Texas Family Physician, Fall 2015 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 4 2015

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TEXAS FAMILY PHYSICIAN VOL. 66 NO. 4 2015

Telemedicine: A disruptive revolution Patients value access and convenience above all else and telemedicine might be the best way they can get it.

By Jonathan Nelson

19 20

Got any questions about telehealth rules? Check out this set of FAQs from the Texas Medical Board.

Value-based telemedicine

All parties involved—patients, providers, and payers—must be aligned correctly to make high-quality telemedicine a possibility.

By Blake McKinney, MD

The mHealth perspective

Mobile tech plus primary care is the recipe for delivering highquality population health.

By W.C. Thornbury, MD

Top 10 apps for daily practice

Use your smartphone to help your patients and boost your efficiency with these recommendations from an Ohio FP.

By Evan Howe, MD, MPH, PhD 4

TEXAS FAMILY PHYSICIAN FALL 2015

8 FROM YOUR PRESIDENT It’s time for family physicians to step up to the plate. 10 AAFP NEWS Medicaid waivers fund advanced primary care at Texas med school 12 NEWS ALERT Are you correctly billing for services provided by NPs and PAs? Sources say insurance audits are on the rise. 13 MEMBER NEWS TAFP introduces new Family Medicine Leadership Experience | Resident member wins AAFP award | Lubbock member appointed to TMA Foundation Board 27 PUBLIC HEALTH Sports-related concussion in the young athlete: Who plays? Who sits? 30 TAFP PERSPECTIVE The joy of being a preceptor in the Texas Statewide Preceptorship Program

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LETTERS

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 4 2015 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

OFFICERS president

Dale Ragle, MD

president-elect vice president treasurer

Ajay Gupta, MD

Janet Hurley, MD

Tricia Elliott, MD

immediate past president

Clare Hawkins, MD, MSc

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS Adrian N. Billings, MD, PhD, FAAFP Walter L. Calmbach, MD, MPH Evan Howe, MD, MPH, PhD Mark Hutchens, MD Michael Laff Blake McKinney, MD W.C. Thornbury, MD

SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2015 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN FALL 2015

Hospice care and family medicine i read with interest the commentary of Dr. Vincent Mandola in the summer 2015 issue of TEXAS FAMILY PHYSICIAN (First do no harm? A reflection on pain and intervention at the end of life. No. 66, Vol. 3). His experience is diametrically opposite mine, both in my own clinical practice experience and in my personal family experience. Firstly, I began clinical practice in Texas in the mid-1980s. In the early 1990s I took care of an occasional terminally ill patient of mine in the home before hospice was a widely known word and we were able to set up IV morphine even back then for controlling pain. We were able to set up patientcontrolled dosing at the time also. It is certainly possible that Texas regulations have changed in the decade since I left clinical practice, but I am shocked to read that a hospice physician in the case of a terminally ill patient would be wanting to reduce medication in order to investigate symptoms. For what possible reason? People choose hospice because they want no more intervention other than to be kept comfortable. Quality of remaining life is paramount. Dr. Mandola’s experience is certainly not consistent with my clinical experience. In fact, the first patient for whom I cared in the home by seat-of-the-pants hospice was one of my clinical patients during my residency in South Carolina. IV morphine was also available then; the patient was kept comfortable for the month he lived before lung cancer won the war. More recently, my mother was terminal secondary to metastatic breast cancer. She lived in Florida so we were involved with Marion County hospice. I had the privilege of spending the last five to six weeks of mom’s life with her, helping my sisters to care for her and being there to witness hospice care firsthand as a family member who happened to have medical training rather than as the physician. Mom was kept comfortable at all times; she was never denied medication that was needed, whether for pain or anything else, and the hospice people were marvelous in keeping us informed at every step. In fact, hospice was more aggressive with treatment

recommendations than I originally thought necessary, but keeping my eyes and ears open and mouth shut soon showed me they knew what they were doing, and did it well. Medications that were ordered were delivered to the house that same afternoon. Visits always focused on comfort of bodily functions and pain. Mom died peacefully, and as far as we could tell, pain free. Subsequently, in the past few months, I was introduced to the book “Being Mortal.” It lead me to read “The Miracle of Hospice” and “Living at the End of Life.” I wish I had known of and had read these books prior to or while taking care of mom. Many of our questions and concerns during the process would have become neither had I been aware of the information contained in the books. I believe they should be required reading of every family medicine resident. “The Miracle of Hospice” could have been written about the process of caring for my mother, it was that consistent with our experience. One has to wonder just what kind of hospice operation was taking care of Dr. Mandola’s mother. It is so foreign to my experience, both as a practicing physician and as the son of a dying mother cared for by hospice, that one wonders if it were truly hospice. I truly feel for Dr. Mandola and hope that his experience will help him immeasurably as he begins his professional career. I hope, as a retired Texas senior citizen, that this is not the standard for what Texas medicine calls hospice and palliative care. Quality of life is, or at least should be, the premier goal of hospice. Period. Respectfully, John Fieler, MD, FAAFP Conroe, Texas

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PRESIDENT’S COLUMN

TAFP 2016

CME SCHEDULE C. Frank Webber Lectureship & Interim Session April 15-16, 2016 Omni Austin Hotel at Southpark Austin, Texas Texas Family Medicine Symposium June 3-5, 2016 La Cantera Hill Country Resort San Antonio, Texas Annual Session and Primary Care Summit Nov. 4-6, 2016 Nov. 2-3: Business meetings and preconference workshops

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TEXAS FAMILY PHYSICIAN FALL 2015

Time to step up to the plate By Dale Ragle, MD TAFP President this will be my final letter to you as TAFP president. It has been an honor and privilege to serve you and our outstanding organization. This is an exciting and challenging time for family medicine. Health care reform and the sustainable growth rate repeal are expanding the rolls of the insured and will transition us from a volume-based payment system to a quality-based system over the next several years. Some analysts are concerned that increasing the number of insured may strain our health care system in the absence of increasing the physician workforce. While increasing the insurance rolls will generally increase access to care in the younger population, the resultant strain on our health care system could make it more difficult for certain vulnerable populations, such as elderly patients already on Medicare, to access the health system. This effect could be magnified in our state, which has about a 20 percent uninsured rate, unfortunately the highest in the nation. However, I believe that fragmentation of our health care system contributes to access problems as much as the possibility of not having enough physicians. Fragmentation involves patients seeing multiple physicians and using multiple imaging centers, labs, and hospitals. Not all patients with congestive heart failure need to see a cardiologist; not all patients with COPD need to see a pulmonologist. Not all patients with both conditions need to see both specialists. Specialization and subspecialization has led much of our population to believe “the more specialized, the better.” I’m sure most of us have been asked about a referral to a dermatologist for grade I or II acne. As family physicians we need to be diligent in educating our patients about the breadth and depth of our specialty. This should be done not in a spirit of limiting personal choice, but to show them the benefits of one physician caring for the whole person. We must remind our patients with multiple comorbidities that they can often be cared for by one competent and well-trained family physician as well as or better than by multiple specialists. We are certainly a more cost-effective option. To do this it is important that we all practice to the full extent of

our training. This will become important as we move from a payment system based on volume and procedures to one that rewards quality disease management and population health. There are probably not enough family physicians in Texas to provide this level of care to everyone if all of our state’s uninsured were to suddenly gain coverage. However, I believe that increasing our ranks with just a few more well-trained family physicians who practice to the full extent of their training would go far in relieving the physician shortage. Because of our reputation of putting the patient first, we are well-respected among most policymakers and payers. As a patient-centered and community-centered specialty, family medicine is in a unique position to step up to the plate and help shepherd our health care system through these changes. The thought of this energizes and excites me. However, for us to be a part of the solution in this way, there must be more of us. We must advocate for more family medicine training to policymakers and create a bigger pipeline of family physicians. If there are not enough of us to meet the needs in the future, patients and access to care will suffer. I encourage each of you to develop a relationship with your state representative, state senator, and congressional representative. Communicate to them the value of family medicine, our patient-centered approach, and remind them of the need to increase our ranks in the future to fulfill the health care needs of our state and nation. For those of you who are less active in our organization, I encourage you to become more involved. Attend your local chapter meetings. I would also encourage you to attend the annual and interim state meetings. Almost all committees and commissions are open for attendance. If you would like to join a committee or commission, contact TAFP headquarters and our staff can help you gain appointment. Family medicine is at a crossroads. We must continue to distinguish ourselves with a sustained focus on the welfare of our patients, providing quality evidence-based care, and positioning ourselves to be a part of the solution. If we do this, we have a bright future ahead.

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AAFP NEWS

START SAVING MONEY ON VACCINES NOW! Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase! Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management. The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine. Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered. Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.

TEXAS FAMILY PHYSICIAN FALL 2015

Medicaid waivers fund advanced primary care at Texas medical school By Michael Laff one medical school in texas was able to fund advanced primary care initiatives and increase the number of family medicine residency positions without waiting for policy changes in Congress or the state legislature. Instead of relying on increased federal funding for graduate medical education, which has been capped since 1997, or state expansion of Medicaid, which Texas rejected, the University of Texas Health Science Center at San Antonio is using Medicaid waivers to fund both endeavors. Part of the Social Security Act, the 1115 Medicaid waiver program supports innovative approaches to expanding access to care for low-income patients. It can be used to expand Medicaid eligibility for individuals, as well as to fund services that Medicaid typically does not cover and new service delivery systems that improve care, increase efficiency, and reduce costs. UTHSCSA obtained three waivers to hire health care professionals for population health and increase the number of family medicine residents from 13 to 15 annually, a change that is expected to be approved by summer 2016. The health center used one waiver to hire two nurse care managers—one dedicated entirely to patients with diabetes—as well as three medical assistants for population health management and a health coach. Another waiver helped the health center hire additional faculty and pay the salaries of residents in the family medicine program. A third waiver covers the recruitment of 13 community health workers who will address residency clinic patient needs such as home visits, community resources, medication, transportation, and language services. “When you are transforming the residency program, it is about more than just increasing the number of residents,” said Carlos Jaén, MD, PhD, professor and chair of family and community medicine at UTHSCSA. “You are getting more resources to practice community health or hiring RN care managers who monitor ER visits and hospital discharges to optimize transitions of care.” Funding from the waivers will last five years, gradually rising from $1 million

to $1.7 million, and Jaén hopes that with additional funding from local partners, the health center can extend the initiatives to seven years. Jaén said the waivers enable the medical school to accelerate its transition to a comprehensive care model. The next step is persuading insurers to increase payment for greater coordination. “Now that we have something in place, we can have a discussion with payers to demonstrate that we need to find ways to get paid differently,” he said. “When you are making the transition, it’s difficult to have a dialogue with insurers if you don’t have anything to show for it.” Finding financial support for family residencies is vital given the cap on graduate medical education imposed by the 1997 Balanced Budget Act and the limited expansion of family residency slots at university health centers. Although the overall number of first-year residencies in Texas increased steadily between 2000 and 2012, the number of family residencies during that time declined from 247 to 211. Since 2002, three family medicine residency programs have closed in the state, according to TAFP. Elsewhere in Texas, UTHSCSA is using another waiver to fund a new family medicine residency at Doctors Hospital at Renaissance in Edinburg—an area with a high concentration of low-income residents —and to help restructure one that was in jeopardy at McAllen Medical Center. “A few years ago, the trend was that we were closing family medicine programs,” Jaén said. “We’re moving in the opposite direction now, which is exciting to see.” Jaén said the tide is turning in efforts to recruit medical students into family medicine residencies. “We live in an academic health center that is still focused on specialist care,” he said. “We’re starting to see hopeful signs, particularly among older medical students who are learning to appreciate the totality of experience of whole-person care.” Source: AAFP News, Aug. 24, 2015. © American Academy of Family Physicians.

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NEWS ALERT

Doctors report insurers are auditing billing procedures for services provided by NPs, PAs Physicians should examine insurer contracts, provider policy and procedure manuals to ensure compliance By Jonathan Nelson

if you employ nurse practitioners or physician assistants, you should make sure you’re complying with each payer’s protocols when billing for services provided by nonphysicians. TAFP has recently heard from members who thought they were billing properly but have found themselves under investigation by payers. If these practices are found to be out of compliance, they may owe payers substantial refunds. Many payers pay reduced fees for services provided by NPs and PAs but the rules and billing procedures doctors should follow when filing claims differ from payer to payer. For instance, Blue Cross Blue Shield of Texas pays 15 percent less for services provided by NPs or PAs than they would for services provided by the supervising physician. The insurer requires that practices include a “Modifier SA” when filing claims to indicate that a service was performed by an NP or a PA. Other payers do not require the modifier and instead require other forms of notification. If a practice has not been following those protocols and has been receiving full payment for services as though they were provided by a physician, the practice could be required to refund the insurer for the overpayment. “There are so many different complexities to this that it has every single primary care doctor confused,” says Bradley Reiner of Reiner Consulting and Associates, TAFP’s practice management consultant. He believes many physicians may not be aware of these requirements and may be at risk if audited. “It is absolutely critical that any physician who is considering hiring a PA or NP or who has an existing physician extender review their contracts with insurers and the provider policy and procedure manuals for each of their payers to make sure they know how these services are supposed to be billed.” Here is a list of billing procedures insurers might require when filing claims for services provided by NPs and PAs, but we are fairly certain this is not a complete list. Physicians should check their 12

TEXAS FAMILY PHYSICIAN FALL 2015

contracts and the provider policy and procedures manuals for each of their payers to make sure they are following the correct protocols. • Some payers require practices to bill under the physician’s name using the modifier SA for services provided by NPs or PAs. • For Medicaid, The Texas Medicaid and Healthcare Partnership requires practices to use modifier U7 for services provided by PAs, and to use modifier SA for services provided by NPs. The Texas Medicaid Providers Procedure Manual also allows NPs and PAs to be credentialed, and Reiner suggests physicians check with their Medicaid managed care plans to make sure they are following the proper procedures. • Some payers will credential NPs or PAs. They may require practices to bill under Unique Physician Identification Number or the National Provider Identifier of the NP or PA who provided the service. • Payers may require practices to bill under the physician’s name but include on the claim the UPIN or NPI of the NP or PA who provided the service. • Some payers follow Medicare’s “incident to” guidelines, whereby if an NP or PA provides a service to a physician’s established patient while that supervising physician is on the premises, the physician may bill for the service as though he or she personally provided it. • Some payers may not pay at a different rate for services provided by an NP or PA, so the practice can bill under the physician’s name as though he or she personally provided the service. Reiner says these protocols are not new and have likely been on the books for each insurer for some time. “I think this is coming up now because there are more and more primary care physicians hiring physician extenders and with that comes understanding how to bill for those services properly. A lot of physician don’t understand that and so we’re beginning to see payers looking at this a little more carefully because, hey, it’s an opportunity to get a little money back.”

FMLE 2016 Schedule at a Glance Dates for June, August, and November will be announced soon, but they will most likely take place on weekends.

April 15, 2016 | Team Leadership and Interpersonal Skills The inaugural group session will be held along with TAFP’s C. Frank Webber Lectureship and Interim Session. Participants will discuss the importance of personality types in teams, how to lead change, negotiation, and motivational skills. They will embark upon a yearlong project, the result of which will be presented at the program’s conclusion.

Introducing the Texas Academy of Family Physicians’

Family Medicine Leadership Experience In today’s rapidly changing environment, health care enterprises need leaders who can anticipate what’s coming next, make solid decisions in the face of ambiguity, and deploy their talent effectively. At TAFP, we believe these leaders should be well-trained family physicians capable of articulating a compelling vision for the future and of winning the trust and support needed to carry out this vision. Welcome to the Family Medicine Leadership Experience, TAFP’s yearlong leadership development program designed to equip family doctors with the skills they need to lead their physician groups, health care systems, academic institutions, community organizations, and professional societies. Through interactive learning sessions, didactic lectures, case presentations, multimedia presentations, and small-group breakouts, the Family Medicine Leadership Experience will provide expert training in: ✗ strategic planning

✗ public speaking

✗ negotiation and conflict resolution

✗ persuasive communication

✗ winning media engagements

Are you ready to gain the skills you need to take the next step in your career? Join the Family Medicine Leadership Experience.

Applications are due by Dec. 15, 2015.

PROGRAM GUIDELINES • Applicants must be active TAFP members and should be new physicians, mid-career physicians, or residents. • A maximum of 30 members will be selected to participate in the program. PROGRAM STRUCTURE Over the course of one year, participants in the Family Medicine Leadership Experience will attend four in-person sessions lasting one to two days and presented in a variety of formats including didactic lectures, small

group discussions, and interactive learning exercises. Participants must attend all four sessions to graduate from the program, but the curriculum will repeat annually, so a participant could pause and resume the program if he or she were to have difficulty making all four events in one year. FEES AND EXPENSES There is no tuition fee, but scholars are required to pay their travel expenses and some housing expenses. TAFP provides meals and program materials during training.

June 2016 | Advocacy & Influence Participants will gather in Austin to learn about leadership in advocacy. • Understanding policy issues, state and national, that affect health care and family medicine. • Role playing scenarios: How to have successful meetings with legislators and how to give persuasive testimony to a legislative committee.

August 2016 | Communications and Organizational Leadership After spending the day training in Austin, the group will join TAFP’s Board of Directors for dinner. • Public speaking and media training. • Running a meeting, governance, and organized medicine. • Presentation skills.

November 2016 | Sharing Your Knowledge and Graduation The group will graduate from the program at TAFP’s Annual Session and Primary Care Summit in Dallas. Participants will be asked to present their projects during the FMLE final session.

APPLICATION AND SELECTION Download the application at www.tafp.org/membership/ FMLE or request an application by email: jwilliams@tafp.org. The application asks for a brief description of your leadership and management experience as well as a statement describing why you would like to pursue advanced leadership training. The TAFP Leadership Development Committee will review all applications to compose the FMLE class of 2016.

SUBMIT YOUR APPLICATION BY DEC. 15, 2015. Email: kmccarthy@tafp.org Fax: (512) 329-8237 Mail: TAFP, 12012 Technology Blvd. Ste. 200, Austin, TX 78727 STILL HAVE QUESTIONS? Contact Kathy McCarthy at kmccarthy@tafp.org or (512) 329-8666 ext. 114.

Applicants will receive notification no later than Jan. 15, 2016. www.tafp.org

MEMBER NEWS

Today

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Resident member wins AAFP award tafp resident member Nish Shah, MD, received the 2015 AAFP Award for Excellence in Graduate Medical Education for his hard work as a resident and commitment to the specialty of family medicine. “My involvement with TAFP has been such a gratifying experience,” Shah says, Nish Shah, MD “and has absolutely enriched my residency by allowing me to reflect on the political and social advocacy aspect of family medicine, and I cannot wait to further my experiences with TAFP in the years to come. I urge all residents who want the opportunity to get involved with TAFP to do so.” Shah is currently the chair of TAFP’s Section on Resident Physicians and has previously served as a delegate representing TAFP at AAFP’s National Congress of Family Medicine Residents. He is a third-year

resident at the Houston Methodist San Jacinto Family Medicine Residency program in Baytown and received his medical degree from Baylor College of Medicine in Houston.

Lubbock member appointed to TMA Foundation Board tafp member Eldon Stevens Robinson, MD, was recently appointed to the Finance Committee for the Texas Medical Association Foundation Board of Trustees, which oversees the Foundation’s investments and assists the executive director regarding gifts. Robinson will serve on the Board for a threeyear term. He has a BBA in marketing, and said that he is excited to add his expertise in the subject to an “already excellent board.” Robinson received his medical degree from the Texas Tech University Health Sciences Center School of Medicine and currently practices in Lubbock. He is also an active member of the Lubbock-CrosbyGarza County Medical Society and currently chairs TMA’s Committee on Rural Health.

SEEKING RURAL PRIMARY CARE PHYSICIAN

Supported in part by a grant from the American Academy of Family Physicians Foundation.

www.tafp.org

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Lavaca Medical Center in Hallettsville, Texas, is seeking a physician for its rural health clinic. Applicants should be experienced in either family practice or internal medicine, either MD or DO, experienced or recent graduates, and must be licensed to practice in Texas. The clinic is located at 1400 North Texana, Hallettsville, Texas 77964. Interested providers should call (361) 798-3671 ext. 1207 or visit www.lavacamedcen.com.

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Join the Coastal Health & Wellness Healthcare Team! Excellent federally-qualified primary care clinics on the coast in Galveston County seeking PRIMARY CARE PHYSICIANS to join our clinician team serving residents of all ages. Family practice training and certification preferred. Excellent work hours and benefits. SALARY NEGOTIABLE! Applications and additional information may be found at http://www.gchd.org/hr/job.htm or by contacting HR at apply@gchd.org or (409) 938-2260.

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TELEMEDICINE: The evolution of consumer-driven care By Jonathan Nelson

today’s patients prize access to care above all else. They want their care when and where they choose, and the more of that care they pay for out of their own pockets, the more demanding they become. In a recent webinar on trends and projections for health care delivery, athenahealth executive vice president and COO Ed Park said consumerism among patients is driving disruption in how, when, and from whom patients seek care. “If you ask patients what they care about in this day and age where everything is moving at hyper velocity, patients care most about access and convenience, even more so than service and affordability. Those certainly come into play but access is the dominant factor that explains why a patient will go to a certain location, particularly for primary care services.” In an Advisory Board study published last year on the rise of consumerism in health care, patients consistently rated access and convenience higher than quality, affordability, and other attributes when deciding on a primary care physician. Of the practice characteristics respondents reported they cared most about, six out of 10 were tied to access. What statement received the most votes? “I can walk in without an appointment and I’m guaranteed to be seen within 30 minutes.” That is the defining characteristic of a retail health clinic. Is it any wonder the numbers of retail clinics, urgent care centers, and free-standing emergency centers are booming? Wellfunded venture capital and investment firms are pouring money into these delivery models, but Park thinks this is just the beginning. “What we see is that retail urgent care is just the first salvo. The next salvo coming along is telehealth, which is coming of age.”

www.tafp.org

he new generation of telehealth platforms is rapidly increasing in sophistication, with many offering instant high-definition video consultation. Companies like Doctor on Demand, American Well, meVisit, CirrusMD, and Teledoc—which went public this past summer—are rolling out marketing campaigns and negotiating partnerships fueled by significant private and venture capital investment. According to Ken Research, the telehealth market generated $9.6 billion in revenue in 2013, up 60 percent from the previous year, and the market is expected to generate annual revenue of $38.5 billion by 2018. As patients get more comfortable receiving acute care services through telehealth interactions, the complexity of those visits is certain to increase. Couple these advancements with a burgeoning market for integrated personal health apps for smartphones and tablets like EKG monitors, blood pressure tracking, and more, and it’s a short hop to imagine the use of telemedicine to manage conditions like chronic diabetes. “To see CVS partner with American Well, Doctor on Demand, and Teledoc tells you something,” Park said. “This is a market reaction, a capitalist reaction to real demand. … Developing an intentional strategy for how to meet these patients as consumers—patients as shoppers—where they are will be crucial.” TAFP CEO Tom Banning agrees. How family physicians in Texas can incorporate telemedicine and compete in a consumer-driven market is top of mind for the Academy. “There are tremendous disruptive, competitive forces coming to the fore that doctors are going to have to deal with,” he says. “Physicians have an opportunity right now to start looking at this technology, how to implement it, put it into their office, how to engage their patients in using it before some very well-heeled entities come in and compete against those doctors.” If implemented and utilized correctly, telemedicine could be a powerful tool to help physicians improve the quality of care they give patients while increasing their efficiency. Many patient visits in the exam room could be handled remotely via telehealth or mobile technology, saving resources and time for the patient and the doctor. “Think about the inefficiencies and the cost of having a patient with a chronic problem who has to come into the office repeatedly for treatment, and what if that patient is fragile? Coming to a doctor’s office is not always easy,” Banning says. As the health care industry moves away from fee-for-service toward value-based payment, telemedicine holds big potential for expanding access to after-hours care and keeping patients out of high-cost settings, which can be a huge help in achieving shared savings goals and other efficiency measures. On the other hand, the speed of telemedicine’s growth and adoption constitutes a threat to physicians’ status quo. “When you look at where retail health is moving and the commoditization of health care services, there is a lot of interest from hospital systems, from private companies to move into the primary care sphere and essentially carve up services that I would argue should be maintained by the patient’s primary care doctor.” Banning predicts as patients use more telemedicine and realize the benefit of not having to leave their home or office to go to a doctor’s office or even a retail health clinic, telehealth could render retail health obsolete. “How physicians get ahead of this trend is going to be critical going forward.” TAFP is committed to helping family physicians realize the opportunities telemedicine offers. First, the Academy is working with health plans to ensure that physicians who want to provide telehealth services are compensated appropriately for doing so. 18

TEXAS FAMILY PHYSICIAN FALL 2015

“To see CVS partner with American Well, Doctor on Demand, and Teledoc tells you something. This is a market reaction, a capitalist reaction to real demand. … Developing an intentional strategy for how to meet these patients as consumers—patients as shoppers—where they are will be crucial.” — Ed Park, COO of athenahealth

“There is no less cognitive skill used whether the patient is in your office or you’re treating them over a mobile or telehealth device,” Banning says. “The liability still exists.” Secondly, TAFP will continue to ensure that patient safety is first and foremost, whether care is delivered in person in a clinic setting or via the use of telehealth technology. “Patient safety must be the cornerstone,” Banning says. Within that boundary, the Academy will work with the Texas Medical Board and other regulatory agencies to make sure physicians have the flexibility to determine what each patient needs, whether he or she can be treated using telehealth or whether the patient should come into the office. “I think the real challenge is that the technology is growing at such a rapid rate that the regulations, the laws, and the reimbursement are having trouble keeping pace. But as of now the medical board has written very thoughtful rules that emphasize patient care and the importance of continuity.” Lastly, TAFP will monitor the telehealth market and seek to evaluate vendors and technologies to help family physicians make confident decisions when implementing telehealth products and services. For years the concept of telemedicine was stuck in a mire of regulation and technical impracticality, relegated to the list of potential solutions for delivering care to poor folks in far flung rural areas. With the rise of consumerism in health care, those days are over. Patients want instant access and they’re willing to pay for it. For them, telemedicine offers the greatest convenience. Physicians will have to find ways to embrace this disruptive technology to engage their patients in a new virtual paradigm.

Telemedicine Q&A from the Texas Medical Board For a complete set of rules and FAQs regarding telemedicine in Texas, go to www.tmb.state.tx.us/page/laws-gc-faqs-telemedicine.

■ What is telemedicine?

■ Where may telemedicine care be provided?

In Texas, telemedicine involves a health care provider’s medical care delivered to patients physically located at sites other than where the provider is located, with the use of technology that allows the provider to communicate with and see and hear the patients in real time.

If a patient is being seen for the very first time by a distant site provider, or is presenting with a new condition, telemedicine may only be used at a location that has qualified staff present and sufficient technology and medical equipment to allow the distant site provider to conduct an adequate physical evaluation. Such a location is referred to under the board rules as an established medical site.

■ Who may treat a patient in Texas using telemedicine? A physician, physician assistant, or advanced practice nurse who is supervised by and has delegated authority from a physician may treat a patient using telemedicine. Such a provider is referred to under the rules as a distant site provider. All distant site providers must be licensed to practice in Texas. ■ What requirements must be met in order for a distant site provider to provide medical care via telemedicine? To provide medical care via telemedicine, a distant site provider must in all cases establish a physician-patient relationship, which at a minimum includes: • establishing that the person requesting the treatment is in fact who the person claims to be; • establishing a diagnosis through the use of acceptable medical practices, including documenting and performing patient history, mental status examination, appropriate diagnostic and laboratory testing, and for medical care other than mental health services, a physical examination; • discussing with the patient the diagnosis and the evidence for it, the risks and benefits of various treatment options; and • ensuring the availability of the distant site provider or coverage of the patient for appropriate follow-up care. In addition, the care must be provided at an appropriate location and—unless an exception applies—include the presence of qualified staff, also referred to as patient site presenters, to assist in the evaluation of the patient. Treatment and consultation recommendations made via telemedicine are held to the same standards of acceptable medical practices as those made in the traditional inperson clinical settings.

If not at an established medical site, a distant site provider will be permitted to provide medical care using telemedicine, contingent upon the following requirements being met: • Follow-up care for an established patient’s previously diagnosed condition. The provider will be allowed to provide telemedicine care to a patient at a site other than an established medical site, contingent upon the provider having previously diagnosed the condition either through an inperson evaluation (meaning, while at the same physical location as the patient) or an evaluation conducted at an established medical site. • Referral by a physician who completed a proper evaluation. The provider will be allowed to provide telemedicine care to a patient at a site other than an established medical site, contingent upon the patient having received an evaluation either inperson or at an established medical site by another physician who referred the patient to the provider for additional care. • Established patient with new condition advised to seek appropriate follow-up care. The provider will be allowed to provide telemedicine care for an established patient’s new condition at a site other than an established medical site, if the distant site provider advises the patient to see a physician (either at an established medical site or in-person) within 72 hours if the symptoms do not resolve, and provides no additional care for such symptoms if the patient is not seen by such a physician.

■ What are some examples of places that meet the definition of an “established medical site?” In order for a location to qualify as an established medical site, the key criteria are the availability and presence of: • qualified staff, also referred to as patient site presenters, who are health care professionals licensed or certified in Texas, such as a nurse, emergency medical technician, or pharmacist; • sufficient technology and medical equipment to allow for an adequate physical evaluation, as appropriate for the patient’s presenting complaint; and • sufficient size to accommodate patient privacy and to enable the presentation of the patient to the provider. Contingent upon the locations meeting the above criteria, they could include a nurse’s station in a public or private school, volunteer fire department, emergency medical services station, oil rig, mental health and mental retardation centers, community centers, pharmacy, or even a patient’s home. In the case of a patient’s home, the rules further specify that a patient site presenter must use sufficient communication and remote medical diagnostic technology to allow the provider to carry out an adequate physical examination appropriate for the patient’s presenting condition while seeing and hearing the patient in real time. ■ Who may act as a patient site presenter? A person that is licensed or certified in Texas to perform health care services or a qualified mental health professional-community services may act as a patient site presenter. The patient site presenter may be delegated only tasks and activities within the scope of his or her licensure or certification. Patient site presenters assist in the interaction between the patient and the provider, who is located at a distant site. If only mental health services are being provided to the patient, a patient site presenter may not be required unless the patient poses a danger to himself or others. ■ Are patient site presenters always required to be present during patient visits, in order for a physician to treat a patient via telemedicine? No. It will depend on the nature of the services provided and conditions being treated. If the only services being provided relate to mental health services (not including behavioral health emergencies), or to follow up on evaluation or treatment of a previously diagnosed condition, it is at the discretion of the distant site provider whether the presence of a patient site presenter is necessary. www.tafp.org

TMB Telemedicine Q&A Continued ■ Does a distant site provider have to see a patient in person prior to providing treatment using telemedicine? No. What is required is that either the provider conduct a face-to-face evaluation via telemedicine at an established medical site (see discussion above for basic requirements related to an established medical site) prior to providing such ongoing care, or provide treatment for a patient referred by another physician who completed a face-to-face evaluation via telemedicine at an established medical site. ■ What is the difference between a face-toface and an in-person evaluation? A face-to-face evaluation is defined under the rules as including an evaluation performed by a distant site provider for a patient who is located at a different location qualifying as an established medical site. An in-person evaluation is one that is conducted by the provider for a patient located in the same physical location as the provider. ■ May a distant site provider make an initial diagnosis for a new patient via telemedicine at the patient’s home? Yes, on the condition that the provider establish a defined physician-patient relationship, utilize the presence of a patient site presenter during the interaction (except for mental health services not including behavioral health emergencies), and ensure that the patient site presenter has sufficient communication and remote medical diagnostic technology to allow the distant site provider to carry out an adequate physical examination appropriate for the patient’s presenting condition while seeing and hearing the patient in real time. ■ May telemedicine services be used to treat chronic pain with scheduled drugs? No. ■ For mental health services to be provided via telemedicine, must a distant site provider conduct a physical examination? No. For mental health services to be provided, a distant site provider must, however, conduct a face-to-face visit and ensure that a defined physician-patient relationship is established, which includes documenting and performing patient history, mental status examination, and appropriate diagnostic and laboratory testing. 20

TEXAS FAMILY PHYSICIAN FALL 2015

VALUE-BASED TELEMEDICINE By Blake McKinney, MD

when a family member was a new mom, she called me concerned about her 7-day-old baby’s breathing. I almost sent them to the ER. Then she asked me if we could FaceTime. What I saw was a warm, pink, dry baby looking around, looking quite well to me. I was able to tell that she had no labored breathing, no retractions, or nasal flaring. She just had a little stuffy nose. I had been answering questions, treating minor ailments, and triaging the acutely ill for several years via text, but it was in that moment that I knew the iPhone and other smartphone devices would fundamentally and forever change the way physicians can deliver our services. Fast forward to next year. An eMarketer report estimates 2 billion people will have smartphones across the world in 2016. Industries are being transformed radically by the widespread uptake of these devices. Health care will be no different and will continue to move toward more virtual care enabled by smartphones. As the example above demonstrates, it makes sense for both care and economics. Virtual care and telemedicine worldwide is expected to be a $34 billion market by 2020 according to a Morder Intelligence report, with the U.S. accounting for 40 percent of that, nearing $15 billion in the next five years. Several early stage telemedicine companies have raised many millions of dollars in the last several months. Payment reforms are driving the market toward value-based care and will only accelerate the use of telemedicine via smartphone. Many new forms of payment for medical services are emerging that are not tied to the legacy fee-for-service reim-

bursement model. Patients are paying more out of pocket and therefore have increasingly aligned interests with payers to reduce costs while achieving better overall health. These changes are, in turn, driving the empowered health care consumers’ demand for a better experience and convenience. Estimates are consistent that more than half of all clinic, urgent care, and ER visits “could be handled safely and effectively over the phone or video,” according to the American Medical Association and the Wellness Council of America. A recent JAMA study found no difference in quality between in-person and telemedicine visits for minor conditions. Physicians and payers are both looking for ways to adapt to these new realities. In this new context, the old ways of treating many ailments in an expensive facility across town or even across the neighborhood no longer fit with modern consumer expectations. If a patient can

visit with a physician by phone, video, or secure text in the middle of the night or during working hours at little or no cost for the individual, in-person visits in many circumstances may become unnecessary. In-person care can be a drain on resources and productivity, with substantial opportunity costs associated with missed work or school. To get to high quality telemedicine, it will take more than just a doctor on a phone. To help align patients, providers, and payers toward achieving telemedicine that works for each, the following are necessary for getting value-based telemedicine right. 1. Close the loop, continue the story. It’s often been said, recently by The Commonwealth Fund, all health care is local. Ironically, the same is true for telehealth. Providers in value-based systems want to ensure their patients get the care they need in a way that takes care of urgent issues but also ensures that physicians can communicate with primary care and hospital services when needed. It isn’t as simple as an isolated video chat, text message, or phone call: it requires working remote physician access into an entire continuum of traditional care; supplementing and integrating virtual with in-person visits and closing the loop. Telemedicine shouldn’t create yet another silo of data and care. Each patient is a story, but treating a patient out of network turns a chapter in a story into an isolated event, in a separate book, kept in another library. It can become very difficult to enable true patient engagement and behavior change when episodes of care all too easily disappear from a longitudinal record. 2. Don’t add a co-pay to telemedicine services. Adding a co-pay or other fee-for-service component creates a cost barrier for the patient to use the service and therefore doesn’t meet the litmus test of the triple aim. Co-pays disincentivize individuals from using the service (and possibly receiving needed care) and create perverse incentives for providers to try to accumulate more individual calls rather than providing treatment in the most effective and efficient way possible. Payers and risk-bearing providers are learning that it makes more sense to provide a free service to their members. When more than half of in-person visits to the ER and urgent care are unnecessary and virtual care provides equal results, the value-based approach is the more sensible one.

In this new context, the old ways of treating many ailments in an expensive facility across town or even across the neighborhood no longer fit with modern consumer expectations. If a patient can visit with a physician by phone, video, or secure text in the middle of the night or during working hours at little or no cost for the individual, in-person visits in many circumstances may become unnecessary. 3. Make it convenient, available anywhere via text and video. Direct access to a physician can be valuable anywhere, anytime and in an unpredictable fashion. The telemedicine of yesterday was built on closed-circuit TVs, video teleconferencing technology, and hub-and-spoke network architecture. However, today’s telemedicine is based upon technology that most Americans carry in their pockets. We spend a lot of time on our phones and on our computers, asking questions and holding conversations. As many doctors currently text, call, and video chat with their own friends and family when a medical issue arises, often conferring great value, so should doctors be able to care for large populations, supported by the right technology and business models. 4. Help doctors work the way they want to work, the “quadruple aim.” Physician dissatisfaction is rampant. What many doctors acknowledge as a workforce-wide collective depression results in large part from how physicians today spend the majority of their time: entering documentation into bulky electronic health record systems designed primarily to maximize fee-for-service billing rather than clinical utility or doctor-patient engagement. According to Dr. Bob Wachter, a UCSF physician and the author of “The Digital Doctor,” a large part of physician dissatisfaction stems from the time they spend interfacing with EHRs and their billing apparatus, often called “administrative overhead.” What this really means is that physicians have to spend more time figuring out how they are going to get paid and entering data to justify why they

should be paid than actually listening and interacting with patients. Physicians hate it, and patients feel irrelevant. By making the interaction with technology a byproduct of a conversation that is self-documenting within the technology platform, physicians can get back to working the way they want to work. If we then structure physician compensation around value-based payments and measure success against outcomes, we can reward physicians for delivering the type of high-quality, customer-centric care that most doctors got into medicine to provide in the first place. Because physician burnout endangers the triple aim, the Annals of Family Medicine suggests it be expanded to the quadruple aim by including physician satisfaction. Data capture around a clinical encounter doesn’t have to be a chore. Value-based care with the right technology allows for the capture of real interactions the way they happen in nature, so to speak, without the need for artificial billing codes. It enables us to return to one of the oldest and most intimate forms of human interaction – the doctor-patient encounter. Moving to a new health care model based on value requires more than just repackaging old technology systems. It requires enabling the ways people are already communicating, and the right telehealth solution reinforces new business models that create the right financial incentives and physician/patient workflows to align the interests of all participants.

Blake McKinney, MD, is chief medical officer and co-founder of CirrusMD. This story first appeared on The Health Care Blog. www.tafp.org

Mobilizing online care to deliver population health mTelehealth + primary care = population health By W.C. Thornbury, MD

Health care’s necessity for cost-control and consumer demand for access will inexorably drive a portion of health care delivery online. Recent advances in mobile technology have enabled telehealth to become efficient—and, for the first time, practical for family physicians to implement.1

which accounts for 75 percent of the health dollar.3 Over time, upwards of 40 percent of office-based encounters may well be amendable to the virtual clinic. Thus, family medicine can influence and substantively change the nation’s delivery of outpatient care.

Online health care delivery is undergoing rapid change. In the past, care has been directed by technology into two divergent paths: Store-and-forward (e-visits) or live telemedicine (secure video). Store-and-forward is convenient and efficient for the physician to use; secure video provides an emotional comfort and the visual nuance face-to-face interaction affords.

mTelehealth links chronic disease to population health. More consequential is mTelehealth’s ability to drive population health. Hospitals presently retain the majority of health providers and will leverage their capacity to work efficiently with patients, families, caregivers, and colleagues inexpensively online to provide an extended suite of services. Primary care enables virtual follow-up during transitional care, thus reduced readmissions. Increased access allows for chronic diseases to be addressed before unnecessary time, travel, or higher level care is required. Assisted-living, skilled, and long-term care facility adaptation may reduce transportation costs and ED misuse. It provides a vehicle to implement CMS’s chronic care management initiative addressing needs online before a costly intervention. Most importantly, it opens access to brick-andmortar facilities that don’t have a provider for patients requiring face-to-face care.

There is an emerging generation of technology, mTelehealth, which leverages the capabilities of the mobile platform, like smartphones and tablets, and marries them to e-visits and video. mTelehealth distributes mobility and the system’s computational power to both patient and provider. This close combination yields synergistic advantages that allow the physician to direct the virtual care encounter rather than the technology dictating the direction of the physician. Health professionals may now address online care in the same manner as they do in-office care, determining how much and what type of information and communication are most appropriate for an encounter. Efficiency is premium. A family physician with a well-established relationship with his or her patient understands how much information will contribute to an efficient online care encounter. The clinic, be it in-office or virtual, presents a variety of clinical complexities. Physicians invest differing amounts of intellectual capital in the gentle care and disposition of each case. It is illogical and inefficient to restrict clinicians in their approach to care, though past technology has conspired to do so. What is clinically important to the physician is that the appropriate amount of information be collected and documented to safely and efficiently provide care. The practicalities of practice management demand it. mTelehealth links primary care to the virtual clinic. mTelehealth’s mobility allows care requests to follow the provider. Further, its store-and-forward capability affords the clinician flexibility in his or her response. The technology can render care up to 300 percent more efficiently than older generations of telemedicine—in as little as four minutes for a fully documented encounter.2 Thus, this new generation of telehealth yields an ability to incorporate virtual medicine seamlessly during a hectic office or after hours. This efficiency is the catalyst that overcomes important previous impediments of first-generation technology, finally making it practical for the family physician and the medical home. mTelehealth links the virtual clinic to chronic disease. Family physicians are in a unique position to leverage their patient relationships with the cost-savings of the virtual platform. Their capability to render continuity of care via mTelehealth offers the mechanism to expand the palate from the treatment of minor acute care to the management of chronic disease care,

mTelehealth is evolving as a new generation of delivery technology offering clinicians the ability to provide online care practically. Its breadth of influence will place family physicians in the position to support the patient-centered medical home, impact population health, and bend the cost curve of the nation’s escalating health care system. It has the means to help end medical homelessness. Time and talent will be required to embed this new delivery model between patients and their providers. However, such investment will open the door to increased provider productivity, lower per-capita cost of care, and an improved consumer experience—the tenets of the triple aim. Family physicians and their leadership should respect the developing megatrend that mTelehealth will bring to the profession and implement a global mHealth strategy moving forward.

REFERENCES 1 Kaibara P. Should You Treat Patients Virtually? Fam Pract Manag. 2015 Jul-Aug;22(4):16-20. 2 Thornbury W. How Mobility Within the Medical Home Can Positively Disrupt Healthcare. Journal KAFP. 2013 Summer; 79;20-23. 3 Thornbury W, Thornbury S. mHealth in Chronic Disease Management: Case Study of a Mobile-to-Mobile Delivery Model. Global Telemedicine and eHealth Updates-Knowledge Resources. 2014 Apr(7):649-653. Dr. Thornbury is a family physician in private practice and medical director of Medical Associates of Southern Kentucky in Glasgow, Kentucky. He is the founder of a mHealth technology company, meVisit Technologies.

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learned in my medical education that while it was important to know the answers, it was more important to know where to find the answers that I didn’t know. This once meant exploring shelves of notable tomes. The portability of information has opened up new avenues for accessing the information that I need in order to get through my day. Using my phone as an information portal to assist my work in my family medicine clinic has become part of my daily routine. Most patients appreciate the use of the technology to assist in decision making. There is a skill to using technology as a teammate alongside the patient-physician dyad rather than as an intermediary or, even worse, a barricade to prevent genuine interaction. I have learned to suggest to the patient that these apps enhance the treatment plan, not substitute for my judgment. Here are 10 of my favorite apps I use on a regular basis in my daily practice, mostly on my mobile phone.

Epocrates ➜ Free app with subscription upgrade for iOS and Android

TOP APPS in my DAILY

PRACTICE , M P H, PhD D M e, w o H n va By E Dr. Howe practices family medicine in his hometown of Jefferson, Ohio. This story originally appeared in the summer 2015 issue of The Ohio Family Physician and is reproduced with permission from the Ohio Academy of Family Physicians. 24

TEXAS FAMILY PHYSICIAN FALL 2015

This is a well-known service with both web-based and app-based access points. I find it most helpful for checking medication dosages and drug interaction. There are disease-based monographs with bullet point information that identify priorities for diagnostic testing and clarify treatment alternatives. Other features include searchable databases of ICD-10 and CPT codes, and an antibiotic selection aid with information on local drug-resistance patterns.

Calculate by QxMD ➜ Free for iOS and Android This is another mega app that contains far more information than I typically need. However, it is a very efficient repository of the calculations I need in a typical day such as CHADS2, CURB-65, TIMI, APACHE, FENa, Bishop score, Ottawa knee and ankle rules, Epworth sleepiness scale, corticosteroid equivalence, and peak flow prediction, among others. The peak flow calculator tops my list for office management. Calculators are organized within the app in categorical or alphabetical order.

BiliCalc ➜ $1.99 for iOS and $0.99 for Android For those of us providing inpatient newborn care, this app makes quick work of calculating risk stratification and phototherapy threshold. It provides guidelines for next bilirubin check and a list of neurotoxicity risk factors. The app simply asks for information on birth time or age in hours, lab time, and bilirubin level, and calculates the next steps for you. This definitely beats the time I used to spend trying to find a bilirubin chart and plot these out on a graph where the boxes were too small to be certain that I was just below the curve.

E/M Coder ➜ Free with $39.99 upgrade for full version; iOS only This app is a bit pricey for its function, but it has focused the time I spend documenting my encounters. It includes E/M calculators for all of the contexts in which family physicians provide care— office, hospital, nursing home, house calls, emergency department, and rest home. The user inputs the number of elements in each category, and the app provides tips on requirements to meet the next level of documentation in each of the history, exam, and medical decision-making components. This helps me identify where adding a bit of information (already collected, but often overlooked) can help me become eligible for reimbursement for care I am already providing. The app’s summary report also provides information on the associated relative value unit for each code, and reminds me whether I should code an encounter as a two of three or three of three.

American Academy of Family Physicians ➜ Free for iOS and Android This is another multifunctional app that I’m sure each person uses differently. This mobile access point for your AAFP account includes links to job searches, residency and fellowship directories, meeting calendar, links to familydoctor.org, and the Family Practice Management journal. I mostly use this app for the legislative tracker with its easy link to send my representatives and senators an email stating my support for issues critical to family medicine and the AAFP.

ABFM Exam Prep ➜ Free for iOS and Android

Agency for Healthcare Research and Quality ePSS

This app helped me maximize my spare time waiting in line somewhere or before drifting off to sleep this past summer as I prepared for my board exam (passed!). It continues to be useful to keep me sharp and focused with exam-type questions that highlight some of those areas where I need to touch up. The app generates short, 10-question quizzes and enables a quick review of the reasoning for any incorrect answers.

➜ Free for iOS and Android This app provides a mobile platform for accessing all of the AHRQ guidelines on current screening tests. While I might have the colonoscopy guidelines on the tip of my tongue (how many times a day do I have to run through that?), I don’t necessarily remember the frequency of other services. Additionally, the app provides the clinical reasoning behind the guidelines and recommended screening modalities. The app can generate a list of recommendations after inputting information on the age, sex, pregnancy status, tobacco use status, and sexual activity status. Within each recommendation are relevant tools and applicable risk calculators. This is another great app to use alongside patients to include them in shared decision making over health maintenance schedules.

ASCCP ➜ $9.99 for iOS and Android Interpretation of Pap and colposcopy results was another area where I felt buried in stacks of papers and algorithms as I figured out which table came next in my evaluation. This app takes age, HPV status, pregnancy status, and Pap results into account when identifying where on the algorithm your patient lies. It even provides the opportunity to input colposcopy results and follow-up co-testing results. I use this app in a number of settings. When I receive the Pap or pathology reports, it is often handy to calculate quickly the next follow-up. I have also found it to be quite helpful during new patient encounters when I need to review recommendations with patients in real time during the visit.

Shots ➜ Free for iOS and Android; by the Society of Teachers of Family Medicine This is a great app for keeping the up-to-date immunization schedules at your fingertips. It provides pediatric and adult immunization schedules, information on integrating combination vaccines into your schedule, plus helpful tips on the epidemiology, administration, and contraindications of each vaccine. As with most of the information relevant to the other apps listed above, there are paper charts that do this work, but this digital portal makes the same information ubiquitous.

ASCVD Risk ➜ Free for iOS and Android This calculator contains all of the updated 2013 American College of Cardiology/American Heart Association recommendations including the 10-year risk estimator. This output serves as a teaching tool with patients to help them understand the impact of changing modifiable aspects of their risk profile. For example, when patients return to my office for discussion of lipid results, I use this calculator to explain the modifiable and non-modifiable risk factors for cardiovascular disease. It is easy to toggle through the independent risk factors to show the potential impact of quitting smoking or controlling blood pressure.

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Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/μL) with HIV infection. HIV Medicine. 2004;5:93-8.

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TEXAS FAMILY PHYSICIAN FALL 2015

6/12/11 7:18:42 PM

PUBLIC HEALTH

Sports-related concussion in the young athlete: Who plays? Who sits?

BACKGROUND: Concussions are a common injury among athletes, with an estimated 300,000 sports-related concussions occurring annually in the U.S.1 However, as many as 50 percent of the concussions may go unreported.2 Recent studies have shown that young athletes are more susceptible to concussions than older athletes, and due to the ongoing neurocognitive development that occurs throughout adolescence, concussions can have severe acute and long-term complications in young athletes.1 These findings have serious implications because participation in high school athletics has increased for years, with more than half of all high school students, over 3.1 million girls and 4.2 million boys, participating in sports during the 2009-10 school year. HIGHER RISK FOR YOUNG ATHLETES: Worryingly, children seem to be more vulnerable to the effects of brain injury than adults. After concussion, there are specific changes at the cellular level resulting in a “metabolic mismatch:” increased glucose utilization and reduced cerebral blood flow.3,4 Physicians must be aware of the athlete’s increased vulnerability to injury during the recovery period, which typically takes seven to 14 days.5

By Walter L. Calmbach, MD, MPH Department of Family and Community Medicine, UT Health Science Center at San Antonio Mark Hutchens, MD Texas Sports and Family Medicine, Austin

BOYS AND GIRLS: It is important for primary care physicians to be aware that while overall, boys have a higher concussion rate than girls, for some sports (e.g., soccer and basketball) girls actually have a slightly higher concussion rate than boys.6 CONCUSSION–A FUNCTIONAL DISTURBANCE: After a blow to the head or helmet, the athlete commonly experiences the rapid onset of usually short-lived neurological impairment. These include a range of clinical symptoms that may or may not involve loss of consciousness (see Table 1). The symptoms could be very subtle, such as lack of focused concentration or balance disturbance. Typically, these symptoms resolve spontaneously. It is important to recognize that these acute clinical symptoms reflect a functional disturbance rather than structural injury. Because of this, neuroimaging studies are typically normal. INDIVIDUALIZED MANAGEMENT: Recently, recommendations on treating athletes have undergone a major paradigm shift, with a new focus on individualizing management after sports-related concus-

sion. In the past there was an overreliance on published guidelines, which were not uniform, lacked prospective validation, and over-emphasized loss of consciousness as a marker of severity. However, published guidelines remain useful as a starting point when evaluating athletes.7 Importantly, outdated guidelines once allowed for sameday return-to-play, but the new consensus is that there is no same-day return-to-play for an athlete with a concussion. We now recognize the broad individual variation in presentation and recovery after concussion. Therefore, current recommendations focus on individualized management based on the athlete’s signs and symptoms, guided by routine use of standardized assessment tools. Some of these common assessment tools include the Standardized Assessment of Concussion, the Sport Concussion Assessment Tool 3rd Edition, the Balance Error Scoring System, and various computerized neurocognitive testing systems.4,8 The SAC is a simple paper-andpencil scoring tool that assesses orientation, immediate recall, common neurological symptoms, concentration (both numbers and months), and delayed recall. The athlete receives a total score that guides diagnosis, management, and return-to-play decisions. You can find the SCAT3 form at http://bjsm. bmj.com/content/47/5/259.full.pdf. NEUROCOGNITIVE TESTING: Computerized neurocognitive testing systems measure concussion-related symptoms, verbal and visual memory, processing speed, and reaction time. They can objectively evaluate post-injury status, and track recovery for safe return-to-play, especially if baseline testing is present. Neurocognitive testing is useful as one component of the evaluation, but should not be used in isolation to manage athletes or make return-to-play decisions. It can be helpful in the overall management along with past medical history (e.g., history of previous concussion), presence of comorbid conditions (e.g., anxiety, depression, and learning disability), presence or persistence of post-concussion symptoms, and physical examination. PHYSICAL AND COGNITIVE REST: Athletes with concussions benefit from a brief period of physical and cognitive rest immediately after the injury to allow symptoms to abate.6 The rest period varies for each individual. In the immediate post-injury period, athletes should avoid activities that www.tafp.org

Table 1. Signs and symptoms of concussion4 PHYSICAL

COGNITIVE

EMOTIONAL

SLEEP

Headache

Feeling mentally “foggy”

Irritability

Drowsiness

Nausea

Feeling slowed down

Sadness

Sleeping more than usual

Vomiting

Difficulty concentrating

More emotional

Sleeping less than usual

Balance problems

Difficulty remembering

Nervousness

Difficulty falling asleep

Visual problems

Forgetful of recent information

Fatigue

Confused about recent events

Sensitivity to light

Answers questions slowly

Sensitivity to noise

Repeats questions

Dazed Stunned

Table 2. Indications for transport to an emergency facility4

Table 3. Indications for neuroimaging4

Repeated vomiting

Seizures

Severe or progressively worsening headache

Focal neurological findings

Seizure activity

Repeated emesis

Unsteady gait

Significant drowsiness/difficulty awakening

Slurred speech

Weakness or numbness in the extremities

Poor orientation to person/place/time

Signs of basilar skull fracture

Neck pain

Altered mental status

Significant irritability

Glasgow coma scale < 15

Hx LOC > 30 seconds

Severe headache

Table 4. Return to schoolwork progression6 Cognitive rest

No school/work, homework, texting, video games, computer work

Relative rest

Reintroduce short periods (5–15 minutes) of aforementioned activities that do not trigger severe symptom exacerbation

Homework/work at home

Longer periods of cognitive activity (20–30 minutes) to build stamina, avoiding triggering severe symptoms

Return to school/work

Partial-day school/work with accommodations after tolerating 1–2 cumulative hours of homework at home

Ramp up to full day

With accommodations for full work load, limited make up work

Full return to schoolwork

Full day, full work load, fully caught up with makeup load

Table 5. Return to play progression6

Physical rest

Encourage healthy sleep, additional sleep may be needed, no activities that result in sustained increased heart rate or breaking a sweat or severe symptom exacerbation

Light activity associated with everyday life avoiding triggering severe symptoms

Walking

Light aerobic exercise

Brisk walking, light jogging to increase heart rate without triggering severe symptom exacerbation

Sport-specific aerobic exercise

Noncontact skating, dribbling, or running drills as tolerated

Advance to complex noncontact sport-specific training drills and add resistance training as tolerated

After medical clearance

Full contact practice

Normal game play

TEXAS FAMILY PHYSICIAN FALL 2015

exacerbate concussion symptoms. It is also essential the athlete avoid any contact or collision activities that increase the risk for a repeat head injury during this vulnerable acute post-injury period. After a brief period of physical and cognitive rest, during which symptoms usually decrease, athletes can gradually resume routine cognitive and physical tasks, while being careful to avoid activities that cause an increase or return of symptoms [see Tables 4 and 5]. PREDICTORS OF PROLONGED RECOVERY: Several factors have been suggested as predictors of prolonged recovery after concussion, including younger age, female gender, history of multiple concussions, and learning disability.6 Other neurocognitive impairments, including slowed reaction time and impaired visual memory, have also been shown to be predictive of prolonged recovery.Ibid Finally, posttraumatic migraine has been associated with a more severe and protracted recovery after concussion. UNIVERSITY INTERSCHOLASTIC LEAGUE: Due to changes to the Texas Education Commission mandated by the 82nd Texas Legislature, the University Interscholastic League now requires a concussion management team at each UIL-aligned school district. One key task of the concussion management team is to design a return-toplay protocol that describes in detail the steps athletes must follow before they are allowed to resume full athletic competition. The UIL also requires a concussion acknowledgement form to be signed by the student and parent or guardian, as well as a concussion management protocol returnto-play form to be signed by a school official and the parent or guardian. The UIL site also provides a link to concussion management recommendations published by the National Federation of State High School Associations, found at www.uiltexas.org/ health/concussions. SUMMARY: Sports-related concussion is common, with more than 300,000 occurring each year in the U.S. Family physicians must be aware of the special circumstances of young athletes, who are at greater risk of injury, and tend to recover more slowly than adults. When possible, preseason baseline cognitive assessment is recommended, whether with the paper-and-pencil Standardized Assessment of Concussion or computerized neurocognitive testing

systems. When managing an athlete with a sports-related concussion, the physician should follow a structured follow-up and return-to-play protocol. Finally, as primary care physicians we have a special responsibility to protect young athletes: “When in doubt, sit them out.” CONCLUSION: Family physicians should take every concussion seriously. The concussed athlete has a decreased ability to process new information, and the degree of impairment is proportional to the severity of the injury. Moreover, symptoms worsen with repeated injury (the so-called cumulative concussion). Thus, no head injury is “minor;” all need prompt evaluation before returning to play.

Online Resources “Sport-Related Concussion in Children and Adolescents.” Mark E. Halstead, Kevin D. Walter and The Council on Sports Medicine and Fitness http://pediatrics.aappublications.org/ content/126/3/597.full AAFP’s American Family Physician www.aafp.org/afp/viewRelatedDocumentsByMesh.htm?meshId=D001924 FamilyDoctor.org http://familydoctor.org/familydoctor/en/ diseases-conditions/concussion.html American Academy of Pediatrics HealthyChildren.org www.healthychildren.org/English/ health-issues/injuries-emergencies/ sports-injuries/Pages/Concussions.aspx

REFERENCES 1. Marar M, McIlvain NM, Sarah K. Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes across 20 sports. Am J Sports Med 2012; 40(4): 747-755. 2. Harman KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, Kutcher JS, Pana A, Putukian M, Roberts WO. The American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013; 47(1):1 15-26. 3. Scorza KA, Raleigh MF, O’Connor FG. Current concepts in concussion: evaluation and management. Am Fam Phys 2012; 85(2): 123-132. 4. Halstead ME, Walter KD. Clinical report – sport-related concussion in children and adolescents. Pediatrics 2010; 126(3) 597-616. 5. Lovell MR, Fazio V. Concussion management in the child and adolescent athlete. Curr Sports Med Rep 2008; 7(1): 12-15. 6. Master CL, Balcer L, Collins M. Concussion. Ann Intern Med 2014; 160(3):ITC2, 1-16. 7. Practice Guidelines: Evaluation and management of concussion in athletes: recommendations from the AAN. Am Fam Physician 2014; 89(7): 585-587. 8. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47:5 250-258.

American Academy of Neurology Concussion Management guidelines www.neurology.org/content/80/24/2250.full Centers for Disease Control and Prevention Heads-Up program www.cdc.gov/headsup Sport Concussion Assessment Tool, 3rd Edition http://bjsm.bmj.com/content/47/5/259. full.pdf University Interscholastic League www.uiltexas.org/health/concussions National Federation of State High School Associations Suggested Guidelines for Management of Concussion in Sports www.uiltexas.org/files/health/2013_Suggested_Guidelines_for_Management_ of_Concussion_in_Sports.pdf Neurocognitive testing: Immediate Post-Concussion Assessment and Cognitive Testing www.impacttest.com

www.tafp.org

PERSPECTIVE

Why I precept medical students By Adrian N. Billings, MD, PhD, FAAFP

why do i precept medical students? Luckily, I ask myself this question less and less frequently because I enjoy having these junior colleagues with me, especially at 2 a.m. while delivering babies. However, I recently explored this question with some reflection on my past seven years of precepting around 100 medical students and 20 resident physicians in my practice. Unequivocally, the answer to the preceding question is that I precept medical students because my patients receive better care if I have a medical student working with me. It does not matter how fresh a medical student is into clinical training, two sets of eyes and two sets of brains examining and thinking about a patient’s problem are better than my own brain by itself. I have had preclinical students consider and make diagnoses that I have not been able to. Even if the students don’t make the correct diagnosis and they hear zebra hoofbeats instead of horse hoofbeats, this mental task causes me to consider a broader and more thorough differential diagnosis with their valuable input. I consider it an honor and privilege to be entrusted by medical schools with these young student physicians. I also precept medical students because of the Hippocratic Oath. When I took the Hippocratic Oath as a medical student I held it as one that is binding and sacred to my role as a physician to society to include “treat the sick to the best of one’s ability, preserve patient privacy, teach the secrets of medicine to the next generation.” I firmly believe I am a better physician because of my role as a medical student preceptor. Medical students challenge me on a daily basis for academic answers to their questions. I am comfortable in my own skin enough to know I do not have all the answers, and when I don’t, that’s when the medical student is assigned homework and we review that lesson and answer the next day. My patients by in large enjoy the medical students’ enthusiasm, attention, and extra time they spend with the patients. My practice is accustomed enough to me hosting medical students that my patients and staff miss them when we do not have one rotating with our practice. I miss the students as well when they are not present. Also, I have found that I am more efficient when working with a medical student alongside me. Additionally, my day is more interesting and fun with medical students around.

I initially began hosting medical students when I was in solo private practice because I was lonely and missed the camaraderie of medical school and residency. The selfish side of me wanted to find a future partner to share hospital call with. My community and I have been blessed to have three former trainees return to practice in the Big Bend with me. Medical students are a great investment and we should invest our time and energies in them. I want to open the door for medical students to rotate with me in a federally qualified health center in one of the most medically underserved areas of Texas, which has limited health care resources. This demonstrates to them the full potential of a family physician who practices full spectrum family medicine, from cradle to grave, including house calls. My hope for them is that they work with a physician who loves his or her job and practice, and they see how important and vital a family physician is to their patients and community. For many of these students, this rotation will be their only exposure to this kind of domestic missionary medicine and my hope is that all of them will become family physicians. However, they all will not enter family medicine nor even primary care. Perhaps, these future physicians will have a healthier respect for the challenges underserved patients and their primary care physicians have if they ultimately become a specialist physician. Maybe, later in their career, if they are practicing at a larger tertiary care hospital as a specialist and they get that 2 a.m. telephone call for help from me or someone like me, they will remember their rural, underserved family medicine experience and have a better understanding of the challenges of family medicine. Please volunteer to precept medical students. It does not matter whether you practice in Pampa or Plano, in direct primary care or in a federally qualified health center, or whether you include hospital medicine or obstetrics in your practice, you are needed as a mentor to these student physicians. Once you have precepted medical students in your practice, the rewards are tremendous and my hope is that you feel as I do, incomplete, without a young enthusiastic and brilliant medical student shadowing you. Thank you for all you do for our profession.

I want to open the door for medical students to rotate with me in a federally qualified health center in one of the most medically underserved areas of Texas, which has limited health care resources. This demonstrates to them the full potential of a family physician who practices full spectrum family medicine, from cradle to grave, including house calls.

TEXAS FAMILY PHYSICIAN FALL 2015

Billings is the director of the Texas Statewide Family Medicine Preceptorship Program.

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