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If you are like most Americans, you feel less secure about the U.S. economy.  Certainly, this is justified.  While we may be technically out of the recession, our dependence on foreign oil, behemoth deficits, and the weak dollar are all fundamental threats to our national fiscal health and our investment marketplace that are not going away anytime soon.  For this reason, it is crucial that savvy investors, including physicians, learn from the past two years and adjust their investment behavior accordingly.  This article touches on a few thoughts in this arena.

Investment Theory for Doctors

Most savvy doctor investors understand that portfolio diversification is a key consideration to reducing some of the risk of loss in a portfolio.   In historically volatile markets, mitigation of loss is not a luxury – it is a necessity.  Though most savvy investors who thought they were “adequately diversified” also lost almost half of their portfolio over the last two years, there is an explanation.  Most investors were diversified “within” the stock market with holdings in various sectors.  What these investors suffered was “market risk.”  As the entire market came crashing down, so did all investors within the market.

What many experienced investors don’t understand is that diversification need not be limited to securities like traditional stock and bond investments or bank deposits.  Proper diversification, especially in a highly volatile market like the one we are experiencing today, must also be across investment classes and not just within a class (like securities or real estate).  A balance of domestic and foreign securities, real estate, small businesses, commodities, and other alternative investments would prove to be much less risky than holding the majority of your investments in real estate and securities (which is what most doctors do).

Since most doctors who contact us are either very successful already and want to fine tune their planning or want to know the secrets of the more financially successful, it may not come as a surprise that many of our physician clients have taken a more active interest in surgery centers, medical office buildings and other healthcare related real estate. This strategy apparently contradicts the idea of achieving portfolio diversification by avoiding any investments within the healthcare arena.  One strategy of portfolio diversification for doctors is to avoid all healthcare related investments. The theory is that doctors already have so much of their income related to healthcare that they should not invest in healthcare related investments.  Unless a doctor has a very good reason to think that a particular company will excel in its arena, this theory suggests that doctors typically avoid healthcare stocks.  For doctors who have the ability to personally influence the success of a surgery center or MediSpa, this is obviously an attractive investment.

Alternative Investments

For those doctors who can’t build or participate in surgery centers or other profitable healthcare investments, a popular investment strategy is to take advantage of different investment programs that are not traded on a public exchange like the New York Stock Exchange (NYSE).  Non-Traded Real Estate Investment Trusts, Leasing Funds and Oil & Gas Drilling programs are a few examples.  As with any investment, there are pros and cons for each type of offering.

Given recent market conditions, many physician investors have been attracted to non-traded programs because they offer a certain level of stability.  Most of these programs are sold to investors at a flat price, for example $10 per share, during the offering period.    An advantage to these programs is that their performance is not correlated with any particular market or index, making them an additional form of diversification.  Holding non-correlated offerings can help reduce the “volatility rollercoaster” of a traditional portfolio.  They should be an additional allocation in your portfolio, not a substitute for proper allocation.

Another significant benefit for physicians in the higher income tax brackets (which are sure to increase as government bailouts and the upcoming budget ranges in the multiple trillions) is the potential tax benefit an alternative program can offer.  Some programs offer tax deductions on the initial investment.  Others pay tax efficient dividends.  Some programs offer both.  For example, there are Oil & Gas Drilling programs that offer tax deductions on the initial investment due to intangible drilling costs AND tax deductions on the program’s cash flow due to depreciation & depletion allowances.  Real Estate Investment Trusts’ & Leasing Funds’ dividends are often only partly taxable to the investor.  These tax efficiencies vary by program and from year to year.

CAUTION

It is important to note that one of the advantages of a non-traded offering is also a disadvantage.  There is typically no market for shares of these programs.  As an investor, you are expected to hang on to the security for the life of the investment – which can be as long as 4 to 10 years.  This can make your investment relatively illiquid.  In addition, these programs are not without risk.  You could invest in an oil and gas drilling program that finds no oil. Sure you will get a deduction, but you may not get much of the initial money back.  Like any other investment class, some offerings are more aggressive than others, and none make any guarantee about future performance.

CONCLUSION

There has never been a better time to focus on investment risk management and tax reduction planning.  For physician investors seeking ways to diversify traditional stock and bond portfolios and reduce portfolio volatility while possibly reducing unnecessary taxes, non-traded investments are an attractive alternative.  Please contact a financial advisor to see if alternative investments or other planning strategies might reduce your investment risk, reduce your taxes by $5,000 to $500,000 annually and increase the total after tax return of your portfolio.

Jason O’Dell, CWM, is a founder of O’Dell Jarvis Mandell (www.ojmgroup.com) and author of “Investing Secrets for Physicians.” David Mandell, JD, MBA, is the author of nine books, including “For Doctors Only: A Guide to Working Less and Building More.”   Kim Renners, CPA (inactive), MBA, is the Director of Wealth Management for OJM Group. Sign up for a free e-newsletter on Advanced Asset Protection, Tax and Investing at www.ojmgroup.com.  Contact us directly at odell@ojmgroup.com or 877-656-4362. This article contains general information that is not suitable for everyone.  The information contained herein should not be construed as personalized advice.

Physician practices are inundated with requests for medical information of every nature: encounter note copies, health and life insurance authorizations, managed care referrals, handicap parking certificates – forms to sign, forms to copy, forms to mail out … it is a never-ending stream of administrative requests all based on medical record (MR) documentation.  Documentation, whether paper-based or in electronic form, is critical to the long-established and far-reaching responsibilities of the modern physician practice.

It is also from documentation that oversight entities for federal and state programs under the Centers for Medicare and Medicaid Services (CMS) like Medicare and Medicaid audit physicians and ultimately approve or deny services, take back monies, suspend claims in pre-payment reviews, levy fines, and even prosecute providers.  In an arena where so much MR documentation is created, handled, processed and managed, it is a surprise to many providers that judgments issued by official entities such as “no documentation submitted,” “lack of documentation to support services billed” and/or “documentation does not indicate medical necessity of the service” tend to be the most prevalent reasons for provider service denials and stern repayment demands.

Physician practices have long received MR requests from its local Medicare carrier (Medicare Administrative Contractor or “MAC”) and/or state Medicaid entity; these promise to increase as the government tightens its grip on fraud, waste and abuse.  One high profile initiative under the Comprehensive Error Rate Testing (CERT) program oversees each Medicare Administrative Contactor’s payment systems and originates MR demands called Additional Documentation Requests (ADRs).  Providers can expect to see these requests grow exponentially.  More recently the Recovery Audit Contractor (RAC) initiatives are beginning to sound familiar to many providers.  Physicians can certainly expect RAC requests for MRs to be a part of the norm going forward, with such requests being issued as early as every 45 days, going back to services beginning Oct. 1, 2007, with ceiling limits for MR request quantities depending on the size of the practice.

The track record for success under these mounting requests and ADRs thus far, by the typical provider, is less than stellar.  The RAC enterprise, recognized now by the federal government as both quite imposing and uncovering potential high risk areas of organizational “vulnerability” because of the enormous quantities of MR demands being sent to providers, has recently been addressed in part by CMS in an article via the Medicare Learning Network (MLN) in MLN Matters article SE1024 in late July 2010.  Though addressed to inpatient hospital and skilled nursing providers, it has implications and lessons for physicians as well.  Addressing “RAC high dollar improper payment vulnerabilities,” CMS has issued warnings that provider vulnerabilities lie in “(1) non-compliance with timely submission of requested medical documentation and (2) insufficient documentation that did not justify (the) services billed, were medically necessary and/or (were) correctly coded/billed.”

However, that issuance was only a warning and the situation can be remedied; providers should not forfeit hard-earned, legitimate revenue in repayment demands back to the federal and/or state entities because of such “vulnerabilities.”  Simply put, in many physician practices there are no internal administrative structures or response mechanisms set up in an intelligent way to process, track and manage these all-important MR requests.  Now, with the RACs gearing up for medical necessity and complex visit reviews thereby set to increase their MR requests, providers should take this opportunity to establish an internal MR request management system.

How does the average physician practice operating under typical administrative processes, already burdened with excessive documentation demands, exert a measure of control and compliance over the numerous federal/state MR demands, and keep from becoming overwhelmed with these official requests?  Establishing a simple but effective three-step enterprise to manage this growing aspect of routine physician administration is tantamount to success.  The three steps in this process are: (1) establish straightforward, methodical protocols for the receipt, processing, tracking and fulfillment of all official MR requests; (2) appoint an internal MR request “response team” to handle and manage these requests; and (3) perform post-fulfillment analyses of each request, reviewing the final adjudication of each audit case to assess potential influence on clinical operations (e.g., documentation), administrative processes (e.g., coding) and/or negative impact on revenue.

Establish Protocols for Managing MR Requests

Whether set up via a paper-based system or via eHR software (with automatic chart flagging/tracking functions), protocols should be established to respond to all federal and state MR demands.  Protocols should administer various aspects of the MR request fulfillment process in a premeditated and thoughtful way, avoiding a reflexive response that might adversely influence practice staff.  Such knee-jerk responses can cause personnel to hurriedly fulfill these important MR demands just to get them done and out the door, perhaps overlooking critical aspects of the documentation that might otherwise save the cases from turning into downcoded or denied encounters with repayment demands from Medicare or Medicaid.  The protocols should include steps for: (a) receipt and logging of all official MR demands; (b) retrieval of charts and culling of pertinent date-of-service (DOS) information; (c) inspection and final verification of the information to be sent; (d) copying the documents; and (e) mailing the requested information by certified means.  Such protocols also entail internal monitoring and tracking the fulfillment process along the way, as well as having an analysis and response mechanism at-the-ready when the practice receives the final judgment of each audit case.

An important consideration for physician practices with multiple locations is centralization:  will this fulfillment process be centralized, working through one appointed MR request response team, or will there be a team in place at each of the practice locations?  A plan of action in these scenarios is essential.

Forming the MR Request Response Team

Forming a MR request “response team” for official MR demands is a smart thing to do.  Even in the smallest of physician practices, in which the physician would play an active role on the team, a highly effective team can be appointed.  There are four main elements of the response team with various assigned duties that can be mixed and matched, comprised of: (1) Practice Manager – responsible for overseeing the entire process and ensuring internal compliance as well as performing post-fulfillment analyses; (2) Administrative Leader – responsible for ensuring all administrative personnel assigned to the team perform their functions and performs final inspection and verification of all submitted audit packages; (3) Clinical Leader – responsible for reviewing all culled clinical data to ensure appropriateness and accuracy of the data, e.g., demonstration of medical necessity, data from earlier episodes such as an earlier review of systems questionnaire influencing the DOS under audit etc., and (4) Medical File Clerk or Medical Secretary – responsible for receiving (via the office mail) and logging the official MR demands, pulling the charts, initially culling the targeted MR documents from the chart, routing the chart to the next level (i.e., Clinical Leader for clinical data verification), and receiving, after final approval for copying and certified mailing, the various chart documents selected to fulfill the official MR request.  This person, if he/she is responsible for opening/routing the practice mail, will also direct all post-fulfillment adjudications to the Practice Manager for appropriate follow up.  Obviously, if other persons are responsible for retrieving and opening/routing the daily mail, those persons would be injected into this process at the appropriate points. Alternates should be appointed as well in the case of staff vacations, absences, etc.  This is a highly flexible arrangement of roles and responsibilities, and can be constructed in many different ways depending on the size, staffing and physical location(s) of its various team members.

Performing Follow-Up Analyses

Post-fulfillment analysis of each case must be performed; it is essential the physician practice leaders view each final ruling by the overseeing entity (e.g., CERT or RAC) as an opportunity for growth and possible reorganization of duties.  This can include necessary modifications in documentation (techniques, processes or quality of information), coding fortification, improved billing standards, or all of these items.  This might also include opportunities to appeal the decisions, which should be carried out if the encounters in question have been misjudged or assessed prematurely in some crucial way, e.g., specific documentation was not available and therefore left out of the original audit package, or a signature log or physician attestation is needed to authenticate the documents after-the-fact, etc.  The various audit types will lumber under different assessment rules and appeal rights for the provider.  Physician practices should be aware of the various rules under MAC, CERT and RAC audits.  Negative impact on revenue should be viewed with a critical eye and questions asked:  Are the MR requests resulting in denials with attached repayment demands for simple services that, if documented with higher quality or coded more accurately, would be approved and paid?  Opportunities for internal practice growth may not always be obvious, but even minor documentation and/or coding changes can potentially save the practice thousands of dollars annually.

The ubiquitous and ever-growing number of Medicare and Medicaid MR requests sent out to physician practices should be treated the same way an IRS federal tax audit financial records request would be treated: with great care, attention to detail and inspection of all documents copied and sent.  Once the requested records have been mailed to the entity, each practice should anticipate receipt of final results or judgments on every case and perform appropriate follow up actions to correct functional inadequacies in practice administration, clinical operations, or coding and billing.

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Michael G. Calahan is an independent health care consultant working in the Washington DC Metro area. He specializes in compliance, revenue cycle management, CDI, coding, and billing in the physician, facility inpatient/outpatient arenas. He may be contacted by e-mail at mikiecal@hotmail.com.

Endoscopic ultrasonography, or EUS, provides an important bridge between a suspected diagnosis and appropriate therapy. The procedure uses a thin, flexible endoscope containing a tiny ultrasound probe to examine the upper and lower gastrointestinal tract as well as nearby organs such as the pancreas, gall bladder and liver.

EUS enables gastroenterologists specially trained in its use to identify, evaluate and stage a wide range of benign and malignant conditions. Although its therapeutic applications have been expanding recently, EUS still might best be described as an intermediary diagnostic procedure that provides accurate diagnoses that can lead to the appropriate endoscopic, surgical or medical treatments.

Those capabilities have advanced dramatically since endoscopic ultrasound first was  developed to evaluate the difficult-to-examine pancreas. Today, through EUS, patients are able to be assessed for bile duct blockages, chronic pancreatitis, staging of esophageal, stomach or rectal cancers, enlarged lymph nodes in the chest or abdomen, pancreatic cysts, submucosal gastrointestinal lesions, bile duct stones and more.

At Abington Memorial Hospital, one of the few non-academic centers in the region with EUS services, patients are referred for the procedure due to both presenting symptoms, such as unexplained abdominal pain or jaundice, and disorders that are detected only incidentally during other tests.

For example, we recently saw a patient who had undergone magnetic resonance imaging (MRI) for back problems. That test had incidentally noticed a one-centimeter pancreatic cyst. Such incidental findings are happening more and more frequently as computed tomography (CT) and MRI technologies improve.

When I examined the cyst with EUS, I discovered a nodule within it. Since endoscopic ultrasound also enables me to do fine-needle aspiration, we were able to determine that the nodule was pre-cancerous or cancerous based on cytology. This condition was detected in a patient who had no pancreatic cancer symptoms and only a very small lesion (less than half-an-inch). Because EUS identified that the nodule was suspicious for malignancy, the patient could have it surgically removed instead of having a deadly lesion grow silently over the next few years until it might be too late for surgery.

This is not an isolated example. At one time, pancreatic cysts were thought to be only the result of previous attacks of pancreatitis. Advanced technology now is showing us many instances in which patients have such cysts without having had pancreatitis. Currently, about 30 to 40 percent of the EUS patients I see—the largest patient category in my experience—are being evaluated for pancreatic cystic lesions, many of which are discovered incidentally.

EUS also provides excellent differentiation of the characteristics of submucosal lesions throughout the gastrointestinal tract. Patients being evaluated for these lesions comprise my second-largest EUS patient category. By investigating with EUS, we can determine which layer of the intestinal wall a lesion is arising from as well as its imaging characteristics. We are also able to sample it through fine-needle aspiration or core biopsy. Through this evaluation, we are often able to determine the character of the lesion and whether it can be watched or needs to be removed. The types of submucosal lesions commonly seen are lipomas, leiomyomas, carcinoid tumors and gastrointestinal stromal tumors.

Endoscopic ultrasound has proven to be a highly accurate adjunct for local and regional tumor staging in addition to CT or positron emission tomography (PET) scans. With EUS, we are able to pick up cancer spread to even very small lymph nodes—spread that may not be detected on CT or PET—and sample nodes for malignancy. By avoiding under-staging, we may spare the patient having to undergo a treatment that would not have brought any benefit.

As a therapeutic endoscopist, I use EUS and endoscopic retrograde pancreatography (ECRP) for therapeutic procedures including the placement of stents to drain blocked bile ducts and the extraction of bile duct stones or sludge. EUS is a less-invasive procedure that can help guide the treatment of patients with disorders of the bile ducts and pancreas. EUS may also be used to drain pancreatic pseudocysts that are symptomatic or not resolving on their own.

It can also be used to help manage pain that has not responded well to medication by injecting medication adjacent to the celiac plexus, a group of nerves that supplies sensation to the pancreas and other abdominal organs. This medication can be delivered as a celiac plexus block (temporary) in patients with non-malignant pain or as a neurolysis (permanent) in patients with cancer-related pain.

The only patient preparation needed for EUS is fasting after midnight, although rectal EUS usually requires enema to clean out the lower colon. Patients on blood thinners, aspirin or non-steroidal anti-inflammatory medications should discontinue such use for a week beforehand, to minimize the risk of bleeding if fine-needle aspiration is used. For aspirating a cyst, patients may receive an antibiotic before and after the procedure.

Endoscopic ultrasound is very safe, with risks similar to routine endoscopy. EUS procedures take longer than routine endoscopy—an upper EUS might last 60 to 75 minutes, compared with 10 to 15 minutes for the routine version—so prolonged sedation is an issue. An anesthesiologist usually manages the sedation. In the more than 550 EUS procedures I’ve performed, there have been very few complications.

With more than half of our EUS cases related to cancer evaluation, we know that patients may be anxious going into these procedures. We would always like to give them good news after EUS. When that isn’t possible, we are usually able to give them some hope, through accurate staging that gets them to the correct therapy they need as quickly as possible.

Daniel A. Ringold, MD, is a gastroenterologist and therapeutic endoscopist with Gastrointestinal Associates, Inc., and consulting physician at Abington Memorial Hospital (www.amh.org).

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Americans are exposed to more preventable medical errors than patients in other industrialized nations. Each year, 1.7 million infections occur in U.S. hospitals, associated with upwards of 100,000 deaths. It is estimated that preventable errors cost the United States $17-$29 billion per year in healthcare expenses, lost worker productivity, and disability. And as healthcare expenditures grow at more than seven percent each year, patient safety is improving by no more than one percent per year.

Health and Human Services Secretary Kathleen Sebelius recently had the unhappy duty of reiterating these facts through the release of a new federal government report on patient safety.  The report reaffirms that patients in the United States are at the same risk of death and injury from hospital-acquired infections, medication errors and other safety lapses as they were a dozen years ago.  The tragedy is that a large majority of infections and patient injuries and deaths are preventable, usually through standardization of relatively simply procedures.

There was a time when patient injuries were considered to be unavoidable. But one after another, the causes of common health care errors have been identified, and effective preventive measures have been brought forward.  The Pittsburgh Regional Health Initiative (PRHI), a non-profit, multi-stakeholder regional healthcare improvement coalition founded in 1997, was in the vanguard of this work.  An early (2001) PRHI initiative with the Centers for Disease Control engaged more than 30 Pittsburgh-area hospitals in a joint effort to reduce central line-associated bloodstream (CLAB) infections.  By sharing information and standardizing procedures, CLABs were reduced by an average of 68%.  Several of the participating hospitals went on to use the Lean management principles advocated by PRHI (PRHI’s Perfecting Patient Care system) to achieve and sustain CLAB infection rates of virtually zero.

Since then, parallel projects have been conducted in southwestern Pennsylvania and around the country to demonstrate the feasibility of preventing other hospital-acquired infections, medication errors, pathology errors, wrong-site surgeries, patient misidentifications, patient falls and other common safety issues.

Today we know how to avert most safety risks. But it’s up to individual health care organizations and individual health care professionals to put this knowledge to use. Unfortunately, as annual federal reports document, voluntary compliance with best practices and safety protocols isn’t working.

It is time to consider direct government intervention to make health care safer.  Government regulation alone won’t prevent tens of thousands of patient deaths and millions of preventable patient injuries. But it can certainly help.  In other areas – for instance, aviation, food, manufacturing — federal regulation has been the catalyst for quantum leaps in safety.  A common sense federal regulatory involvement in patient safety could produce results of the same magnitude.

The Institute for Safe Medication Practices (ISMP) lists hundreds of look-alike and sound-alike medications that cause frequent mix-ups resulting in deaths and injuries. Nevertheless, these problems often go unaddressed for years.  Actor Dennis Quaid’s two infant children nearly died in 2007 after being administered a look-alike adult dosage of heparin. The ensuing international publicity brought to light the fact that at least 250 other infants in the U.S. had already died or been seriously harmed by identical heparin overdoses.  Only after the uproar over the Quaid family’s ordeal was the look-alike packaging problem fixed.  If there had been a government agency authorized to order rapid remedial action in the face of a demonstrable threat posed by look-alike heparin packaging, hundreds of infants could have been spared from harm.  Instead, the ISMP problem medication list documents the inadequacy of voluntary action.

Similarly, compliance with safety checklists for surgeries has been proven to prevent wrong-site surgeries.  Nevertheless, these protocols are ignored daily in operating rooms across the country.  Two years ago, one of the most prominent teaching hospitals in New England acknowledged three instances in one year of wrong-site brain surgeries, each performed by a different neurosurgeon.  Notwithstanding the resultant furor, the same hospital was recently cited for another wrong-site surgery.

Closer to home, the Pennsylvania Patient Safety Authority is one of the foremost agencies of its kind in the country.  It performs an invaluable public service by tracking and reporting wrong-site surgeries in our state’s hospitals.  But from one year to the next, the annual reports of dozens of wrong-site surgeries in Pennsylvania show little or no change.  In other industries, government regulation assures compliance with proven safety protocols.  Airplane pilots must adhere to proven safety protocols and checklists, or face public and private penalties. A federal patient safety agency could hold all surgeons to equivalent standards.

In another area of patient safety, a simple step — standardized patient-identification – would yield important safety progress. Studies indicate that hospital patients’ wristband IDs contain potentially dangerous, inaccurate information as much as 5 percent of the time. Most of these inaccuracies do not cause serious patient injuries, but the opportunity for dangerous mistakes is present — ranging from inaccurate indications for drug allergies, to mix-ups due to hospitals using different wristband color codes to denote do-not-resuscitate orders. A single color-code system for all patient wristband identification would make patients demonstrably safer.

The Pittsburgh Regional Health Initiative concluded last year to endorse creation of a federal patient-safety agency.  Others have recently come to the same conclusion.  Dr. Peter Pronovost – a Johns Hopkins anesthesiologist and a top patient safety expert – is among those who believe that tens of thousands of lives and tens of billions of dollars could be saved by establishing and enforcing national patient safety standards.  He has proposed “a Securities and Exchange Commission type of federal agency” to collect and analyze data, and promulgate quality and safety regulations.

Martin Hatlie, president of the Partnership for Patient Safety says, “The question isn’t whether we need a federal patient safety agency in the United States.  Nor is it whether one will be established.  The issue is when.  How many more people have to be harmed, how many more families fractured by loss, before lawmakers address the national need to regulate effectively on behalf of all Americans?”

Rather than advocating a large, new federal agency with field offices and staff across the country, we believe an agency with a modest mandate and resources could have a substantial, positive effect.  Set up as an independent public organization or embedded within an existing federal office (such as the Agency for Healthcare Research and Quality), we envision a federal patient safety agency that would be authorized to concentrate on serious, recurring medical errors.  Its work would not require a national event reporting system because existing public and private patient-safety data (from the 20 states, federal agencies and private organizations that currently collect and analyze medical errors information) are an adequate resource for identifying the most serious, repetitive safety threats. Furthermore, this new agency wouldn’t require a new research budget.  As noted above, there is already a large body of clinical evidence that details causes and solutions for most common healthcare errors, and new research is being conducted continuously by other public agencies and private groups.

What is lacking – and needed – is a federal agency with authority to order immediate action in the face of an imminent threat.  For instance, ordering physical separation of look-alike medications on shelves would lessen the threat of medication errors (while manufacturers made expedited changes in confusing packaging or drug names).  As noted above, a national wristband color coding system would eliminate the opportunity for many serious errors.

Would such steps step eliminate all threats to patient safety overnight? No.  But by focusing attention on serious, recurring lapses that harm patients, a federal patient-safety agency could make a big difference for millions of patients.  The alternative, illustrated by more than a decade of, at best, marginal improvements in patient safety, is a continuing, needless waste of money and lives.

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Karen Wolk Feinstein, PhD, is President and CEO of the Pittsburgh Regional Health Initiative (www.prhi.org).

Loathed by associate physicians and loved by practice owners, non-compete clauses are standard features in physician contracts.  An understanding of these provisions is thus essential for all concerned.

What exactly is a “non-compete” or “restrictive covenant” clause?  The standard provision prohibits a departing associate from practicing in the immediate vicinity of his former employer.  For example:

“Physician agrees that upon his termination of employment by Medical Practice for any reason, and for two (2) years thereafter, he shall not practice [insert medical specialty] with a 5 air mile radius of any office of Medical Practice that exists on the date of termination.”

The purpose of such a clause is to protect the medical practice’s intangible assets, in the form of its patient base.  To make a new associate physician successful, the employing medical practice must promote the associate and introduce him or her to the existing patients and referral sources.  By virtue of such introductions, the associate develops “insider” status and enhanced ability to appropriate these patient and referral relationships for himself, should he leave the employing medical practice.  The non-compete clause is intended to neutralize this threat.  The clause effectively prohibits the associate, should he leave, from using his insider status to unfairly compete with his former employer.

Sounds like a good deal for the employer, right?  Absolutely.  But the employer’s ability to restrict its former employees is not unlimited.  A non-compete clause is not “self-executing” like a physical wall or fence, that performs its function simply by existing.  Non-compete clauses depend on enforcement via the court system, and many judges are suspicious or even hostile to non-compete clauses as unfair restrictions on the associate’s right to practice his or her profession.

The rules governing non-compete clauses are state laws, and these vary widely.  For example, in California and Massachusetts, non-compete clauses are prohibited entirely for associate physicians.  In Delaware, non-compete clauses for physicians are allowed only if the remedy is money damages, as opposed to a court injunction (outright prohibition on competitive practice.)  In Texas, non-competes are allowed, but only if the departing physician has the option of a reasonable money “buy-out” of the restriction, and has access to his patient list.

In most states, though, a “reasonable” non-compete is enforceable.  “Reasonable” means that the covenant is not excessive in terms of the geographic territory that the employer seeks to protect, or in terms of the length of time that the employer seeks to keep the associate out of that territory.  For example, it would be unreasonable for a family practitioner with one office in in New York City to attempt to keep his associate from competing in the “New York metropolitan region” because this far exceeds the scope of the practitioner’s drawing area, and constitutes an undue restriction on the associate’s ability to make a living.

So for the employer, there is a tension between two factors:  (a) the employer wants to keep the associate as far away as possible for as long as possible; but (b) if the non-compete clause is too expansive, the court may refuse to enforce it at all, because it is too much of a restriction on the right of the associate to earn a living, or because it would deprive too many patients of access to needed medical services.

The challenge, for the employer and employer’s attorney, is to come up with a clause that adequately protects the employer but is still legally enforceable.

Aside from this drafting challenge, there is the separate challenge of actually getting the associate to agree to such a clause.

For example, the associate may be attracted to the employer’s practice because it is located in the associate’s home town or region, where the associate has close family relations.  The associate may refuse to sign a non-compete that would require him to relocate his family too far from these relations.

Another problematic situation is this. An entrepreneurial young physician is contemplating starting his own practice in the employer’s vicinity.  At the same time, he is attracted by the employer’s practice as a means to avoid the hardships of building a new practice.  However, if the proposed non-compete is too onerous, he plans to simply proceed his original plan: the start-up.  Should the associate do this, the employer will have a new competitor.  Perhaps it is better for the employer to “soften” the proposed non-compete, such as with a pre-agreed money buyout option, rather than risk the chance that the associate will refuse to sign and then start a competitive practice.

One way of “softening” a non compete is this to add the following provision.  “This non-compete shall only apply if Physician voluntarily resigns employment, or he is terminated by Medical Practice with cause.  This non-compete shall not apply if Physician is terminated by Employer without cause.”

This change is frequently requested by the associate (or his attorney).  The idea is that if the employer terminates the associate “without cause,” the employer may be acting arbitrarily or unfairly.  In this case, it is argued, it would be unfair to restrict the associate’s future practice options.

This sounds reasonable, but from the employer’s perspective, it is a compromise that should be rejected.  Why?  Because a “without cause” termination is not necessarily, or even likely, to be arbitrary.  The termination of an associate physician represents the loss of a huge time-and-money investment by the employer in human capital (personnel).  Such a painful step is nearly always undertaken only as a last step, when all else is failed.  The termination is characterized as “without cause” not because there is no reason for the termination; rather, it is characterized as such because the term “cause” has been defined very narrowly (e.g., loss of medical license) or would otherwise be legally problematic to invoke.  “Cause” typically includes dramatic events like loss of medical license, sanction by government health care program, or commission of a felony.  “Cause” generally does not include “bad attitude”, poor production, or personality conflict, all of which are less dramatic but still good reasons to end the relationship.

If the non-compete is drafted to exclude “without cause” terminations, the employer may be forced to pay an unfairly high price to end the relationship.  Specifically, the employer may be required to accept the associate as a new competitor, setting up shop just across the street, as the price for terminating the associate, “without cause.”

Another challenge with non-compete clauses is selecting the appropriate remedy, if the clause is breached.  There are two possibilities: (a) a court injunction (an absolute prohibition on competitive practice for the duration of the non-compete period); or (b) money damages (the associate is permitted to practice competitively, but must pay damages to the former employer, as compensation).

In some states, such as Delaware, only money damages are allowed.  In most states though, either remedy is potentially allowed (assuming that the covenant otherwise meets the state’s criteria for enforcement).

In most cases, if state law permits, the preferable remedy, from the employer’s perspective, is the court injunction.  It is simply too hard, many times, for employer and employee to agree on the money damages remedy, which is a dollar figure (or formula, such as a multiple of W-2 monies previously paid to the associate) that is inserted into the contract.  The associate is outraged by the high dollar figure proposed by the employer as adequate compensation.  The employer is insulted by the paltry, token sum proposed by the associate.

By contrast, the injunctive remedy simply says that the associate will not compete.  There is no need to agree on a damages number.

Separate and apart from the non-compete prohibition, the associate contract may also contain a non-solicitation/confidentiality covenant, as follows:

“Physician agrees that upon his termination of employment by Medical Practice for any reason, and for two (2) years thereafter, he shall not solicit any patient of Medical Practice or otherwise directly or indirectly attempt to divert such patient from continuing with Medical Practice.  Physician further agrees that all patient lists are proprietary to Medical Practice and that shall not copy or remove from Medical Practice’s premises any such patient lists.”

Such a non-solicitation/confidentiality clause supplements the non-compete clause.  For example, assume that the non-compete radius is 5 miles around the employer’s sole office location.  Without a non-solicitation clause, the associate could potentially set up a practice that is 5.1 miles from the employer’s office, just outside the non-compete radius, and then (unfairly) solicit all of the employer’s patients to see him in his new location.

*   *   *

Daniel M. Bernick, Esq., M.B.A. is an Attorney and Principal of Health Care Law Associates, P.C. and The Health Care Group (www.thehealthcaregroup.com) in Plymouth Meeting, Pennsylvania.

Physicians and other healthcare providers are more concerned than ever about how they will implement electronic health record (EHR) systems in their practices by 2011 to qualify for the first phase of American Recovery and Reinvestment Act (ARRA) funds and ultimately be eligible for the maximum reimbursement. The systems can be complex, the reporting requirements and processes for demonstrating meaningful use are not yet clear, and the resources to help are still emerging.

With the recent release of the Final Rule for “meaningful use” requirements for electronic health record systems (July 12, 2010) and the first of several deadlines rapidly approaching in 2011, the need to find help and implement EHR systems is at an all time high. Failure to meet the deadlines means missed opportunities for financial incentives. Failure to start now may also mean missed opportunities for federally supported implementation assistance.

The Health Information Technology for Economic and Clinical Health Act (HITECH Act) within ARRA provides incentives in the form of higher Medicare and Medicaid reimbursements for physicians and other medical care providers who implement certified EHR systems (up to $44,000 per provider from Medicare or $63,750 from Medicaid). The incentives require providers to use the systems in a meaningful way as defined by the government guidelines just released.  This article will discuss various options that providers can chose for assistance in the selection and implementation of an EHR.  These options include Regional Extension Centers, EHR software vendors, and consultants.

Regional Extension Centers

ARRA provides funding to support implementation assistance organizations known as Regional Extension Centers (commonly RECs). In eastern Pennsylvania, the REC is known as Pennsylvania REACH East. REACH stands for the Regional Extension & Assistance Center for Healthcare IT. PA REACH East has a counterpart in the western part of the state as well, PA REACH West. The Pennsylvania centers are supported with a grant to Quality Insights of Pennsylvania and the services will be delivered through several contracted healthcare technology organizations. The New Jersey counterpart to PA REACH is the New Jersey Health Information Technology Extension Center (NJ-HITEC), which is supported with a grant to the New Jersey Institute of Technology.

HITECH subsidizes PA REACH East, NJ-HITEC, and other RECs to provide a set of assistance services to primary care physicians, nurse practitioners, physician assistants, and others who provide ambulatory healthcare services. Primary care practices can include internal medicine, family practice, OBGYN, pediatric, and gerontology practices. The RECs are not subsidized to provide services to specialists and larger practices (greater than 10 providers); however, many will be offering membership in their programs for a fee.

PA REACH East is gearing up to provide the following services:

• Selecting a certified EHR product
• Achieving effective implementation of a certified EHR product
• Enhancing clinical and administrative workflows to leverage an EHR system’s potential to improve quality and value of care.
• Guidance and training on achieving “meaningful use”

• Support for participation in health information exchanges
• Group purchasing opportunities

NJ-HITEC will offer a similar set of services, though they are behind PA REACH in setting up their programs.

Getting help from a REC to adopt an EHR system will be the right choice for many practices.  They offer services, for free or for a modest fee, that traditionally were only available to large hospital systems with internal information technology departments, or from experienced consultants.  Smaller primary care practices, especially in underserved and poorer communities, are the main targets for help through the RECs, as they have not had many options for assistance.

Extension centers are required to be software vendor agnostic. They will provide services that support the implementation of any certified EHR system. They are likely, however, for practical and logistical reasons, to select a subset of available certified EHRs for consideration.  While a cross section of available EHRs will be on the preferred list, be aware that these systems may not fit some providers’ needs or work with all practice management software, such as registration and billing systems.  This could lead to the practice switching practice management software, creating additional interfaces for the new EHR, or working with a software package the REC is less familiar with.

To be sure, the Extension Centers will make a great effort to provide working solutions that will assist practices in achieving meaningful use. However, because there are so many diverse practices to work with, the RECs will concentrate on processes and configurations that lean towards common denominators and quick wins.

PA REACH East will be conducting a series of information sessions throughout the month of August for practices and providers across the eastern region of Pennsylvania to answer questions and more fully explain the program. Registration, location and dates for these events, requesting Extension Center assistance, and more information on PA REACH can be found at http://www.pareacheast.org/.

NJ-HITEC, at press time, is in the process of setting up their services. According to Bill O’Byrne, the Executive Director of NJ-HITEC, their Web site should be operational by the end of August, with plans to conduct information sessions throughout New Jersey in October. For the moment, any New Jersey provider who has questions about the Regional Extension Center should email him directly at obyrne@njhitec.org.

Vendors

Most vendors of EHR systems have implementation services that can be purchased separately from the software. It is best to negotiate these services when you buy the software, because negotiation leverage is at its greatest. Vendor implementation teams have a great deal of experience in implementing their product. They are experts of their systems. However, they are not usually experts of medical practices.

Software vendors will know WHAT needs to be configured within the system to make it work, but they will expect the practice to tell them HOW it should be configured. Regional Extension Centers and experienced consultants are great resources to help determine HOW these systems should be configured and HOW workflows can be optimized. Without such services, there is a greater risk of dissatisfaction and future re-works to the system, which can lead to lost productivity and delays in achieving meaningful use.

Experienced Consultants

Specialties, large practices, multi-specialty practices, and other providers who have unique needs may want to work with consultants who have had experience in their fields of expertise. In addition, there may be unique needs in terms of integrating or interfacing with existing systems and medical devices, which will require an expertise in those areas. Specialized consultants can provide additional services that will be helpful in these situations.

Seasoned consultants have in-depth knowledge of practice types, practice workflows, and processes for implementing solutions effectively. Good consultants work as advocates for individual practices, helping them meet their specific needs. EHR, practice management, and medical device systems are becoming more complex. Consultants should have a good understanding of how these systems fit together and can help practices get the greatest value out of these systems by supporting integration.

Practices should expect to pay more up front for focused and specialized consulting services. However, these services should cost less in the long run by helping practices get up to speed faster, capture charges more completely, and create more efficient workflows. They can also help practices develop solutions like patient access to online functions for bill paying, appointment scheduling, requests for patients’ basic health information, and renewing prescriptions.

Experienced consultants can be found on lists from professional medical and healthcare IT organizations (see the section on Other Resources, below for details), on the Web, and from recommendations from other practices.  Going forward, many of the RECs plan to also develop a preferred service provider list, including consultants.

Internal Resources

Whatever type of help is chosen — Regional Extension Center, experienced consultants, software vendors, or other outside assistance — providers will get the most out of their systems if they make the investment in time to learn how these systems work. These systems can help providers maintain records and see trends over time. By tracking patients’ allergies and medications, the systems can help providers avoid dangerous or contraindicated prescriptions. These safety mechanisms are only effective if providers adapt their practice processes to utilize them effectively.

Care providers must plan how they will adopt the new systems and effectively incorporate them into the patient care experience. Planning time to learn the systems will make adoption smoother and practices gain efficiencies faster.

Failure to plan and practice can result in awkward and frustrating patient experiences. Without proper planning, the computer terminal can become an unwanted third party in the room distracting the provider from the patients’ needs rather than making the provider more informed and enhancing the patient experience.

Other Resources

Many medical specialty societies make available free or discounted EHR system selection tools, implementation field guides, and advice for their membership. Some examples include the American College of Physicians, American Gastroenterological Association, and American College of Cardiology. The advice is designed to help their members decide which systems fit best with their practice types.

Professional organizations such as the Healthcare Information and Management Systems Society (HIMSS) and the Medical Group Management Association (MGMA) also have a wealth of information through their websites. They have tools and advice concerning the selection and implementation of EHRs, as well as information on HITECH, stimulus funds, and meaningful use. Other good sources of advice are colleagues who have successfully implemented EHR systems, though bear in mind that every practice is different and a rigorous analysis of what is right for your practice is still required.

What to look for in EHR assistance

Regardless of the source of help, there are a several factors to consider with any EHR consultant. With over $30 billion from the stimulus package slated to help physicians adopt EHRs, there will be individuals who claim expertise in healthcare information technology, but without the right experience. It is important to ask the right questions before you enter into a contract.

Any group that is under consideration to help select and implement an EHR should:

• Provide reference clients and the EHRs they’ve worked with
• Have experience with your type of practice or specialty
• Understand EHR contracts to assist in negotiation
• Provide a list of deliverables for the engagement
• Disclose biases and financial incentives in the EHR selection process

Going Forward

Selecting and implementing an EHR system is a major undertaking for a practice.  However, thousands of providers have successfully adopted this exciting technology.  The key is finding the right partner to help you take advantage of what has worked for others, and avoid what has not.  Experienced consultants, Regional Extension Centers, and vendors are all good choices.  Which you choose (or in which combination) will depend on the specifics of your practice, your goals, and available resources.  The ultimate success of any implementation is determined by your commitment and ability to understand how the system can best work for you.

Ken Frantz and Mark Newman are partners at EHR Associates; a consulting firm dedicated to helping physician practices adopt information technology. They can be reached at 215.690.4133 or info@ehr-associates.com.

Fast food outlets could provide statin drugs free of charge so that customers can neutralize the heart disease dangers of fatty food, researchers at Imperial College London suggest in a new study published this week.

Statins reduce the amount of unhealthy “LDL” cholesterol in the blood. A wealth of trial data has proven them to be highly effective at lowering a person’s heart attack risk.

In a paper published in the Sunday 15 August issue of the American Journal of Cardiology, Dr. Darrel Francis and colleagues calculate that the reduction in cardiovascular risk offered by a statin is enough to offset the increase in heart attack risk from eating a cheeseburger and a milkshake.

Dr. Francis, from the National Heart and Lung Institute at Imperial College London, who is the senior author of the study, said: “Statins don’t cut out all of the unhealthy effects of burgers and fries. It’s better to avoid fatty food altogether. But we’ve worked out that in terms of your likelihood of having a heart attack, taking a statin can reduce your risk to more or less the same degree as a fast food meal increases it.”

In Britain, one statin, simvastatin, is already available in low doses (10mg) over the counter at pharmacies without a prescription. Other statins are so far only prescribed by doctors, and limited by cost to patients at particular risk of heart attack or stroke. However, the cost of the tablets has fallen sharply in recent years (from ~£40/month to ~£1.50/month), such that the cost to the NHS of seeing a doctor is much greater than the cost of the tablet.

“It’s ironic that people are free to take as many unhealthy condiments in fast food outlets as they like, but statins, which are beneficial to heart health, have to be prescribed,” Dr Francis said.

Statins have among the best safety profiles of any medication. A very small proportion of regular statin users experience significant side effects, with problems in the liver and kidneys reported in between 1 in 1,000 and 1 in 10,000 people.

“Everybody knows that fast food is bad for you, but people continue to eat it because it tastes good,” Dr. Francis added. “We’re genetically programmed to prefer high-calorie foods, and sadly fast food chains will continue to sell unhealthy foods because it earns them a living.

“It makes sense to make risk-reducing supplements available just as easily as the unhealthy condiments that are provided free of charge. It would cost less than 5p per customer – not much different to a sachet of ketchup.

“When people engage in risky behaviors like driving or smoking, they’re encouraged to take measures that minimize their risk, like wearing a seatbelt or choosing cigarettes with filters. Taking a statin is a rational way of lowering some of the risks of eating a fatty meal.”

Studies have shown a clear link between total fat intake and blood cholesterol, which is strongly linked to heart disease. Recent evidence suggests that trans fats, which are found in high levels in fast food, are the component of the Western diet that is most dangerous in terms of heart disease risk.

Dr Francis and his colleagues used data from a previous large cohort study to quantify how a person’s heart attack risk increases with their daily intake of total fat and trans fat. He compared this with the decrease in risk from various statins, based on a meta-analysis of seven randomized controlled trials.

The results showed that most statin regimes are able to compensate for the relative risk increase from eating a cheeseburger and a small milkshake.

The researchers note that studies should be conducted to assess the potential risks of allowing people to take statins freely, without medical supervision. They suggest that a warning on the packet should emphasise that no tablet can substitute for a healthy diet, and advise people to consult their doctor for more advice.

(Source: Imperial College London)

Telemedicine as a technology is advancing so rapidly that it seems like something you might have seen on Star Trek.

Telemedicine as policy has become an integral part of the law as $27 billion was earmarked for health care information technology as part of the 2009 American Recovery and Reinvestment Act (ARRA) stimulus plan.

But telemedicine as a successful practice or an everyday tool for physicians and patients has remained a mystery.  Until now.

Physicians will ask: How do I squeeze telemedicine in between my daily 35 – 40 patient visits, phone calls, hospital rounds, and insurance b.s.?  How can I make money at this?  It looks really cool, but, in the end, it’s just a high tech version of a patient calling after hours to avoid a co-pay.  Can telemedicine really succeed?

Yes.

Rapid Remedy, based in Pennsylvania, has designed a business model that allows all active participants – including doctors, patients, dependents, and employers — to benefit from telemedicine.

While most telemedicine models promote the technology as the reason to use the service, John Lawlor, Managing Partner for Rapid Remedy, gives away the secret: “It’s all about access.”

Rapid Remedy is reaching out to small, medium and large companies “as a convenient access to Board Certified licensed family practitioners,” said Mr. Lawlor.  Companies will use this service as an employee benefit to provide workers and their families with efficient access to family docs for minor illnesses and health advice.

Traditional telemedicine services often use physicians who simultaneously run their own practice and call back the patient, via video conferencing, as their schedule permits.  That’s a huge flaw in the system.  The technology provides for instant access, therefore, doctors need to be immediately available to the user on the other end – the patient.

Rapid Remedy employs its own physician network to be available whenever the patient calls during regular office hours (9AM – 5PM).  “Our physician network provides video conferencing evaluations from the controlled environment of our practice sites not from their offices or homes,” said Mr. Lawlor.  Having the docs on-site allows each patient videoconference to commence within two minutes.

The Rapid Remedy physician network includes an expanding group of board certified primary care physicians, some who continue to practice outside of Rapid Remedy and others who may seek alternatives to traditional office or hospital work. “We are focused on building a national network of board certified family physicians who provide videoconference evaluations from our practice sites,” said Mr. Lawlor.

Given that 30+ million currently uninsured people will be added to patient rolls thanks to health reform, Rapid Remedy provides an answer to potential physician shortages.  “Our physician network has already admitted they will practice longer than expected — foregoing retirement for several years due to the ease of practicing with Rapid Remedy,” explained Mr. Lawlor.

In fact, one of the doctors in the Rapid Remedy physician network is the CEO’s brother, Dr. Robert Lawlor – a board certified family practitioner with a large, successful practice based in Devon, PA and over 30 years of experience.  For Dr. Lawlor, Rapid Remedy offers a big advantage over traditional telemedicine models: “I am being paid to provide a service that usually does not get paid,” he said.

There are only 12 states that mandate reimbursement for telemedicine including California, Colorado, Georgia, Hawaii, Kansas, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Texas and Virginia.  Each state determines its own guidelines for reimbursement.  Certain states will supplement Medicaid reimbursement, like Maine, while others, such as New Hampshire, will only qualify telemedicine in selected pilot programs.

Rapid Remedy’s model is advantageous to the participating physician, as the company does not rely on public funding or reimbursement to compensate its doctors.  “This model also benefits the patient as they have no co-pay, co-insurances or deductibles,” according to Mr. Lawlor.

The participating businesses also receive several benefits.  “Clients with self-funded insurance plans can save up to 50% on their primary care,” says Mr. Lawlor.  “In addition, it’s hard to put a dollar value on providing your employees the convenient access to a quality doctor right from their home or workplace.”

Many primary care office visits can be handled through telemedicine.  Dr. Robert Pizzaketti — a board certified family physician with a large, successful practice in York, PA, and part of the Rapid Remedy physician network — says “common problems are URI’s, skin conditions, musculoskeletal injuries, and conditions requiring medical advice.”  A visit with a Rapid Remedy physician is a seamless experience and, as Dr. Pizzaketti proudly announces, “patients are usually very appreciative.”

David Schlager, Managing Partner with Rapid Remedy, walks us through the typical visit: The patient logs on to the Rapid Remedy website –through a home computer with webcam or at an employer-based health station.  “The patient is met online via video conference by the Rapid Remedy receptionist who confirms their eligibility and chief complaint, and then transfers the patient to the physician. The physician — via videoconference with the patient  — conducts the evaluation, including the diagnosis, prescriptions, and treatment plan. The patient selects whether they or their local primary care Provider wants a consult letter of the videoconference. The patient visit ends.”

After the conference with the patient, the physician is able to create medication prescriptions and electronically forward these prescriptions to a pharmacy of the patient’s choice.  The Rapid Remedy telemedicine system will be a tremendous compliment to the traditional office visit.  Dr. Lawlor states “there are advantages to the patient in terms of saving time and cost.”

Research firm Pike & Fischer predicts that annual revenues for telemedicine services will exceed $3 billion by 2013.  Several Fortune 500 companies – including UnitedHealth, Intel, Verizon, Samsung, and more – are developing products to compete in the marketplace.  Rapid Remedy is ready to go.

Mr. Lawlor’s goal is to “establish videoconference primary care telemedicine as a common acceptable delivery model for 50% of the care that is currently provided in the primary care physician office.” The company is targeting various corporations, large and small, that want to offer their employees an added benefit to their current insurance plan, which may become a greater expense as health reform mandates take effect.  Rapid Remedy will allow those corporations to save on costs while providing a quality medical experience for patients and physicians.

Many are concerned about the looming physician shortage, particularly in primary care. It may become worse as a result of the goal of the health care reform bill to provide health insurance for the currently uninsured. The July 2010 issue of Physicians News Digest highlighted the upcoming need for physicians in our region.  Patricia Costante, CEO of MD Advantage and writer of that article, clearly proposed numerous viable possibilities of addressing this shortage.  We suggest that another way to address the physician shortage is to return inactive physicians to clinical practice.

Returning a non-practicing physician to clinical medicine is appealing.  First, it is significantly less expensive to re-train an inactive physician than to train a new one.  Second, one can re-train physicians much faster than one can train new physicians, so more physicians would be available in less time. Also, in the current economic climate, many retired physicians are looking to return to medicine.

However, re-entry also has its limitations. Physicians wanting to return to clinical medicine face numerous challenges: low self-confidence in their skills, lack of professional networking possibilities, limited resources for gaining up-to-date skills and knowledge, and cumbersome regulations from licensing and credentialing bodies or employers.  Of equal concern, programs offering reentry face financial and (educational) resource challenges.

Across the United States, a number of organizations (the American Medical Association, the American Academy of Pediatrics, the Federation of State Medical Boards) are working together to address these challenges.  Though sparse in number, several programs address physicians’ assessment and educational needs. Regionally, the Drexel Medicine Physician Refresher/Re-Entry Course of Drexel University College of Medicine has served the physician communities’ needs since the program was originally developed in 1968 by Women’s Medical College of Pennsylvania.

Please allow a minor digression to explain the history.  The Female Medical College of Pennsylvania was founded in 1850 as the first medical school for women.  It was renamed Medical College of Pennsylvania (MCP) in 1969.  It then merged with Hahnemann University in 1998 to become MCP Hahnemann University School of Medicine.  In 2002, the latter became Drexel University College of Medicine (DUCOM).

In 2006, the reentry program was enhanced using MCP’s experience, DUCOM’s instructional technology resources, and the program’s excellence in medical education to create innovative curricular strategies for physicians around the world to access resources designed to enhance their professional and clinical skills. The Drexel Program has several courses that physicians may take independently or sequentially to refresh and enhance their skills.  Thus, the Drexel Program helps physicians in need of remediation or refresher courses for reentry.  A few have taken the courses for retraining, as well.  Physicians from overseas wanting acculturation to the American medical system have also taken advantage of the courses.

The Drexel Program currently offers several educational opportunities online and on-site.  The goal of the online program is to allow physicians anywhere in the world to access the courses according to their own schedules.  The on-site courses are given in Philadelphia at DUCOM’s university hospitals.   Preceptorships are offered in internal medicine, obstetrics-gynecology, surgery, pediatrics, and subspecialties—as needed.  Furthermore, focused training is available on specific topics such as medical documentation.  In addition to traditional learning experiences, the Drexel Program offers a novel online technology that allows live WebEncounters between trainees and selected standardized patients (actor-patients). This new learning format features online practice, assessment, mentoring, and assignment of learning tasks in addition to the mere learning of the knowledge (see http://webcampus.drexelmed.edu/webosce/).

In addition to excellent educational resources, the Drexel Program offers a comprehensive approach to re-entry, remediation, or re-training because the ultimate goal of the physician is to return to clinical practice.  DUCOM’s full faculty and staff offer help in becoming up to date in various “newer skills” pertinent to a practicing physician, such as electronic medical records, medical documentation changes, computer or research skills, medical errors, and health policy changes. Equally important, the Drexel Program staff guides physicians in the maze of career counseling and regulations before they take any of the courses (to determine the best way of achieving the individual physician’s goals) and long after they finish.

From 1968 to 1993, 412 physicians went through the MCP Physician Refresher Program.  From November 2006 through spring 2010, about 50 physicians completed the Drexel Medicine Physician Refresher/Re-Entry course. Though most physician trainees are from the local area, others have come from all over the United States and the world.  Physicians who have completed the program have stayed in touch with us, seeking guidance with letters and credentialing and reporting on their progress.  All participant evaluations of the program have been excellent, with some making comments such as “Participating in your program really helped my self-confidence,” “Nothing short of remarkable,” “I will never forget this learning experience at Drexel.” As such, the Drexel Medicine Physician Refresher/Re-Entry course is another way of returning physicians to clinical practice and a way of addressing the physician shortage in our region.

Nielufar Varjavand, MD, is Program Director, Drexel Medicine® Physician Refresher/Re-Entry Course.  For more information, please visit http://webcampus.drexelmed.edu/refresher/ or call 215-762-2580.

Cancer Therapy and Women’s Fertility

Each year, cancer is estimated to occur in 113 per 100,000 women under age 50 in the United States. Treatment of cancer has improved dramatically over the past several years, and it is estimated that 77% of patients under 45 survive at least 5 years. The trend toward delaying childbearing means that many patients will not have had children when they are diagnosed. While there is recognition that cancer therapy can affect a patient’s fertility, less than 25% of oncologists inform their patients about their risks and options.

Chemotherapy or radiation therapy for malignant and nonmalignant diseases often results in premature ovarian failure and infertility. One of the strongest predictors of emotional well being in cancer survivors, besides sexual function, appearance, and employability, is feeling healthy enough to be a good parent. Cancer survivors are often fearful that their history of cancer or its treatment will have an adverse impact on their offspring by placing them at risk for malignancy, congenital anomalies, or impaired growth and development. They are also concerned about the risks of cancer recurrence, infertility, miscarriage, and achieving a successful pregnancy outcome.

Despite these concerns, surveys have reported that fewer than 60 percent of respondents had received information about fertility after cancer treatment.  There are several methods to preserve fertility in women diagnosed with cancer.

Fertility preservation requires individualization. The optimal approach depends upon the type of cancer treatment (radiation versus chemotherapy), time available, patient’s age, type of cancer, and whether the patient has a partner. However, there are no large randomized clinical trials evaluating the majority of the interventions described below, nor are there long-term follow-up studies assessing the possible impact of fertility treatment on cancer survivors.

One option includes In Vitro Fertilization and embryo cryopreservation. Women who must undergo chemotherapy or radiation therapy may go through early menopause. In vitro fertilization and embryo freezing will allow a woman to delay conception until she has completed her treatment, and deemed in remission, even if treatment causes early menopause. There are several steps to this including hormone therapy, egg retrieval, fertilization, laboratory development of the embryo, and freezing.  Frozen Embryos can survive for many years and once the patient is in remission and ready to use the embryos, the process of transferring the embryos can begin.

Any woman who has gone through normal puberty and still has regular menstrual cycles may be a candidate for embryo freezing. Success rates decline as women get older, and are best if women are under 38 years old. Some women may have poor ovarian function even at a young age, but fertility tests can predict success rates. Women who do not have a partner may have the option to freeze eggs. This new technology has led to live births, but is still considered experimental, and requires a specialized embryology laboratory.

Egg Donation is also another option. Egg donation allows a woman who has gone through menopause to carry a pregnancy. The process is similar to in vitro fertilization, except that a fertile woman (a relative, friend, or anonymous donor) is given fertility drugs to stimulate multiple eggs to develop. Once the eggs are harvested, they are fertilized with the infertile woman’s partner’s sperm (or donor sperm) and the embryos grown in the laboratory for several days.

The infertile woman receives hormone therapy to develop a normal uterine environment, and then the resulting embryos are placed in the infertile woman’s uterus. Hormone therapy is maintained for several weeks and then pregnancy progresses normally.

Cancer Therapy and Men’s Fertility

Male cancer patients have long been able to preserve their fertility by freezing their sperm. Unfortunately, sperm quality is often affected by cancer, and there may be poor sperm quality at the time of diagnosis. Sperm Banking is a great option for men. Most large cities have sperm banks that can freeze sperm. If a sperm bank is not located near your home, you can find sperm banks across the country that can provide long term sperm storage. The Internet is a great resource, and all reputable sperm banks have detailed websites.

Options for fertility treatment depend on how cancer therapy has affected the man’s fertility, and how normal the semen analysis is after treatment. Options may include artificial insemination with washed sperm if the sperm is relatively unaffected by cancer treatment, or if frozen sperm are available from before cancer therapy.

Insemination with donor sperm can allow conception when there are no sperm present after cancer treatment. If there are any sperm available, even very poor quality or extremely low numbers of sperm, than in vitro fertilization can allow conception. Once the eggs have been harvested from the patient’s wife, the embryologist can pick up a single sperm and inject each egg to ensure normal fertilization. Live birth rates are excellent with this procedure, and are largely dependent on the age of the patient’s wife.  In addition, adoption remains an option for family building. There are local and international adoption agencies, and private adoption through an attorney may also be possible. Unfortunately, adoption can be very expensive, and international adoption laws often change, causing frustration for infertile patients.

All of the above are viable and real options for cancer survivors who wish to have a family. As the oncology community becomes more aware of fertility preservation options, these are offered to more patients. There are advocacy organizations that can help, such as the Lance Armstrong Foundation, and Fertile Hope, to assist patients as they negotiate treatment options in their quest for a family.

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Carolyn R. Kaplan, M.D. is Director of In Vitro Fertilization at Georgia Reproductive Specialists and specializes in the initial diagnosis of infertility, egg donation, alternative approaches to the control of menopause and the holistic approach to infertility treatment. Visit www.ivf.com for more information.