibility to train and watch these seven webinars “on demand” wherever and whenever is convenient. Best of all, you don’t have to spend a fortune — the Webinar All-Access Pass costs $599! To see a listing of webinars scheduled in 2015 visit www.aad.org/webinars. Webinar All-Access Pass:$599 Individual Live Webinar: $199 each Save over $700! Visit www.aad.org/store to purchase Copyright © 2015 American Academy of Dermatology. All rights reserved. BUILDING AN OFFICE CULTURE THAT WORKS Physician-practice manager partnership is key 34 DERMATOLOGY WORLD // February 2015 www.aad.org/dw BY TERRI D’ARRIGO, CONTRIBUTING WRITER O ffice culture: It sounds like one of those corporate terms bandied about companies like Microsoft. But a good office culture — one where employees are enthusiastic about their work and performing at their absolute best — is essential to any dermatologist’s practice. “If employees are happy at work, they focus their energies on the task at hand, that of patient care, and that makes patients happy. If you create a culture that is extraordinarily pleasing to patients, it builds your business. Patients tell friends and family, and you will get external referrals,” said Victor J. Marks, MD, associate in the department of dermatology at Geisinger Health System in Danville, Pennsylvania. “It will also draw the kinds of employees you want as your office becomes known as the place to work.” Culture derives from the vision of the practice and what clinicians and staff do to achieve that vision, Dr. Marks said. “It’s the way you do things, meaning behavior as opposed to attitude, which is what you think. If your vision is to have people walking out of your practice feeling like they’ve never been treated so well, think about what behaviors are necessary of the people working there to lead to that.” Once there is a vision for the practice, a blend of strong management, appropriate staffing, and clear communication will produce a thriving office that will not only achieve that vision, but enable the practice to change and grow. >> DERMATOLOGY WORLD // February 2015 35 BUILDING AN OFFICE CULTURE THAT WORKS HIRE THE RIGHT PRACTICE MANAGER Perhaps the most important hiring decision dermatologists can make as practice owners concerns practice managers, said Ali Hendi, MD, clinical assistant professor of dermatology at Georgetown University Hospital in Washington, D.C., and a Mohs surgeon in solo practice. “The practice manager is the eyes and ears of the doctors and practice owners,” Dr. Hendi said. “That person is in a position of leadership and has to have the right personality and ability to see what is going on in the office, what the morale is like, and what can be done to elevate it.” Dr. Hendi added that trustworthiness is crucial in a practice manager because that person will be a partner in maintaining the practice’s financial health. “Do your due diligence when you hire someone you don’t already have a relationship with. Trust gradually, and go by the old saying of ‘trust but verify.’” Dr. Marks encourages dermatologists to interview prospective practice managers with the goal of finding out how they would behave on the job. “Ask questions that deal with real-life situations, such as how the person would deal with a coworker who was caught stealing or an employee with a negative attitude who brings the whole group down,” Dr. Marks said. Dermatologists should look for a practice manager who shares their work ethic but whose approach is complementary, said Leslie C. Gray, MD, of the Dermatology Center of Atlanta, a comprehensive medical, surgical, and cosmetic practice. “It’s like getting married. You have to know yourself, and the better you know yourself, the better you can choose.” Dr. Gray said her partnership with practice manager Melinda Lomax, CMOM, CPCD, works because Lomax has the room to voice a differing opinion. PERSONALITY GOES A LONG WAY Even with the best of intentions, hiring a practice manager can be a matter of trial and error. For Jonathan S. Weiss, MD, and the other dermatologists at Gwinnett Dermatology, PC, and Gwinnett Clinical Research Center, Inc., in Snellville, Georgia, the third time was the charm. First one practice manager, then another crumbled under the pressure of seeing the practice through expansion and technological advancement. “We had a couple of practice managers who were very controlling,” Dr. Weiss said. “We had a front office manager, a clinical coordinator, and staff who worked out of three offices. The practice managers managed so tightly that those people felt powerless.” For example, one practice manager, though a hard worker, had a tendency to get bogged down in procedure, particularly in matters of technology. “Whenever someone took on a minor project, she would produce a 25- to 50-page manual that was virtually unreadable and want it followed to a T. She wanted a level of attention that led to angst among the staff,” Dr. Weiss said. When the time came to update the practice management system and convert paper charts to electronic medical records (EMR), Dr. Weiss and the other dermatologists knew that such micromanagement simply wouldn’t work. “We wanted someone with a calm demeanor who could bring focus to the practice,” Dr. Weiss said. “We needed someone who knew how to build and grow and could delegate, but who would maintain a managerial role and take on huge tasks.” Enter Randy Haviland, CPA, CMPE, experienced practice administrator. A year prior to implementing an EMR, he chose a practice management system that would integrate with the practice’s chosen EMR system. He then negotiated a good deal with the EMR vendor, and learned what kind of training would be necessary for 36 DERMATOLOGY WORLD // February 2015 www.aad.org/dw “I’m the visionary and she’s the detail person, and when I come up with 12 different ways we can do something, she tells me what’s reasonable. She’s strong enough to say she doesn’t agree,” Dr. Gray said. “The practice manager needs to be able to work independently. If they have the experience and they mesh with your practice, respect their knowledge.” HIRE THE RIGHT STAFF Thoroughly screening candidates for the skills and experience a practice needs seems like a no-brainer, but dermatologists and practice managers would be wise to look for a winning disposition, Dr. Hendi said. “You can teach people skills and train them on the technical aspects of the job, but you can’t change their personalities,” Dr. Hendi said. “If you want an upbeat office, you’ll need an upbeat staff. A negative person only poisons the well.” Dr. Hendi’s office manager, Bobbie Warren, noted the impact a staff member’s personality can have on patient care. “When patients come here, they know they have cancer. They can be anxious, so we need a calming presence. Type A, high-strung, or loud people don’t do well here.” At the Dermatology Center of Atlanta, Lomax uses the Gary Smalley Personality Types Inventory (http://smalley.cc/images/Personality-Test.pdf), which categorizes workers according to various traits such as confidence, spontaneity, sensitivity, and predictability. “We found that it’s a good way of determining what someone’s strengths may be — as leader, someone with empathy, or someone who is detailoriented, and we look for certain traits for certain positions,” Lomax said. Current staff members have an opportunity to interview job candidates, as well. “New hires work the staff. Ultimately, he designed a training plan that broke the practice into teams, taking into account each person’s personality and tech savvy and urging the dermatologists to take ownership of the transition. “He imbued the dermatologists with the idea that we had to take on the transition personally, and invest ourselves in the process,” Dr. Weiss said. “He impressed upon us that the doctors really had to be the ones to drive it.” Haviland admits there were challenges, but also surprises. “There were some generational aspects to address. The senior partner was in his early 70s, and the youngest was in her 30s,” Haviland said, noting that it’s not uncommon for seniors to resist the transition to EMR after using paper charts for so long. “But our eldest partner is probably the best adapter.” There were also logistical challenges, as the best laid plans went awry. The staff wanted a trainer on-site on the first day the system was installed, but because of scheduling conflicts, the trainer couldn’t be there for two weeks. “That actually ended up working in our favor,” Haviland said. “We struggled the first week, but by the time the trainers came in, we knew what to ask them.” As a result, when the system went live, the practice did not lose any money in collections, and the entire transition was complete within three months, at which time the practice qualified for the Centers for Medicare and Medicaid Services’ incentives for meaningful use. “We really got an optimal return on Randy,” Dr. Weiss said. “He spent a few months organizing it on two or three hours of sleep a night, and he drove us along. A change of this scope can be daunting, but when you have a manager who does advance work and stays calm, it makes everything easier.” DERMATOLOGY WORLD // February 2015 37 BUILDING AN OFFICE CULTURE THAT WORKS with other employees when they first come on board so they can learn [the ropes] and pick up good habits, and we know our employees don’t want to work with people who just wouldn’t get it,” Dr. Gray said. Once good employees are in place, a practice should do whatever is necessary to retain them, said Shannon Page, practice administrator for New England Dermatology and Laser Center, a comprehensive practice that serves western Massachusetts, northern Connecticut, and southern Vermont. “The most important aspect in an office culture is support for employees,” Page said. “I’m referring to training support, because if they are comfortable and knowledgeable, it shows. But they also need resource support so they have [what they need] to ensure they are successful; and management support such as feedback and praise, and the feeling they can openly go to management with any concerns or issues.” asked to do this so they can describe procedures to the patients more accurately.” Practice managers should be flexible, Page said. “I am ready, at any time, to jump in and help any employee. They know this, and they appreciate it. Leading this way leaves no room for anyone to hesitate or complain about jumping in to help others.” COMMUNICATE The key to a well-adjusted, smoothly run office is communication. It ensures that everyone knows what his or her role is and it allows leadership to nip problems in the bud, said Dr. Martin, who makes it a point to speak to her practice manager, April G. Mulkey, CMOM, at least twice a day. “We have a brief meeting at the beginning and end of each clinic day, and she fills me in on what is going on in the office,” Dr. Martin said. “I know how scheduling went, any patient issues that have arisen, whether someone was out with a sick child, all of the day’s events.” Dr. Martin added It starts with leadership that she maintains an open-door policy and the dermatologists are the leaders. not only because she wants everyone to feel comfortable speaking to her, but because she LEAD BY EXAMPLE needs to trust that they’ll handle issues as they arise. As leaders, dermatologists and practice managers set “You can’t do all things at all times, and you have to be the tone for a practice, and they should be aware of comfortable delegating. A lot goes on every day in human how even the smallest actions can affect the staff, said resources or billing, and I trust my managers to handle it, Elizabeth S. Martin, MD, of Pure Dermatology and but they need to tell me about it,” Dr. Martin said. Aesthetics, PC, which specializes in medical, surgical, Clear communication extends to the patients, as pediatric, and cosmetic dermatology in Hoover, well. At Pure Dermatology and Aesthetics, staff informs Alabama. patients if the dermatologists are running more than 30 “My staff told me they knew what kind of day minutes late and offer patients the option of waiting or we would have by the cadence of my footsteps rescheduling. when I arrived. It opened my eyes to how unspoken “The patients love it because they have a choice, interactions can have an impact on the atmosphere of and the employees appreciate it, especially at the front the office,” Dr. Martin said. desk, because the patients won’t be staring them down,” Dr. Hendi stressed the importance of enthusiasm. Mulkey said. “It starts with leadership and the dermatologists are At Dr. Hendi’s practice, staff gleans important the leaders. If you don’t like what you do and you are information from patient satisfaction surveys. grumpy throughout the day, it rubs off on staff and “We look for trends and if we see something that the patients.” needs work, we address it at one of our regular staff New non-clinical staff at Dr. Hendi’s practice meetings,” Warren said. scrub up and shadow him during procedures, a form of education that Warren said is vital. REMEMBER THE DETAILS “Sometimes you need to see what goes on in the When creating an office culture, the little things mean a surgery room to understand why the practice is set lot: a staff member’s choice of words or attire, the décor, up the way it is, why we bill a certain way, and so on,” even television programming in the waiting room. Warren said. “Most of our employees have actually 38 DERMATOLOGY WORLD // February 2015 www.aad.org/dw run slides of artwork,” Warren said. “We don’t show news on our televisions. We don’t need our patients’ blood pressure going up.” At Pure Dermatology and Aesthetics, administrative and clinical staff have different dress codes. “We don’t put administrative, front office, or back office staff in scrubs. It’s too confusing to the patients,” Mulkey said. Mulkey encourages dermatologists to remember that a practice is a business. “Patients are customers, and these details help keep them satisfied and the business running,” she said. “When dermatology patients make appointments, they are usually not dealing with an urgent condition. They can take their time and decide who to see. It’s a choice, and you want them to choose you.” dw VISIA® Dr. Marks encourages dermatologists to think of every point of contact a patient has with the practice — from the initial request for an appointment, through registration, examination, and follow-up care — and to lay out specifically how interactions should go along the way. “Behaviors can be scripted and specified in your cultural documents. You can script how your nursing assistants greet patients in the waiting room, and put reminders at the front desk for answering the phones,” Dr. Marks said. The physical layout of an office can help prepare patients for their examinations or procedures, said Warren, Dr. Hendi’s office manager. “Our suites are spa-like, with calming colors. We offer snacks to patients who will be here all day, and we ® IntelliStudio® VEOS® Reveal® HAND-HELD 3D CAMERA innovative 3D imaging www.canfieldscientific.com [email protected] | +1.973.276.0336 from the president academy perspective BY BRETT COLDIRON, MD Health care is changing rapidly — will dermatology keep pace? D riving down the interstate, you’d be hard-pressed to miss the dozens of billboards advertising quick and cheap tele-health dermatology services. Think back to the last time you went into your local pharmacy or grocery store — I’d be willing to bet that there was a health clinic inside that store. Haven’t noticed any of these signs or clinics? You will soon. Recent trends in health care indicate that venture capitalists are starting to see medicine as the new cash cow, as patients look for cheaper and more convenient methods to receive health services. For example, although the retail clinics’ share of patient visits is a small portion of total health-provider visits in the U.S., according to a 2012 Health Affairs study (31(9):2123-2129), visits to these clinics increased from 1.49 million in 2007 to 5.97 million in 2009. Imagine how many visits will take place in 2015! However, the question remains: when our patients text a photo of their ailment to one of these companies or visit their local grocery store for a diagnosis on a rash, are they seeing a dermatologist? The companies that are funding these endeavors are likely utilizing non-physician providers to fill the patients’ need for convenience and to keep immediate costs down. As a result, patients will continue to support these systems, and insurers will delight in the theoretically reduced price tag. However, if this commoditization of medicine becomes the norm rather than the alternative, the quality of health care could suffer. We know, in addition to convenience, that patients value quality and safety. The American Medical Association conducted a survey of patients, and found that 91 percent of respondents believe that a physician’s years of medical education and training are vital to optimal patient care, especially in the event of a complication or medical emergency. We also know that patients value our dermatologic services. I have written before that — according to a study conducted by the Mayo Clinic — access to dermatology is an important indicator of patient satisfaction. However, because many patients are now required to pay high deductibles out of pocket either way, they’re more inclined to utilize quick clinics and telemedicine. 40 DERMATOLOGY WORLD // February 2015 Additionally, while some patients may be cured of their skin disease by these new means, many won’t, and they will eventually find their way back to a dermatologist. As a result, the total cost of their treatment will be higher because it will require more physician visits, more useless or even harmful medications, and likely more biopsies. Finally, because consumers and insurance companies are buying into this market-driven system of health care, one has to wonder if the metrics for evaluating a physician’s worth will change as well. Will we soon be graded on our availability instead of our clinical acumen? If the marketplace becomes the primary driver of how we define value within our health care system, this may be the case. The majority of our specialty is made up of solo practitioners or physicians in small practices. Inevitably, that means that by default we are business people. However, I would bet major odds that most of us didn’t go into medicine because we wanted to open a business, or because money was our primary goal. Unfortunately, there are many entities entering the health care arena because they see it as such. Dermatologists are valuable as we possess a wealth of knowledge and we add value to the system in terms of quality and cost. But we are up against a powerful force. We can’t sit back and watch as we are taken out of the system. We are cost effective, we are the experts in skin disease, and we provide incomparable care. Physicians’ paramount concern is quality of patient care while venture capitalists are interested only in making a profit. I call on all members to continue to remind payers and consumers of this fact. It is incumbent upon us to be advocates for, and protectors of, our patients in the face of purely profit-driven medicine. We cannot let the marketplace advances discount the value that our specialty offers our patients, both in cost effectiveness and quality. dw www.aad.org/dw news + events Academy Advisory Board invites members to submit policy resolutions academy update DATEBOOK WHAT’S COMING UP T he Academy’s Advisory Board (AB) invites all AAD members as well as state, local, and specialty dermatology groups to submit proposed AAD/A policy resolutions on issues of interest and/or concern. The AB convenes every year at the AAD Annual Meeting to deliberate on issues of importance to individual practitioners and propose new policies on those issues to the Academy’s Board of Directors for consideration. If there is an issue of interest and/or concern, now is your opportunity to submit a resolution from which an official Academy position might arise. To view the Academy’s current position statements visit www.aad.org/Forms/Policies/ps.aspx. To ensure full consideration, all resolutions must be received by Feb. 27. The author and/or their AB representative must be present at the Reference Committee Hearing on Friday, March 20, at 2 p.m. (PT) at the Academy’s 73rd Annual Meeting in San Francisco, to introduce and discuss the resolution. The full AB will vote on resolutions on March 22. Even if you do not submit a resolution, all members are invited to attend the Reference Committee Hearing to be a part of this influential debate. For general questions, or to obtain a template resolution form or submit a resolution, contact Ashley Cook at acook@ aad.org by Feb. 27. – ASHLEY COOK 2015 Annual Meeting registration and housing still available REGISTER NOW at the discounted registration rates to attend the Academy’s 73rd Annual Meeting in San Francisco, being held March 20-24, by registering online at www.aad.org/ AM15. Online registration and housing is now open. Discounted registration rates will apply until Feb. 11 at 12 p.m. (CT). After this date and time standard registration rates will apply. Guest rooms are being held at several major hotels in San Francisco at AAD discounted meeting rates available only to those who book through the AAD. For a current listing of official AAD hotels, visit www.aad.org/AM15. Hotel reservations must be made online in conjunction with registration for the meeting. More information is available on the Academy website and in the 2015 Annual Meeting Advance Program. You can add a donation as you register for the Annual Meeting. Be a part of the Academy’s efforts to create a world without skin cancer by contributing to SPOT Skin Cancer™, or help support a unique summer camp opportunity for young patients by giving to Camp Discovery. – SUSAN JACKSON dw DERMATOLOGY WORLD // February 2015 41 classifieds PROFESSIONAL OPPORTUNITIES Central Florida Dermatology and Skin Cancer Center (CFD) is seeking an ACMS fellowship trained Mohs Surgeon and/or a BE/BC General Dermatologist. We are also looking for qualified ARNPs who have dermatology experience. CFD is located in Winter Haven, FL. Winter Haven is the home of Legoland and is also known as the Chain of Lakes area. Winter Haven offers the suburb experience with quick access to Tampa, Orlando, and the beach. Interested parties, who want to join a busy and successful practice, can submit resumes/CVs to our Practice Manager, Dan Lackey, at [email protected] or call 863.293.2147 for more information. Please visit us on the web at www.centralfldermatology.com. Manchester & Wolfeboro, NH APDerm® is a vibrant, growing practice of clinically accomplished and patient-focused dermatologists who practice in a community distinguished as among the best places to live on the east coast/ Boston area. We are seeking a full or part-time dermatologist/Mohs surgeon to join our group of twelve board certified dermatologists in a professionally run practice with dermatopathology lab, Mohs surgery and medical aesthetics. This opportunity would allow a highly qualified dermatologist/ Mohs surgeon to practice with excellent support staff in a collegial practice in our Manchester and Wolfeboro, New Hampshire offices with competitive salary, benefits and opportunity for practice ownership. For more information, please contact: Glenn Smith, MHA, Administrator and Chief Operating Officer, at (978) 849-7501 or email [email protected]. Meriter Medical Group, a 125-physician multispecialty group in Madison, Wisconsin, is actively recruiting a BC/BE Dermatologist. • Join two experienced colleagues in a busy and established practice •Flexible practice model includes general medical dermatology, procedural dermatology, cosmetics dermatology and opportunity for some Mohs • Excellent supportive, collaborative and collegial team environment • Top recipient of “Best Companies to Work For” by In-Business Madison magazine •Scenic Madison is home to the University of Wisconsin-Madison and the State Capital, and consistently ranks as one of the top places in the country to live, work, and play! For more information about this excellent opportunity, please contact our recruiter Susan Shurilla at (800) 528-8286, ext. 4114, or [email protected]. PORTERVILLE, CALIFORNIA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. MONTROSE, COLORADO Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. BOULDER, COLORADO Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. GROTON, CONNECTICUT Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. 42 DERMATOLOGY WORLD // February 2015 OCALA, FLORIDA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. SANFORD, NORTH CAROLINA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. TAMPA, FLORIDA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. BOUNTIFUL, UTAH Associate Opportunity. Contact Karey, (866) 488-4100 or www. MyDermGroup.com. WEST PALM BEACH, FLORIDA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. MOHS SURGEON Multiple Part Time Opportunities CHICAGO, ILLINOIS Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. ANN ARBOR, MICHIGAN MEDICAL DERMATOLOGY FELLOWSHIP 1 – 2 years experience in management of complex medical dermatology patients in both private practice and teaching clinic. Biologics, immunsuppressants, immunomodulators, clinical trials. PGY 5/6. Send CV & 2 LOR to: David Fivenson, MD, [email protected]. SANTA FE, NEW MEXICO Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. NEW YORK FT/PT BC/BE dermatologist needed to join as associate. Excellent opportunity to join busy Plastic Surgery solo practice on LI. Forward CV to [email protected]. HICKORY, NORTH CAROLINA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. Montrose, CO 1-2 days/mo Enfield, CT 2-3 days/mo Groton, CT 1-2 days/mo Tampa, FL 1-2 days/mo Reno, NV 1-2 days/mo Hickory, NC 1-2 days/mo Sanford, NC 2-3 days/mo Bountiful, UT 3-4 days/mo Contact Karey, (866) 488-4100 or www.MyDermGroup.com. PRACTICES FOR SALE TEXAS Well-established , small, solo medical dermatology practice in south Dallas suburb. Considering retiring for the right offer that is best for loyal patient base and excellent staff of two. Contact correspondencecym-practice@ yahoo.com. No brokers please. We Buy Practices •Why face the changes in Health Care alone? •Sell all or part of your practice •Succession planning •Lock in your value now •Monetization of your practice •Retiring Please call Jeff Queen at (866) 488-4100 or e-mail [email protected] Visit www.MyDermGroup.com Contact Carrie Parratt at (847) 240-1770 www.aad.org/dw ad index PROFESSIONAL OPPORTUNITIES We gratefully acknowledge the following advertisers in this issue: Company Product/Service Canfield Imaging Systems...................Vectra..................................................... 39 Care Credit...........................................Corporate............................................... 13 Modernizing Medicine.........................EMR...................................................IFC-1 NexTech...............................................EHR....................................................... BC Valeant Pharmaceuticals....................Onexton................................................ 7-8 Vancouver Derm World Congress.......CME...................................................... IBC Recruitment Advertising Adult & Pediatric Dermatology, PC.................................................................... 42 Central Florida Dermatology & Skin Cancer Center......................................... 42 Meriter Medical Group....................................................................................... 42 Northwest Permanente, PC............................................................................... 43 Help Build a Gateway for Better Health At Northwest Permanente, P.C., we want every patient we see to receive the medical care they need to live long and thrive. We also offer NWP physicians the opportunity to pursue their personal and professional goals with equal passion through cross-specialty collaboration and work-life balance. We invite you to consider this opportunity with our physicianmanaged, multi-specialty group of 1,100 physicians who care for approximately 500,000 members throughout Oregon and Southwest Washington. DERMATOLOGISTS Portland, Oregon We’re seeking BC/BE Dermatologists to join our team of 16 Dermatologists. Our Dermatologists have an active practice with an unusual number of complex cases and opportunities, if desired, for cosmetic procedures. Ours is a collegial and stimulating practice in one of the most successful managed care programs in the country. Physicians with Northwest Permanente, P.C. receive competitive salaries in addition to an extensive benefit package which includes medical, dental, disability and life insurance; generous retirement plans; vacation, sabbatical and educational leave; and professional liability coverage. Physicians are also eligible for Senior Physician and Shareholder standing after approximately three years with the group (must be Board Certified by that time). To submit your CV and learn more about this opportunity, please visit our website at: http://physiciancareers.kp.org/nw/ and click on Physician Career Opportunities. Or call (800) 813-3762 for more information. We are an equal opportunity employer and value diversity within our organization. Classified ads are welcomed from dermatologist members of the American Academy of Dermatology, from dermatology residents of approved training programs and institutions with which they are affiliated, as well as from recruitment agencies or organizations that acquire and sell dermatology practices and equipment. Although the AAD assumes the statements being made in classified advertisements are accurate, the Academy does not investigate the statements and assumes no liability concerning them. Acceptance of classified advertising is restricted to professional opportunities available, professional opportunities wanted, practices for sale, office space available, and equipment available. The Academy reserves the right to decline, withdraw, or edit advertisements at its discretion. The publisher is not liable for omissions, spelling, clerical or printer’s errors. For more information about classified advertising, contact Carrie Parratt at [email protected] or visit www.aad.org/recruitmentopportunities. FOR DISPLAY ADVERTISING INFORMATION, CONTACT: Ascend Integrated Media, Publisher’s Representatives Bridget Blaney (Companies A-D and Q-R) Email: [email protected] Phone: (773) 259-2825 Cathleen Gorby (Companies E-L and S-T) Email: [email protected] Phone: (913) 780-6923 Maureen Mauer (Companies M-P and Tu-Z) Email: [email protected] Phone: (913) 780-6633 ADVERTISING STATEMENT: The American Academy of Dermatology and AAD Association does not guarantee, warrant, or endorse any product or service advertised in this publication, nor does it guarantee any claim made by the manufacturer of such product or service. Northwest Permanente, P.C., Physicians and Surgeons EOE THE AD INDEX IS PROVIDED AS A COURTESY TO OUR ADVERTISERS. THE PUBLISHER IS NOT LIABLE FOR OMISSIONS OR SPELLING ERRORS. DERMATOLOGY WORLD // February 2015 43 facts at your fingertips data on display MODEST INCREASE WOULD KEEP AAD’S DUES LOWER THAN MANY SIMILAR ORGANIZATIONS T he AAD is asking members to approve a two-part dues increase on its spring ballot: a $50 increase starting in 2016 followed by cost-ofliving adjustments annually thereafter (which the Board of Directors can forgo if deemed unnecessary). The additional funding will be used to launch an ongoing, multi-pronged effort that includes: • a dermatology-owned data platform to demonstrate the quality of care, outcomes, and performance measures within the specialty; • practice tools that help dermatologists determine their practice value within the health care system; and • a robust data-driven communication plan to ensure payers and policymakers understand the value dermatologists bring to patients. The chart below shows how the AAD’s current dues ($750 for fellows) compare with several other medical organizations in 2015. The organizations were chosen because their dues pay for a similar suite of benefits. The Academy is in the middle of the pack in terms of dues, a position it would retain if the increase is approved. – RICHARD NELSON dw Comparison of dues against other organizations in 2015 $1500 $1,274 $925 $895 $890 $770 $750 $683 $665 $600 $900 $900 $615 DUES AMOUNT $1200 $451 $300 0 y et ci ns So eo an rg ic u er tic S y m Am las de P ca y of A og an ol ic m f er al yo h Am pht em s O ad on of Ac rge an u of ic S n er dic io e at s Am op ci n th so eo Or As urg an l S ic a er gic o y Am rol em eu ad N Ac ogy an ol ic g er ryn Am ola ge Ot lle of Co an ic gy er iolo y Am rd em Ca ad of Ac y an g ic lo c er ato hi at Am rm op De te of Os an ic n er tio f Am ocia yo et s ci As So ists an g ic lo er esio of Am th ge ns es lle cia An Co ysi an h ic y P er c al en ic Am rg e og ol Em Ur an ic n er tio Am ocia s As 44 DERMATOLOGY WORLD // February 2015 www.aad.org/dw WCD2015 is presented under the auspices of the International League of Dermatological Societies. The ILDS has 157 national and international member organizations including the AAD, ASDS, and SID. Approved for AMA Physician ’s Recognition Aw ard Category 1 CME CreditTM A TRULY UNIQUE GLOBAL DERMATOLOGY EXPERIENCE THE WORLD’S LONGESTRUNNING DERMATOLOGY CONGRESS A FRIENDLY AND STUNNINGLY BEAUTIFUL HOST CITY PHOTO COURTESY OF TOURISM VANCOUVER SO MUCH TO SEE AND DO IN VANCOUVER Over 200 sessions, 1,500 speakers and 3,500 abstracts—all in ONE great meeting! www.derm2015.org
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