One of my partners asked if our practice could use free GMail instead of replacing our old and failing mail server (not free) and having to purchase the licensing for the Microsoft software (definitely not free). When I looked into it, it turned out to be a bit more complicated than just deciding between a free mail service or one that has recurring expenses.

You see, with the advent of recent privacy regulations, there are increasing responsibilities being placed on the shoulders of medical practitioners to insure the protection of patient medical information. Before we get down to the details, let’s discuss some terminology:

Privacy vs. confidentiality. According to Gary Kurtz, in an article in the Journal of Healthcare Information Management, privacy is the right of an individual to control disclosure of his or her medical information. Confidentiality is the understanding that the information will only be disclosed to authorized personnel. This is what is known as a “need to know” basis.

Information Security. Since patient information will be increasingly common in a digital-only format, loss of electronic medical records could have an adverse impact on patient care. So it is up to the guardian of that information, typically the physician, to ensure that there are proper procedures for protecting both the safety and the integrity of that data.

The data safety relates to such issues as access to the information with minimal downtime, proper backup of the data with redundancy, and a disaster recovery plan which is regularly tested.

Integrity refers to processes which insure a true, uncorrupted and legal record. Most EMR systems maintain what is known as an audit trail, which tracks every change made to a record, when and by whom. Without an audit trail, it would be nearly impossible to tell if a patient’s record had been altered. Imagine a physical chart written on a dry-erase whiteboard – changes could be made at any time without discovery.

That said, the two main issues of information security relate to Who is controlling the information and Who has access to the information.

Who controls the information. Previously we discussed the two main types of EMR systems available: server-based and web-based. In server-based systems, the patient data is typically located on a computer or server in the doctor’s office. The upside: the doctor has ultimate control over the information. The downside: the practice is responsible for maintaining the security of the patient records, something which most medical practices have little experience with.

In a web-based system, the doctor accesses the EMR system via the internet, and the data is located off-site, usually on the server of the EMR vendor or a third party. The upside: these entities usually have a lot of experience with information technology security processes as well as the resources to implement them. The downside: the information may be stored on the same server as information from other medical practices; there is the potential for the information to be accessed by someone other than an authorized party. In addition, loss of the internet connection means loss of access to your patient files.

Who has access to the information. As stated above, access to patient information should be on a “need to know“ basis. There may also need to be additional provisions for restricted types of visits such as patients with HIV, mental health issues, or those undergoing drug treatment.

HIPAA (the Health Information Portability and Accountability Act) determines how patient health information may be shared electronically. So a medical practice would need, according to HIPAA language, to insure the confidentiality of the patient information not only within its domain, but would also need to take any steps necessary to make sure that third parties who have access to the same information (outside vendors, laboratories, consultants, etc.) maintain confidentiality as well. This could even be carried, in the extreme perhaps, to anyone who potentially has access to patient records, such as cleaning service companies or maintenance contractors. A practice would be well-advised to sign Business/Vendor Associate Agreements for HIPAA compliance with these companies. You can find many examples of these online that you can use.

Other potential gaps in information access include:

• computer monitors within sight of other patients (these should be locked if an employee leaves her station)
• printers or faxes located in ‘public’ locations
• lost or misplaced laptops or thumbdrives with critical information and without password protection
• passwords taped on monitors (you should have a strict password policy including passwords which expire periodically)
• doctor or staff smart-phones or PDAs which are not password-protected
• a wireless network in the office with inadequate security encryption
• unattended EMR workstations (these should automatically lock after a short period of inactivity)
• unauthorized software downloads which could allow breach of the network

So, going back to our story about GMail…for a medical practice to use GMail for its email service, it would need to enter into a Vendor Associate agreement with Google Inc. and require Google to adhere to the practice’s procedures and policies for privacy of patient information (and every medical practice that used GMail would have to do the same). Needless to say, Google is highly unlikely to agree to signing these types of agreements with possibly thousands of doctors, and be potentially exposed to significant liability.

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It doesn’t matter if your practice is just a single doctor at one location, or numerous physicians across multiple satellite offices. Either way, even before you can implement an EMR system, you’ll need to start by developing your system infrastructure. Although typically a contractor will take care of the network wiring for your office network, it is still a good idea to be familiar with some issues related to network wiring as well as terminology so you don’t get taken advantage of. Consider using a contractor who has been certified by the Building Industry Consulting Service International (BICSI), as this certification is the standard for contractors who deal with complex data and voice cable installations.

Some of the specific issues with which you should be familiar include:

Wiring: Typical Cat5e network wires have either a T568A or T568B standard. Select either, and be sure everything is wired to the same standard. The Cat6 wire standard is newer and more expensive, possibly a bit much for most medical practices. Copper wires between telephone communications closets shouldn’t contain segments over one hundred meters. Consider using fiberoptic cable for wiring over longer distances, as these cables can move more information and aren’t as vulnerable to interference and lightning. Fiberoptic, however, is more expensive.

Wireless: Are you considering wireless networking, also known as WiFi? If so, you will have to select a standard: either 802.11a, 802.11b, 802.11g, or 802.11h. Some newer standards provide higher data transfer speeds, but cost significantly more. The wireless standard that you choose should depend on whether you’re running a thin or fat client ( see Designing the Office Network for more about thin vs fat clients. Also, beware of interference from such common devices as cordless phones and microwave ovens.

Overwire: Most existing buildings are wired above the ceiling. Wiring is then dropped down the walls. When wiring, I would recommend ‘double drops,’ as the largest cost of wire installation is the labor. You will thank yourself later when you want to add more network devices (scanners, printers, diagnostic equipment, etc.), as these additional network connections will already be there.

Cooling: Network and server equipment create heat, and tend to shut down when over-heated. Plan for this by being sure that you have adequate cooling – you may want to consider installing a small, dedicated air-conditioning unit.

Electrical connections: It’s a  standard IT practice to have a certified electrician install isolated circuits for your network and servers – usually the outlets are orange so you can tell them apart.

Security: Don’t forget about security! Make the wiring closet secure, and remember that anyone with access to this closet can dismantle your network at any time.

Multiple locations: You’ll have to create a WAN, or wide-area network, to make a connection between remote office locations, so do your research and check out all your options. Larger metropolitan areas will generally have more options available for wide-area networks.

Fiber Backbones: Local utilities commonly maintain a fiber backbone which they allow businesses to access. These fiber backbones allow for high bandwidth rates between office locations (10-100Mbps) at a reasonable cost.

Local Phone Service: Meet with your local telephone sales people and service technicians. They understand the offerings in your geographic area. Some of the key points to discuss are:

• T1 lines: would a Metropolitan Area Network (MAN) or a Point to Point (PTP) be better?
• Inquire about both burst and committed information rates. A fast T1 connection may not cut it if the maximum isn’t available when you need it most.
• Will the phone company supply you with and maintain your router hardware, or will you need to take on this task yourself?

The costs of network infrastructure are much lower in new buildings. Apart from easier (and less costly) installation, the ability to oversee the network wiring in a building under construction is an advantage for clear design. Unfortunately, the majority of practices are located within existing buildings, so sound design and forethought in planning will help save your practice excessive costs and headaches later.

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Regardless of whether or not you use an EMR system, you may already have computerized billing and scheduling. And if you have multiple computers at your practice, most likely these computers operate on some sort of network. Even if you are not the ‘technical’ person in your practice, you should understand the designs and capabilities of computer networks, especially when a complex, multi-user EMR system is finally put into place.

Below are some basic principles of computer network design you should be familiar with:

Networking Basics (WAN, LAN, or MAN?)

Certain network hardware and system software may be incompatible with some EMR and EPM systems. Obviously, you should know this in advance. If you plan on adding users to your network at a later time, it’s often better to buy multi-user licenses rather than individual retail software packages. You can connect computers and printers in a practice on a Local-Area Network, or LAN. The LAN can link up with other local area networks via wireless connectivity. But be sure to check with the vendor of the EMR software to insure that it can operate on a wireless network.

A Wide-Area Network (WAN) can connect other smaller LANs, or Metro-Area Networks (MANs). Large practices can use these WANs to connect multiple satellite offices over a wide geographic area, for example.

The most recognized WAN is the Internet. The Internet can also create the possibility of an Intranet, or a private Internet, on which employees can communicate and collaborate with each other, regardless of where they are located. For such a system to function well between dispersed offices, a hi-bandwidth connection is a must in order to maintain smooth operations. We use an Intranet for such things as employee manuals, a practice Wiki, staff newsletters, photo sharing, and educational materials.

Bandwidth and Topology

Data capacity, or network Bandwidth, is often measured in bits-per-second (bps). In most cases connection rates range from 56kbps to millions of bits per second. Even so, the rates achievable may be limited by the hardware or sometimes even the software used. Overall speed on the network can be drastically reduced when many users are trying to use the system at the same time. If network speeds are slow because the hardware is underpowered or the network design is bad, ‘fast’ connection speed rates promised by the internet service provider won’t really mean much.

Network Topology is also important. Topology is the ’shape’ of the network, as in the wiring between a series of computers. This topology should have a clean, intelligent design and not simply daisy-chaining PCs in a random, haphazard way. Optimal topography may mean more wires, but this can contribute to overall system resilience from failure due to a weak spot. Otherwise, if one part of the network fails, the entire network could collapse as a result. Proper topography protects against this sort of situation with redundancies. A network consultant should recommend a good balance between expandability and redundancy.

Wiring

In most cases, a practice running an EMR system will employ hard-wired computers connected to a server. However,  some physicians may prefer to input data via a wireless device, as this can be carried throughout the areas in a practice. However, wireless networks present some new points to address:

Signal

Wireless devices have less-than-expected ranges when functioning in an office with many walls. Many consumer-level devices may be inadequate for the needs of a medical practice network. And they may suffer from interference due to common appliances such as microwave ovens or cordless telephones.

Bandwidth

The useful speed on your local network can be limited by the speed of your wireless connection, even if your LAN has good bandwidth rates.

Wireless Security

A hacker can destroy your network if it isn’t protected. Even simple wireless access points need to have built-in security. This is especially important in the age of HIPAA compliance.

Firewall

And speaking of security, you can protect yourself further by having what is know as a firewall. These are software programs, either stand-alone or as part of a hardware device, which protect private networks against intrusion from the outside world. These have become relatively inexpensive for the small business, especially compared to the cost of a successful network attack.

Fat or Thin Clients?

Should you employ laptops (fat clients) that directly run software and connect to your network via a wireless connection? Or, should you run the software virtually with a network appliance (thin client) via a remote connection? With wireless networks, disconnects are an unavoidable reality. In this case, the thin client lets the software continue to run, and you can later pick up where you left off. A broken connection on a fat client may cause a software crash. On the other hand, the latter has certain other capabilities such as running video programs.

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If you talk to anyone who is involved in the electronic medical records (EMR) industry, one of the biggest points of discussion is what is known as “Meaningful Use of EMR.” What started as a well-intentioned (by some) effort to establish standards for EMR software systems has morphed into political jockeying by corporations, consumer watchdogs, and others.

The US Dept of Health and Human Services (HHS) outlined these criteria for Meaningful Use of EMR:
1)    Improve quality, safety, efficiency, and reduce health disparities
2)    Engage patients and families
3)    Improve care coordination
4)    Improve population and public health
5)    Ensure adequate privacy and security protections for personal health information

And although each of these has defined goals followed by specific objectives and measures for the years 2011, 2013, and 2015, these still sound a bit ambiguous. Many industry experts, however, expect these to be more fine-tuned as the dates approach, but medical practices will have to stay informed to keep ahead of the curve.

Financial Incentives

As part of the ARRA (American Recovery and Reinvestment Act of 2009), financial incentives will be given to those physicians whose practices demonstrate “meaningful use” beginning January, 2011.

The incentive payment, according to CMS, is equal to 75% of Medicare-allowable charges for covered services in a given year, and maxes out as follows:

• Year 1 – $15,000
• Year 2 – $12,000
• Year 3 – $8,000
• Year 4 – $4,000
• Year 5 – $2,000

For those practices who are early adopters of the technology and hit the threshold for meaningful use in 2011 or 2012, the first year payment would be $18,000. Note that this only applies to Medicare; there are additional incentives for healthcare providers who have a certain threshold of Medicaid patients and/or who practice in a rural area. The threshold for office-based pediatricians is lower, and so they would be more likely to qualify for those additional funds.

[table courtesy of SoftwareAdvice.com]

Even considering the fact that EMR implementation may cost anywhere from $10,000 to $50,000 per provider, these incentives would certainly make that investment more palatable.

Those practices that procrastinate, however, will be penalized with cuts in Medicare and Medicaid payments:

• 2015 – 1%
• 2016 – 2%
• 2017 – 3%
• 2020 – 5% (maximum reduction)

So, how do you know if you qualify? According to the health IT blog NetDoc, to be a “meaningful EHR user”, a physician must satisfy three criteria:

1. Must use “certified EHR [EMR] technology”
2. Must demonstrate that the certified EHR technology is connected in such a way that it provides for the electronic exchange of health  information to improve the quality of health care, such as promoting the coordination of care (using HL7 or XML standards)
3. Must submit information on clinical quality measures specified by HHS (such as PQRI)

Some physicians have told me that because there isn’t a final definition of what is considered “certified EHR technology” they are just going to wait. Big mistake. Most health care IT experts working on and advising on this issue feel fairly strongly that the Office of the National Coordinator for Health Information Technology (ONCHIT) will set CCHIT (Certification Commission for Health Information Technology) criteria as the standard for EMR certification.

CCHIT is a non-profit organization funded by various corporations and groups such as the American College of Physicians and the American Academy of Family Physicians, and was recognized by the US Dept of Health and Human Services (HHS) as a certifying body in 2006.

Some critics, however, charge that CCHIT is a shill for the Healthcare Information and Management Systems Society (HIMSS), the healthcare industry’s membership organization focused on healthcare IT. Although made up of both corporate and individual members, these critics feel that their goal is to corner the market for certain major EMR players. Nevertheless, unless or until there is an alternative, most EMR vendors are using CCHIT certification as the benchmark.

In addition to the EMR certification criteria, the ONCHIT is expected to adopt an initial set of standards and implementation specifications by the end of the year 2009.

Timeline

So, is too late to implement EMR in your practice and still qualify for the financial incentives? Well, that depends on the size of your practice, type of specialty, and how motivated your doctors and staff are to go paperless. Just don’t expect to run down to Office Depot, buy an EMR program and launch it the next day (although there is talk about WalMart getting into the EMR business, but we’ll leave that story for another day…)

According to MBA HealthGroup, these are some reasonable time frames to expect for EMR Implementation:

• Stage 1 – up to 6 months – researching vendors, getting buy-in, setting up an EMR committee, checking out demos, and making a final decision on the EMR system
• Stage 2 – up to 5 months –  time it will take to actually ‘go live’. In the meantime, adapting workflow to EMR system you chose, ordering hardware, and standardizing processes
• Stage 3 – between 6 and 12 months – amount of time it will likely take to achieve “meaningful use”, which includes ePrescribing, documenting electronically, and ability to report certain items (which are still being determined)

[timeline courtesy of MBA HealthBlog]

Smaller groups and solo doctors may be able to purchase a more basic, “out-of-the-box” EMR system and more quickly adapt their workflow to the system, rather than vice versa in the case of larger medical practices. But, the one thing you can count on with EMR implementation is that you can’t count on anything – that is why some sort of timeline is important [see EMR Implementation Rollout].

What this boils down to is that those practices that have already started implementing EMR will have a good shot at getting those higher financial incentives. On the other hand, physicians who have been wishing that the whole idea of EMR was just a fleeting fad may not only miss out on these incentives but may also face cuts in their reimbursement.

Questions? Comments? Post them below

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There are many benefits associated with having a computer office network, regardless of whether you are ready to implement electronic medical records (EMR) or not. For example, what may begin as a helpful suggestion from an employee can blossom into a practice-wide tool which can improve overall productivity.

ProtoQue is a program which was developed in response to a problem we were having with our phone triage: we noticed that many patients were not called back in a timely fashion. This program, which is web-based, lets operators register calls automatically. The patient is then subsequently passed off from there to either medical records or a medical assistant. This program manages the ‘chain of custody’ so that the patient doesn’t slip through the cracks. The issue remains open until the problem is resolved. Every time a patient receives a return phone call, a time stamp is created, so our attempts to contact them are documented. The supervisors can use this application to monitor information flow, delegating calls to additional staff if the team falls behind, regardless of where they are located. We no longer have patients waiting until the next day to have their concerns addressed by our staff. Even though our EMR system, like most, has a messaging feature, we still find this program to be more robust and have continued to use it for over three years.

In addition to the phone triage program, we have designed some in-house programs that help us manage specific tasks, and which would not be possible without our computer network:

• The first helps calculate our eyeglass prescription capture rate, which is broken down by location and individual doctor.
• We also have an optical lab tracker program, which tracks jobs in real time, so an optician can tell a patient precisely when their order will be ready.
• Another custom application completes work-orders, and is located on a network that is accessible by IT, Human Resources, and Facilities. If supplies are needed, or a piece of equipment is damaged, an employee can complete a work-order and send it on to the right person. This facilitates full accountability while the chain of custody among the departments is being managed.
• Our Human Resources staff is working on an application that will let new employees enroll using our own electronic interface.
• A new PQRI Tools program which resulted in a significant federal incentive bonus. It attaches to the practice management system and identifies missed reporting before billing.

If you have any comments, please post them here. You can also post any questions you might have about some of our software tools.

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In order to implement important changes at your practice, you must gain buy-in from the staff. The executive search firm Korn/Ferry International cites a lack of employee buy-in as one of the most common management mistakes a new executive makes when trying to implement any new strategies or changes. If this executive fails to take the existing culture into consideration, the initiatives often fail.

For example, consider the controlling manager who arrives at a business only to discover that the employees work collaboratively. This combination can lead to significant struggles. Alternately, let’s consider the savvy executive who approaches the situation with an ability to acclimate, and who discovers ways to work in harmony with the existing culture and style at the firm. The latter approach can significantly assist your efforts to gain cooperation from staff when implementing the transition from paper records to electronic medical records (EMR).

Proper planning and the ability to adjust during the process are two tools that can help you avoid the need to pull the plug on your EMR project, with a potentially disastrous economic effect on your practice. The ‘Change Management’ process, which touts navigating change in a careful and systematic way, is a great tool to employ during this time.

Change Management: 10 Key Factors

1. Be clear and concise in speaking to each individual. Everyone should understand what is happening and what is expected from each. As long as having confidence doesn’t mean being unrealistic, it can be good for morale when problems arise. Be prepared to calm the fears of some staff.
2. The need for change will not go unquestioned. Present your case in a formal, referenced way which proves the benefits of changing over to a paperless system. Users need an incentive to change their habits, and will actually resist using the new tool otherwise.
3. Maintain good communications by keeping a dialogue channel open, encouraging participation at each step. The plan should also include a time line of actions for completion. Make sure to give the staff all the required information in the implementation process.
4. Address the aspects of the culture with explicit intent and detail. People can be expected to learn new skills on a gradual basis, taking baby steps toward learning more about more basic technology (using a computer, using a mouse. etc.), then advancing to more complex systems such as EMR.
5. Problems are a given; expect the unexpected. These may push back the system go-live date, and the effects will reverberate throughout the organization. Use the correct degree of flexibility to manage these effects.
6. When gaining acceptance, start at the top. The top tier of staff members, especially physicians and administrators, should be on board with the program, including any champions for the cause. If you have strong allies with the right technological skill and without a naive level of optimism, that is especially helpful.Resistant doctors in particular can be detrimental to the project, so stay on top of the nay-sayers.
7. Always acknowledge the human aspects. Without acceptance from the staff, a change to a new system could ultimately fail. The prospect of change often adds anxiety to the mix of human emotions, and this should be acknowledged during the process.
8. People should get involved at every level, so that everyone feels they contributed to the outcome. A committee of staff members, formed to create a proposal for delivery to the physicians, is another excellent tool. This committee should be representative of those who will ultimately use the EMR: administrators, business staff, and medical assistants.
9. Always make identifications and assessments of core values and beliefs in a cultural assessment, including possible sources of conflict or resistance. People often become set in their ways, resisting change as a general rule.
10. The leaders of the group should take ownership over project elements. As these staff members have better credibility with their subordinates compared to the physicians, these people are crucial and should be the first trained in the new system (’super-users’), then passing the info on through training.

Ultimately, every employee needs to buy-in to the change, and for this to occur successfully, a helpful framework is known as the ADKAR model (Prosci):

• A = Awareness of why the change is needed
• D = Desire to support and participate in the change
• K = Knowledge of how to change
• A = Ability to implement new skills and behaviors
• R = Reinforcement to sustain the change

Have you already implemented EMR in your practice? Did you have issues related to the Change Management? Post a comment below and let us know.

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I frequently see, coming across Twitter or other social media, posts or articles about ‘Free’ EMR systems or EMR at ‘No Cost.’ This presumption here is that, if your practice qualifies for financial incentives from the Federal Government, your initial investment will more than be covered. And if you can talk your local hospital into giving you one of those inexpensive web-based EMR systems (or Saas Software-as-a-Service), you might actually come out ahead.

So, what’s the catch?

Well, this assumes that your practice and employees are ready to go with an EMR system. Just install the software and you’re off to the races! For free, gratis, zippo. And then it’s like you’ve always been using EMR, right?

Not exactly. You still need to consider such things as:

• ‘end-user’ hardware – computer and monitors
• network hardware – servers, switches, routers
• network software – to run the network
• wireless hardware
• network wiring and installation labor
• scanners to scan old records
• high-speed internet connection, extra bandwidth
• staff overtime costs for training on the new EMR system
• EMR technical support/maintenance charges for installed EMR software
• EMR monthly recurring fees for web-based (Saas) systems

Oh, do I sound like someone who is against EMR? (At this point, that would be like being against inflation or against aging – they’re kinda inevitable). No, we have successfully launched EMR ourselves. But, you need to be realistic when you hear someone touting a free EMR system. It is sort of like inheriting a free car from your great aunt: if you don’t think there will be any other associated or on-going expenses, you’re kidding yourself.

Comments? Do you have a ‘Free’ EMR system? Is it really no-cost?

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Do you plan on implementing electronic medical records (EMR) at your medical practice? If so, you’re taking on a sizable project. Something this large must stay on a time-line or it may never reach completion. At our practice we experienced some setbacks including back-to-back hurricanes, construction of two new buildings, and hiring of a couple of partners - all of these events pushed the date of launch back over a year. Even so, having a firm date to ‘go live’ helps get everyone on board, allowing them to team together to engage in what could be one of the more challenging changes in their career.

Choose someone to be the project manager in charge of implementing the project. It could either be someone from staff such as an IT person or supervisor, or you could hire an outside consultant. Next, you want a comprehensive plan which covers the how, who, what, where, when, and why of the project from start to finish. Before going forward on your EMR plans, be sure your assets are ready. It just takes one poorly-prepared component to send well-laid plans down the path to failure.

Regardless of the practice, physicians’ attitudes towards EMR will range from gung-ho optimistic to downright resistant. Whoever is in charge of leading the project must decide when all of the physicians will roll-out on EMR, whether in unison or staggered on various launch dates or locations.

Some doctors may be quite comfortable allowing colleagues to test the waters first; but this may lead to more work and stress for the staff. If one doctor sees a patient using EMR, and the patient returns on a follow-up visit with another doctor using a paper chart, how will the patient’s chart be reconciled?

If there are multiple locations at your practice, you may want to implement EMR at one office before going on to the others. However, if your employees rotate between locations, your training plan must take this into account; if too much time passes between the launches at different locations, training may suffer.

Again, a project this large requires a firm commitment from the top authority at your practice, typically a physician ‘champion’, along with buy-in at all levels. One single voice of negativity from someone in a power position can drag down the entire campaign. A managing partner may have to intervene if the practice discovers that a doctor is actively working against the project – your administrator should not be put in this no-win situation. It’s also important that patients are well-informed of  the practice’s goals, so that they are more likely to tolerate the expected delays and hiccups while your team is working out the kinks in the system.

If you’d rather not make the big switch to digital all in one day, you may prefer to see only some patients using EMR. At our practice, we began with new patients requiring complete exams only, to prevent our clinics from grinding to a halt. As these patients gradually return for follow-ups, they continue to be seen using the EMR system. In this way, we were able to launch all locations simultaneously so clinics would not suffer from disparities in employee training and skills. This has also allowed us to gradually ramp up EMR with little effect on productivity.

Other items which shouldn’t be left to the last minute:

• Are your desktop machines or wireless tablets configured correctly?
• Has the software been installed and tested?
• Is there a proper disaster recovery plan in use?
• Is your infrastructure (wiring and wireless networks) ready to go? Adequate bandwidth?

Your schedule should include at least a month of intensive training for staff, which concludes well before the launch date. You may have to rotate staff during the day, or train people after hours at the usual overtime rate. Supervisors must have the ultimate word to ensure that the employees are trained to work with the EMR system in a live clinical setting. Naturally, they will need to practice to keep their skills sharp.

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Medical practices across the US will be well-advised to have processes in place for dealing with the certain outbreak of flu infections within their ranks, whether it is the Influenza virus or the H1N1 (Swine) Flu. It is not unrealistic to predict that a significant percentage of a practice’s employees could be affected – this could be further compounded by illness within the employee’s family, leading to further absence from the workplace. What follows is information we distributed to our staff (thanks to Bob Tilley and our administrative staff for the research).

Government Resources for Influenza Pandemic

Flu.gov This single source offers updates from the Centers for Disease Control and Prevention (CDC), Department of Human Services and Department of Homeland Security. We have found it to be quite helpful in collecting information on how employers can best prepare for the anticipated pandemic.

MyFluSafety The Florida Department of Health maintains this site to provide the latest information on the influenza pandemic in the Sunshine State.

Most of the information coming from the experts is consistent. But still it falls upon each employer to make its own decisions about how to best work with staff and to continue daily business operations.

Influenza Vaccination

In addition to the H1N1 virus, the CDC recommends that everyone receives the seasonal flu shot just as an additional precaution. Most adults will require just one dose but children may require a second injection – check with a pediatrician. In our practice, we purchase the seasonal flu vaccine and make it available to all staff members and their immediate family members. As I mentioned above, protecting the employee only could result in lost time if his or her children fall ill and they need time off anyway.

H1N1 (Swine) Flue Vaccination

The H1N1 flu vaccine is not for sale but, in most states, will be distributed by their Departments of Health. Practices should contact the Director of the Health Department and arrange for their employees to get the vaccine if possible. The CDC’s Advisory Committee on Immunization Practices, a panel made up of medical and public health experts, recommended who should receive the new H1N1 vaccine when it becomes available on a priority basis:

• Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated
• Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus
• Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity
• Children from 6 months through 18 years of age because we have seen many cases of H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread
• Young adults 19 through 24 years of age because we have seen many cases of H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population
• Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

CDC officials do not expect a shortage of H1N1 vaccine, but vaccine availability and demand can be unpredictable. Initial supplies may be available only in limited quantities. Once the demand for vaccine for the prioritized groups has been met at the local level, the CDC recommends vaccinating everyone from the ages of 25 through 64 years. Current studies indicate that the risk for infection among persons age 65 or older is less than the risk for younger age groups.

Precautions Within the Office

Precautions for Patients:

We have placed hand sanitizer dispensers at key locations such as the check-in and check-out counters, and will ask patients to use them before they sign in. If staff members observe any patient displaying signs of a flu-like illness, they will report this to either their supervisor or a physician. These patients should be asked to reschedule if at all possible. In addition, employees should immediately use hand sanitizer or wash their hands if they come in contact with one of these patients.

Precautions for staff are more complex:

First, establish whether the employee has a cold or the flu. Public health officials differentiate between the two by defining the flu as a temperature of 100 degrees or higher, plus one or more of the following symptoms – cough, sore throat, runny or stuffy nose, body aches, headache, chills, fatigue, diarrhea, and vomiting.

For those staff members who are experiencing flu-like symptoms, they should be told…

If you have a temperature of 100 degrees or higher plus one or more of the symptoms outlined above, you cannot continue to work and you will be sent home.  You then have two options:

1) You can visit your primary care doctor and have a Rapid Test for the H1N1 virus.  If the test is negative for H1N1, you may return to work and wear a mask to reduce exposure to patients and co-workers as long as you are symptomatic.  If the test is positive for H1N1, you will need to follow the CDC advisory:

• The CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. Your supervisor will take the temperature of any employee returning to work after being out with either the H1N1 or seasonal flu virus. (Your fever should be gone without the use of a fever-reducing medicine)
• Keep away from others as much as possible to keep from making others sick
• Be prepared in case you get sick and need to stay home for a week or so. We recommend that you keep a small supply of items on hand, including over-the-counter medicines, alcohol-based hand rubs, tissues and other related items that could be useful and help avoid the need to make trips out in public while you are sick and contagious

2)  If you decline the Rapid Test, we will have to assume you have the H1N1 virus and you will not be permitted to return to work for at least 7 days, or until your fever is gone for at least 24 hours, whichever is longer.

For those staff members who are sick but do not have the flu:

• The employee can elect to take a couple of days off, rest, and then return to work when feeling better
• If the staff member has no fever, but feels that he or she can return to work and perform the assigned duties, the employee with lingering cold symptoms should wear an N95 respirator mask at all times when in the office

What You Can Do to Stay Healthy

The CDC advises that influenza spreads mainly person-to-person through coughing or sneezing of infected people. It recommends the following everyday actions to stay healthy:

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.  If you do not have a tissue, cough or sneeze into your sleeve
• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hands cleaners are also effective
• Avoid touching your eyes, nose or mouth – germs spread that way
• Stay home if you get sick – CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them
• Follow public health advice regarding school closures, avoiding crowds and other social distancing measures (keeping a minimum of six feet between people, whenever practical)

Masking up

Understand that the N95 respirator or facemask is used primarily to prevent an infected person from spreading their infectious organisms to other healthy individuals.  However, use of a facemask or N95 respirator may also be of benefit if used correctly and consistently when exposed to an ill person. The use of facemasks may be considered as an alternative to respirators, although they are not as effective as respirators in preventing inhalation of small particles, which is one potential route of influenza transmission.

For specific work activities that involve contact with people who have influenza-like illness, the CDC recommends the following:

• Workers should keep their interactions with the ill person as brief as possible
• The ill person should be asked to follow good cough etiquette and hand hygiene and to wear a facemask, if able, and one is available
• Workers at increased risk of severe illness from influenza infection should avoid people with influenza-like illness (possibly by temporary reassignment); and
• Where workers cannot avoid close contact with persons with influenza-like illness, some workers may choose to wear a facemask or N95 respirator on a voluntary basis

Family members who become ill

Employees who are well but who have an ill family member at home with H1N1 flu can go to work as usual. These employees should monitor their health every day, and take everyday precautions including washing their hands often with soap and water, especially after they cough or sneeze.

If they become ill, they should notify their supervisor and stay home. Employees who have an underlying medical condition or who are pregnant should call their health care provider for advice, because they might need to receive influenza antiviral drugs to prevent illness.

If you become ill and experience any of the following warning signs, the CDC recommends that you seek emergency medical care.
In adults, emergency warning signs that need urgent medical attention include:

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough

In children, emergency warning signs that need urgent medical attention include:

• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough

Treatment

Public health officials state that they expect most people to recover from the H1N1 virus without needing medical care. If you have a severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed. Be aware that if the flu becomes widespread, less testing will be needed, so your health care provider may decide not to test for the flu virus.

Antiviral drugs can be given to treat those who become severely ill with influenza. These antiviral drugs are prescription medicines with activity against influenza viruses, including H1N1 flu virus. These medications must be prescribed by a health care professional.

The CDC recommends two influenza antiviral medications for use against H1N1 flu: oseltamivir (trade name Tamiflu ®) and zanamivir (Relenza ®). As the H1N1 flu spreads, these antiviral drugs may become in short supply. Therefore, the drugs may be given first to those people who have been hospitalized or are at high risk of severe illness from flu. The drugs work best if given within 2 days of becoming ill, but may be given later if illness is severe or for those at a high risk for complications.

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“There is No Obamacare”

- Cecil Wilson, MD, President-Elect of the American Medical Association

Members of the Marion County, Florida, Medical Society and their guests were treated to a special treat.  The guest speaker was Cecil Wilson M. D., the President-elect of the AMA.  And the quotation above is how he describes the current healthcare reform proposal. On counsel from his team of advisers, some of whom were present during the Clinton healthcare reform debacle (remember ‘Hillary-care’?), President Obama has opted to take a more hands-off approach.  So far, he has been no more than a cheerleader during the entire process of the formulation of HR 3200, also known as America’s Affordable Health Choices Act of 2009.

At the risk of sounding cliché, there was palpable tension in the audience.  Had the AMA sold-out to the White House?  Were physicians once again facing higher taxes only to see lower compensation in return?  Was this, in fact, government takeover of health care with the AMA as a willing ally?

Dr. Wilson stated that, unfortunately, most physicians are misinformed when it comes to the specifics of health care reform.  And part of that may be due to a disconnect between what the AMA is trying to achieve and the vociferous public debate which appears to have taken control of the issue.  His job, he feels, is to set the record straight. [ed. note: what follows are notes I took from his lecture, including questions from physicians in the audience (in italics)]

Did You Know…

• There are approximately 40.5 million uninsured persons in the US
• 75% of these people are employed
• In the past 2 years, 85 million people have been uninsured at some point (1 out of 4 Americans)
• 1% rise in unemployment = 1.1 million additional people Medicaid eligible + 1 million more uninsured

‘Why do we need health reform?’

• We have the finest health care but it is not universally available
• It costs more than in any other country
• Increasing costs are outstripping inflation
• It is having an adverse effect on business
• Employers are discontinuing employer-sponsored insurance
• Employees are forced into job lock (cannot leave their job for fear of losing coverage)

The AMA’s policy is “to support health system reform alternatives that are consistent with the principles of pluralism, freedom of choice, freedom of practice and universal access for patients.”

Therefore, the AMA has set the following criteria for health system reform:

• expand affordable coverage
• permanent repeal of the sustainable growth rate
• seek quality improvement versus profiling
• ensure adequate physician payments
• seek administrative simplification
• push for medical liability reforms
• empower physician practices with antitrust relief

In a July 16 letter to leaders of the United States House of Representatives, the AMA announced support for HR 3200. According to the Congressional Budget Office (CBO), it would provide health insurance coverage for nearly 97% of legal residents.  It would also include market reforms such as eliminating denial of coverage for pre-existing conditions, provide choice of plans to uninsured, self-assured and small business employees, improve coverage for preventive services, and expand Medicaid eligibility to those up to 133% of the federal poverty level, as well as increasing payments for primary care services.

The AMA decided it would support HR 3200 for the following two reasons:

1. Much of what was already in the bill was consistent with AMA policy
2. The AMA felt that it was important to give support to help move the bill through the House of Delegates (without which there would be no reform this year, or many years to come), and also to lock in the gains that have been made thus far.

Some of the key components of HR 3200 include:

• erasing the SGR (sustainable growth rate) debt and raising targets for Medicare physician updates
• increasing Medicare primary care payments without cutting other physician services
• investing in primary care training
• providing bonuses for physicians in low cost localities, and
• reducing red tape for physicians and patients.

‘Why Did the AMA Sell Out and Go Along with a Public Option?’

The AMA, in fact, has had reservations about this specific issue, because it sees this as another possible entitlement. It has said from the start that it does not feel that we need a public plan for health system reformed to be successful.  The AMA believes that insurance reforms, along with the increased numbers of people having the ability to purchase insurance and the ability to make the choice which insurance to purchase, will stimulate a market, resulting in lower cost, quality health insurance. Dr. Wilson believes that a truly public option will probably not pass, although there is a small possibility of some sort of a co-op, nonprofit hybrid.  However, there is still some doubt as to whether this will be a part of the final legislation.

Nevertheless, if health care reform legislation ultimately includes a public plan, the AMA has criteria which it believes are essential for that plan:

• physician participation should be voluntary
• patients enrolled in a public plan should be able to receive care from any physician, regardless of participation status
• physician payment rates should be based on fairly negotiated levels
• the public plan should be subject to the same regulatory requirements as private plans in order to have a level playing field
• the public plan should be self-sustaining; i.e., not rely on federal subsidies

‘Why Not Let Free Market Principles Promote Competition in the Insurance Arena?’

Because this hasn’t happened over decades now, according to Dr. Wilson. Familiar with Medicare Advantage plans?   Although these were supposed to save money, they are paid a 12%  administrative premium and usually pay physicians less than Medicare reimbursement rates.  Dr. Wilson also stated that there is something inherently unfair about more Medicare dollars going to some Medicare recipients than others.  Several founders of these companies, some of them physicians, have had quite lucrative payouts when these companies have sold. Under the new legislation, Medicare Advantage plans are slated for a gradual phase-out.

‘I Don’t See a Hard Line Being Taken on Tort Reform’

Initially there was no tort reform in the legislation.  However, the AMA has worked hard to have tort reform be the part of the major components that they have expressed to legislators should be included if the AMA is going to support it.  As such, there is language in the bill that provides incentives to states to explore alternatives such as certificate of merit, early offer programs, and medical courts.  There is no specific thing as a tort reform ‘law’, and he said that drawing a line in the sand over a single issue would be naive; otherwise, there is a distinct possibility that physicians could walk away with nothing.

Perhaps the most important component in the legislation is the SGR fix. This would result in substantial funding for physicians at a time when other healthcare stakeholders are facing steep cuts.  This includes about $230 billion in investments for physicians, specifically:

• $228.5 billion to eliminate the accumulated SGR cuts
• $1.6 billion for PQRI quality reporting changes
• $5 billion for the primary care bonus
• $1.8 billion for the medical home pilot
• $1.3 billion to extend the floor on Medicare’s geographic adjustment

“Making Laws Gives Making Sausage a Bad Name”

- Cecil Wilson, MD

Dr. Wilson also gave the audience a lesson in the legislative process, which he says at times can be so distasteful that it gives making sausage a bad name.  Negotiations occur between committees and subcommittees with multiple amendments and renegotiations.  A bill is likely to be sent to the House for debate sometime in September, and there will be a separate vote on a single-payer alternative.  The bill will then go to conference committee with the Senate. Meanwhile on the Senate side its HELP committee (Health, Education, Labor and Pensions) has yet to insert about 180 amendments.  The Finance committee is still working and has set a goal of September for September 15.  After that the two Senate bills will be merged into one for action by the Senate, but there could possibly be a separate Finance bill.

If there is no action by October 15, there is possible consideration of the reconciliation process.  This is also sometimes referred to as the ‘nuclear option’.  This occurs when the majority party can pass a bill with a simple majority, while avoiding a filibuster.

The AMA’s focus is maximum influence for the endgame negotiations.  What this means is that the health system reform is still in the early stages and we will see provisions that we don’t like at various stages of the legislative process.  However, the AMA is working with key members of Congress and administration to try to influence what’s most important: the critical negotiations at the point when the different approaches and ideas are reconciled.

‘Why Won’t President Obama Take a Bipartisan Approach? What Specifically are House Republicans for in Order to Support HR 3200?’

The House Republicans do not want health care reform, says Dr. Wilson. Even those legislators who are physicians have stated that they have their marching orders: not a single one will vote for any bill coming out of Congress. The goal is to bring down the President over this issue. Contentious issues such as the public option, which probably won’t pass anyway, are a bit of a smokescreen.  On the other hand, there is a genuine bipartisan attempt in the Senate to come up with a health-care reform deal which both sides can stomach.

“Grow Up and Quit Squabbling”

Meanwhile, Dr. Wilson admonished the audience, which obviously consisted mostly of physicians, to quit arguing with each other and stop the infighting.  Nobody doubts that within certain groups such as attorneys or insurance company executives there are both Democrats and Republicans, yet you do not see any public squabbling among the constituents of those groups.  Physicians, on the other hand, have historically resorted to fighting over minor issues.  The result, then, is that there is no united front on the major issues.  This, along with the position of putting all their eggs in one political basket, has resulted in little progress for any substantial health-care reform gains for the medical community.

Fair compensation and tort reform received little support under the previous administration, and the AMA feels that this is the best chance for righting the wrongs in health care. Dr. Wilson feels that the AMA’s  current strategy of sticking to key principles, willingness to negotiate, and not drawing a line in the sand will ultimately lead to legislation that will improve access to care.

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