northeast florida medicine - winter 2011 - internet and medicine

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3 Vol 62 No 4 2011 Northeast Florida Medicine www DCMS online org

Features

11 Internet and Medicine Made Ridiculously Simple Daniel Kantor MD Guest Editor

12 Mind the Gap Generational Differences in Medicine Danielle S Walsh MD FACS

17 Electronic Health Records Gaining Ground amp Improving Quality of Care (CME) Radley Remo MPH and Robert Harmon MD MPH

24 Effective Communication amp Marketing Strategies for Todays Busy Physicians AJ Beson and Vanessa Wells 27 Social Networking Who are Your Friends Daniel Kantor MD

31 HIPPA amp the Internet Christopher L Nuland JD

33 Technology for the Physician Danielle S Walsh MD FACS

Special Articles

8 Philip H Gilbert Invited Editorial

38 An Overview of the Preventive Care Provisions of Health Care Reform Seth Phelps Esquire

VOLUME 62 NUMBER 4Internet and MedicineWinter 2011

EDITOR IN CHIEFRaed Assar MD

MANAGING EDITORLeora Legacy

ASSOCIATE EDITORSSteven Cuffe MDRuple Galani MDKathy Harris (Alliance)Sunil Joshi MDJames Joyce MDNeel Karnani MDMobeen Rathore MDJames St George MD

Executive Vice PresidentJay W Millson

DCMS FOUNDATION BOARD OF DIRECTORSBenjamin Moore MD PresidentTodd L Sack MD Vice PresidentKay M Mitchell MD SecretaryJ Eugene Glenn MD TreasurerGuy I Benrubi MD Immediate Past PresidentMohamed H Antar MDRaed Assar MDAshley Booth Norse MDJ Bracken Burns DOLT Orlando Cabrera MC USN ResidentMalcolm T Foster Jr MDJeffrey M Harris MDMark L Hudak MDSunil N Joshi MDDaniel Kantor MDNeel G Karnani MDHeather Kearney MD ResidentJohn W Kilkenny III MDHarry M Koslowski MDEli N Lerner MDJeannine Mauney MD ResidentJesse P McRae MDJason D Meier MD ResidentNitesh N Paryani MD ResidentNathan P Newman MDMobeen H Rathore MDRonald J Stephens MDJeffrey H Wachholz MDDavid L Wood MDNortheast Florida Medicine is pub-lished by the DCMS Foundation Jacksonville Florida on behalf of the County Medical Societies of Duval Clay Nassau Putnam and St Johns Except for official announcements from the County Medical Societ-ies no material or advertisements published in NEFM are to be seen as representing the policy or views of the DCMS Foundation or its colleague Medical Societies All advertising is subject to acceptance by the Editor in Chief Address correspondence and advertising to 555 Bishopgate Lane Jacksonville FL 32204 (904-355-6561) or email llegacydcmsonlineorg

COVER Fantasy Hacker used with permission of Wallpaperherecom

Departments4 From the Editorrsquos Desk5 From the Presidentrsquos Desk9 Residents Corner35 Trends in Public Health43 DCMS History Book

Inside this issue of

Northeast Florida Medicine


From the Editorrsquos Desk

Accountability in Accountable CareAt my first exposure to the concept of the Accountable Care Organization (ACO) I found the use of the term ldquoAccountablerdquo

intriguing to say the least There is agreement that health care delivery is largely dependent on physicians who already consider themselves accountable for the quality of care Does the name imply that this new structure places more concrete accountability measures solely on the shoulders of physicians If so is this a realistic expectation I would argue that physicians should welcome more accountability as long as ACOs account for other factors that extend beyond their influence

ACO arrangements have recently achieved notoriety as a Shared Savings Program established by the Department of Health and Human Services (HHS) under the provisions of the Patient Protection and Affordable Care Act (PPACA) for Medicare beneficiaries It is set to begin next year The law promises to reward teams of physicians nurses and others who collaborate across the continuum of care to deliver improved outcomes at lower costs The medical market is organizing in anticipation and preparing for the inclusion of commercially-insured (non-Medicare) patients in ACOs According to industry groups about half of physician practices were hospital-owned in 2008 with 74 percent of hospitals planning to hire more doctors in the near future The structure of ACOs is not specifically defined in PPACA but will likely evolve from various ingredients with different degrees of central control All will be preparing to take on activities to focus on the integration of health care delivery to improve quality eliminate unnecessary services and control health care costs So what are some of the factors that extend beyond the influence of physicians

The aging population is a large factor in the overall increase of health care costs New technolo-gies and treatments have extended the lives of millions but also with significant added costs More patients have complex psychosocial and medical issues linked with unhealthy lifestyle choices and lack of concern for preventive care Lack of patient adherence to medical advice or treatment contributes to excessive spending Additionally physicians have to navigate a complex health care system with all of its imperfections Financial issues and a burdensome litigious and

regulatory environment often overload the system and make it far from efficient

Many interventions have been proposed to help tame uncontrolled medical spending related to the aforementioned factors patient education case management disease management population health management aligning financial incentives shared decision making consumer driven health plans transparency of quality and cost measures adherence to evidence based medicine guidelines Integrated Electronic Medical Records (EMR) clinical decision support systems Patient Centered Medical Home (PCMH) and finally ACOs Regardless of how extensive this list is it is likely to grow and morph as many ideas intertwine and return in part or whole under different cloaks

Many experts feel that all these methods have to integrate to be a viable solution The answer has to move us all in the same direction to bend the spending curve by improving health care quality and efficiency It is likely that ACOs will market themselves to include all of the initiatives listed above Intuitively these initiatives if designed well with physiciansrsquo input should work since most are intellectually sound However such initiatives may face considerable issues during implementation and beyond if they do not address insidious factors such as conflict of interest moral hazard of insurance and misaligned benefits From such details come larger issues which could erode effectiveness and further support

Will ACOs offer the final solution This is a difficult question to answer Another participant less emphasized if we primar-ily place accountability on care organizations yet playing a pivotal role in the quality and cost equation is the patient Patients need to be accountable ACOs will have to develop strategies to better engage patients and help them be more accountable for their own health conditions and outcomes

What comes next Are we likely to see an Accountable Patient Act Have we as a nation embraced the betterment of our lifestyles and adherence to evidence based medicine guidelines We will find father time serving again as both the clock and the judge

Dr Assar is Aetnarsquos Medical Director for North Florida Articles or opinions provided by Dr Assar do not necessarily reflect the views of Aetna

Raed Assar MD MBAEditor-in-ChiefNortheast Florida Medicine


From the Presidentrsquos Desk

A Swan Song with Dissonance and Harmony

As I prepare to write my final ldquoFrom the Presidentrsquos Deskrdquo as DCMS President this Swan Song or my good-bye has more dissonance than I would prefer Why Well it is because medicine continues to be in turmoil The recently passed Afford-able Care Act (ACA) is the subject of a consolidated lawsuit going before the US Supreme Court to rule on its constitutionality (ie can Congress pass unfunded mandates on to the states and a few other lesser constitutional questions)

This decision will come down some time in 2012 and the medical community needs to be prepared for any eventuality If the Supreme Court rules the ACA is constitutional then the full implementation begins in 2014 However if the Court rules

against part or all of the ACA what will physicians do

The other urgent issue continues to be the so-called Medicare formula referred to as the Sustain-able Growth Rate (SGR) which needs to be completely revamped SGR is likely to be in delibera-tions by the Committee of Twelve whose responsibility it is to find additional cuts to the federal budget or deficit reduction of approximately one and a half trillion dollars This Committeersquos deadline is Thanksgiving of this year

What can you do Write your representatives and senators Also support organized medicine that is lobbying on your behalf And whether you like or do not like the ACA it will likely prove to have a profound impact on medicine and the healthcare delivery system for years and decades to come Finally there is no question that we need a permanent fix to the SGR replacing it with a sound economic model

The DCMS will need its entire membership and key leaders to rally behind those state and national legislators who champion the right causes for medicine and the medical profession

Now to the harmonious part of my Swan Song Let me take this opportunity to salute two longstanding physician leaders in our community One is Dr Robert Nuss the retiring University

of Florida Dean for the University of Florida College of Medicine Jacksonville His counsel to DCMS leaders and support of DCMS membership for his faculty has been invaluable

The other is Dr Yank D Coble Jr Director of the University of North Florida Center for Global Health and Medical Di-plomacy He has been championing efforts to increase the number of residency positions in North Florida with an emphasis on primary care It is an age old debate but one Dr Coble and his Biosciences Council are addressing admirably

And as my DCMS presidency comes to an end I want to thank a hardworking DCMS Board of Directors and Executive Committee the officers and the committee chairs and members Also my thanks to the DCMS Alliance for its continuing support of DCMS programs and activities

In particular I want to thank Jay Millson our Executive Vice President who speaks for all of medicine and does it well The DCMS also has a wonderful staff in Patti Ruscito Barbara Braddock Marigrace Doran Leora Legacy and Deana Hadden each of whom plays a vital role in accomplishing the DCMS Mission ldquoto promote the delivery of and access to high quality ethical medical care for the community and to serve as an advocate for physician members and their patientsrdquo

All of the groups and people I have mentioned have worked hard this year to represent you the physicians of Duval County Every effort has been made to ensure that the practice of medicine remains a noble profession and the patient physician relation-ship continues to come before politics and questionable public policy

It has been my pleasure to serve as president of this storied medical society and I look forward to assisting my successor Dr Ashley Booth-Norse and others in supporting the medical profession in Northeast Florida

Malcolm T Foster Jr MD2011 DCMS President

The 2011 DCMS Annual Meeting is December 1 2011

See full coverage in the next journal issue


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bull A network of 26 outpatient clinics with specialties in Sports Therapy Balance Orthopaedics Womenrsquos Health and Chronic Pain

bull An established home health services division

bull A cutting-edge research facility

bull An award winning skilled nursing and rehabilitation facility

bull A physical medicine amp rehabilitation physician practice

bull An extensive array of preventive educational and community-based services such as adaptive sports and the Brooks Clubhouse

Offering the most comprehensive care possible so our patients can achieve the most complete recovery possible

BrooksRehaborg

Rehabilitation Hospital bull Skilled Nursing bull Home Health Care bull Outpatient Therapy bull Research bull Community Programs



Philip H Gilbert Invited Editorial

Editors Note Philip H Gilbert served as the Executive Vice President of the Duval County Medical Society (DCMS) from 1984 until his unexpected death in 2004 During those decades he was an outspoken advocate for the physicians he served and for the needs of their patients With no fear of retribution Phil shared his honest informed opinions with his DCMS colleagues and with the community they served In his honor the DCMS Board of Directors established the Philip H Gilbert Invited Editorial to celebrate his spirit for addressing issues that he championed such as advocacy tort reform community activism and caring for the underserved

The ldquoRequest for the 2011 Philip H Gilbert Invited Editorialrdquo invitation was sent in July to local state and national leaders (physician or layperson) All editorials received were reviewed by the DCMS Journal and Communications Committee Two editorials were chosen for publication - one in this issue and the other was published in the last journal

The Changing Face of MedicineJohn F Lovejoy Jr MD - 1988 DCMS President and Life Member

Doctor and Patient ChangesWith three generations of physicians in my family I have

seen the face of medicine change My dad Dr John F Lovejoy Sr frequently brought home food given to him in payment for medical services House calls and weekend rounds were a usual thing and as a young boy if I behaved I could go with my father to see his patients HIPPA would not allow

that now And today to get a house call you would have to join a practice that charges monthly service fees

The doctor used to be respected in society and still is but the expectations in the relationship were different The doctors used to wear professional clothes and car-ried black bags The patient addressed the doctor as ldquoDoc-torrdquo not a provider and hisher suggestions were usually followed without multiple second opinions

The practice model used to be individuals or small specialty groups Now there are few individual practitioners Sadly physicians gave up their independence because it was more profitable and less stress-ful to have a hospital or managed care group handle the paperwork headaches I am sure it makes life easier for the doctor but the patient relationship is less personal and more rushed Interestingly enough the administrators now make more money than the doctors and have more control over the doctorsrsquo lives

Hospital and Healthcare ChangesThere have been changes in the hospital system as well I

donrsquot remember anyone being denied care but hospitals were different and not as sophisticated When I started practice in the early 1970s the hospital had one administrator a head nurse and department heads The patient employee ratio was less than one to one

Now there are more employees per patient and many sub-layers of administrators I know medicine has progressed and

is more complex but it seemed to work well when the nurses made rounds with the doctors and pertinent information was entered in a chart not a template so the hospital can get maximum reimbursement

Time was spent with the patients not on the computer That is not to say that progress is bad but the all-important patient contact and empathy communication and personal touch that is part of the healing psyche is often overlooked Instead time is spent meeting all the regulations mandates and requirements of the present system

The brightest and most interested youth were able to be aides in the hospitals and clinics and could observe surgery and treatment without HIPPArsquos interference With this hands-on experience they were often stimulated to follow a physician or some other healthcare professional into a medical career Now it is almost impossible to give them that exposure

Questions and ConclusionsWhere is medicine going I am not sure It will always

attract those who have compassion for others But will they be able to provide the type of care as in past generations I think not Technology innovation and society will demand a different type of care that is less personal more streamlined and burdened with government restrictions and public rela-tions concerns

I am proud to have practiced when I did and hope the next generations do not lose that patientdoctor relationship that made the medical profession one of the most important parts of my life

Is there a solution that will make these changes palatable Yes it is an age old solution ldquoGet involvedrdquo To ensure all of the changes work for and not against the profession it takes involvement with patients civic groups the community and most importantly within organized medicine

Those of us in the medical profession can still control our future But it wonrsquot happen if we leave our fate to the politi-cians and lawyers because they are looking out for their own interests We must advocate for our patients and the medical profession Such advocacy can only happen as we get involved and stay active in DCMS and other professional groups that can direct us wisely in an ever changing medical environment

John F Lovejoy Jr MDDCMS Past-President


Residentsrsquo Corner St Vincents Family Medicine

Editorrsquos Note In an effort to connect more Duval County Medical Society members with residents in each 2011 issue there has been a ldquoResidentsrsquo Cornerrdquo with information about a residency program in the area details about research being done andor a list of achieve-mentsaccomplishments of the programrsquos residents This ldquoResidentsrsquo Cornerrdquo features St Vincents Family Medicine Residency Program

Overview of Residency ProgramSt Vincentrsquos Family Medicine Residency Program was developed in 1972 and has been a successful program ever since The

program hosts 30 residents in total with full-time OBs a maternity-trained family physician pediatrician psychologist and 10 family medicine faculty In addition to the full-time faculty physicians the residents receive teaching from a complete spectrum of private practice physicians who have a dedication to resident education There are 34000 clinic visits 322 deliveries and 2000 hospital admissions annually The program emphasizes outpatient care and continuity and is designed to develop critical clinical skills and decision-making abilities An Electronic Health Record (EHR) has been fully implemented since November 2006 Over 100 graduates are currently practicing in the Jacksonville area

St Vincentrsquos Family Medical Center (SV FMC) embraces the patient centered medical home (PC-MH) in its approach to providing comprehensive primary care for children youth and adults It has developed the characteristics of the PC-MH by providing each patient with a personal physician who is trained to provide first contact continuous and comprehensive care through the use of registries clinical information systems that track referrals lab results and templates to guide clinicians through evidence-based treatment recommendations SV FMC also supports patient self-management through group visits such as birthing classes diabetes and renal education classes and nutrition consultations Care is coordinated seamlessly from the clinic to the hospital and nursing home EHR help to reduce medical errors improve patient care and facilitate work flow processes for optimal productivity

The Family Medicine Residency Program is part of St Vincentrsquos Health System which was founded by the Daughters of Charity in 1916 St Vincentrsquos is a member of Ascension Health the nationrsquos largest Catholic and nonprofit health system

Community OutreachMobile Health Unit

St Vincentrsquos Mobile Health Outreach Ministry is a doctorrsquos office on wheels that travels throughout the region to minister to adults and children From migrant farm workers in Putnam County to inner city children in Duval County the Mobile Health vans reach the isolated and the underserved with immunizations health screenings physicals laboratory and diagnostic testing and many other services

In a typical year St Vincentrsquos HealthCare provides medical care to more than 7800 individuals and the demand is growing This includes more than 800 school and summer program physicals for children including immunizations each year

Haiti Every year since 1980 several physicians and surgeons travel to St Boniface Haiti Foundation at Fon Des Blanc Hospital

to provide medical care to the needy The surgical team visits the hospital monthly and a pediatric team travels there annually

Seton Center for Women and ChildrenThe goal of the Seton Center is to offer new moms and families consistent information and support in pregnancy The center

provides information and classes regarding childbirth breastfeeding and newborn care Newborns come to the center routinely for postpartum assessments at 3-5 days of age

Reach Out and ReadReach Out and Read prepares Americarsquos youngest children to succeed in school by partnering with doctors to prescribe books

and encourage families to read together Doctors nurse practitioners and other medical professionals incorporate Reach Out and Readrsquos evidence-based model into regular pediatric checkups by advising parents about the importance of reading aloud and giving developmentally-appropriate books to children The program begins at the 6-month checkup and continues through age 5 with a special emphasis on children growing up in low-income communities The annual Read and Romp a family event where children participate in games activities and crafts stations takes place each fall

Resident HonorsDr Lara Church was awarded the AAFP Foundation Pfizer Immunization Awards Program 2011 for Immunization Coverage

of 90-94 of 2-year-old children in the pediatric population at St Vincentrsquos Family Medicine Center Dr Lindsey Westberg was recognized as a FAFP Foundation Exceptional Resident Scholar 2011 for her outstanding work as a third-year resident

Drs Lindsey Westberg and Ross Jones have served as Presidents of the Florida Association of Family Medicine Residents (2010 - present)

Dr Heather Kearney is a third year resident at St Vincents Family Medicine Residency Program in Jacksonville FL Dr Kearney served as the programs resident representative to the DCMS Board of Directors for the 2010-2011 year She is a graduate of the University of South Florida College of Medicine and plans to enter private practice in the fall of 2012



This Issuersquos Focus Internet and Medicine

Internet and Medicine Made Ridiculously Simple

Special thanks to wallpaperherecom for permission to use

Fantasy Hacker for the cover art

iPads iPhones Droids Blackberrys hellip the world has changed forever with the dizzying array of new modes of commu-nication made possible by the computer chip Yet computers are a fairly new invention in the history of mankind From Turingrsquos thought experiment in 1936 on a theoretical device that manipulates symbols on a strip of tape according to a table of rules to my alma materrsquos (University of Pennsylvania) ENIAC (Electronic Numerical Integrator And Computer) designed to calculate artillery firing by the United Statersquos Army in 1946 to IBM mainframe computers to PCs and then to handheld deviceshellipcomputing technology has advanced at a dizzying speed

While Medicine has embraced aspects of the Digital Age such as robotic surgery and tele-medicine other elements of the Information Age have only been accepted half-heartedly Look at the uphill battle faced by Electronic Medical Records and Health Information Exchanges Meanwhile society has progressed even further to the Social Media Age and physicians are often lost in a confusing array of new terminologies

In this issue of Northeast Florida Medicine Danielle S Walsh MD tackles the generational gaps explaining much of how physicians see the world and interact with colleagues family and patients In her article ldquoMind the Gap Generational Differences in Medicinerdquo she emphasizes that the value in understanding the important differences between Baby Boomers Generation Xers and Millennials is crucial to the physician recruiting process Regardless of generational differences Radley Remo MPH and Robert Harmon MD MPH recognize the need to update all physicians on the new reality of Health Information Technology (HIT) terminology and Electronic Health Records (EHRs) in their article ldquoElectronic Health Records Gaining Ground and Improving Quality of Carerdquo This article is approved for Continuing Medical Education (CME) credit

Harnessing the internet may seem foreign to less computer savvy physicians but in an article entitled ldquoWe All Need to Listenldquo AJ Beson and Vanessa Wells argue that ldquoYou want your patients interacting with you You want an easy and natural flow of two-way communication between your patients and your brandrdquo Like any tool there are potential dangers and we need to protect our patientsrsquo and our own safety In ldquoSocial Networking Who Are Your lsquoFriendsrsquordquo this Guest Editor explores practical issues surrounding the use of social networking and I weigh the advantages and disadvantages of entering the worlds of Facebook and Twitter Despite the advantages of interacting online there are potential legal ramifications to your use of the internet which is explored by Christopher L Nuland JD in his article ldquoHIPAA and the Internetrdquo Legal and regulatory pitfalls are weighed against how ldquointeractive patient portals save staff and provider time and can lead to hap-pier patients who often can obtain vital information without having to wait for routine appointmentsrdquo Finally Danielle S Walsh MD further helps to close the generational gap by giving practical suggestions in ldquoTechnology for the Physician

The authors and I have ensured that the articles in this issue of Northeast Florida Medicine are current as of December 2011 but we also caution you that the internet a medical tool is changing rapidly just as all medical technologies do The future of medicine may rest in cognitive computing as heralded by the Jeopardy champion Watson1 Now more than ever the foundation laid out by the late Steve Jobs co-founder of Apple remains true that ldquoInnovation distinguishes between a leader and a followerrdquo2

Sources 1httptechnewsworldstort68678html 2 httpblogsubconsciousfilmscom

Daniel Kantor MDMedical Director Neurologique


Mind the Gap Generational Differences in Medicine

Danielle S Walsh MD

Address Correspondence to Danielle S Walsh MD East Carolina University 600 Moye Blvd PCMH TA-207 Greenville NC 27834 Email walshdecuedu

Abstract This article seeks to address the generational differences between Baby Boomers Generation Xers and the Millennials and the void this creates in the medical environment The differences will be analyzed by reviewing the information available extrapolating from other industry and providing insight into the implications of genera-tional issues in medicine

Introduction

The current physician work force consists largely of three generations the Baby Boomers Generation Xers and the Millennials The fourth generation the Traditionals or Pre-Boomers have largely retired and play a significantly smaller role in the dynamics of the physician workforce For each generation differences in historical events and social norms in childhood and adolescence manifest as divergent priorities values and career expectations These dichotomies are known to create misunderstandings and conflict in the workplace but little attention is paid to understanding the underlying differences particularly in the medical arena Physician re-cruitment and retention are areas in which tailoring efforts to different generations can significantly improve success

Itrsquos no secret that groups of people born in different time periods with varying external influences develop somewhat divergent viewpoints in priorities preferences and values Scientists who study social and demographic trends note that the differences in the currently identified four generations in the workforce are among the most dichotomous reported1

Leveraged by the entertainment industry and marketing firms for decades to target their products these generational differences can and do create significant friction when not recognized and addressed The physician world has been slower than some fields to study the impact of these dif-ferences on the profession In 2006 the Online Journal of Issues in Nursing dedicated an entire issue to the impact of generation differences on the nursing world but this topic has had limited visibility for physicians2 Yet the impact of generation difference is felt in hiring work habits financial decisions and even patient interactions

Generational Groups

In order to study differ-ences in generations it is necessary to make general-izations about large groups

of people Demographic profiles are created by categorizing people with similar historical events and social influences during a particular age in life An example of this is the de-scriptor ldquoGeneration Xrdquo for describing people born between 1965 and 1980 and exposed to the Cold War of the 1980s as adolescents and young adults While not every person who fits that demographic profile will conform exactly to the characteristics of the group itrsquos important to note that these categorizations are not about the individual person but rather the collective Additionally the nomenclature in the study of generation differences lacks standardization result-ing in one study calling a generation ldquoGeneration Yrdquo while another reporting on the same demographic calls them the ldquoMillennial Generationrdquo or ldquoGen Merdquo Despite these small differences the outcomes characteristics and interpretations of trends in these groups tend to be consistent and reproduc-ible across the field

Table 1 summarizes the four generations currently encoun-tered in medicine

Traditionals also known as Pre-Boomers were born in the Depression Era and represent a fairly small population largely due to poverty engendering lower birth rates Most members of this group have already entered retirement and play less of a role on the current physician work force Baby Boomers are named for the post World War II population boom that occurred in a period of relative prosperity in the US This generation is by far the largest demographic in the work force though the first members of the group are now in their late 60rsquos and entering retirement Significant influences on Boomers include the culture of the 1960s the assassinations of President John F Kennedy and Dr Martin Luther King Jr the Watergate scandal and the turbulent Korean and Vietnam wars Generation X is one of the smaller generational populations and was influenced by not only the

Alexander Dumas once said ldquoAll generalizations are dangerous even this onerdquo

Traditionalsbull Born 1925 to 1944 bull Ages 66 and upbull 40 million

Generation Xersbull Born 1965-1980 bull Ages 30-45 bull 61 million

Baby Boomers

bull Born 1945-1964 bull Ages 45-65 bull 79 million

Gen Y or Millennials

bull Born 1980-2000+ bull Ages under 30 bull 43 million

Table 1 Demographics of the Generations3


Cold War but also by the Iranian hostage crisis economic recessions and the Challenger space shuttle explosion The last generation in the current work force Generation Y has seen the rise of terrorism and economic instability Sentinel historical events for this group include the Columbine shoot-ings and the 9-11 terrorist attacks

Establishing the characteristics of a particular generation requires that its members have enough economic and social separation from their parents to make independent decisions Thus the up and coming generation remains an unknown quantity until young adulthood

Generational Priorities and Values

With each generation come distinct priorities and values that shape their decisions and actions For example Boom-ers grew up in large highly competitive classrooms where academic success was essential The competition played a significant role in future career choices This contrasts with the ldquoEveryone is specialrdquo message of the Gen X classroom and the decreased emphasis on grades alone as a measurement of potential Gen Y found their childhood filled with structured play dates scheduled afternoon activities and sports and increased involvement of their parents in the oversight of their education

The impact of the varied historical and social influences can be seen in the priorities of each demographic in adulthood Boomers value working hard being honest and maintain-ing integrity But ldquoBeing Happyrdquo is the primary aspiration of the Gen X They also focus on being ldquotrue to yourself rdquo and expressing individuality Gen Y were consistently told they could be anything they wanted to be and manifest this as confidence and pursuit of setting short term satisfying goals all the while ensuring there is good worklife balance4

The impact of these different motivations and values become apparent when the three dominant generations converge in the workplace For the employer an understanding of these motivations is useful for recruiting retaining and generally maintaining employee satisfaction

Boomers are the most likely to embrace the corporate culture of their respective workplace Once a member they readily seek promotions responsibility and the authority it brings and anticipate a pay raise with each respective promotion Their profession is much of their identity in that their career is the dominant component of how they perceive themselves and want other to perceive them5 Many value owning their own medical practice and view the ability to do so with a profit as success Communication is by formal meetings formal letters phone calls and some email Dress is typically business formal Continued education in their field is via print journal textbooks and attendance at live CME presentations Time outside the office may include active involvement in professional groups such as the local medical association or philanthropic organizations and their spouses often join them in supporting these efforts Maintaining a Boomer in

the workplace involves ensuring they can continue to move up the leadership ladder and providing opportunities to control the working environment Many respond well to incentive programs based on duration of employment and productivity

Generation X brings a striking contrast to the workplace They tend to view medicine as a job through which they make a living and achieve personal goals as opposed to an identity Despite valuing learning new skills and interest in new technologies they are not necessarily interested in leading the team or becoming ldquothe bossrdquo Most favor employee status where the issues of rent overhead and billing are handled by other individuals Once no longer challenged or faced with an undesirable work environment most will elect to move on rather than await change Their relaxed approach to work will manifest as casual dress speech and communication

With a focus on technology and evidence-based medicine this group does a web search for every topic watches videos of new procedures or devices and limits memberships in professional organizations to those that provide a tangible benefit Gen X employees generally change jobs every 5 years6

Recruitment and retention of this generation involves care-ful attention to worklife balance and allowing freedom to determine work hours within a structure of expected volume and productivity They respect a boss not because of hisher title or years of experience but rather on the basis of per-formance skills and ability to assist employees on achieving their individual goals As students they were encouraged to ask ldquowhyrdquo and this tendency does not disappear at entry into the workforce Micromanagement is discouraged explanations are encouraged and the opportunity to bring new skills and services to the group is valued by this demographic7

The Millennials newest generation in the workplace ex-perienced a childhood emphasizing working as a team with credit for victories and accomplishments being distributed to all members of the team They thrive under a well-defined structure with detailed guidance and clear rules Like Gen X they espouse a highly technical but informal style of com-munication best demonstrated in their use of smartphones and texting for managing their personal and professional lives Though demanding of themselves and others they thrive on frequent positive feedback and anticipate promotion and sal-ary raises at frequent intervals The restriction to an 80-hour work week or less in training has been the norm and the expectation of a reasonable worklife balance is engrained Electing for additional time off over opportunity for addi-tional income Millennials are likely to use some of this time for volunteerism in indigent care and medical mission trips9

Part-time positions are of interest to both women and men

Gen X is likely to believe the boss should impress them in order to keep them8


with 13 of male and 36 of female physicians practicing part time in 2010 compared with 7 and 29 in 200510

Most have eschewed joining organizations just for the sake of membership they need a clear sense of identity within a group a voice at the table of leadership in the association and the belief that their efforts will bring value and change Their inquisitive nature and free-spirited quest for adventure may translate into frequent job changes with some staying in positions for only 2-3 years at a time11 Few are interested in taking on the cost challenges and lifestyle of a physician owned practice12

The technology ldquodividerdquo is one area in which the generational differences can be staggering While many Boomers may use email comfortably others have an account but allow their secretary to print out the message and place the paper note on their desk Their response may even be dictated Fewer are facile with editing and uploading videos and many are uncomfortable sharing credit card numbers and account information online for purchases and banking Many prefer a written check or a personal bank interaction for transac-tions Generation X readily embraces online shopping and accounts viewing the electronic secure sites as more reliable than the human or paper worlds Millennials carry this a step further and perform financial transactions via smartphone and are likely to embrace the integration of credit cards into their hand-held device

Generational Differences When Recruiting

Not surprisingly the differences in generational values and priorities can become more apparent during the recruitment of a new physician into a medical practice In placing a job ad to recruit a partner Boomers tend to write ads that would appeal to them even if seeking a junior partner Figure 1 contrasts the type of job listing likely to appeal to the dif-ferent demographics Consideration should also go into the medium in which the ad is placed Boomers head to the classified section of the prominent journals in their field or allow a recruiter to perform the search on their behalf In contrast Generations X and Y head directly to the internet to begin and end their job search ndash all but ignoring the print versions of the journals containing the ads The quality of the potential employerrsquos website and the amount of information it contains about the position factor into whether they even inquire further Other media likely to catch the attention of the younger generations include Twitter job postings video announcements and Facebook pages

Once a candidate for a position is found to be a good fit generational preferences should also be considered for development of the contract Boomers strive to negotiate the highest salary a strong bonus incentive often desiring a short buy-in period to a private group and paying close attention to retirement programs Gen y will accept a slightly lower salary if balanced by a significant amount of vacation

time supplements for training and travel to conferences and access to cutting edge technology13 Companies that believe a standard one-size fits all package should be offered to all employees without consideration of the priorities of the applicant may quickly find that they have limited their search to a single ldquotype of applicantrdquo and fail to understand why the position goes unfilled for years

Experts agree that the secret to a stable physician workforce is largely in understanding the generational differences and avoiding perceiving them as either good or bad14 Diversity should be welcomed and programs to encourage productivity and career satisfaction should be individualized a sometimes challenging endeavor in larger organizations that tend to favor a single standardized policy

Leaders need to be approachable provide frequent and specific feedback involve others in critical decisions and encourage initiative and new ideas from all demographics1516

A keen awareness of worklife balance and flexibility in work schedules while maintaining productivity standards are also helpful in tailoring to each group

In contrast demands that younger generations simply con-form to the norms set by the Boomer generation are likely to

(Appeals to Boomer generation)Surgeon

The University of ____ is seeking a General Surgeon to join the prestigious faculty of this top tier academic program The candidate will pursue basic science research in addi-tion to teaching and clinical responsibilities Candidates should be board certified or board eligible Rank and salary is commensurate with experience Submit curriculum vitae and two letters of recommendation to

John Smith MD FACSChief Department of Surgery

100 Main StreetCity State 12354(555) 555-5555

(Attracts a Gen Y Physician)The Job of Your Dreams

Bring your cutting edge surgical techniques to our grow-ing surgical practice and find the worklife balance yoursquove always dreamed of With our talented team of physicians residents and in house critical care physicians your patients will be well cared for Our city is family friendly and offers opportunities for enjoying the arts theatre and sports A generous compensation and relocation package round out this unique opportunity Explore this opportunity and more at our website funjobcom or email your resume for immediate review to jsmithfunjobcom

Figure 1 Job Listing Samples


fail after a time Advertising interviewing and on-boarding a new physician is a remarkably expensive endeavor estimated to cost over $226000 per physician17 In recognition of this it makes sense to make every effort to retain the physicians brought on board and avoid the fees associated with a search

Conclusion

Exploring the impact of having multiple generations in the workplace with an eye towards understanding norms accommodating differences where possible can prove benefi-cial for all physician groups Baby boomers thrive in formal atmospheres and work towards positions of increasing prestige and leadership Generation X is most productive when al-lowed flexibility in a relaxed setting that incorporates the use of technology to produce efficient outcomes Gen Y values

a team approach with guidance but places great emphasis on worklife balance While it may seem easiest to expect all generations to conform to a single work paradigm employers with such expectations may find difficulty when recruiting experience high turnover and have to deal with continuing employee dissatisfaction

Resourcesbull Deal Jennifer J Retiring the Generation Gap John Wiley

amp Sons San Francisco California 2007 bull Orrell Lisa Millennials Incorporated Intelligent Women

PublishingWyatt-MacKenzie Publishing Deadwood Oregon 2007bull The Center for Generation Studies wwwgentrends com Accessed 2009

References1 Associated Press Study Generation gap in US largest since

rsquo60s Available at httpwwwmsnbcmsncomid31598018nsus_news-lifetstudy-generation-gap-us-largest-s Accessed September 17 2011

2 Sherman R Leading a Multigenerational Nursing Workforce Issues Challenges and Strategies Online Journal of Nursing 2006 May 06 11(2) Available at httpwwwnursingworldorgMainMenuCategoriesANAMarketplaceANAPeriodicalsOJINTableofContentsVolume112006No2May06tpc30_216074aspx Accessed September 17 2011

3 United States Census Bureau Available at httpwwwcensusgovcompendiastatab2011tables11s0007pdf Accessed September 17 2011

4 Zemke R Raines C Filipczak B Generations at work Man-aging the clash of veterans boomers Xers and Nexters in your

workplace Amacom New YorkNew York 2nd ed 2000

5 Value Options The Baby Boomer Generation [Born 1946ndash1964] Available at httpwwwvalueoptionscomspotlight_YIWbaby_boomershtm Accessed September 17 2011

6 Mezzapelle D Generation Y Going to Work ndash Hopefully Available at httpbloggoliathjobscom20081025generation-y-going-to-work-hopefully Accessed September 17 2011

7 Value Options Generation X [Born 1965ndash1980] Available athttpwwwvalueoptionscomspotlight_YIWgen_xhtm Accessed September 17 2011

8 Gravett L Throckmorton R Bridging the Generation Gap Career Press Franklin Lakes New Jersey 2007

9 Ladika S Bridging generations How your club can attract new age groups The Rotarian 2008 Sept 187(3)27-28

10 CejkaSeachAvailable athttpwwwcejkasearchcomnewsmedia-mentionspart-time-doctors-shaking-up-small-practices Accessed September 17 2011

11 Robert Half International What Millennial Workers Want How to Attract and Retain Gen Y Employees Available at httpwwwrhicomGenY Accessed September 17 2011

12 Stagg-Elliott V Ownership loses its luster American Medical News 2009 Oct 2652(23)23-24

13 Arbel T Millennials value time off pay more than Gen X Available at httpwwwmsnbcmsncomid35783784nsbusiness-personal_financetmillennials-value-time-pay-more-gen-x Accessed September 17 2011

14 Stagg-Elliott V Generation gaps American Medical News 2010 June 21 53(12)20-1

15 Mocke D The Generation Gap and Motivation Available at httpwwwsustainable-employee-motivationcomgeneration-gaphtml Accessed September 17 2011

16 Smith G Baby Boomer Versus Generation X Managing the New Workforce Available at httpthecitizencomarchivemainarchive-010509businessb-03html Accessed October 8 2007

17 Buchbinder SD Wilson N Melick CF Powe NR Estimates of costs of primary care physician turnover Am J Manag Care 1999 Nov 5 111431-8

18 Twenge JM Generation Me Simon amp Schuster New York New York 2006

Dr Jean Twenge said Asking young people today to adopt the personality and attitudes of a previous time is like asking an adult American to instantly become Chinese18

While it may seem easiest to expect all generations to conform to a single work paradigm employers with such expectations may find difficulty when recruiting experience high turnover and have to deal with continuing employee dissatisfaction


Trends in Public Health

The Internet and Public HealthNiketa Walawalkar MD MPH Thomas Bryant III MSW and Robert Harmon MD MPH

Computers and the Internet have become a daily aspect in our lives making it easy to search for information and keep up with the activities of the world The Internet is increas-ingly utilized by researchers health care professionals and the general public to seek health-related information The Internet also provides a medium to allow mass communica-tion for health campaigns generate consumer awareness and influence health behaviors

The National Center for Health Statistics recently found that 74 of all US adults use the Web and 61 have looked for health or medical information on the Internet Public health organizations around the world use the Internet to keep communities informed about their health and well being Web technology offers new capabilities for people committed to protecting and promoting the publicrsquos health from combining data resources for detecting and monitoring early outbreaks of infectious diseases to using social networks for information sharing A study by the Centers for Disease Control and Prevention (CDC) demonstrated that using a website to display health-related information is an effective means to inform people and it serves as an important public health tool for community outreach1

The Florida Department of Health (DOH) seeks to in-corporate internet technology into its services (wwwdohstateflus) The Vital Statistics division uses ldquoe-vitalsrdquo to allow consumers to request and print birth certificates via the Web The Environmental Health (EH) office and many county health departments have online service request forms to expedite environmental services EH is also planning to replace the current paper-based tracking of food water and arbovirus borne diseases with a new web-enabled system that will be integrated with the DOH disease surveillance systems

The DOH Epidemiology unit now uses an electronic laboratory reporting system that facilitates sharing laboratory data from clinical laboratories and hospitals with DOHrsquos internal stakeholders to help them identify disease outbreaks provide treatment and prevent the spread of disease Florida SHOTS (State Online Health Tracking System) a free state-wide centralized online immunization registry sponsored by DOH helps healthcare professionals and schools to track immunization records (wwwflshotscom)

DOH operates the Health Management System (HMS) which is a Web-based clinic practice registration scheduling billing and reporting system It is being used as the platform to launch a new electronic health record over the next year A web-based e-Lab module is already implemented and e-prescribing will be launched next year

The county health departments and the city of Jacksonville are embracing the possibilities associated with the Internet making it easier for people to access reports and publications compare data across cities counties states and countries and access current and past programs and projects The DCHD uses its website wwwdchdnet to inform the Jacksonville community of its health status and DCHD services Visits to the website have increased considerably since 2008 with an estimated 6310 visits per day and an average of 800 pages viewed daily as of August 2011 DCHDrsquos research division the Institute for Public Health Informatics and Research (IPHIR) had an average of 1770 hits per month and ap-proximately 3050 downloads of Duval County Center for Health Statistics reports an 18 increase from 2008-09

Public health organizations are now investing resources to make their websites more accessible user-friendly and infor-mative DCHD will launch its newly renovated website by the end of 2011 This will simplify access to information on DCHD clinics health related data health status updates and emergency alerts IPHIR will introduce a web-based interac-tive mapping software to view health-related data Visitors will be able to create maps and graphs of selected indicators making comparisons across zip codes health zones and years

Another important new web-based health resource is wwwnefloridacountsorg This website was launched in May 2011 by a coalition of more than 25 regional partners led by the Health Planning Council of NE Florida It includes more than 170 up-to-date health education and socioeconomic county-level indicators covering seven counties It also contains more than 1500 promising practices and 250 special data sets

The effective use of the Internet in public health requires an understanding of user needs characteristics and interests A website functions as a bidirectional medium through which public health professionals send out health information and receive public feedback The number of visits to a web page reflect the interests of users and is found to be often influenced by the trends in population health Public and private sector organizations are utilizing web usage data to modify their websites to meet community needs and influ-ence health behaviors As we head towards the new age of ldquoe-public healthrdquo we need to work together to increasingly use technology to achieve the public health goals of ldquoPrevent Promote and Protectrdquo

References1Tian H Brimmer DJ Lin JM Tumpey AJ Reeves WC 2009 Web Usage Data as a Means of Evaluating Public Health Messaging and Outreach J Med Internet Res 200911(4)e52


Electronic Health Records Gaining Ground and Improving

Quality of CareBackground - Benefits that Matter

The Duval County Medical Society (DCMS) attempts to provide its members with the benefits that consistently meet your professional needs One example of how this is being accomplished is by providing to DCMS members free Continuing Medical Education (CME) opportunities in the subject areas mandatedand or suggested by the State of Florida Board of Medicine to obtain and retain medical licensure The DCMS would like to thank the St Vincentrsquos Healthcare (SVHC) Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME) Helena Karnani MD Chair of the CME Committee Betsy Miller Director Medical Staff Quality Management and Cindy Williamson CME Coordinator from SVHC deserve special recognition for their work on behalf of DCMS

This issue of Northeast Florida Medicine includes an article ldquoElectronic Health Records Gaining Ground and Improving Quality of Carerdquo authored by Radley Remo MPH and Robert Harmon MD MPH(see pp 19-23) which has been approved for 10 AMA PRA Category 1 credit(s)trade For a full description of CME requirements for Florida physicians (MDDO) please visit the DCMS website (httpwwwdcmsonlineorgcme_requirementsaspx)FacultyCredentials Radley Remo MPH has been the Coordinator Center for Health Informatics Duval County Health Department in Jacksonville FL since July 2006 He earned his BA degree in health from the University of North Florida in Jacksonville FL and his MPH degree from the University of South Florida in Tampa FL Robert Harmon MD MPH has served as Director of the Duval County Health Department in Jacksonville FL since August 2006 He is also an adjunct professor in the School of Public Health at the University of Minnesota Dr Harmon received his MD degree from Washington University in St Louis MO and his MPH degree from Johns Hopkins University in Baltimore MD

Objectives for CME Journal Article1 Differentiate between the three types of electronic records (EHR EMR and PHR)2 Recognize the benefits and challenges of adopting and using an EHR3 Identify resources to help with EHR adoption and to achieve meaningful use

Date of Release November 30 2011 Date Credit Expires November 30 2013 Estimated time to complete 1 hr

Methods of Physician Participation in the Learning Process1 Read the ldquoElectronic Health Records Gaining Ground and Improving Quality of Carerdquo article on pages 19-23

2 Complete the Post Test and Evaluation on page 18

3 Members or non-members must fax the Post Test to DCMS (FAX) 904-353-5848 OR members can also go to wwwdcmsonlineorg amp submit the test online Non-members must arrange for the CME fee payment before submitting the post test Call 904-355-6561 x106 or fax

CME Credit EligibilityIn order to receive full credit for this activity a minimum passing grade of 70 must be achieved Only one re-take opportunity will be granted if a passing score is not made on the first attempt DCMS members and non-members have two years to submit the post test and earn CME credit A certificate of creditcompletion will be emailed faxed or USPS mailed within 4-6 weeks of submission If you have any questions please contact the DCMS at 355-6561 ext 103 or llegacydcmsonlineorg

Faculty Disclosure InformationMr Remo and Dr Harmon report no significant relationships to disclose financial or otherwise with any commercial supporter or product manufacturer associated with this activity

Disclosure of Conflicts of InterestSt Vincentrsquos Healthcare (SVHC) requires speakers faculty CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content and appropriateness of patient care recommendations

Joint Sponsorship Accreditation StatementThis activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medi-

cal Education through the joint sponsorship of St Vincentrsquos Healthcare and the Duval County Medical Society St Vincentrsquos Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physiciansThe St Vincentrsquos Healthcare designates this educational activity for a maximum of 10 AMA PRA Category 1 credit(s) TM Physicians should only claim credit commensurate with the extend of their participation in the activity


5 How many stages of Meaningful Use will there be

a One

b Two

c Three

d Four

6 Which of the following is not a potential benefit of using an EHR

a Resource efficiency

b Quality of care improvements

c Cost savings

d Easy to implement

7 What is the most frequent reason for not implementing an EHR

a Lack of comfort with technology

b High cost of EHR

c Too close to retirement

d Dont believe EHRs are beneficial

8 Which of the following are resources for EHR and HIT

a Office of the National Coordinator

b Agency for Health Care Administration

c Regional Extension Centers

d Centers for Medicaid and Medicare Services

e All of the above

Electronic Health Records Gaining Ground and Improving Quality of CareCME Questions amp Answers (Circle Correct Answer) Free-DCMS Members$5000 charge non-members

Members or non-members - fax Post Test to DCMS (FAX) 904-353-5848 mail to 555 Bishopgate Lane Jacksonville FL 32204OR members can also go to wwwdcmsonlineorg amp submit the test online Non-members must arrange for the CME fee payment beforesubmitting the post test Call 904-355-6561 x106 or fax 904-353-5848 with charge information

Return by November 30 2013

Evaluation questions amp CME Credit Information

(Please evaluate this article Circle one number using this scale 1= Strongly Agree to 5= Strongly Disagree)The article met the stated objectives 1 2 3 4 5The article was appropriate to my practice 1 2 3 4 5The topic was current and well presented 1 2 3 4 5Comments__________________________________________________________________________________________________________________________________________________________________________________Name (Print)___________________________________________Email_____________________________________AddressCityStateZip_____________________________________________________________________________

Phone__________________________Fax_____________________DCMS Member (circle) YES NO

Non-Member Charge ($5000) - See payment options below (Call 904-355-6561 x106 or Fax information)

Credit card Visa MasterCard American Express Discover

Account ___________________________________Expiration date_______________________________________

Signature_______________________________________________________________________________________

1 An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created managed and consulted by authorized clinicians and staff across more than one health care organization is called a PHR b ERH c CPOE d EHR 2 The capability of different information technology systems and software applications to communicate to exchange data accurately effectively and consistently and to use the information that has been exchanged is a Interoperability b HITECH c RHIO d Interchangeably 3 The electronic movement of health-related information among organizations according to nationally recognized standards is a RHIO b PHR c HIE d Interoperability 4 Approximately what percent of clinicians in the US are using a fully operational EHR a 5 b 10 c 50 d 100


Electronic Health Records Gaining Ground and Improving Quality of Care

Radley Remo MPH and Robert Harmon MD MPH

Address Correspondence to Radley Remo MPH Center for Health Informatics Coordinator Duval County Health Department Jack-sonville FL Email Radley_Remodohstateflus

Abstract This article provides a general overview of Health Information Technology (HIT) terminology and Electronic Health Records (EHRs) It provides definitions reviews the current ambulatory EHR literature and documents the benefits and challenges of implementing and using an EHR It describes the current state of HIT and EHR progress in the US Florida and locally Lastly the article lists resources and references for practices to learn more about HIT and EHRs

Overview

Many specialty and technical areas have their own termi-nology and HIT is no different It is important to have a consistent language so that each term is used in the correct context The Office of the National Coordinator (ONC) for Health Information Technology understood that many HIT terms had multiple and sometime conflicting meanings Con-sequently the ONC issued a contract to the National Alliance for Health IT (NAHIT) to reach a consensus on definitions for the following terms Electronic Medical Record (EMR) Electronic Health Record (EHR) Personal Health Record (PHR) Health Information Exchange (HIE) and Regional Health Information Organization (RHIO)1 Defining these terms should make it easier to have discussions on developing policies for and technical standards around HIT1 2

EMR EHR PHR The Differences

EMR and EHR have been used interchangeably by clini-cians their staffs HIT professionals and electronic record vendors NAHIT has identified a distinct difference between the two concepts and defines the EMR as ldquoAn electronic record of health-related information on an individual that can be created gathered managed and consulted by authorized clinicians and staff within one health care organizationrdquo1

They define EHR as ldquoAn electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created managed and consulted by authorized clinicians and staff across more than one health care organizationrdquo1

The key difference between the concepts is the ability to exchange data interoperably In healthcare interoperability is the capability of different information technology systems and software applications to communicate to exchange data accurately effectively and consistently and to use the infor-mation that has been exchanged3

The EHR can exchange

information interoperably with external providers while the EMR is limited to sharing information within its network only

A third concept Personal Health Record (PHR) is an electronic record of health-related information on an indi-vidual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed shared and controlled by the individual1 What distinguishes the PHR from the EHR is the control of information In a PHR the individual decides how the record is used and accessed not the clinician

The NAHIT also defines the following network terms HIE HIO and RHIO HIE has been used in many instances to describe both the process of health information exchange and the entity overseeing and governing the exchange therefore HIE and RHIO are often viewed as synonymous1 NAHIT defined each term and developed an additional term HIO (Health Information Organization) to help distinguish each meaning

HIE according to NAHIT is defined as ldquoThe electronic movement of health-related information among organizations according to nationally recognized standardsrdquo It defines RHIO as ldquoA health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that communityrdquo It also describes an HIO as ldquoAn organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standardsrdquo1

In simpler terms the oversight structure (HIO) is the organization that governs the process of sharing information (HIE) The RHIO is a type of HIO that covers a specific region or area such as a state or part of a state

EHR Prevalence

The adoption of EHRs has been slow but has increased in recent years The 2010 preliminary estimates from the Nation-al Ambulatory Medical Care Survey (NAMCS) show 249 of physicians reported having systems that met the criteria of a basic system while 101 met the criteria for a fully functional system Since 2003 there has been an increase of

The adoption of EHRs has been slow but has increased in recent years


144 and 70 percentage points for physicians having a basic or fully functional system respectively4

In the same 2010 survey 507 of US physicians re-ported using full or partial EHR systems in their office-based practices compared to 394 of Florida physicians This was significantly lower than the national average

Another national survey conducted in late 2007 and early 2008 showed only 4 of physicians reported having an extensive fully functional ambulatory EHR system and 13 report having a basic system5 The results from these two surveys tell us that the US has made progress but is still a long way from reaching mass EHR adoption

Many experts believe that EHRs ar the next step in the continued progression of health care that can also strengthen the relationship between patients and clinicians The data and the timeliness and availability of it will enable clinicians to make better decisions and provide better care6

Federal GoalMandate

President Barack Obama stated in 2009 that ldquoTo lower healthcare cost cut medical errors and improve care wersquoll computerize the nationrsquos health record in five years saving billions of dollars in health care costs and countless livesrdquo On February 17 2009 he signed the Health Information Technology for Economic and Clinical Health (HITECH) Act which was legislation created to stimulate the adoption of EHRs and support technology in the United States The HITECH Act is part of the American Recovery and Rein-vestment Act (ARRA) of 2009 an economic stimulus bill

The HITECH Act stipulates that beginning in 2011 healthcare providers will be offered financial incentives for demonstrating meaningful use of EHRs The government is using a ldquocarrot and stickrdquo approach to increase EHR adoption among clinicians Initially there will be EHR-related financial incentives for clinicians who treat Medicare patients starting in 2011 until 2015 After 2015 penalties may be levied for failing to demonstrate such use Those clinicians who are not adopting EHR by 2015 will see reductions in their Medicare reimbursements of 1 in 2015 2 in 2016 and 3 in 20177

Meaningful Use (MU) basically defines what hospitals and clinicians must do to reach EHR utilization targets8 MU is also being introduced as a three-stage process The first stage focuses on electronically capturing health information in a coded format using that information to track key clinical conditions communicating for care coordination purposes implementing some clinical decision support tools and ini-tiating the reporting of clinical quality measures and public health information9

In Stage 2 set to take effect in 2013 and 2014 the Cen-ters for Medicare and Medicaid Services (CMS) proposes to expand on the earlier measures to focus on continuous quality improvement at the point of care and the exchange of information in the most structured format possible Stage 3

for 2015 and beyond focuses on promoting improvements in quality safety and efficiency decision support patient access to self-management tools access to comprehensive patient data and improving population health CMS will specify the requirements for both Stages 2 and 3 in future regulations9

In the final Stage 1 regulation the MU elements were di-vided into two groups a set of core objectives that constitute an essential starting point for MU of EHRs and a separate menu of additional important activities from which clinicians will choose several to implement in the first two years8 The core objectives comprise basic functions that enable EHRs to support improved health care These functions include the tasks essential to creating any medical record including patientsrsquo vital signs and demographics active medications and allergies up-to-date problem lists of current and active diagnoses and smoking status9

In addition to the core elements the rule creates a second group a menu of 10 additional tasks from which clinicians can choose any five to implement in 2011ndash2012 This gives clinicians the latitude to pick their own path toward full EHR implementation and MU The regulation also specifies the rates at which clinicians will have to use particular functions to be considered meaningful users These rates of meaningful use will enable significant progress toward improving care but are also achievable by average practices and clinicians in the early years 9 For example ldquopatient remindersrdquo is one of the 10 menu set objectives ldquoPatient remindersrdquo is defined as sending reminders to patients per patent preference for preventivefollow up care In order to sufficiently meet the objective more than 20 of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period

The Impact

Implementing and adopting an EHR will affect everyone involved in the healthcare process The whole practice espe-cially the clinicians office staff and even the patients will be impacted in many ways

Initially the learning curve for use of EHRs is expected to be fairly steep When clinicians first begin using EHRs for order entry and note authoring it will take them longer to see patients The decrease in patients seen may be as much as 30 at first and facilities must be prepared for this10 However time saved by directly entering orders and by not having to search for information will soon begin to reverse the productivity impact This impact can be reduced further if the facility provides adequate support and training for clinicians and staff Eventually clinicians will be able to document both

Implementing and adopting an EHR will affect everyone involved in the healthcare process


more thoroughly and more rapidly on standardized documen-tation templates than previously possible by handwriting10

One study showed that employees of the clinic perceived few changes in their work after the implementation of the EHR system except for increased dependency on comput-ers and a small increase in perceived workload The work analysis showed a dramatic increase in the amount of time spent on computers by the various job categories The EHR implementation did not change the amount of time spent by physicians with patients On the other hand the work of clinical and office staff changed significantly and included decreases in time spent handling charts transcription and other clerical tasks 11

Current studies have derived the following conclusions regarding how the physician-patient relation is affected by the use of EHRs12

bull Generally patients are equally satisfied with physicians who use EHRs and those who use paper charts13 how ever some patients feel confused by certain behaviors such as the physician looking at the computer monitor without explanation14

bull How physicians use EHRs during an office visit (and how much time they spend typing on the computer versus talking with the patient) is influenced by their communication style and perception of their professional role in relation to the patient15

bull The presence of the computer monitor improves the patient-centered behaviors of physicians who exhibited good behaviors with paper charts however the computer monitor worsens the patient-centered behaviors of physicians who had poor interpersonal skills before the introduction of EHRs16

The clinician and hisher staff will need to be aware of these issues and effectively plan to minimize the impact on the patients and the practice

Potential EHR Benefits

There are many potential benefits for adopting and using an EHR in a small practice17-20 The benefits can be grouped into the following categories resource (clinician and staff) efficiency quality of care improvements and financial per-formance and cost savings

Efficiencies can be seen from a reduction of staffrsquos time spent finding and pulling paper charts using more medical transcription or reducing unnecessary health care services such as duplicate diagnostic tests

Quality of care improvements realized from an EHR can be identifying and preventing harmful drug interactions or possible allergic reactions to prescribed medicines or helping physicians manage patients with complex chronic conditions

An additional way an EHR can improve quality of care is by reminding clinicians about discussing appropriate preventive care measures with their patients

Several studies show that practices that implement an EHR have better financial performance and cost savings21-23 One study shows a positive return on investment to a healthcare organization in an ambulatory setting21 Another study reviewed 14 solo or small group practices which adopted EHRs The result showed that the average practice paid for its EHR in 25 years and profited handsomely after that22 A recent report by the Medical Group Management Association (MGMA) also concluded that EHRs over time will help a practicersquos bottom line23

Hesitations in Implementing EHRs

With the many benefits of EHR there are also many bar-riers and challenges particularly among small ambulatory practices24-26 The major barriers can be categorized into financial technological organizational and consumers26

The high cost of implementation is one of the most frequent barriers to implementing an EHR22-25 Even large organizations such as hospitals cite cost as a major barrier27 At the American Health Information Management Association conference in October 2006 panelists estimated that purchasing and in-stalling an EHR will cost more than $32000 per physician and maintenance may be about $1200 per month Vendor costs only account for 60-80 of these expenditures Other cost such as the on-going maintenance and training make EHR adoption prohibitive for some organizations2426 Many small practices would not be able to afford these initial and on-going costs unless they plan and save for the planned cost

Technology barriers consist of the clinicianrsquos comfort with computers navigation of the EHR marketplace and inadequate technical support26 Many seasoned clinicians are not comfortable with computers and therefore are quite resistant to using an EHR Another barrier is technology overload There are so many EHR vendors and products on the market that the clinician could spend a large amount of time researching and identifying the best EHR for hisher practice Lastly is technical support There are not enough highly skilled health IT experts to support clinicians in the adoption and MU of EHRs28

Implementing an EHR will have major impacts on an organization Moving from paper to paperless will probably disrupt the clinicrsquos workflow and will slow down the practice In some temporary situations practices will be using both paper and paperless concurrently and lose any efficiency gained from going paperless

Acceptance and privacy rank as the top consumer barriers The need for patients to become more computer literate and to have Internet access can be potential barriers Concerns for privacy such as how information accessed disseminated and stored must also be fully addressed

The federal government has passed legislation that addresses many of these challenges and will help clinicians adopt EHRs


HIT and EHR Landscape

In Florida there is a large volume of HIT activity The Agency for Healthcare Administration (AHCA) is coordi-nating the statewide HIE Recently AHCA also provided financial support for the development of RHIOs To date there are ten RHIOs in Florida with three being active in exchanging data AHCA also coordinates the HIT policy issues affecting the state The Health Information Exchange Coordinating Committee (HIECC) provides guidance to AHCA as it develops and implements specific programs for creating a statewide health information exchange network adopting EHR systems and ensuring the privacy and security of health information29 AHCA is also in charge of designing and implementing the Florida Medicaid Electronic Health Record (EHR) Incentive Program This program started in September 2011 30

AHCArsquos sister organization the Florida Department of Health (FDOH) is also working on HIT projects It is in the midst of developing and launching a statewide EHR for its 67 county health departments The EHR program is called Healthcare Management Systems (HMS) and is a homegrown product that will utilize some commercial products to enhance its modules The plan is to certify HMS as a certified EHR by the end of 2012

The FDOH is also considered a leading agency for e-public health Its Bureau of Epidemiology recently received the 2011 HIMSS Public Health Davies Award for its Electronic Surveil-lance System for the Early Notification of Community-based Epidemics Florida or ESSENCE-FL project31 FDOH has also implemented a statewide immunization registry and data exchange called Florida SHOTS32

In addition to state government activities the federal government has also funded four Regional Extension Centers (RECs) in Florida33 The purpose of the RECs is to provide education outreach and technical assistance to help clini-cians in their geographic service areas to select successfully implement and meaningfully use certified EHRs to improve the quality and value of health care Each of the RECs covers specific counties and all target small primary care practices and Federally Qualified Health Centers (FQHC)

Other statewide organizations are also supporting HIT ac-tivities The Florida Medical Association (FMA) has presented a number of EHR workshops around nine cities throughout Florida34 The Florida Academy of Family Physicians (FAFP) has implemented the EHR NOW program and continues to provide its members links and resources in navigating EHR implementation35

Northeast Florida has a number of coalitions that evolve around HIT The Northeast Florida Health Information Exchange (NEFHIE) and the Northeast Florida Health In-formatics Consortium (NEFHIC) are the two most active NEFHIE formerly JaxCare manages the Jacksonville Health Information Network (JHIN) The JHIN is the local HIE that

receives and shares EHR data on the uninsured and Medicaid population The purpose of the JHIN is to help practices and hospitals manage the care of these patients more effectively by sharing data and reducing costs

NEFHIC is a consortium of eleven community partners that promotes and helps to realize the use of electronic health information to improve medical care and improve public health Its vision is that the Northeast Florida Community can appropriately access utilize and benefit from interoper-able and secure electronic health information36

Resources

For help with the adoption of an EHR or achieving MU the Regional Extension Center (REC) is a good place to start It doesnrsquot matter if you have an EHR or not The REC can help clinicians and their practices get to meaningful use and receive CMS incentive payments If your practice is located in Northeast Florida the Advancement of Health Information Technology (AHIT) REC is the REC that covers the area

The links below provides additional information on HIT EHR and where need to find a local Regional Extension Center

bull ONCHITmdash-httphealthithhsgovportalserverpt communityhealthit_hhs_gov__home1204bull CMS EHR Incentive Programmdashhttpwwwcmsgov

ehrincentiveprogramsbull AHCAmdashhttpahcamyfloridacommedicaidehr about_ehrshtmlbull AHIT RECmdashhttpwwwchcallianceorgServices RegionalExtensionCenteraspx

References1 Defining Key Health Information Technology Terms The

National Alliance on Health Information Technology Apr 2008 httphealthithhsgovportalserverptgatewayPTARGS_0_10741_848133_0_0_1810_2_hit_termspdf Accessed August 15 2011

2 Electronic Medical Record vs Electronic Health Record Yes there is a difference HIMSS Analytic White Paper Jan 2006 httpwwwhimssanalyticsorgdocswp_emr_ehrpdf Accessed August 15 2011

3 Adapted from the IEEE definition of interoperability and legal definitions used by the FCC (47 CFR 513) in statutes regarding copyright protection (17 USC 1201) and e-government services (44 USC 3601)

4 Hsiao CJ Hing E Socey TC Cai B Electronic Medical RecordsElectronic Health Record Systems of Office-based Physicians United States 2009 and Preliminary 2010 State Estimates National Center for Health Statistics Health E-stat December 2010

5 DesRoches CM Campbell EG Rao SR et al Electronic Health Records in Ambulatory Care ndash A National Survey of Physicians N Engl J Med 2008359-50-60


6 Centers for Medicare and Medicaid Services web page httpswwwcmsgovEHealthRecords Accessed August 15 2011

7 Centers for Medicare amp Medicaid Services The official web-site for the Medicare and Medicaid EHR Incentive ProgramsAvailable from httpwwwcmsgovEHRIncentivePrograms01_OverviewaspTopOfPage Accessed August 15 201

8 Blumenthal D Tavenner M The ldquoMeaningful Userdquo regulation for electronic health records N Engl J Med 2010363(6)501-4 httphealthpolicyandreformnejmorgp=3732 Accessed August 31 2011

9 American Hospital Association HIT Incentive Payment ProgramDefinition of ldquoMeaningful Userdquo httpwwwahaorgahacontent2010pdf10-ib-def-meaning-usepdf Accessed August 31 2011

10 US Department of Health Indian Health Services web page httpwwwihsgovCIOEHRindexcfmmodule=faq20 Accessed August 31 2011

11 Carayon P Smith P Hundt AS et al Implementation of an electronic health records system in a small clinic the viewpoint of clinic staff Behavior amp Information Technology 2009285-20

12 Ventres W Shah A How do EHRs affect the physician-patient relationship Am Fam Physician 2007 May 175(9)1385-1390 httpwwwaafporgafp20070501p1385html Accessed August 31 2011

13 Solomon GL Dechter M Are patients pleased with computer use in the examination room J Fam Pract 199541241-4

14 Als AB The desk-top computer as a magic box patterns of behaviour connected with the desk-top computer GPsrsquo and patientsrsquo perceptions Fam Pract 19971417ndash23

15 Ventres W Kooienga S Marlin R et al Clinician style and examination room computers a video ethnography Fam Med 200537276-81

16 Frankel R Altschuler A George S et al Effects of exam-room computing on clinician-patient communication a longitudinal qualitative study J Gen Intern Med 200520677-82

17 Sidorov J It ainrsquot necessarily so The EHR and the unlikely prospect of reducing health care costs Health Affairs 200625(4)1079-85

18 Congressional Budget Office 2008 Evidence on the costs and benefits of health information technology Available at wwwcbogovftpdocs91xxdoc916805-20-HealthITpdf Accessed August 31 2011

19 Hillestad R Bigelow J Bower A et al Can electronic medical record systems transform health care Potential health benefits savings and cost Health Affairs 200524(5)1103-16

20 Buntin MB Burke M Hoaglin MC Blumentahl D The benefits of health information technology A review of the recent literature shows predominantly positive results Health Affairs 201130(3)464-71

21 Wang SJ Middleton B Prosser LA et al A Cost-Benefit Analysis of Electronic Medical Records in Primary Care American Journal of Medicine 2003114397-403

22 Miller RH West C Brown TMet al The Value Of Electronic Health Records In Solo Or Small Group Practices Health Affairs 200524(5)1127-37

23 Electronic Health Records Impacts on Revenue Costs and Staffing 2010 Report Based on 2009 Data httpwwwmgmacompressdefaultaspxid=39824 Accessed August 15 2011

24 Fleming NS Becker ER Culler S et al Financial performance of primary care physician practices prior to electronic health record implementation Proceedings 200922(2)112-18

25 Menachemi N Barriers to ambulatory EHR who are ldquoimminent adoptersrdquo and how do they differ from other physicians Informatics in Primary Care 200614102-8

26 DOQ-IT EHR Adoption A Barrier Analysis httphealthitahrqgovportalserverptCommunityID= 666ampspaceID=399ampparentname=ampcontrol=SetCommunityampparentid=ampPageID=0ampspace=CommunityPageampin_tx_query=ehr+adoption+barriersampSubmitx=0ampSubmity=0 Accessed August 15 2011

27 Jha AK DesRoche CM Campbell EG et al Use of Electronic Health Records in US Hosptials N Engl J Med 2009360(16)1628-38

28 ONCHIT Health IT Workforce Development Pro-gram website httphealthit hhsgovportalserverptopen=512ampobjID=1432ampmode=2 Accessed August 31 2011

29 AHCA FHIN website http168827517contentcommitteesAndCouncils Accessed August 30 2011

30 AHCA website httpahcamyfloridacommedicaidehr Accessed August 30 2011

31 HIMSS Conference Chicago 2011httpwwwhealthdatamanagementcomnewshimss-davies-award-public-health-43061-1html Accessed August 30 2011

32 Florida SHOTS httpwwwflshotscom Accessed August 30 2011

33 AHCA website httpahcamyfloridacommedicaidehrregional_extension_centersshtml Accessed October 5 2011

34 Florida Medical Associationhttpflmedicalorgehr Accessed August 30 2011

35 Florida Academy of Family Physicians httpwwwfafporg Accessed August 30 2011

36 NEFHIC httpwwwnefhicorg Accessed August 31 2011

DCMS Alliance Presents Donation to We Care

(Photo L to R) Dr Sue Nussbaum Executive Director of We Care accepts a $1000 donation from Mrs Dena Pulley DCMS Alliance President to be used for Caring Awards scholarships The 2011 Caring Award reception was November 10 We Care is a voluntary coalition of healthcare professionals clerical personnel and local church groups that provide primary and specialty care to the uninsured homeless and the medically underserved people of Jacksonville


Effective Communication and Marketing Strategies for Todays Busy Physicians

AJ Beson PresidentCEO and Vanessa Wells Editor Beson 4 Media Group

Address Correspondence to AJ Beson President and CEO of Beson4 Media Group 13500 Sutton Park Drive South Suite 105 Jacksonville Florida 32224 amp (904) 992-9945 Email ajbeson4com

Introduction - A Good Physician Listens

I once knew a surgeon who gave this advice to incoming residents ldquoDonrsquot be a physician Just listenrdquo The premise was that the best doctors are also the best listeners and that one of the best ways to help patients is to take the time to listen to them When it came time to write about how the internet can help physicians better market their practice these words echoed in my head As healthcare marketers in 2011 the best way to effectively reach our customers is by opening channels of communication and hearing what these customers have to say

Both the healthcare and the marketing industries have experienced unprecedented shifts in the last few years In one aspect these changes have created better informed healthcare consumers who feel that they have more ownership over their individual health and the health of their families The other side of the coin demonstrates healthcare consumers are overwhelmed by the amount of misinformation out there and eager to find a reputable and trusted source It is now the responsibility of individual physicians to market themselves and serve as that reliable resource

The internet turned 20-years-old this year The first web-site was launched August 6 1991 According to the leading digital blog Ecoultancy there were more than 640 million people on Facebook 175 million Twitter users and over 100 million LinkedIn profiles as of August 2011 Itrsquos no longer questioned that technology has forever changed the way we live and the way we do business The internet has changed who we are We need immediate access to everything That includes immediate access to our physicians Your patients donrsquot want you to be on the internet ndash they require you to be on the internet The consumer is now in control

Communicating Through the Noise

There is plenty of digital noise out there How can you communicate with your patients through the noise How can you differentiate your practice How can your existing patients gain immediate access to you How can new patients learn enough about you to pick up the phone and call to schedule an appointment

Implementing any type of marketing effort can be daunting Implementing an effective web marketing campaign can be overwhelming Combine that with the fact that many physicians already have limited resources and even less time it is no wonder so many doctors are hesitant to begin such an endeavor While online marketing does require an additional investment of money and time the proper strategy can mean more new patients and better communication with existing patients Thatrsquos why it is so critical to make the right decisions in the beginning Take your time Talk to experts Interview marketing firms follow blogs ask your grandchildren and most importantly ask your patients The site wwwsurveymonkeycom is a free resource where you can create quick surveys Send a survey to all of your patients and ask them where they spend their time online ask them if theyrsquod like updates via Facebook if they would subscribe to an enewsletter or

if theyrsquod follow a blog Collect the results and consult an expert Spend time evaluating your options and take your time making a decision Many physicians decide to slowly integrate into web marketing If you do this just make sure as you add more and more outlets you maintain a cohesive identity If you make smart well-informed choices you will have success reaching existing and new patients via the web At the end of this article there is a list of marketing industry resources that will provide further information and insight

Beginning a Campaign

There are many facets of an effective web marketing campaign Where do you begin Step one is developing an integrated plan that you can execute and measure You need a clear strategy and defined goals Figure out if someone in your company will be responsible for executing that strategy and attaining those goals or if you will be consulting an outside resource Monitor the competition and monitor your audience Be fluid in your strategy in case you need to change or adjust something Basic components would likely include a website which has a blog you can update frequently an e-newsletter campaign Facebook Twitter LinkedIn and YouTube

For instance an orthopedic surgeonrsquos website and blog would be comprised of useful orthopedic content pertinent

If you make smart well-informed choices you will have success reaching existing and new patients via the web


to patients and referring physicians The doctor might also send a monthly e-newsletter detailing timely and topical tips on sports injuries bone health and ways to avoid slips and falls They would post fun and interactive content on Facebook such as fitness quizzes or photos from a recent open house The same doctor would utilize Twitter as a way to disseminate information quickly ldquoDonrsquot 4gethellipfree con-cussion prevention class the clinic this weekend Be sure to RSVP to helliprdquo They would use LinkedIn to connect with professional associations specialty groups and others in the healthcare field and as a recruitment tool On YouTube they would post informative videos such as ldquoHow to Prepare for a Marathonrdquo or a tutorial that prepares patients for a knee replacement Everything would link back to the orthopedic surgeonrsquos website

Branding Yourself and Defining Your Audience

Your website needs to define your practice and completely represent your brand consider it your practicersquos online identity You need to define your audience as well Who are they and what are they looking for Are you a specialist who relies on referrals Then your website needs concise information about the latest innovations and news in your field thatrsquos quick and easy for doctors to access Are you a pediatrician who needs to reach busy moms Then offer valuable parenting tips Maybe you rely on both patients and doctors for referrals Then con-sider separate sections dedicated to two different audiences

Once yoursquove determined who you need to reach you can get started on how to reach them From an optimization standpoint you need fresh content You should update your website at least once a month If you plan to update weekly or even daily it might make sense to look into a content management system so yoursquore not calling the web company every five minutes for changes

When writing text for your site consult a search engine optimization (SEO) expert When it comes to SEO forget the fluff in the first 100 words Stay away from words and phrases like ldquocaring loving compassionate friendly staffrdquo and ldquopatient carerdquo Determine which key words and phrases your audience is searching for and include them in the first 100 words If you are an oncologist key words may be ldquocancerrdquo ldquolumpsrdquo and ldquochemordquo If you are an allergist key phrases may be ldquorunny noserdquo ldquoitching eyesrdquo and ldquorashrdquo People looking for an orthopedic surgeon may type in ldquotorn rotator cuffrdquo ldquohip replacementrdquo or ldquoback painrdquo

Include video on your site You can buy a fairly inexpensive pocket video camera like the Kodak Zi8 and download inex-pensive editing software so you can edit and upload video to your site Great video content includes doctor bios patient testimonials and a virtual tour of your office Yoursquoll want to upload video to your actual site as well as your YouTube channel

Make sure the design elements of your website communicate the tone of your brand Think of how you want your patients

to feel when they walk into your office Make sure the design photos videos and copy on your website communicate that same feeling If you are a pediatrician bright bold colors and photos of the playroom at your office are appropriate If you are an oncologist who wants your waiting room to be reminiscent of a spa use cool calming hues and softer tones

Once yoursquove created a website and are uploading great fresh content on a regular basis make sure you have an integrated consistent brand across all online platforms When commu-nicating via social media or another online mode take every opportunity to link back to your site

Using Email Effectively

An e-newsletter campaign is a great way to stay in front of your patients on a monthly basis When collecting patient information be sure to have a place for an email address Start by sending quarterly or monthly e-newsletters Send quick and easy tips and facts about your specialty and the practice itself E-newsletters are great for announcing new staff members office locations or any other pertinent infor-mation about your practice Keep your e-newsletters short and add lots of photos andor video Stick to catchy headlines that are only a few words long Be aware of the words you

use and consider what may or may not hit a spam filter For instance ldquoPink Ribbon 5Krdquo might be a better title than ldquoBreast Cancer Walkrdquo Include links to surveys discounts and offers and contests in your e-newsletters People like to click on pictures so make sure every photo links through to your website for more information

Winning Fans and Influencing Followers

When posting on Facebook the most important thing to consider is interactivity When businesses set up a Facebook page it needs to be a fan page Friend pages are reserved for individuals Once your fan page is created you can invite people to ldquolikerdquo your page While everyone would love a ton of ldquolikesrdquo on their page ldquolikesrdquo donrsquot really matter unless your viewers are engaged ldquoLikesrdquo in fact are beginning to matter less as Facebook changes the way it does things The word of the day is ldquosharingrdquo Itrsquos important to post things viewers are likely to share such as photos from a recent event or a video of an inspiring patient story When it comes to your tone on Facebook opt for a conversational approach ask questions and be original Understand your audiencersquos interest and cater to those interests Be upbeat and use familiar language

E-newsletters are great for announcing new staff members office locations or any other pertinent information about your practice


Avoid technical jargon and be approachable Ask for input Perhaps most importantly understand the power of the word ldquoYourdquo Sometimes directly addressing your audience via social media or even through an e-newsletter is the quickest way to engage them ldquoSeven Steps to a Slimmer Yourdquo is better than ldquoWeight Loss Tipsrdquo Asking fans their opinion goes further than telling them yours

Twitter is a two-way street Itrsquos a place to connect with po-tential patients but itrsquos also a place to get quick insight about your industry Follow your favorite sources of information on Twitter for an easy accessible way to keep up-to-date

LinkedIn provides a great opportunity to network with referring physicians and industry organizations Itrsquos a great place to recruit for your practice While LinkedIn may not be something you use daily keep it updated and check in from time-to-time

Utilizing Search Engines

While search engine optimization plays a huge role in establishing a cohesive and effective online marketing strat-egy keep in mind other ways search engines like Google and YouTube can help your brand

YouTube is the second largest search engine in the world next to Google Have a branded YouTube channel and post all of your videos there YouTube is great for sharing Patients can email videos or post them on their own Facebook page People will also search medical conditions and procedures via YouTube so you should be ready with the information they are looking for Again keep your audience in mind and donrsquot be afraid to create something lighthearted and fun if thatrsquos what is going to resonate with viewers

Google is your friend Sign-up for Google alerts Google alerts are email updates of the latest relevant Google results (web news etc) based on your choice For Google alerts create alerts on anything pertinent to your brand including the name of your practice and the name of each physician in your practice That way you will get a daily email letting you know if there is any ldquotalkrdquo about you or your practice on the web Be sure to update Google maps and places as well Thatrsquos the first place potential patients tend to look when they are trying to find you For more information visit httpwwwgooglecomalerts and wwwgooglecomplacesforbusiness

Developing Real-time Results

Developing a reporting structure and analyzing data are both critical in executing an effective online marketing strategy There are plenty of inexpensive reporting mechanisms out there but you may want to consult an expert to make sure you are collecting the data specific to your goals Google analytics and Facebook insights are two great places to start Itrsquos fairly easy and straightforward to set up a Google analytics account Check out Google Analytics Getting Started Guide (httpwwwgooglecomanalytics) for more information Once your account is set up you can run reports and collect data on such things as number of visits pageviews new visitors and average time viewers spent on your site Facebook insights are automatically generated when you create a fan page and will show you such things as page likes post feedback and weekly activity For more information visit httpswwwfacebookcomhelpsearchq=insights

Conclusion

Whether it is you a fulltime staff member an agency or consulting firm or all of the above getting your message out make sure your voice is engaged relevant receptive and ac-cessible This will truly help you connect with your patients where they are Communicate through as many channels as your patients are plugged into This may include your website e-newsletter Facebook Twitter LinkedIn and YouTube Be ready to change strategy when you discover something is or isnrsquot resonating with your audience Do more of what works and eliminate what doesnrsquot You want your patients inter-acting with you You want an easy and natural flow of two way communication between your patients and your brand Chances are if your customers arenrsquot talking they probably arenrsquot listening either

Online ResourcesBelow are industry websites that provide pertinent insight into online marketing

bull wwwbeson4com local healthcare marketing insightbull httpwwwgooglecomalerts Google alertsbull httpwwwgooglecomanalytics Google analyticsbull wwwgooglecomplacesforbusinessGoogleplacesbull httpswwwfacebookcomhelpsearchq=insights Facebook insightsbull wwwmashablecom marketing and social media insightbull wwwfastcompanycom technology marketing and design insightbull wwwhelpareportercom sign up to receive daily emails

of journalist queriesbull wwwsurveymonkeycom create surveys to email patients and referring physiciansbull httpebennettorg hospitals and social media insightbull general business and marketing tips bull wwwsethgodincom general business and marketing

tips


Social Networking Who Are Your Friends

Daniel Kantor MD

Address Correspondence to Daniel Kantor MD Medical Director of Neurologique and the President of the Florida Society of Neurol-ogy in Jacksonville FL Visit wwwneurologiqueorg

Abstract Whether you are ready or not social media has become an integral part of the way patients expect to interact with their physicians For the harried physician engaging in social media may seem daunting at first But the benefits of developing a comprehensive social medial campaign outweigh any potential disadvantages Social media can be an effective way of recruiting new patients and is crucial in the growth of a medical practice Instead of dismissing the importance of social media as simply a teenage fad physicians should look carefully at how this user-friendly medium can be harnessed for the ultimate benefit

Introduction

Tweets Facebook These dizzying new words in our diction-ary have become central to the way our patients communicate with each other and with us their physicians

Social Media has not only changed the way that people communicate with each other or the way that consumers identify with their favorite brands but also the way that patients seek contact with their physicians Many of us are approached by patient-oriented sites to volunteer our time and answer patient questions while other physicians have created their own interactive websites and Facebook pages

The fundamental principle behind social media is that it is a way to connect ldquofriendsrdquo to each other Many (if not most) of these ldquofriendsrdquo are virtual only and there have never been face-to-face human interactions While the idea of connecting with friends especially with patients (or potential patients) may seem foreign to many physicians the fact that prior interaction is unneeded can lend itself to a model of virtual interaction among physicians and the general public

Social media allows physicians access to thousands of potential patients and may allow the physicians the ability to control the tone of the discussion a well as the content There are various ways of structuring the interactive dy-namic Some physicians choose to disseminate information in a unidirectional manner (simply using the Internet as a publisher such as disseminating an e-newsletter or updating content on a website) while others choose to create a truly interactive experience

The choice of which method of interaction is appropri-ate depends on your practice type how much time you are willing to invest in a Web presence and your individual goals Importantly your level of computer savviness is fairly unimportant as the social media tools available are fairly user friendly and do not require advanced computer knowledge Tackling an EMR (Electronic Medical Record) makes hav-ing a social media presence seem like introductory Biology

Facebook and Patient ldquoFriendsrdquo

Facebook currently the most popular social media site with over 300 million users uses the term ldquofriendsrdquo to describe the connection between individuals While some physicians use Facebook to connect with their real-life friends and family it is important to separate these connections from the public You should be cognizant of the privacy options (fairly straight-forward) available to you Remember that if your profile is visible to others your patients will have access to it as well

Brief Guide to Facebook TermsWhile Facebook is currently the most popular social media

website it also contains the most number of novel terms This is a brief glossary of the most important terms for a novice

bull Fan ndash A Facebook user that follows the content of a Page This person does not necessarily need to be your Friend of your individual Facebook accountbull Friends ndash The foundation of social media is that you are connecting with others (but this doesnrsquot need to be socially) Your Friends are theses connections with othersbull Friend Request ndash This is usually how Friends connect with each other ndash you can accept deny or ignore this Friend Request The person making the request only sees when you accept their request but they may also notice when you deny or ignore it since you will not be connected (but they do not get an announcement stating ldquodeniedrdquo)bull Group ndash A collection of Facebook users who post comments

to each other Group updates may be received as emails and or in the Notifications section Many physician practices choose to create Pages rather than Groups since updates on Pages appear on an individualrsquos Wall while an individual needs to visit the Group (or read Notifications or emails) in order to see Status updatesbull Like ndash A way of letting others know that you appreciate something that others have posted The goal of many Face book users is to collect as many Likes as possible to show others that their content is popular Individuals Like your Page in order to follow your Status updates This is often indicated by a thumb up image bull Member ndash A participant in a Groupbull Messages ndash A way for Facebook users to send private mes sages to each otherbull News Feed -- The place on Facebook where your individual

content will be posted and visible to othersbull Notifications ndash A list of changes that your Friends have made

to the profile of their accounts including initially accepting your Friend requestbull Page ndash As opposed to an individual Facebook account a Page allows you a more clearly professional way to disseminate information that others follow on their Wallsbull Profile ndash The individual Facebook account You control the

user data that others see Profiles have different level of privacy including being Public and visible to allbull Status ndash The individual pieces of content that you create and

that Friends view on their Wallsbull Wall ndash The place on Facebook where your Page content will

be posted and visible to others


One way of avoiding this is to put the minimum amount of information on your profile and to set your privacy controls to the maximum An even more private method is to keep yourself ldquohiddenrdquo so that only your true friends who know that you are on Facebook can become part of your social network

If your patients discover you on Facebook then they may want to befriend you and you will be forced to either accept their friendship or to deny or ignore their requests Therefore it may be desirable to use Facebook only as a professional tool and to treat ldquofriendshipsrdquo as connections with the public People on Facebook tend to befriend (and collect) others This may be used to your advantage by growing your audi-ence and potential patient base

Of course many physicians will choose to have their own social Facebook presence and will not want to avoid Facebook simply because their patients use it also A way to get around this is to select strict privacy settings and to create a separate Facebook page for your practice

Facebook is the social media outlet with the largest number of users Initially Facebook allowed individual users to con-nect with each other but it has progressed to Fan Pages A doctorrsquos practice could open a Facebook Fan Page that allows the practice to communicate with the public Once patients join the Fan Page their lsquofriendsrdquo could be encouraged to join as well and then their friends would join ndash the viral idea of social media would mean that others would join

The key to keeping the Public engaged is to update content frequently and to make it relevant to the ldquoviewing audiencerdquo Interaction between the users and the physician (or physician representative) is crucial Facebook users are accustomed to immediate and timely responses and this means that allowing others to comment on your Facebook Wall (the page where you are expressing your ideasthoughts) would be seen as inviting questions and would mean that you are giving up complete control of the content because some of these comments may not be entirely appropriate You can easily adjust the Facebook settings and not allow such bidirectional communication

Pediatric PerspectiveAs opposed to much of Medicine where Pediatrics may feel left

out social media is one glaring exception While you may need to devise ways to have adults Friend you on Facebook and other social media outlets teens and twenty year-olds have been brought up in a world of virtual friendships and online information seeking

This does however raise additional concerns While there may be concerns about doctors giving any sort of general advice online this can be especially sensitive when minors misinterpret general education for actual medical advice Furthermore answering questions posed by minors (without parental consent or even knowledge) may be seen as inappropriate by both the physician and the parents It is difficult to simply state ldquoyou must be 18 or olderrdquo since there is no way of assuring that people on the internet are whom they claim to be

While these issues should be taken into account they should not dissuade you from entering the Social Media Age as the benefits may outweigh the risks Consulting an attorney knowledgeable in this area is advised

How to Open a Facebook PageThe way Facebook is structured is that each individual has a

unique account with a ldquoWallrdquo where the user or the userrsquos ldquoFriendsrdquo can post ldquoStatus Updatesrdquo about what they are thinking doing or other items of interest

For many physicians even once privacy concerns are allayed by the userrsquos ability to define who sees their posts (certain Friends all Friends the entire Public) the social nature of Facebook includ-ing the sometimes frivolous postings may not be appropriate

This is where Facebook Pages become useful A Fan Page allows a business organization product brand etc to promote itself and to invite comment by others regarding various topics For example a physician may want to (on a regular basis) remind Facebook Fans that new patients are being accepted along with details on how to make an appointment Other physicians may want to post updates pertinent to their field of interest (and even more importantly what interests their patients) For example they could post ldquoNew research trial confirms the need for good sugar control in people with diabetesrdquo This endocrinologist could even go further and post ldquoIs your diabetes under good control New research trial confirms the need for good sugar control in people with diabetes Call (904)555-5555 to make an appointment today and visit wwwdrsmithcom for more updatesrdquo

How to Create a Facebook Pagebull Creating a Facebook account and connecting

with Friendsbull Creating a Facebook Page and inviting the Friends

to sign up for the Page ndash those invited will receive a request that states

Dr Smithrsquos Clinic Page You have been invited by Dr John Smith (Jacksonville FL) Do you like this

By having your Friends like your Page you will be accumulat-ing followers and these people will be reading your postings whenever they log in to Facebook This is valuable because you will assemble a captive audience for the information that you are trying to disseminate whether it is advertising for your practice or purely educational Your goal should be to have as many people as possible Like your Page because this will increase your audi-ence This can happen by you directly inviting Friends and by having them spread the word to others and invite them to Like your page as well

Step-by-step guide

1 Go to wwwfacebookcom2 Sign up for Facebook and create an account3 To create a Facebook page go to wwwfacebookcom

page4 Choose a category for your business (it could be your

practice brand etc)5 Invite ldquofriendsrdquo to join your Facebook page6 To find people that you may know simply type their

name in the Search bar on the top of the Facebook screen7 When you link to another personrsquos ldquoWallrdquo click on ldquoAdd

Friendrdquo8 Type your postings on your ldquoWallrdquo where it says ldquoWrite

somethingrdquohellip and click on ldquoSharerdquo


LinkedIn for Colleagues

Social media outlets are not only appropriate for interactions with the public but with other health care professionals as well Generally sites such as LinkedIn are more appropriate for physician-physician interaction than sites such as Facebook Myspace or Google+ (Google Plus) LinkedIn encourages users to update their online CVs and to form networks based on employment education and interests This means that you may use LinkedIn to update your professional profile (publications presentations employment) while you may use other avenues to create and disseminate novel content

Twitter and Tweets

Contrary to its name Twitter has nothing to do with ornithology Instead Twitter allows users to publish 140 characters of content that can be ldquofollowedrdquo by an unlimited number of people These content updates are termed ldquotweetsrdquo and are often read through mobile devices An example of an appropriate tweet would be ldquoDr Smith is now accepting new patients at her new location ndash 1345 New Wales St Jacksonville FL 32204rdquo This timely brief reminder serves as an advertisement for a new location and could potentially increase patient traffic

Other physicians use Twitter to also update the public (current and prospective patients) on new developments in their field of interest For example a tweet could read ldquoNue-dexta receives FDA approval as the first and only treatment for pseudobulbar affect ndash to learn more visit wwwdrsmithcomrdquo The advantages of Twitter are that you only need to write a short blurb and that you can control the message while the disadvantages are that you are constrained in terms of space and in reach

Creating Online Content

While you may need help from a web savvy employee friend or perhaps offspring to initially set up your social media framework you need to decide who will be responsible for actually creating and updating your content You have three main choices in deciding who is responsible for updating your social media presence

1 You ndash The advantage of doing this on your own is that you completely control your online presence just as you are responsible for how you interact with others in the real world The disadvantage is that it is time consuming but it does not need to be too much of a bur- den if your social media setup is designed well Twitter is especially useful in this regard because of the character (140) limitation 2 An employee ndash The advantage of having someone else

invest the time is obvious but the disadvantage of en couraging social media use during the workday is obvi ous Social media use and Internet surfing can severely limit the productivity of your staff3 An outside vendor ndash The advantage is this frees up some

of your own time but beware of the disadvantage of still having to let the outside vendor know what content you want updated Social media users are used to timely updates and using a third party can significantly delay this

While it may make sense for you to make your own up-dates it is important to take a step back at the beginning and to devise an appropriate and comprehensive social media plan You will probably need to engage others for help with this but you may not need to go to the expense of a formal consultant or company A partnerrsquos children in their teens or twenties may suffice (and even be more desirable as they understand your local concerns) With website design you probably want to hire a professional but since social media updates need to be timely and relevant it is best to make these updates on your own

Disseminating Content

The whole idea of social media is to create an audience for your content While you can invite individual users it is important to grow your audience by creating value Value is defined as information that your intended audience will be interested in and want to share with others This will increase your viewership and potentially your patient base

You should first start with text-based information timely updates on advances in your field and practical suggestions and health tips It is important to keep this information general and not to give individual medical advice This becomes even

Practical Suggestions to Increase Your Friends

1 Put a line in your email signature line that states ldquoDr Smith is now on Facebook ndash Join facebookcomdrsmithrdquo

2 Add a Facebook icon and link to your webpage

3 Announce your Facebook presence on a sign in your waiting room

4 Make a Facebook announcement handout for patients to pick up in the waiting room and while checking out

5 If you choose to Facebook make sure to avoid doing it until you are blue in the face


rating websites but this may be drowned out by positive useful content created by you the physician

Conclusion

While you should proceed with a social media campaign with some caution there is no question that your patients and potential patients demand it of physicians Whether you are ready or not for Facebook Twitter a website or anything social media has to offer the public is ready They are online and looking for you Start to research how you your practice and your expert advice can get ldquoout thererdquo to a growing audi-ence Once you do there will be no turning back and that wonrsquot even be a consideration because you will be hooked or should we say ldquoLinkedInrdquo

ResourcesMajor Social Media Websites This is not a comprehensive list of social media outlets but it may be used as a starting point in understanding the reasons to explore these sites further

bull Facebook ndash The most popular social media site with more than 300 million users People link up with Friends Go to httpwwwfacebookcomhelp bull Google+ ndash In 2011 Google entered the world of social

media and has created its own site to compete with Facebook but Google+ has not yet attracted nearly as many users Go to httpsplusgooglecombull LinkedInndash As opposed to the other social media sites discussed in this article LinkedIn is mostly a way for professionals to network and to post resumesac- complishments Go to httplinkedincom bull Myspace ndash A social media site that predated Facebook

but that is not currently as popular with adults Go to httpmyspacecom bull Twitterndash A site where you can post 140 characters (tweets) at a time This limitation also makes it useful for busy physicians Go to httptwittercom

Examples of Social Media Usagehttpblogspotneurologiquecom

httpfacebookcomNeurologique

httpsplusgooglecom105771490907410660075

httplinkedincominNeurologique

httpmyspacecomNeurologique

httpworldsecondlifecomresidentaff4b366-0d61-4360-9a3a-d0931c649842

httptwittercomNeurologique

httpustreamtvchannelNeurologique

httpyoutubecomNeurologique

more important if your existing patients ask you a question in a public forum Since you have already established a doctor-patient relationship your answer may be seen as violating your patientrsquos privacy Additionally social media sites are not secure or HIPAA (Health Insurance Portability Affordability and Accountability Act) compliant

Social media sites also allow links to outside content such as your own website or an article of interest Even videos such as your appearance on news stations or video content that you may have produced may be used Patients especially appreciate video content since it allows them to see you and hear your explanations Many people choose to repost these videos for others to see and in this manner your content may be spread throughout the Web

You can learn to produce video content on your own computer with a connection to an inexpensive webcam Most teenagers will be able to show you how to do this and to make it look semi-professional Patients do not necessar-ily expect studio quality videos nor is this feasible for most physicians Remember to keep your content general and do not give personal medical advice

Keeping ldquoFriendsrdquo Friendly

While social media encourages connections and lively discourse sometimes this discourse becomes abrasive The virtual anonymity of internet-based communication may encourage normally polite individuals to write things that they would never say face-to-face This type of communica-tion may be damaging to your professional reputation or create an environment not conducive to positive medical discourse Most people on the internet will understand that angry and rude comments should be ignored But in order to safeguard against this you may want to make your social media presence unidirectional and to moderate all comments While this may increase the amount of time that you need to invest in your social media campaign it will also allow you to control your face to the world

These words of caution shouldnrsquot be used an excuse to avoid social media since even without ever posting anything online physician rating websites where patients rate physicians have become popular They are mostly unmoderated Some of these sites are very simplistic with a thumb up or down and while the comments posted by patients may seem preposterous to you potential patients do visit these sites and make decisions about which doctor to see based on the ratings Sometimes however these comments step over the line and may be seen as libel The Florida Medical Association has endorsed Medical Justice a company designed to help safeguard your reputation by reacting legally to these harmful or defaming comments

The potential for negative comments is actually one of the best reasons to have a strong social media presence It is the best way for you to control your own web presence This means that when potential patients search for you on the Web they wonrsquot only see comments made by others on


HIPAA and the Internet

Christopher L Nuland JD

Address Correspondence to Christopher L Nuland JD 1000 Riverside Avenue Suite 115 Jacksonville FL 32204 Email nu-landlawaolcom

Introduction

In an era in which patients are demanding more information and are unwilling to wait for normal appointments health care providers are hard-pressed to the provide meaningful information while still complying with strict medical con-fidentiality laws The essential tension between the Health Insurance Portability Affordability and Accountability Act of 1996 (ldquoHIPAArdquo) and the current era of immediate online gratification is often frustrating to each side but as this article will demonstrate it is not insurmountable

As with all interactions between providers and patients managing the expectations of each party is essential to the success of any online program In other words patients need to understand immediately that while a provider may be doing everything possible to provide requested information as quickly and completely as possible outside factors such as HIPAA preclude the patient from having unfettered access to such information

What HIPAA Requires

The HIPAA Security Rule requires that ldquocovered entitiesrdquo (including all providers of health care) take ldquoreasonablerdquo precautions to protect the privacy and security of so-called ldquoProtected Health Informationrdquo (ldquoPHIrdquo) It is essential to understand that PHI includes far more than just traditional medical records In fact any information that could even tie a patient to a specific provider of health care as well as any personal information regarding that patient would constitute PHI

Of course HIPAA does allow the patient to request cop-ies of their own medical information and no provisions in HIPAA or Florida law preclude the online dissemination of such information in accordance with the patientrsquos wishes The key is to ensure that it is the patientrsquos wishes that are being obeyed

It is the first priority of the provider to obtain a written consent of the patient While such consents can be performed online if the patient can produce sufficient personally iden-tifiable information to authenticate the patientrsquos identity in-person authentication is preferable as an examination of a driverrsquos license or other form of picture identification remains the best way of authenticating a patientrsquos identity

Simple consent however is not enough Under HIPAArsquos Security Rule it is the providerrsquos responsibility to ensure

the security of the transmitted information by adhering to eighteen different standards for the transmission of such data each of which must be documented A description of each of these standards is found in the HIPAA Security Rule They are divided into Administrative Physical and Technical categories as follows

Administrative Safeguards1 Security Management Process Standard The practice

is required to perform a risk analysis and information system review to ensure that there are no inherent controllable risks in the system Most HIPAA Compli- ance Plans include such risk analysis tools as do most health care attorneys in Northeast Florida If and when such risks are identified the practice must then take documented steps to address the identified threats2 Assigned Security Responsibility Standard The

praticersquos existing HIPAA Compliance Officer may serve in this position which requires that an identifiable individual within the practice be ultimately responsible for compliance issues With regard to Internet exchanges with patients responsibility for such communications should be limited to specific individuals3 Workforce Security Standard The practice must de-

termine who within the office should have access to PHI and under what circumstances and must ensure that such access is terminated upon termination of employment Likewise upon termination of employ ment all keys hardware and software should be re- turned and any passwords associated with the separat ing staff member should be rescinded Again only those assigned the responsibility of communicating with patients should have access to the system4 Information Access Management Standard The Prac-

tice must have policies and procedures as to how authorized persons may access information such as passwords for electronic informationThis standard is equally important for staff members and for patients each of whom should have separate means of accessing only the information necessary to comply with the specific data request5 Security Awareness and Training Standard All staff

must be trained in the new security standard and its applicability to Internet communications This train ing may be combined with the HIPAA Privacy training but experience has shown that documented attendance of all staff is critical Of course instruction on the nu ances of Internet communication should be included in any such training6 Security Incident Procedures Standard Even under

the best of programs unauthorized disclosures are bound to occur The Practice must therefore have policies and procedures to deal with unauthorized disclosures including the documentation of such disclosures and efforts to mitigate the harmful effects of any such breach


7 Contingency Plan Standard Likewise the office must have policies to deal with the sudden loss of PHI in cluding data backup and an emergency plan8 Evaluation Standard This standard requires the

Practice to periodically evaluate itself to determine if it is in compliance with the Security Regulations Again compliance with this (or any other) standard does not necessarily require the engagement of outside personnel However the person(s) responsible for this task will document the results of such an audit as well as the date of such audit and shall present the results to the HIPAA Security Office Any necessary correc- tive action will be taken no later than 30 days after such a finding is made9 Business Associates Standard As in the Privacy Rule

Business Associates who may have access to the system must guarantee that they will provide security for PHI as well as identify and mitigate any inadvertent disclo sures

Physical Safeguardsbull Facility Access Controls Standard The Practice must

have policies and procedures to control access to PHI and the facility Only authorized staff shall have access to PHI and such access shall be restricted to a need to know basis Should a staff member be found to have violated this policy disciplinary action should be takenbull Workstation Use Standard The Practice must have

policies and procedures detailing what may or may not be done at a workstation including protocols for secur- ing workstations at the conclusion of each workday bull Workstation Security Standard Policies and proce-

dures must be developed and implemented to ensure that only authorized employees have access to worksta tions Patients and guests shall not be allowed in workstation areas and workstation computers shall be located in such a way so that the screens may not be regularly visible by patients or guestsbull Device and Media Controls Standard Offices must

have policies to ensure that hardware software and media storage are erased before being disposed reused or leaving the building

Technical Safeguardsbull Access Control Standard Access to electronic PHI

either by patients or staff must be restricted by office policies that require unique user identification emergency access procedures and disclosure to staff and patients as to when information may be accessed and the inherent limitations of such accessbull Audit Controls Standard The actual systems that

house PHI must be auditedinspected periodically to ensure the integrity of electronic PHIbull Integrity Standard Finally Practice Policies and

Procedures must be in place to ensure that electronic PHI cannot be inappropriately altered or destroyed]

Managing the Risks

While technical compliance with the above standards is essential to maintaining HIPAA compliance perhaps a bigger challenge for the Practice is managing the expectations of the patient Research and personal experience have shown that most HIPAA and malpractice claims are brought by patients who have unrealistic expectations as to what the health care provider could offer No interactive Internet system can be instantly available at all times and there are logistical barriers to providing the full range of information and medical records for which a patient may ask Therefore it is essential that patients be informed as to what the Internet access program can and cannot do what the typical response time might be and what to do if the patient believes that they are having a medical emergency

All too frequently malpractice cases stem from the errors and omissions of administrative staff in recording patient phone and Internet communications Therefore health care providers and their staff should be cognizant that the contents of any internet communication should be included in the patientrsquos medical record Only in this way may the practice protect both itself and the patient from future misunderstandings as to what information has been disseminated

Finally care should also be taken when participating in online forums and social media Because patients are likely to rely on any advice that is given over the Internet one could argue that a patient-physician relationship could be formed along with all of this relationshiprsquos inherent risks and dangers Therefore physicians should limit their online posts to statements of general medical education avoiding any statement that could be construed as a diagnosis or treat-ment recommendation Ideally such posts would include a disclaimer that directs the patient to seek personal professional assistance from a qualified physician

Conclusion

While the above may appear daunting many practices have found that creating an interactive patient portal saves staff and provider time and can lead to happier patients who often can obtain vital information without having to wait for routine appointments Also the cost of such a system need not be prohibitive as the increasing use of such systems has made everything from the legal consents to the actual software more readily available at an affordable price Nevertheless as this article has shown such programs need to be established with care and with constant vigilance being necessary to protect the provider from regulatory and malpractice risks The good news is that most health care attorneys are well-versed in the above requirements and can provide appropriate inexpensive guidance


Technology for the Physician

Danielle S Walsh MD FACS

Abstract Just as each medical journal brings a new round of knowl-edge to assimilate into our patient care paradigm each day brings new technology into the digital world gradually transforming the landscape of how we create share and utilize information Physicians have been leading the adoption curve of these technologies in both the personal and professional spectrum1 While some may professionally equate integra-tion of technology with adoption of electronic medical records so much more is available This article reviews a variety of resources available for improving your efficiency online presence and digital communication outside the spectrum of electronic medical records

Website Marketing

Physician advertising has been frowned upon and even legislated but physician marketing is not only accepted but an industry unto itself2 A brief web search will reveal a significant number of companies willing to establish a plan of website twitter and video presence to attract patients promote your practice and demonstrate your skills in the digital world ndash for a fee Additional services may include development of bro-chures organization and scheduling of seminars performance of demographic analysis and creation of complete practice strategic planning Use is not just limited to private practice groups looking to attract new patients Medical students and residents use institution websites in deciding where to pursue training and for employment considerations3 Even if physicians choose not to create an online presence for their practices or themselves one has likely already been created for them At least seven different organizations provide online information and reviews of your practice all without need for you to request inclusion Basic information such as practice type location and phone number are commonly free but a more thorough report with patient reviews training and background and malpractice record are available for fees in the range of $10 per report4 (DCMS has an online Physician Directory Go to dcmsonlineorgdirectory)

With few exceptions most physicians can take charge of their own marketing with some easy steps First perform a web search of yourself Enter your own name credentials and city and see what comes up Check the accuracy of the information and contact the webmaster of the site if any in-formation is misleading or untrue If negative patient reviews are posted these may be more difficult to have removed However some sites will allow you to post a response When doing so word your response in a positive light For example if a patient complains of a long wait comment on how your

practice prides itself on ensuring each patient gets the time and attention heshe needs for the type of problem you treat and that this unfortunately sometimes leads to unexpected delays Avoid directly engaging in any criticism in a review to ensure there is no perception of breech in patient confidenti-ality Additionally encourage patients who are satisfied with your care to post positive reviews The presence of multiple positive reviews can often lessen the impact of an occasional negative one5

Other tools in creating an online presence include a practice website instructional media and web based consultation While web design used to require a programmer a number of programs are available for free or a small fee that guide you through a simplified process Among the highest rated include Intuit Website Creator Web Easy Professional and Yola Silver6 Instructional media encompasses an assortment of tools to assist patients in learning about the type of problems you treat The information can be added to your website distributed as digital newsletters to news sites posted with disease specific online patient communities or even linked to a hospital homepage Examples include patient information sheets for viewing and download access to before and after treatment photographs or instructional videos of the physi-cian actually lecturing on a subject Youtubecom is a web based library of videos into which users can upload and view digital media on almost any topic for free Some physicians elect to dem-onstrate their technical skills or create marketing videos for this site to attract patients Though still a fledgling field web based consultation has begun to gain steam A number of companies aim to satisfy the consumerrsquos desire for immediate physician feedback from the comfort of their own home7 These consultations may range from a text exchange to a scheduled video link in which the patient and physician interact live via web cameras By joining with one of these firms opportunities for offering your professional services move well beyond the local area

Email and Other Social Media

The fledgling internet came alive in 1969 ndash the same year man set foot on the moon8 Its use exploded in the 1980s and 1990s and became entrenched in the medical arena by the end of the 20th century Initially used by most physicians just for email it now serves as the backbone for full-fledged

Some physicians elect to demonstrate their technical skills or create marketing videosto attract patients



patient care A study by Google in 2009 found 86 of US physicians use the internet to garner information on health diseases and medications and 59 did so from a mobile device9 More controversial for physicians is whether email should be used for communicating with patients In 2009 a survey found that 42 percent of physicians were communi-cating with patients online10 That same year the HITECH Act to enforce HIPAA confidentiality protections for elec-tronic health records came into practice placing the onus on the physician to ensure their electronic communications are secure11 As such electronic communication must be encrypted a service not available in most commercial email services Patients should provide written consent for using email and physicians should develop guidelines for how to handle communications

For example patients may need to be advised on how long it will take for a physician response what to do if the problem is emergent and when the physician is unavailable An automated response to a unique patient email account can help manage these potential issues Additionally the HITEC Act requires that ldquodate time patient identification and user identification must be recorded when electronic health information is created modified deleted or printed and an indication of which actions occurred also must be recordedrdquo1011 The onus is on the physician to maintain these records a clear detraction for many Other recommendations for use of email with patients include confirming an email address is correct avoiding the forwarding of emails and disabling junk filters to minimize the inadvertent discarding of a patient email12

Texting or text messaging is the typing and immediate transmission of the message to another via cellular phone

lines While most cell-phones have texting capabilities texting may not be included in the base wireless phone plan Unlike email the mes-sage is usually concise often uses abbreviations and the sender typically expects a reply within a

few seconds to minutes Younger physicians in particular have embraced texting as a primary form of communication greatly preferring it to phone calls or emails Some physicians have advocated it as quieter than a phone call in the already noisy hospital environment and it could alleviate some pri-vacy concerns when needing to communicate about a patient in a public setting13 Since texts are not encrypted there are concerns about possible HIPAA violations should the text be sent to the wrong wireless or be intercepted A common sense approach to this technology may be to use texting for keeping up with patient conditions or circumstances but not detailed medical recommendations Quick responses such as ldquoschedule for surgeryrdquo or ldquomeet in office at 3pmrdquo but avoiding the use of identifiers may minimize risk It remains

an excellent tool for office staff communications personal communication and schedule updates13

Online social networking refers to the interaction of indi-viduals with a common interest into groups usually through a particular website host Some of the more commonly used sites include Facebook MySpace LinkedIn and Bebo and of these Facebook is the most commonly used14 The sites allow users to create a ldquopagerdquo describing a person business or even a concept add photos and maintain an ongoing conversation with others who become ldquofriendsrdquo of that site Twitter a popular social networking platform allows users to publish and receive short (140 characters or less) ldquotweetsrdquo as texts to their digital devices Users do not have to log in to a website to catch up on the latest information and they are not limited to informing just a handful of individuals about what is going on Surgeons have used tweets throughout an operation to inform family members and others interested in how the procedure is going what steps are being performed and what to expect next15 Other uses include keeping updated on events in a medical conference campaigns for awareness of health issues and even appointment reminders1617

A recent study found that 87 of US physicians use at least one form of social media for personal purposes Professional use lags behind but continues to rise reaching an impressive 6718 Social mediarsquos rapid adoption in the physician arena led the American Medical Association to publish a policy on professional use of social media in August 201119 In it they encourage physicians to separate their personal and professional accounts ensure privacy settings are used and frequently vet the content posted to their sites

Mobile Devices

While most physicians find desktop computers in the office and at the nursersquos station portable computing now leads the way in digital access As opposed to the wired connections found in most hospitals the medical world is increasingly transitioning into the wireless mode of data exchange While the hardware of how that signal is created is largely determined by the IT department of a hospital or practice the device used to access that signal varies tremendously from physician to physician Among the most popular devices for mobile com-puting are smartphones tablets and ultraportable laptops

The Personal Digital Assistant (PDA) of the 1990s merged with the cellular phone to create a single ldquosmartphonerdquo used by 35 of all Americans and an astounding 72 of US physicians2021 A smartphone can send and receive not only phone calls but emails and text messages It maintains your schedule and synchs with your main computer for seamless schedule changes Smartphones allow for a wide array of software or applications (also called rdquoappsrdquo) to include en-try of CPT and ICD-9 codes into a database calculation of medication doses review of radiographic images and patient charts and so much more Design varies from a full albeit miniaturized keyboard and screen to a non-keyboard touch screen design The four most popular platforms in order of

Younger physicians in particular have embraced texting as a primary form of com-munication


market share include the Google Android (418) the Apple iPhone (364) the Research in Motion (RIM) BlackBerry (217) and the Microsoft Windows Phone (57)22 Each has their pros and cons To help guide the user to the most ideal selection it is good to discuss with co-workers who use different smartphones talk to your hospital or practice Information Technology (IT) department and have a hands-on trial of each device in a store carrying a variety of them

Tablet computers first entered the digital world in 2000 but the trickle of use became a geyser in April 2010 with the introduction of the Apple iPad23 An estimated 30 of physicians now use an iPad or similar tablet a rate almost five times greater than the general population2425 While they do not function as cellphones the large crisp screen permits physicians to review imaging studies show patients images or even videos relevant to their diagnosis and perform research and email with ease on the go Users who struggle with the small keyboards on smartphones are often attracted to the larger format and ability to connect to more traditional keyboards Some physicians find the touch format easier to learn as it is more intuitive than the typed search function of other devices25

Ultra-laptops netbooks and traditional laptops bring ad-ditional bulk and size but with the added benefit of power and memory Many physicians prefer these devices for their ability to capture patient encounters with electronic medical records (EMRs) in a way not possible on the smaller smartphone or tablet Due to the additional hardware and screen size battery life may be limited to less than 3 hours without a charge or a battery pack However physicians using EMR in a variety of locations on the same day may prefer the ergonomics and clear graphics of the laptop while maintaining portability

Each class of devices carry pros and cons as do the individual devices of each class Frost amp Sullivan a consulting firm recently studied the process of selecting a wireless device and developed seven criteria for consideration functionality us-ability security network connectivity durability application availability and price26 Functionality and ease of use are very individualized and may be best evaluated by the user Battery life screen size type of keyboard or input device durability and compatibility with other electronics also are consider-ations The ability to connect to your workplace network the availability of local service providers and the strength of the signal reaching your device in the common areas you wish to use it should all be considered Devices do break and investment in a protective cover and insurance against breakage not covered by a warranty should be considered

Security is essential for any physician who intends to use the device for identifying patient or personal information Minimal security should consist of a password protection to enter the device each and every time Additional security may include encryption limitation of email available on the device to 14 days or less and ability to remotely remove all information on the device should it be stolen

Other Technologies

The adoption of electronic medical records has created the need for physicians to input significantly more data into a computer system Manual entry by typing is time consuming and dictation via a transcrip-tion service is costly27 Speech r e c o g n i t i o n software such as market share leader Dragon Dictation al-lows a physician to dictate emails patient notes and more into a microphone with near instantaneous transcription Though earlier versions of the software were deemed frustrating to many newer ver-sions with improved microphones have 95 accuracy allow speech rates up to 160 words per minute and in many cases allows you to command the software you are dictating into28 Some physicians still eschew the need to edit their own dic-tation and user adoption is likely to be very individualized

Cloud computing refers to technology that runs on the Internet and uses shared resources that can be accessed ex-panded and updated quickly For the physician the embrace of cloud computing can result in both efficiency and cost sav-ings29 Most physician practices currently purchase a server for their office on which they store all their patient records data and software to permit users in the office to all access the information from different computers In this format an information technology specialist is paid to perform updates and maintenance of the server With cloud technology the server is in an alternate location maintained by the company that owns it with multiple users and can be reached with any computer or mobile device with internet access The resulting lower cost and improved access make this up and coming technology appealing to small practices in particular As with all electronic systems HIPAA compliance must still be ensured30

Summary

Healthcare technology has already changed the way phy-sicians live both professionally and personally Physician marketing has moved to the mainstream via the internet and social networking Smartphones and wireless devices have improved communication and efficiency Technology continues to evolve quickly and the use of remote access to patient records scientific data and even real-time patient data promises to continue altering the way we practice medicine Digital technology aims to improve the lives of both patients and physicians not unlike the medical research we depend on for advancement

The adoption of electronic medical records has created the need for physicians to input significantly more data into a computer system


References1 Weiss T Doctors are heavy tech users ndash early adopters for

healthcare technology Available at httpwwwtrendsspottingcomblogp=2090 Accessed on 10122011

2 Texas Medical Association The Regulation of Physician Advertising Available at httprightnowtexmedorgcifattachget24756 Accessed on 10142011

3 Kutikov A Morgan TM Resnick MJ The impact of residency match information disseminated by a third-party website

J Surg Educ 2009 Jul-Aug66(4)212-54 Vara V Sites offering data reviews of doctors Available at http

onlinewsjcompublicarticleSB113259854512303267-WH

YGSaEP2uLrswmLmo1fTuf15rQ_20061130htmlmod=tff_main_tff_top Accessed on 10152011

5 Lefebvre C How doctors can manage negative content online Available at httpwwwreputationcomhow_tohow-doctors-can-manage-negative-content-online Accessed on 10152011

6 Top Ten Reviews 2011 Compare Best Website Creation Software Available at httpwebsite-creation-software-reviewtoptenreviewscom Accessed on 10152011

7 Web Rich Marketing Obtain remedy via online medical consultation Available at httpwwwarticlesbasecomwellness-articlesobtain-remedy-via-online-medical-consultation-4487062html Accessed on 10152011

8 Rosenbaum P Web pioneer recalls rdquobirthrdquo of the Internet Available at httparticlescnncom2009-10-29techkleinrockinternet_1_internet-leonard-kleinrock-computer_s=PMTECH Accessed on 10052011

9 Dolan PL 86 of physicians use Internet to access health information American Medical News Jan 11 2010l54(1) Available at httpwwwama-assnorgamednews20100104bisc0104htm Accessed on 10052011

10 Segal J HITECH act decrypted Understand the law before you send your patients an email Florida Medical Magazine Winter 201154-60

11 HITECH Act Breach Notification Guidance and Request for Public Comment Available at httpwwwhhsgovocrprivacyhipaaunderstandingcoveredentitiesguidance_breachnoticehtml Accessed on 10102011

12 Brown J E-mail is quick and easy but it could become evidence in a malpractice suit AAP News October 201031121

13 Dolan PL R U N2 TMing American Medical News February 4 200813-14

14 Wikipedia Social Network Service Available at httpenwikipediaorgwikiSocial_network_service Accessed on 10112 2011

15 Cohen E Surgeons send lsquotweetsrsquo from operating room Available at httparticlescnncom2009-02-17techtwittersurgery_1_twitter-and-facebook-social-networking-site-twitter-tweeted_s=PMTECH Accessed on 10152011

16 Pozo Jatem MC Casey K Kushner A Can Twitter campaigns increase awareness about health issues Bulletin of the American College of Surgeons February 20119644-45

17 Peregrin T Time to tweet social networking for surgeons Bulletin of the American College of SurgeonsFebruary 20119646-48

18 Modah lM Tompsett L Moorhead T Doctors Patients amp Social Media Available at httpwwwquantiamdcomq-qcpdoctorspatientsocialmediapdf Accessed on 10152011

19 American Medical Association Professionalism in the use of social media Available at httpwwwama-assnorgamapubmeetingprofessionalism-social-mediashtml Accessed on 10152011

20 Pew Internet Gadget Ownership Over Time Available at httpwwwpewinternetorgTrend-DataDevice-Ownershipaspx Accessed on 10052011

21 Dolan B 72 percent of US physicians use smartphones Available at httpmobihealthnewscom750572-percent-of-us-physicians-use-smartphones Accessed on 10052011

Selected Websites Software and Applications

Physician Informationbull American Medical Association-httpwwwama-assn

orgbull American Medical Association CPT coding app- http

wwwama-assnorgamapubabout-amaappspagebull Epocrates-medication and prescribing guide httpwwwepocratescombull Florida Medical Association- httpwwwflmedicalorgbull DocGuide- recent publications httpwwwdocguide

combull Duval County Medical Association-httpwwwdc- msonlineorgbull HealthStream-CME and simulationhttpwwwhealth-

streamcomindexaspxbull Medscape (formerly eMedicine) clinical reviews- httpwwwmedscapecombull Sermo- social medical discussion httpwwwsermo combull UpToDate (subscription) comprehensive clinical updates httpwwwuptodatecomindexbull Zygote Body (formerly Google body)- anatomy httpwwwzygotecom

Patient and Physician Informationbull American Academy of Family Physicians- httpfami lydoctororgonlinefamdocenhomehtmlbull American Academy of Pediatrics-httpwwwaaporgbull American Medical Association-httpwwwama-assn orgamapubpatientspatientspagebull Centers for Disease Control and Prevention-http wwwcdcgovbull Centers for Medicare and Medicaid-httpwww medicaregovbull Department of Health and Human Services-http wwwhhsgovbull Healthcom-httpwwwhealthcomhealthbull National Institutes of Health-httphealthnihgovbull Medhelp-httpwwwmedhelporgbull Medline Plus-httpwwwnlmnihgovmedlineplusbull WebMD- httpwwwwebmdcom


22 Parr B Android amp iPhone dominate Smartphone Market at BlackBerryrsquos Expense Available at httpmashablecom20110830android-iphone-blackberry-smartphone-stats Accessed on 10052011

23 Wikipedia Tablet computer Available at httpenwikipediaorgwikiTablet_computer Accessed on 10092011

24 Fuquay J Doctors using smarthones tablets to access medical data Available at httpwwwstar-telegramcom201107053201630doctors-using-smartphones-tabletshtml Accessed on 10092011

25 Dolan PL Doctors cite ease of use in rapid adoption of tablet computers American Medical News April 25 201129

26 Dolan PL 7 things to consider when choosing mobile devices American Medical News September 12 201140-42

27 Torrieri M Talk vs type taking another look at voice recognition Available at httpwwwphysicianspracticecomvoice-recognition-dictationcontentarticle14621681889679 Accessed on 10152011

28 Kleaveland B Voice recognition technology Available at httpwwwphysicianspracticecomvoice-recognition-dictationcontentarticle14621681589730 Accessed on 10152011

29 Dolan PL Cloud computing Is it right for your office Available at httpwwwama-assnorgamednews20101018bisa1018htm Accessed on 10152011

30 HealthWorks Collective Cloud computing in healthcare Available at httphealthworkscollectivecomnrip-nihalani24786cloud-computing-healthcare Accessed on 10152011

Serving NortheastFlorida Since 1898

BUSINESSPERSONAL

LIFEHEALTH

5150 Belfort Road Building 200 bull Jacksonville Florida 322569042963390 office bull 9042966144 fax

trade

Copyright copy 2011 Vandroff Insurance Inc All Right Reserved An Independent Insurance Agentreg

wwwVandroff-Insurancecom

BW adad 41911 416 PM

The Doctors Company and First Professionals

Insurance Company (FPIC) have officially

joined forces With the addition of FPIC we have

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3454_FL_DuvalCMSnewsletter_Nov2011indd 1 102611 1035 AM


Special - Changes to Preventive Care

An Overview of the Preventive Care Provisions of Health Care Reform

Seth M Phelps Esquire

Address Correspondence to Seth M Phelps Esquire Assistant General Counsel with Blue Cross and Blue Shield of Florida Inc in Jacksonville FL Emailsethphelpsbcbsflcom

Background

The Patient Protection and Affordable Care Act (ACA) signed into law on March 23 2010 contained many im-mediate changes that affected group and individual health insurance coverage and coverage offered through self-funded group health plans Coverage of preventive care which of-ficially became effective for plan years beginning on or after September 23 2010 received significant attention from the media However what does the term ldquopreventive carerdquo re-ally mean under the ACA and how does the mandate affect physicians in Northeast Florida

Definition of Preventive Care

As a general rule the ACA requires that self-funded group health plans and insurers offer group or individual health insurance to

bull provide coverage for certain preventive health care services and not impose cost-sharing requirements (eg copayments coinsurance etc) with respect to such services

Preventive care is not directly defined in the ACA In-stead the ACA defines preventive care by reference to the following external sources

bull Evidence-based items or services rated ldquoArdquo or ldquoBrdquo in the current recommendations of the United States Preven- tive Services Task Force (USPSTF)bull Immunizations recommended by the Advisory Com-

mittee on Immunization Practices of the Centers for Disease Control and Prevention (ACIP)bull Preventive care and screenings for infants children and

adolescents provided for in the comprehensive guide lines supported by the Health Resources and Services Administration (HRSA)bull Additional preventive care and screenings for women

as provided for in the comprehensive guidelines supported by the HRSA bull Recommendations of the USPSTF regarding breast cancer screening mammography amp prevention ex- cluding the recommendations issued in or around November 2009

Any services tests consultations or supplies identified in one of the above five sources is considered ldquopreventive carerdquo and generally must be covered subject to the exceptionslimitations discussed

The federal government provides a comprehensive website that provides a complete list of the preventive care services and guidelines that physicians may find helpful The website is httpwwwhealthcaregovcenterregulationspreventionrecommendationshtml

Recent Notable Developments

Several significant changes have already occurred that will impact or have already revised the definition of preven-tive care for purposes of the ACA and health plan benefits The website given earlier also notes specific changes Those changes include

USPSTF Changesbull The addition of screening and counseling for obesity in

children beginning for plan years on or after January 31 2011

ACIP Recommendationsbull Revisions to the HPV vaccination recommendations HPV

vaccination recommendations were expanded to cover the bivalent HPV vaccine These revisions are effective for policy plan years beginning on or after January 8 2011bull Revisions to the Flu vaccine recommendations Expanded

recommendations for adults aged 19 to 49 were adopted These changes become effective for plan years on or after March 2 2011bull Revisions to the pneumococcal vaccine recommendations Recommendations were adopted and become effective for plan years beginning on or after March 12 2011 Changes include expanded use of the pneumococcal vaccine in children from 6 to 71 monthsbull Revisions to the combination measles mumps rubella and varicella vaccine recommendations The revisions become effective for plan years beginning on or after May 7 2011

HRSA Changesbull Revisions to the Heritable Disorders in Newborns and Children Comprehensive Guidelines These revisions become effective for plan years beginning on or after May 7 2011

Continued to p 40


2011 DCMS Annual Meeting

December 1 2011 545-900 pmHyatt Regency Jacksonville Riverfront

Ashley Booth Norse MD 125th President of the Duval County Medical Society

See Spring 2012 NEFM journal for Annual Meeting coverage

2011 Awards Presented at Annual DCMS-Navy Meeting

The 2011 John A Beals Awards for Medical Research the G Shahin Awards for Research by a Physician in Training in Duval County and the Admiral Paul Kaufman Award were presented September 22 2011 at the Annual DCMS-Navy Meeting Beals Award winners are 1st Place - Dr Zbigniew Wszolek and co-authors 2nd Place - Dr Mobeen Rathore and co-authors and 3rd Place - Dr Sandeep Grover and co-authors Shahin Award winners are 1st Place - Dr Eric Roberts and co-authors and 2nd Place - Dr Christopher Worley and co-authors The Kaufman Award went to Dr Tom Davis (First photo below L to R) Cmdr David Boyd accepting for Dr Worley Dr Zbigniew Wszolek Dr Joseph Tepas - DCMS Award Chair who accepted for Dr Grover Dr Mobeen Ra-thore and Dr Eric Roberts (Second photo below L to R) Naval Air Station (NAS) Chief of the Medical Staff Cmdr Jamie Oberman presents award to Dr Tom Davis

The Beals Award was begun by Dr John Beals to recognize outstanding research and publications by DCMS members Dr Shahla Masood created the Shahin Award in honor of her mother G Shahin whom she considered an exemplary teacher The Kaufman award is named after Admiral Paul Kauman who was an NAS Commanding Officer and the awards first recipient and honors a local physician or health care professional who delivers outstanding community service to NAS Jacksonville beneficiaries and staff

The NAS Hospital also presents its Circle of Excel-lence Award to recognize outstanding service to the NAS Jacksonville staff This years recipient was Nancy Silki (not pictured)

AMA Leadership Visit in April

Jeremy A Lazarus MD the current President-Elect of the American Medical Association (AMA) will visit Jacksonville April 15-17 2012 Dr Lazarus will become the 167th AMA President in June 2012 He is only the second psychiatrist in the AMArsquos history to be elected to the position and the first since 1939

While in the area Dr Lazarus will speak at a DCMS dinner meet-ing be keynoter at the Jacksonville Rotary Club visit local academic medical institutions (UF College of Medicine and Mayo Clinic) The Florida Times-Union Editorial Board and other area groups The DCMS has been hosting AMA leadership for more than 20 years as a way to broaden the communityrsquos knowledge of organized medicine and to help motivate grassroots advocacy on is-sues of national importance

A clinical professor of psychiatry at the University of Colorado Denver School of Medicine and a voluntary professor of psychiatry at the University of Miami Leonard M Miller School of Medicine Dr Lazarus is a distinguished fellow of the American Psychiatric Association and is widely published on issues of ethics economics and managed care His most recent book is entitled Entering Private Practice A Handbook for Psychiatrists


bull Womenrsquos Health Guidelines The new guidelines include expanded coverage for contraception (including over the counter drugs and devices) and sterilization services breastfeeding support and supplies domestic violence screening and well- woman visits These new guidelines become effective for plan years beginning on or after August 2 2012

Common Issues

At first glance it may appear that the application of pre-ventive care benefits to health insurance coverage is fairly straightforward Physicians however will find there are several areas where issues may arise concerning application of this ACA requirement For example

bull How many treatmentsvisits are covered The guidelines while providing appropriate general guidance for phy sicians do not necessarily address the number of visits or treatments that are covered over a specific period of time eg annually semi-annually etc for a particular preventive care service In such instances checking with the patientrsquos insurance plan regarding coverage as well as reviewing the specific guidelines noted earlier from USPSTF ACIP and the HRSA are equally important Continued clarification and guidance is ex - pected on the preventive care requirements under the ACAbull What physicians can deliver the treatment In many instances the treatments counseling and other services recommended as preventive care could be delivered by a variety of medical provider types from counselors to physicians This makes it important to understand not only if there are limits to the number of treatments covered but also whether the patientrsquos insurance coverage applies any limits on the types of medical providers that can deliver such preventive care services without cost sharing bull The recommendations have changed so when do the changes become effective As expected revisions have already modified the definition of ldquopreventive carerdquo Those revisions do not become effective until the first anniversary of the health coverage in question follow ing one year from the date of adoption For example the womenrsquos health guidelines adopted on August 1 2011 will not start to become effective for plans until plan renewal following August 1 2012 This may lead to confusion for physicians and patients over the effective dates of certain preventive care changes

ExceptionsLimitations

Several specific exceptionsexemptions to the preventive care requirements exist that affect whether a service is considered preventive care subject to the provisions of the ACA If one

of the exceptions applies then depending upon the plan the provider type and the service preventive care may not be covered without cost sharing These exceptions demonstrate why it is important for physicians to verify health benefits to ensure that both the provider and the patient understand any applicable costs that may apply The major exceptions to note are

bull Grandfathered Health Plans A significant exception from application of the preventive care provisions of the ACA is for grandfathered health plans Any health plan that was in existence prior to March 23 2010 that continues with only relatively minor changes may be a grandfathered health plan and would not be required to comply with the preventive care provisions Not all carriers have adopted this exception with respect to preventive care Checking with the carrier is the best way to determine if the plan covers preventive care or is exempt because the plan qualifies as a grandfathered health plan For more information on grandfathering the following website is helpful httpwwwhealthre-formgovaboutgrandfatheringhtml

bull Out-of-Network Providers While ACA did not specify whether the preventive care benefit applies to both contracting and non-contracting health care providers with a particular health plan regulations issued by the United States Department of Health and Human Services (HHS) have confirmed that health plans are not required to provide the preventive care benefits at no cost sharing for out-of-network providers

bull Value Based Insurance Designs Some employers and health insurers are experimenting with what are known as value-based insurance designs (VBIDs) under the ACA A VBID is a health plan that establishes different cost sharing as an incentive for cost-effective use of medical services based upon factors such as where the services may be delivered Such VBIDs may have many such location based cost sharing differences or just a few For example a VBID may establish cost sharing for preventive care services at certain in-network loca-tions (eg the primary care providerrsquos office) at 100 but require a copayment or other cost sharing at other in-network locations Such an arrangement is allowed under current ACA rules with respect to preventive care but only so long as 1) there is an alternative for preventive care without cost sharing and 2) the cost sharing at another location is waived if it would be medically inappropriate to have the preventive services provided in the favored setting based on the patientrsquos medical situation In some respects VBIDs have been in the marketplace for years with differences between inpatient cost sharing and outpatient Now VBIDs not only include such location based distinctions but also among other designs potentially provider based and overutilization based distinctions

Continued to p 44

Continued from p 38


DCMS Membership Applications

These physiciansrsquo applications for membership in the Duval County Medical Society are now being processed Any information or opinions you may have concerning the eligibility of the applicants listed here may be directed to Ashley Booth Norse MD DCMS Membership Committee Chair (904-244-4106 or Barbara Braddock Membership Director (904-355-6561 x107)

Siddharth Bhatt MDNephrologyClinic For Kidney Disease PAMedical Degree Medical College of BarodaResidency Stony Brook University Medi-cal CenterFellowship Boston University Medical CenterNominated by Dinesh Jayadevappa MD Nilay Nahar MD Helder DePaiva MD

Nitin S Butala MDNeurologyClinical NeurophysiologyBaptist Medical CenterBaptist Neurology-Lakewood DivisionMedical Degree Grant Medical CollegeResidencyFellowship Medical College of WisconsinNominated by Mobeen Rathore MD Carlos Gama MD Rebecca Cooper MD

Jennifer Chally MDPediatricsJacksonville PediatricsMedical Degree University of Miami School of MedicineResidency University of Florida College of Medicine JacksonvilleNominated by Randolph Thornton MD Thomas Stanley MD Nan McClel-land MD

Jasreman Dhillon MDPathologyUF PathologyMedical Degree Postgraduate Institute of MedicineResidency Winthrop University HospitalFellowship MD Anderson Cancer CenterNominated by UFJP

Marc Kaye MDOrthopaedic SurgeryThe Bone amp Joint Institute at ShandsMedical Degree Albert Einstein College of MedicineResidency Cleveland Clinic Foundation UCLA School of Medicine and Mai-monides Medical CenterFellowship University of Pittsburgh School of MedicineNominated by UFJP

Suparna R Krishnaiengar MDNeurologyThe Neuroscience Institute at ShandsMedical Degree University of MysoreResidency University of Oklahoma

Fellowship Oklahoma University Health Sciences Center and Cleveland Clinic FoundationNominated by UFJP

Robert M Levy MDNeurosurgeryUF NeurosurgeryMedical Degree Stanford University School of MedicineInternship Stanford University School of MedicineResidency University of CaliforniaNominated by UFJP

Jeannine V Mauney MDOBGYNSt Lukersquos OBGYNMedical Degree Wake Forest University School of MedicineResidency University of Florida College of Medicine-JacksonvilleNominated by Guy Benrubi MD Andrew Kaunitz MD

Carolyn B Messere MDColon amp Rectal SurgeryColon amp Rectal AssociatesMedical Degree University of Massachu-setts Medical SchoolResidency Baystate Medical CenterFellowship Carle Foundation HospitalNominated by Frank Healey MD Robert Moore MD Frank Chrzanowski MD

Michelle Stalnaker MDObstetrics amp GynecologyCare Center for Women at ShandsMedical Degree University of North Carolina School of MedicineResidency University of Florida Health Science CenterJacksonvilleNominated by UFJP

Alexander Tuan Rose MDTraumaCritical Care SurgeryUF Trauma SurgeryMedical Degree Wayne State University Medical SchoolInternshipResidency Wayne State Uni-versity Fellowship University of Florida Health Science CenterJacksonvilleNominated by UFJP

Jason P Scimeme MDPediatric Critical CareUF Pediatric Critical Care MedicineMedical Degree SUNY Upstate Medical UniversityResidency Long Island Jewish Medical CenterFellowship Nationwide Childrenrsquos Hos-pitalNominated by UFJP

Richard D Ten Hulzen MDOphthalmologyGlaucoma SpecialistBeaches Eye CenterMedical Degree Mayo Medical SchoolResidency Mayo ClinicFellowship Wills Eye HospitalNominated by David Pearson MD Donald Barnhorst MD Kent New MD

Christine Thorogood MDPediatricsUF Pediatric ServiceMedical Degree Robert Wood Johnson Medical SchoolResidency Thomas Jefferson UniversityAlfred DuPont Hospital for ChildrenNominated by UFJP

Gladys P Velarde MDCardiologyThe Cardiovascular CenterUFMedical Degree New York University School of MedicineResidency Columbia Presbyterian Medi-cal CenterFellowship Boston University and Mount Sinai Medical CenterNominated by UFJP

Thomas Wannenburg MDCardiologyThe Cardiovascular CenterUFMedical Degree University of Natal Medi-cal SchoolResidency John Hopkins Bayview MedicalFellowship Wake Forest UniversityBaptist Medical CenterNominated by UFJP

Raquel S Watkins MDAllergy amp ImmunologyWatkins Allergy amp Asthma ClinicMedical Degree University of Maryland School of MedicineResidencyFellowship Wake Forest Uni-versityBaptist Medical CenterNominated by Bradford Joseph MD Vikram Gopal MD Sanjay Swami MD

Velyn Lisa Wu MDFamily MedicineFamily Care PartnersMedical Degree University of South Florida College of MedicineResidencyFellowship Halifax HealthNominated by William Carriere MD TraChella Johnson MD

RESIDENTSFELLOWS ndash MAYO CLINIC

AnesthesiologyJohn Douglas McDonald MDAjay Rajkumar Vellore MD


Behavioral NeurologyQurat Ulain Khan MD

CardiologyPreetham Kumar MD

DermatologyBrent Goedjen MD

Hematology-OncologyFaithlore P Gardner MDJason Starr DO

Internal MedicineAsim Ahmad MDDavid Cangemi MDJennifer Horsley-Silva MDJuan Carlos Leoni-Moreno MDCletus Tanwi Moma MDJulia Mueller MDRicardo J Pagan-Lopez MDCara Prier MDCarl Ruthman MDDavid F Snipelisky MDOral Waldo MD

NeurologyKirstin Eller MDRebecca Hurst MDGlen Robinson MDAmita Singh MDJulia Whitlock MD

PulmonaryCritical Care MedicineLioudmila Karnatovskaia MDPhilip E Lowman MDJose M Soto Soto MD

Radiation OncologyCorey Hobbs MD

RadiologyWilliam Justin Reed MDJoseph Whitlock MD

Transitional YearJordan Michael Brown MDJason Sebesto DOBlake Michael Troiani MD

RESIDENTSFELLOWS ndash UNIVERSITY OF FLORIDA

Cardiovascular DiseaseAlian Aguila MDJ Ryan Altman MDLine Kemeyou MDRaguveer Murthy MD

Clinical Cardiac ElectrophysiologyBosede Afolabi MD

Diagnostic RadiologyMona Ahmed MDSara Fernandez MD

Joshua Holliday MDBrett Horgan DODavid Martineau DOEmergency MedicineKarissa Cerroni MDPaul Diaz-Granados MDSusan Goggans MDAngel Harper MDJohn McLain MDAmber Newell DONataly Saldana MDJames Wheeler MDJennifer Wilkerson DO

EndocrinologyHagop Kojanian MDAnna Szafran-Swietlik MD

GastroenterologyBijo Kythaparampil John MDCamille McGaw MD

Infectious DiseaseDiane Vanhorne-Padilla MD

Internal MedicineAhmad Alkaddour MDChristopher Bailey DOJason Bellardini MDJason Hew MDAlexandra Joseph MDChristina Kanacheril MDAisha Khan DOPaul Maraj MDTrevanne Matthews-Hew MDGarry McCulloch MDKe Ning MDMichael Pizzi DOAvinash Ramdass MDWesley Thompson DOJean Touchan DOKasey Treger DO

Interventional CardiologyShahdad Azmoon MD

NephrologyQurrat Shamim MD

NeurologyWilliam Bossert MDLina Rodriguez Rosario MDKhadijah Shamseddine MDDenys Shapovalov MD

Obstetrics amp GynecologyOluwakemi Adegoke MDDawn Bowers MDRachel Cartechine MDAmy Hammers MDRobert Knowlton MDKristen McMaster MD

Orthopedic SurgeryAnna Acosta MDMark Elliott MD

Kyle Fleck MDWilliam Toole MD

PathologyAnatomic amp ClinicalDawn Butler MDDeepan Mathur MDKerry Nagee MD

PathologyCytopathologyMarisa Varallo MD

PediatricsConcepcion Agnila MDSarah Bajorek DOJoshua Berg DORyan Cantville DOCraig Erker MDAdriana Martinez DOAlexander Ortega MDEmmanuel Pena DOKaitlin Porcaro MDAdam Rappoport MDJames Sierakowski DOYouness Tolaymat MD

Pediatric EndocrinologyRanjana Sarma MD

PulmonaryCritical Care MedicineHammad Bhatti MD

SurgeryMahir Alsalman MDAmanda Bailey DOLori Gurien MDTimothy Hester MDChad Kaplan MDEsther Mihindu DOMartin Rosenthal MDYauhen Tarbunou MD

Surgical Critical CareAngela Jones MDJason Moore MD

Vascular amp Interventional RadiologyRyan Daily MD

Did you know about this

Go online and take a look

Referral Phone NumberAddress or Directions

Use the DCMSonline Physician Directory on your Smartphone

You can easily search for a DCMS memberrsquos practice information and get a map and directions to their office

Check it outwwwdbdcmsonlineorgdirectory

or use your SmartPhone QR reader

Stay Connected wwwdcmsonlineorg



Look how far we have come in 159 Years

The Duval County Medical Society (DCMS) has been keeping in touch with its members and communicating important medical news and events for 159 years

bull In 1853 when it all began information from DCMS meetings was recorded in handwritten minutes and then spread by word-of-mouth posted notices in offices and hotel lobbies or published items in the newspaper

bull Fast forward to 1933 when a legal size printed Monthly Bulletin of the Duval County Medical Society was folded down to business envelope size and mailed to the membership with a 112 cent stamp

bull This progressed to a 30-page saddlestiched 5rdquo x 8rdquo booklet then to the 40-page 7rdquo x 9rdquo Jacksonville Medicine and eventually a full-size journal publication called Northeast Florida Medicine Telephone calls faxes and mailings supplemented any print communication tools

bull Then the computer age hit so phones faxes and even electric typewriters were abandoned for the technological advances of PCs email websites Smartphones Facebook and Twitter

bull Today DCMS members get Society information through an e-newletter a dcmsonlineorg web announcement by reading the virtual edition of the journal or hearing about it all via social media

We have come a long way

The fascinating story of DCMS will be available soon in a book tentatively entitled Floridarsquos Pioneer Medical Society A History of the Duval County Medical Society and Medicine in Northeast Florida Plan to purchase your copy of this coffee table size book with over 200 illustrations It will be a collectorrsquos item but more than thatit will show how DCMS has always been a pioneer society led by its trailblazing membership The same cutting edge spirit will take DCMS into 2012 and beyond Watch for details on ordering the DCMS History Book to be available in 2012


bull Religious Exemptions This exemption allows religious organizations to exclude contraceptive services and was adopted as part of the issuance of the new guidelines in August for womenrsquos health services The religious exemption applies to not-for-profit groups that have the inculcation of religious values as their purpose primarily employ individuals who hold certain religious beliefs and primarily serve a population with those religious tenets HHS has indicated that this exemption was modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception

How to Navigate the Requirements

The best way for physicians to determine what benefits apply to a particular patientrsquos services is to check with the patientrsquos carrier or administrator and the same is true for finding the most accurate information regarding reimbursement Nothing in the ACA establishes exactly how preventive care services may be reimbursed by the carrier in question It just simply states that such services have to be covered as discussed ear-lier Each carrier or administrator may have different policies and procedures regarding payment of preventive care claims including how to bill for such claims Some of the policies may be influenced by whether or not the physician contracts with the carrier or administrator For example if a physician contracts on a capitated basis with a carrier does the capita-tion rate previously negotiated include payment for these new preventive care services Such questions will depend upon the physicianrsquos specific contract

Future

The preventive care guidelines will continue to evolve over time and as a result so will the coverage and benefits required by the ACA for preventive health services It is important to continue to monitor the guidelines discussed that determine the definition of ldquopreventive carerdquo and to pay particular at-tention to the patientrsquos benefits as well as the effective date of any such changes

Continued from p 40

1Based on public ranking data amp iTunesreg Connect the Aetna Mobile App for the iPhonereg mobile digital device has been the top ranked health insurance app in the ldquoHealthcare and Fitnessrdquo category Apple the Apple logo iPhone and iTunes are trademarks of Apple Inc registered in the US and other countries

copy2011 Aetna Inc Plans offered by Aetna Life Insurance Company and its affiliates Health benefits and insurance plans contain exclusions and limitations Providers are independent contractors and are not agents of Aetna Provider participation may change without notice

2011118

It looks like a phone It acts like a personal health assistant

Aetna Mobile is the 1 app in Health care1 Once you try it itrsquos hard to imagine life without it Try it out healthyisaetnacommobile

Know more Get betterSM

Did you know the NEFM Journalis online in a digital virtual version

Go to dcmsonlineorg and NEFM at top mouse down to Current Issue

and over to Current Issue and click The link to the Virtual Edition is at the top

Click and read the journal online

Check it Out


Treasury and Payment Solutions Lending Investments Financial Planning

Deposit products and services are offered through SunTrust Bank Member FDIC

Securities and Insurance Products and Services Are not FDIC or any other Government Agency Insured bull Are not Bank Guaranteed bull May Lose ValueSunTrust Private Wealth Management Medical Specialty Group is a marketing name used by SunTrust Banks Inc and the following affiliates Banking and trust products and services are provided by SunTrust Bank Securities insurance (including annuities and certain life insurance products) and other investment products and services are offered by SunTrust Investment Services Inc an SEC-registered investment adviser and brokerdealer and a member of FINRA and SIPC Other insurance products and services are offered by SunTrust Insurance Services Inc a licensed insurance agency

copy2011 SunTrust Banks Inc SunTrust and Live Solid Bank Solid are federally registered service marks of SunTrust Banks Inc

A financial advisor dedicated to the medical industry can help you navigate changes in your practicersquos finances

The business of medicine much like your practice itself is forever evolving And with new financial opportunities and ongoing concerns mdash like protecting against fraud managing risk and anticipating the impact of insurance and reimbursements on cash flow mdash you need the guidance of an advisor who uniquely understands your industry At SunTrust advisors with our Private Wealth Management Medical Specialty Group work solely with physicians and their practices to deliver solutions designed for the medical community To schedule an appointment with an advisor call 9046322854 or visit suntrustcommedicine to learn more


Dr James St George is proud to join the Jacksonville community bringing more than 20 years experience in treating vascular disorders The recent opening of the St Johns Vein Center provides

you with a new option for patients suffering from lower extremity venous disease including

Your patients no longer have to drive downtown for specialist vein care Our state-of-the-art facility is conveniently located just off the Baymeadows road exit on 9A We provide the following treatment options

James St George MD is a vascular specialist and a diplomat with the American Board of Radiology with a Certificate in Interventional Radiology He completed his fellowship training at Harvard Medical Schoolrsquos

Brigham and Womenrsquos Hospital and served for 12 years as faculty at Harvard Medical School Dartmouth Medical School and Drexal School of Medicine He also held the position of Head of Special Procedures at Hahnemann Hospital in Philadelphia Dr St George takes the time to know each patient and creates customized treatment programs to obtain the best possible results

bull Chronic venous insufficiencybull Chronic distal skin changes including abnormal increased pigmentation eczema ulcerationbull Leg ankle and foot swelling

bull Leg pain cramps discomfortbull Restless legsbull Varicose veinsbull Spider veins

bull Radiofrequency ablationbull Laser ablationbull Ultrasound-guided chemical ablation

bull Foam sclerotherapybull Liquid sclerotherapybull Ambulatory phlebectomy

9 1 9 1 R G S k i n n e r P a r k w a y bull S u i t e 3 0 3 bull J a c k s o n v i l l e F L 3 2 2 5 6

Introducing the St Johns Vein Center

We are a participating provider for Medicare Tricare and most Commercial payers Please visit wwwstjohnsveincom for more information or call (904) 402-VEIN (8346)

to learn more about the care we can provide for your patients

w w w s t j o h n s ve i n co m bull (904) 402-VEIN (8346)

Quality Time with FamilyNow is the time to talk to your patients with advanced illness andtheir families about the benefits of Community Hospice care

By discussing these care options before the holidays you offer them peace of mind that comes with greater comfort and more quality time together allowing them to enjoy favorite traditions and make lasting memories

Call us today to find out how you can givethis gift to your patients Together letrsquos make the holidays a cherished time for all to remember

9044076500 bull toll free 8662536681 bull communityhospicecom

Community Focused bull Community Supported bull Serving Baker Clay Duval Nassau and St Johns counties since 1979

GIVE YOUR PATIENTS A GiftTHIS HOLIDAY SEASONhellip

Duval County Medical Society Foundation555 Bishopgate LaneJacksonville FL 32204

ADDRESS SERVICE REQUESTED

NON-PROFITORGANIZATIONUS Postage Paid

Jacksonville FloridaPermit No 2981

We proudly announce that First Professionals Insurance Company and The Doctors Company have united

Together we set a higher standard We aggressively defend your name We protect good medicine We reward doctors for their loyalty We ensure members benefit from our combined strength We are not just any insurer We are the nationrsquos largest insurer of physician and surgeon medical liability

The Doctors Company and First Professionals Insurance Company (FPIC) have officially

joined forces With the addition of FPIC we have grown in numbers talent and perspectivemdash

strengthening our ability to relentlessly defend protect and reward our 71000 members

nationwide To learn more about how we can protect your livelihood and reputation with our

medical professional liability program call (800) 352-0320 or visit us at wwwthedoctorscom

Richard E Anderson MD FACPChairman and CEO The Doctors Company



3485_FL_DuvalCMSdirectory_Dec2011indd 1 11111 1002 AM

Doctors Co Back Cover ad with mailerindd 1 1132011 112321 AM


Features

11 Internet and Medicine Made Ridiculously Simple Daniel Kantor MD Guest Editor

12 Mind the Gap Generational Differences in Medicine Danielle S Walsh MD FACS

17 Electronic Health Records Gaining Ground amp Improving Quality of Care (CME) Radley Remo MPH and Robert Harmon MD MPH

24 Effective Communication amp Marketing Strategies for Todays Busy Physicians AJ Beson and Vanessa Wells 27 Social Networking Who are Your Friends Daniel Kantor MD

31 HIPPA amp the Internet Christopher L Nuland JD

33 Technology for the Physician Danielle S Walsh MD FACS

Special Articles

8 Philip H Gilbert Invited Editorial

38 An Overview of the Preventive Care Provisions of Health Care Reform Seth Phelps Esquire

VOLUME 62 NUMBER 4Internet and MedicineWinter 2011

EDITOR IN CHIEFRaed Assar MD

MANAGING EDITORLeora Legacy

ASSOCIATE EDITORSSteven Cuffe MDRuple Galani MDKathy Harris (Alliance)Sunil Joshi MDJames Joyce MDNeel Karnani MDMobeen Rathore MDJames St George MD

Executive Vice PresidentJay W Millson

DCMS FOUNDATION BOARD OF DIRECTORSBenjamin Moore MD PresidentTodd L Sack MD Vice PresidentKay M Mitchell MD SecretaryJ Eugene Glenn MD TreasurerGuy I Benrubi MD Immediate Past PresidentMohamed H Antar MDRaed Assar MDAshley Booth Norse MDJ Bracken Burns DOLT Orlando Cabrera MC USN ResidentMalcolm T Foster Jr MDJeffrey M Harris MDMark L Hudak MDSunil N Joshi MDDaniel Kantor MDNeel G Karnani MDHeather Kearney MD ResidentJohn W Kilkenny III MDHarry M Koslowski MDEli N Lerner MDJeannine Mauney MD ResidentJesse P McRae MDJason D Meier MD ResidentNitesh N Paryani MD ResidentNathan P Newman MDMobeen H Rathore MDRonald J Stephens MDJeffrey H Wachholz MDDavid L Wood MDNortheast Florida Medicine is pub-lished by the DCMS Foundation Jacksonville Florida on behalf of the County Medical Societies of Duval Clay Nassau Putnam and St Johns Except for official announcements from the County Medical Societ-ies no material or advertisements published in NEFM are to be seen as representing the policy or views of the DCMS Foundation or its colleague Medical Societies All advertising is subject to acceptance by the Editor in Chief Address correspondence and advertising to 555 Bishopgate Lane Jacksonville FL 32204 (904-355-6561) or email llegacydcmsonlineorg

COVER Fantasy Hacker used with permission of Wallpaperherecom

Departments4 From the Editorrsquos Desk5 From the Presidentrsquos Desk9 Residents Corner35 Trends in Public Health43 DCMS History Book

Inside this issue of

Northeast Florida Medicine











































BrooksRehaborg




























































Danielle S Walsh MD



Introduction




Generational Groups








Baby Boomers









































Conclusion


























































a One

b Two

c Three

d Four




c Cost savings

d Easy to implement



b High cost of EHR








e All of the above










Signature_______________________________________________________________________________________







Overview












EHR Prevalence








Federal GoalMandate








The Impact



































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade



BW adad 41911 416 PM Page 1



















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out























































































BrooksRehaborg




























































Danielle S Walsh MD



Introduction




Generational Groups








Baby Boomers









































Conclusion


























































a One

b Two

c Three

d Four




c Cost savings

d Easy to implement



b High cost of EHR








e All of the above










Signature_______________________________________________________________________________________







Overview












EHR Prevalence








Federal GoalMandate








The Impact



































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out







































































































Danielle S Walsh MD



Introduction




Generational Groups








Baby Boomers









































Conclusion


























































a One

b Two

c Three

d Four




c Cost savings

d Easy to implement



b High cost of EHR








e All of the above










Signature_______________________________________________________________________________________







Overview












EHR Prevalence








Federal GoalMandate








The Impact



































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out

















































































Conclusion


























































a One

b Two

c Three

d Four




c Cost savings

d Easy to implement



b High cost of EHR








e All of the above










Signature_______________________________________________________________________________________







Overview












EHR Prevalence








Federal GoalMandate








The Impact



































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out











































































a One

b Two

c Three

d Four




c Cost savings

d Easy to implement



b High cost of EHR








e All of the above










Signature_______________________________________________________________________________________







Overview












EHR Prevalence








Federal GoalMandate








The Impact



































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out


















































Overview












EHR Prevalence








Federal GoalMandate








The Impact



































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out


















































Federal GoalMandate








The Impact



































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out












































































Resources























































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out

























































































































Conclusion





tips



Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out















































Daniel Kantor MD



Introduction




































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out
































































Step-by-step guide










Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out
















































Twitter and Tweets




















Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out















































Conclusion


























Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out

















































Introduction



What HIPAA Requires


























Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out


























































Managing the Risks




Conclusion






Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out

















































Website Marketing


















Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out






















































Mobile Devices










Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out



















































Other Technologies



Summary














































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out
























































































BUSINESSPERSONAL

LIFEHEALTH


trade






















medical liability









Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out


















































Background




















Continued to p 40
















Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out




























































Common Issues









Continued to p 44

Continued from p 38


















































































Future


Continued from p 40



2011118








Check it Out






























































































































Future


Continued from p 40



2011118








Check it Out













































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