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Telemedicine Care: A malpractice risk? Au Contraire …


In early 2006, four years into running my current medical practice, doctokr Family Medicine, I got a call from my medical malpractice carrier.  Just weeks before I’d received a notice that my malpractice rates could go up by more than 25%.  The added news of a pending investigatory audit was chilling. In 25 years of practicing medicine I’d never been audited.

“Is there a complaint, or a law suit against me that I don’t know about?”

“No,” the auditor told me over the phone, “We’ve never seen a medical practice like yours and feel obligated to investigate your process from a medical-legal perspective.”

“Great,” I thought, with a weary sigh. “I’m already battling the insurance model, the status quo of the medical business model, and slow adoption by consumers who are addicted to their $20 co-pay. All I’m trying to do is to breathe life into primary care and get the consumer a much higher quality service for less money than currently subsidized through the insurance model. And now this.”

The time had arrived to add the concerns of the malpractice companies to the list of hurdles to clear if a new vision of a medical care model was ever to catch flight.

I frequently am asked the question “Aren’t you afraid of the malpractice risk?” when I explain my medical practice model, which is based on the doctor answering the phone 24/7, resulting in the patient’s medical problem being solved by the phone more 50% of the time. The simplest counter to this question is to analyze the risk patients incur when the doctor won’t answer the phone. What happens when the doctor is the LAST person to know what’s going on with patients?   The answer is obvious.  But malpractice companies could have concerns beyond patient safety. Buy-in from the malpractice companies would be critical to the future viability of all telemedicine.

I prepared a summary paper, which included 12 bullet points, explaining how a doctor- patient relationship based on trust , transparency, continuous communications and high quality information systems significantly reduce risk to the person you’re trying to help.

Bullet 1: The industry standard is that 70% of malpractice cases in primary care center on communication barriers. My medical team deploys continuous phone and email communications and 7 days a week- same day office visits when needed between doctor and patient thus significantly reducing these barriers.
The remaining bullets could be summarized by the conclusions from the Institute of Medicine’s visionary book Crossing the Quality Chasm: A New Health System for the 21st Century using a table developed by The American Medical News when they reviewed the book. I carefully plotted our practice standards compared to the traditional business model as it stands today based on this table:

The auditor showed up, spent 4 hours reviewing our practice, electronic medical records, compliance to HIPPA, our intakes, on-line connectivity, procedures, and practice standards. While the auditor reviewed, I sat as unobtrusively as I could, feeling my brow grow damp with perspiration, as I carefully answered her questions. During the auditor’s time, I never moved to sway her to “my way.” I just let the data that I had accumulated from four years of practice do the talking.

Once the auditor left, I waited for two weeks for the results. By the time their letter arrived, I was scared to open it.  The news arriving made me jubilant. The medical practice company announced a DECREASE in my premiums because we used telemedicine and EMR to treat patients so fast (often within 10 minutes of someone calling us we have their issue solved without the patient ever having to come in).

I will admit that I felt, and actually still do feel, vindicated by having my malpractice insurer understand fully the value that the type of telemedicine my practice offers to our patients: round-the-clock access to the doctor, speed of diagnosis, and convenience, which all led to healthier patients and lower risk.

Doctors answering the phone all day for their patients, it’s not just lower risk, it’s better health care at a better price. It’s a win-win-win strategy whose day is arriving.

Until next week, I remain yours in primary care,

Alan Dappen, MD

Half-speed in the NBA: Is it dangerous?

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Midway through the third quarter of an April 2 NBA game between the Cleveland Cavaliers and Washington Wizards, a Cleveland guard tossed a lob pass toward the rim. Most of us sitting in the Verizon Center, in downtown Washington, D.C., had an idea what was about to happen.

Lebron James, the 24-year-old heir apparent to the NBA’s Best Ever moniker, elevated from the left baseline, caught the pass and, as he floated through the lane like a bird on wing, dunked the ball behind his head. The crowd roared its appreciation and even some of the Wizards’ players nodded in approval.

But the theatrical dunk, which came at a point when Cleveland was trailing by double digits, was one of only a small handful of highlights James – the leading candidate for league MVP for the 2008-2009 NBA season – had produced to that point in the contest.

He spent a good portion of his on-court minutes on the periphery, loping up and down the court with little urgency, distributing passes and setting an occasional pick but otherwise leaving the driving and scoring burden to his teammates.

The Wizards held on to win, despite a late flourish by James that left him with 31 “quiet” points.

The outcome hardly mattered: The Wizards were nearing a merciful end to a season that tied the franchise’s worst-ever record. The Cavaliers had all but wrapped up the top seed in the Eastern Conference for the playoffs.

Loafing or saving energy?

But from a health perspective, the on/off performance of James raised a question: How is it that NBA players – and many other professional athletes – are able to switch gears so readily and (seemingly) with few physical repercussions? How can someone go “half speed” without risking injury and still appear competitive on a court with some of the world’s best athletes?

I posed this question to Nick DeNubile, MD, who served as an orthopedic consultant to the Philadelphia 76ers for more than 10 years, and is author of Framework: Your 7-Step Program for Healthy Muscles, Bones and Joints (Rodale Books, 2005).

DeNubile made an important distinction between going half-speed and being tentative. If you’re tentative – in any sport at any time – that’s when you risk injury.

“You need to be relaxed,” DeNubile said, to ensure that all of your faculties are there when you need them (for example, to leap to the rafters of an arena and throw down a reverse dunk). But “relaxed” doesn’t mean you’re not ready to go full speed on a moment’s notice. It’s similar to the difference between a cat stalking prey (relaxed but alert and focused, ready to strike) and a skier standing atop a cliff, doubting that he can navigate the leap (frightened and tense, and becoming increasingly less focused).  Skilled athletes can go partial speed and still stay relaxed, DeNubile notes.

But this doesn’t apply to all sports. Diving, for example, or pitching a baseball require a focused anaerobic punch that would be very difficult to perform lackadaisically.

Why players hold back

For NBA players, the decision to occasionally temper their effort is not always bad.

“Recovery is so important for the players [and] metabolic recovery can vary from athlete to athlete,” DeNubile said.

“A lot of players come into the season three-quarters fit and use the season to get in shape for the playoffs. You’re better off if you come into the season fit,” but in an 82-game season even some of the fittest players have low-intensity nights. They may do it for selfish reasons – a contract dispute, for example. But in most cases they do it because they have to keep some reserves in the tank to stay competitive throughout a season that, for playoff teams, can span almost three-quarters of the year.

DeNubile recalled the 2001 NBA Finals, when his 76ers faced the Los Angeles Lakers.

“When we went to finals some players were dangerously over-trained,” he explained. “We did blood work [on the team] and you could see the guys who were on the brink. When you push too hard the body can start to break down. It’s the reverse effect” of training well.

DeNubile didn’t name players who were over-trained but he did cite Allen Iverson as one player who rarely gives reduced effort. “Every game of the year he’s giving 100 percent, 150 percent, diving for loose balls, playing as hard as he can,” DeNubile said. “That guy is incredible. He just doesn’t have an off switch.”

Somehow Iverson has stayed competitive for 12 (and counting) NBA seasons, defying predictions from many analysts that his all-out, physical style of play would result in a truncated career.

Are you over training?

Most of us will never play professional sports. But that doesn’t mean we can’t learn from those who do.

While the great majority of Americans is in no danger of over training (see: obesity epidemic, 21st century), some of us become addicted to strenuous exercise and tend to push ourselves harder than we should. One easy marker to check for over-training is your resting heart rate. Check it in the morning, right after you wake up, DeNubile says. (If you fear you are already over-trained, take a week off and see if that morning heart rate drops by 10 to 15 percent; if yes, you were likely over-training.)

Most are NBA players are incredibly fit and have resting heart rates around 60 beats-per-minute.

“When you see it start to bump up 10 beats per minute, that’s one of the signs over overtraining,” he says. “Or if a player says he’s getting a good night’s sleep but is still feeling tired.”

This made me wonder how much fuel NBA players burn during a game.

Interestingly, they’re burning about the same number of calories – 10 to 12 calories per minute – as you or I would during vigorous exercise. But because they are so fit their bodies use available energy stores much more efficiently than would a less-fit body, and thus they can accomplish more physically with less energy.

But DeNubile says that doesn’t make NBA players immune to basic exercise risks. “It can get dangerous when you’re tank starts to get low. People who sweat big can get dehydrated. You’ll see a player come off [the court] and he’s not happy about how he was playing or whatever and the trainer will offer him water or Gatorade and he’ll wave it off. That always worries me.”

These guys need to replenish lost fluid just like the rest of us. It’s nice to know we have at least that in common.

Ideas From John Halamka’s Basement


I attended a teleconference meeting* with John Halamka yesterday at the Cisco booth at HIMSS. It was an exciting experience – and quite intimate since I was there with only 1 other reporter and two Cisco staff. The room was closed off from the exhibit hall but we could be viewed through glass and John’s face was about 4 feet tall in front of us. It actually felt a bit like a TV news room – with glowing lights, cameras, and mics everywhere.

I arrived a few minutes late because I was having trouble finding the booth with the McCormick numbering system – but Frances Dare graciously welcomed me, and John immediately responded (from the screen in front of us): “Oh, hello there new person!” It was most amusing.

I’m sure that John had said some brilliant things prior to my arrival – but I had the chance to ask him my very own questions for about 30 minutes. Here are some highlights:

Dr. Val: How are we going to get doctors in solo practice to get on board with a national EMR effort?

Dr. Halamka: What we’ve found in the Boston area is that even if you give solo-practitioners an entire online EMR system for free, they still don’t want to use it because it takes effort to learn how to do so. They’re just not willing to put in the time. However, now that there are financial incentives in place (the stimulus bill includes $44,000/doctor to adopt an EMR system), suddenly their willingness to comply has increased dramatically.

Dr. Val: How do they get the right EMR?

Dr. Halamka: Hospitals pay 85% of the development costs for a good EMR, and professional organizations pick up the other 15%. Then the EMR is licensed for free to the solo practitioners – they’re incentivized to adopt it, and all they see is an online browser. They don’t have to deal with the back end at all.

Dr. Val: Have you used voice recognition systems at your hospital?

Dr. Halamka: Yes. We’ve found that voice recognition systems don’t work well in the ER because it’s too noisy in there. Also, the nurses don’t like having to tote around another piece of electronic equipment to do their jobs. However, we love our voice recognition dictation system – I can call in my note and have it return to me to insert into the electronic chart in near-real time. That’s great. Of course, voice recognition works best for the narrative portion of a note in the medical record, it’s not so good for structured data.

Dr. Val: How are we going to get doctors on the same “practice page” so that patients receive consistent care for similar problems, no matter where they are in the country?

Dr. Halamka: We need to implement more physician decision support tools and create rule sets based on best practices/evidence. Some are already doing this successfully: Health Dialog uses nurses (via phone) to walk patients through treatment decision trees. UpToDate is a good resource for doctors. At our hospital we’ve even negotiated in advance with the local insurance plans to have them automatically approve radiology tests based on pre-determined rule sets. That saves the docs a lot of time because they don’t have to call for approval for every single radiology test that they order. If the test is indicated by the rules, then it’s automatically approved.

Dr. Val: Some doctors have had bad experiences with rule-based quality measures. One ER doc I know was reprimanded for doing the right thing (clinically) because it didn’t comply with a rule set. How do you address the inflexibility of rule sets in the face of complex human lives and situations?

Dr. Halamka: Quality measures must be based upon clinical data, NOT administrative or claims data. Administrative codes are too far removed from what’s actually happening clinically – so if we are going to automate quality scores, they have to be analyzing the right data sets. However, quality scoring is not perfect. My hospital actually got “dinged” for reporting too much. We’re very transparent at BIDMC and tried to supply all our quality measures to a local oversight body. Of course, the other hospitals weren’t reporting anything like the level of detail that we were, so we looked like an outlier – and a really bad hospital. Of course it was just an artifact. But it took some time to clear up.

Dr. Val: I once heard someone say that judging a hospital’s quality based on administrative data is like judging a restaurant’s quality by its grocery list.

Dr. Halamka: That’s a good one. I’ll have to use it. Well thanks for the call – I’m speaking to you here [points to the white curtains behind him on the screen] from my basement!

Dr. Val: Thanks for your time! I look forward to your HIMSS lecture tomorrow on what the stimulus bill means for IT.


*TelePresence Fireside Chat – Sunday, April 5 (3-4pm CT) – Dr. John Halamka, CIO of CareGroup Health System will conduct a live interview via TelePresence, an immersive in-person meeting experience, from his home in Boston along with Frances Dare of Cisco, who will be onsite at HIMSS. The discussion will focus on a number of issues pertaining to the stimulus funding package. Additionally, Mrs. Dare and Dr. Halamka will discuss how technology such as healthcare telemedicine and remote video will play a role in not only time and cost savings but also helping serve rural populations.

Recent AP article about Cisco.

Neuroticism Versus Hypochondria: Dr. Jon LaPook Explores The Differences

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In this week’s video, Dr. Jon LaPook conducts a two-part interview with a colleague who thinks he might be a hypochondriac. I miss New York.

A day to celebrate humor and laughter?!!

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It’s already March 19th and I don’t have any ideas for April Fool’s Day for my kids. I am desperate and need help. In previous years I have put gummy worms in their sandwiches, short-sheeted their beds, convinced them school was cancelled, given them mashed potatoes that looked like ice cream sundaes, and offered cookies with (fluoride-free, of course) toothpaste as the filling. Last year I tried to pretend I had broken my arm. While my adult friends believed me, my kids just rolled their eyes. So, as you can see, my ideas are not working anymore and I need something grand and convincing.

Humor has always been an important part of our family. When my children were younger, we used humor to convince them to do things they didn’t want to do. For instance, in order to get them to clean their rooms we would put shoes on our heads, walk to their rooms, and dump them in the closet. My older daughter’s favorite game was to dress up as Cinderella (in rags, of course) and have me shout orders at her — I was not allowed to say “please” because I was, obviously, the evil stepmother. It’s amazing how clean the playroom could become those days.

When my husband had a brain tumor, I used humor to temporarily destress an incredibly difficult time period. Those days it was not uncommon to see us eating jello through a straw, dessert before dinner, or ice cream without a spoon. One desperate day we all dressed up in our rain gear, with umbrellas, and took a shower together while singing, “I’m singing in the Rain.”

Last year my daughter had 2 friends spend the night before presenting a history project in a county contest. They had worked incredibly hard on this project while continuing their other demanding curriculum, and they were exhausted, nervous, and stressed. So I went to the store and bought shaving cream and whip cream. After dinner I sent them outside in old clothes and let them spray each other. They ran around for over an hour in the dark, laughing and playing. To this day they still talk about it.

Humor and laughter are an important part of our lives. They relieve tension, reduce stress, and provide us with a temporary distraction from unpleasant thoughts or lives. They allow people to forget about anxiety and pain, even if it’s momentary. Scientific studies that have even shown that humor improves overall health and, more specifically, the ability to fight off infections, decrease the risk of developing a heart attack, and improve blood sugar control . Psychologically, it has been related to decreased loneliness and depression, and improved self esteem and feelings of hopefulness . Laughter clubs and therapy have been developed and exist in and out of hospitals throughout the United States.

humor in our family (response to "smelly" fish)

humor in our family (response to "smelly" fish)

So, now you understand why it is so important for me to find some new, more exciting April Fool’s Day gimmicks for my family – ones that will really make them laugh! I am willing to share my “Vanilla” Sundae recipe with you, which has been used by many extended family members and friends.

April Fool’s Day Ice Cream Sundaes


1. Instant mashed potatoes

2. Chocolate sauce

3. Whip cream

4. Maraschino cherry

5. Vanilla ice cream

Make the mashed potatoes according to directions and let them cool. Use an ice cream scoop to put 2 scoops in a bowl. Top with chocolate sauce, whip cream and, of course, a cherry. Serve. Have real vanilla ice cream available to serve so the victim can actually enjoy dessert in the end.

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