In his 2004 State of the Union address, former President George W. Bush introduced a plan to roll out EHRs across the country, stating, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”
	
	Certainly, the desire to avoid medical errors, a major basis of medical malpractice claims, was one of the driving forces behind EHR adoption. But with the implementation of these systems, the country has seen a rise in what used to be a relatively rare malpractice situation: medical liability claims with an EHR as a contributing factor.
	
	EHRs have evolved but variability remains in what different systems offer, says Mark Graber, MD, FACP, chief medical officer of the Society to Improve Diagnosis in Medicine, who has investigated EHR-related events in medical malpractice claims.
	
	“When you introduce any new technology, you are going to see bugs,” he says. “But you also introduce the possibility of users making errors. Doctors who aren’t trained well on the system may make unintentional mistakes.”


	
	A 2017 research report by The Doctors Company, a medical malpractice insurer, revealed that the number of medical malpractice claims among their approximately 80,000 plan members involving EHRs in some way has risen in lockstep with EHR adoption.
	
	The report found two closed EHR-related claims between 2007 and 2010. Between  2011 and 2013, the number jumped to an average of about 23 claims each year. The upward trend continued in 2014, 2015, and 2016: where a total of 92 EHR-related malpractice claims over the three years, or an average of about 30 per year, were closed. 
	
	Such medical errors can have profound consequences for patients. In a 2015 study published in the Journal of Public Safety, Graber and his colleagues discovered most EHR-related errors involved medications, diagnoses, or a complication of treatment in the ambulatory care setting.
	
	Perhaps most strikingly, 80 percent of such claims involved moderate or severe harm to the patient. Daryl Zaslow, JD, an attorney specializing in medical malpractice law, says there are many ways that malpractice could arise from an error in a patient’s EHR.
	
	“What typically happens is that there’s a failure to input or access information that is vital to a patient’s health,” he explains. “Therefore, that information is not communicated to another medical care provider who is also involved with the patient’s care and something bad happens.”


	
	While it would be easy to blame technology for critical information slipping through the cracks, Hardeep Singh, MD, MPH, chief of health policy, quality, and informatics at the Veteran’s Administration and professor at the Baylor College of Medicine, says a physician could have the best EHR system in the world and still be a victim of “unintended consequences.”
	
	“There are instances where, thanks to a technical glitch, there have been medical issues,” he says. “Sometimes, the technology is not safe, it’s got a bug or a virus or it’s down because you don’t have the right updates.”
	
	The Doctors Company study found system errors like fragmented EHRs (i.e., a system where key sections of a patient’s record aren’t located together), technology failures, and electronic data routing issues did contribute to some claims. But Zaslow says true technology-related cases are uncommon.
	
	“Unfortunately, because these systems aren’t as user-friendly as they often claim to be, and because medical providers have a lot of responsibility keeping track of a lot of things for a lot of different patients, important information just isn’t being inputted in the right way,” he says. 
	
	That’s why it’s important to look at where, when, and how users are making those sorts of errors, Singh says. He argues that a lack of standard interfaces for EHR systems makes it more likely that clinicians may incorrectly enter-or fail to enter-patient data into the system.
	In addition, since many physicians use multiple systems across different facilities, it can be difficult to know where information should be entered or accessed. He adds that it’s also important to consider how clinicians are using EHR systems-because errors still occur even in the most user-friendly platforms.
	
	There is now a well-established link between EHR usage and increased physician burnout with studies showing that primary care physicians can spend more than half of their work day on the EHR due to billing and regulatory requirements. These increased demands often result in a more demanding workload and amplified feelings of frustration-and, too often, a physician’s attention being drawn away from what should be their top priority: documenting and assessing important patient data.
	
	To address the issue, many healthcare organizations have tried to find ways to ease those documentation requirements. They may select EHR systems that offer auto-population features, or the ability to automatically fill in different data fields when a user opens or completes the record. They may also appreciate the idea of customized templates for different portions of the patient record, which help automate entry of what is often redundant patient data.
	
	Furthermore, physicians may develop their own short-cuts and workarounds, skipping certain fields in the record or using the copy and paste function to quickly move information from one part of the record to another. Ironically, Singh argues, in doing so they may be inadvertently triggering more EHR-related errors.
	
	“People don’t realize, in their haste to get their work done, just how much extra stuff can be auto-populated, resulting in a doctor missing an abnormal lab result they need to address or a patient getting an unnecessary medication,” he says. “And the next thing you know, you are looking at a malpractice claim.”
	
	


	
	In general, Graber says, well-designed and well-maintained EHRs can easily integrate into a physician’s workflow to save time and help reduce errors. But healthcare organizations need to do their part and adopt strategies to reduce the risk of EHR-related malpractice.
	
	One of the most obvious techniques, and one that EHR vendors often recommend, is regular system audits-relevant reviews of the system to document who has accessed and edited different records as well as what content has changed. Such audits can often identify users who are not meeting organizational policies regarding documentation, and provide insights into how workflows might be modified to better support those efforts.
	
	In addition, those audits should help to ensure platforms are regularly updated and patched to deal with any system or security bugs.
	But while audits can offer valuable information to the information technology (IT) department, Zaslow says physicians may not find the results as enlightening. 
	
	“We lawyers use IT engineers to see where and when people have made addendums and changes to the record to see which providers accessed certain portions of the record for our cases-and most hospitals have the same capabilities,” he says.
	
	There are other strategies that can help reduce the risk of EHR-related medical errors for healthcare organizations and physicians. They start, Singh says, with hospitals and health systems taking a long, hard look at their organizational culture.  Each healthcare organization should include physician champions when selecting and implementing EHR systems so as to find platforms that can best support their needs.
	
	In addition, healthcare organizations should enact policies that assist and perhaps even reward clinical staff for taking the time to become trained on EHR systems, as well as for them to review and document patient data outside the physician-patient encounter.
	
	“If you don’t have a work environment that supports clinicians, that doesn’t have the policies and procedures in place to support them, technology won’t help no matter how good it is,” he says. “Organizations should look at their systems and their users to see where they can make changes to help reduce errors across the board.”
	
	Singh says that physicians also have a vital role to play in decreasing these kinds of malpractice claims. He suggests that physicians take steps to avoid the most common pitfalls that can lead to EHR-related errors.
	
	To start, don’t disable or override alerts or reminders built into the system. If physicians feel they are experiencing “alert fatigue,” or that such alerts are interfering with care, they should inform the organization’s IT department.  In addition, if physicians  use copy/paste functions or auto-population features, they should be sure to double- or triple-check any notes before signing off on them. 
	
	“Having better awareness of the danger of copy/paste, autopopulation, and templates is important-these short-cuts can lead to a lot of problems,” Singh says. “But the other thing I’d say is, don’t skip on your EHR training. No one wants to do this training. But the EHR is a tool that clinicians have to use, it’s not going away-so get the training necessary so you can effectively use it.”
	
	Avoiding EHR-related malpractice truly is a team effort, adds Graber. As these systems become an increasingly integral part of the care process, he says, it’s important to understand that they can affect the quality of care in a variety of direct and indirect ways. And the first step to mitigating those risks  is awareness.
	
	“It’s increasingly important for clinicians to understand how some of these common errors happen, and how to better mitigate them,” says Graber. “And that’s  whether there is a malpractice claim on the table or not.”

Articles

With the implementation of electronic health records, the country has seen a rise in what used to be a relatively rare malpractice situation: medical liability claims with an EHR as a contributing factor.

Is your EHR a malpractice risk?

Millennials (born 1981 to 1996) and Generation Zers (born 1997 to 2012) represent 7 percent of patients in the practice of James Legan, MD, and they also tend to come in for an appointment only once every couple of years. However, this hasn’t deterred the Montana-based internist from devising a strategy to attract and retain these individuals that he hopes will, over time, comprise more of his patient base.
	
	In January, he started using secure texting so patients could ask for prescription refills and request copies of reports, lab results, and office visit summaries. Texting doesn’t require any additional work on his part. His nurse signs patients up for text messages after she takes vital signs, and responds to the messages as they come in.
	
	Legan says patients of all ages-and especially younger generations-tend to prefer texting over phone and email communication. He has seen this in his own practice as well as in his personal life with his 18-year-old son and 16-year-old daughter, both of whom are in Generation Z. “Their phone is their connection to the outside world,” he says. “I hate to say it, but I think email is old technology now. We need to make communication more immediate.”
	
	Nearly 70 percent of Legan’s patients actively use the patient portal that’s tied to his EHR, though he anticipates texting will eventually replace it entirely. He’s also exploring providing secure video chatting to address common medical problems such as a rash or sinus infection. He predicts younger generations will increasingly demand this type of technology as part of their healthcare experience.
	
	According to Accenture’s 2019 digital health consumer survey, convenience is a major factor for younger generations when choosing a provider. For example, 84 percent said they want easy access to test results, and 80 percent want the ability to request prescription refills electronically. This is in addition to the majority of respondents who demand short wait times, responsive providers, and cost-conscious care.

Giving younger generations what they want


	
	Experts say physicians who want to attract and retain younger patients need to rethink how they interact with them and create a technology-driven strategy for engagement.
	
	To do this, physicians must shift their mindset, says Mike Morgan, chief executive officer at Updox, a patient engagement consultant in Dublin, Ohio. “Your practice is a business, and your patients are customers,” he says. “A typical business segments its customers because everyone has different priorities.”
	
	Millennials and Generation Z expect their healthcare experience to mimic that of other industries, says Morgan. Most importantly, they want convenience. They’ll compare healthcare, for example, with the ease of ordering takeout meals online, requesting an Uber or Lyft, or chatting with a company’s customer service rep, he adds. If their healthcare experience isn’t similar in terms of booking appointments, paying bills, and communicating with providers, they’ll simply move on to find a different practice that can provide the type of experience they want.
	
	“Many physicians have built their business based on word of mouth,” says Kaveh Safavi, MD, JD, senior managing director at Accenture, a healthcare consulting and IT company in Chicago. “Now, that’s not enough when convenience is three times more compelling.”
	
	Younger consumers also want the ability to make appointments easily. Legan, for example, tries to accommodate these patients who have acute problems with same-day appointments, when possible. “These patients are hard to capture otherwise,” he says. “If you can’t fit them in, they’ll go to an urgent care.”
	
	Three-quarters (76 percent) of participants in the Accenture study said they want the ability to book, change, or cancel appointments online. “These generations, in general, don’t want to pick up the phone and call,” says Norm Schrager, senior content marketer and strategist at PatientPop, a practice growth technology provider in Santa Monica, Calif.
	
	However, some physicians believe that by offering online booking, they’ll lose control over their schedule. This isn’t true, says Schrager. Many products allow practices to limit scheduling options online. They also fully integrate with EHR scheduling systems, offering a seamless experience for practices, he adds.
	
	


	
	Standing out among competitors is perhaps the biggest challenge in terms of attracting millennials and Generation Z to a physician’s practice, says Morgan. Having a website is a good first step, but the site must include updated information and provide a decent user experience with high-quality photos of your staff and office. Otherwise, it could actually harm your ability to attract these patients. “Some patients look at the website as a proxy for the experience they will receive at the practice,” he says.
	
	Physicians also need to work with a web designer or marketing company to create a plan for search engine optimization (SEO), the process of ensuring search engines can find a website, says Carrie Liken, head of industry for healthcare at Yext, a digital knowledge management provider in New York City. A savvy web designer or marketing company should also be able to add relevant schema tags to the HTML code on each page of the site. These tags help search engine algorithms prioritize the content for patients searching key terms, she explains.
	
	A practice website should also include a page for frequently asked questions, about various diagnoses and procedures says Schrager. Ask-and then answer-these questions on the site. “This starts to build up the idea that you have a level of authority and relevance,” he says.
	Claiming and optimizing a Google business profile is also important, says Schrager. Physicians should go to https://www.google.com/business/, claim their identity, and add specific information about the services they perform. “Not only does this help with search results, it also lets prospective customers know who you are,” he adds.
	
	


	
	As important as a practice website are the myriad healthcare- and consumer-related websites (e.g., Healthgrades, Vitals, and Yelp) that include reviews and ratings provided by patients, says Liken. Over half (59 percent) of patients say online patient reviews are the most critical online resource they consider when choosing a provider, according to the 2019 patient perspective online reputation survey conducted by PatientPop.
	
	In some cases, these third-party websites are the only ones that prospective patients see, either because the practice doesn’t have a website or the practice website isn’t SEO-optimized and thus doesn’t appear in search results. Another reason is that the patient searches the physician’s name not the practice name. If the website only mentions the practice name, it won’t come up in a search for the physician’s name.
	
	The most important step physicians can take regarding these reviews is to simply acknowledge them, says Liken. However, they should be careful not to confirm or disclose protected health information (PHI) during these interactions. Instead, thank patients for their feedback and ask them to call the practice directly to discuss their concerns, she says.
	
	Schrager agrees. “Let the patient know you heard them and that you want to address the issue they had,” he says. “That will help you not only retain that patient, but it shows a level of care and professionalism that will help attract prospective patients.”
	
	Physicians should feel comfortable asking patients to share their experiences online because these reviews are highly influential in terms of choosing a provider, says Schrager. The more recent the review, the more relevant it is for younger patients-many of whom ignore reviews older than three months, he adds.
	
	Many of these third-party sites also include basic information about a practice, such as the address and phone number. Nearly 70 percent of the time, this information is either inaccurate or missing, says Liken. “This leads to a really bad patient experience,” she adds. “When younger generations find information that’s not accurate, or they can’t find the right number, they just go ahead and search for another doctor altogether.” She says physicians should claim and update their profiles on these sites.
	
	


	
	Once they arrive for an appointment, millennials and Generation Z expect to be treated as customers of your business. As such, they’ll appreciate a warm greeting upon check-in, says Schrager. Practices should also offer amenities such as Wi-Fi, coffee, water, TVs, comfortable chairs, and updated magazines. If the physician is behind schedule, staff should let them know they’ll experience a delay and by how long.
	
	“This level of open communication makes such an impression,” he adds.
	
	Younger generations definitely don’t want to be inundated with paperwork once they arrive, says Schrager. Paperless intakes that patients can complete in advance using their mobile device are preferred, he adds.
	
	Once patients are in the exam room, Legan projects the EHR onto a 40-inch screen so people can view their health data trends over time. “These generations are very visual, and they like that effect,” he says.
	
	Upon checkout, they’ll want to know what specific costs they’ve incurred as well as instructions for next steps (e.g., tests or referrals), says Morgan. They also want the ability to communicate with physicians asynchronously through texting. The only caveat with texting is that physicians and staff must use secure texts if they intend to exchange PHI, he adds. In addition to encryption, secure text messaging offers other safeguards, such as accessing a conversation through a link that’s only active for 48 hours. If a patient wants to reactivate the conversation after 48 hours, they must verify their identity using their date of birth or a personal identification number.
	
	

Thinking about long-term return on investment


	
	Engaging millennials and Generation Z isn’t necessarily about generating revenue-at least not initially, says Safavi. It’s about building relationships and being accessible so patients automatically reach out when needs do arise. “Your goal is to think about having these patients think of you as their doctor,” he adds. The idea is that over time, their healthcare needs will evolve and increase as they age.
	
	On the other hand, embracing healthcare consumerism undoubtedly improves patient satisfaction and retention across the board for all generations, says Safavi. “It’s about realizing this is what patients expect now,” he adds.

Millennial and Generation Z patients demand convenience and quicker access, experts say

How to build a practice for younger patients

Depending on who’s talking about CBD-short for cannabadiol, the nonpsychoactive compound found in marijuana and hemp plants-it’s either a cure-all for every ailment, or little better than a placebo. Since 33 states (and the District of Columbia) have legalized medical marijuana, and the 2018 Farm Bill legalized hemp, physicians may be seeing more requests from patients to try these products. What do physicians need to know to best inform their patients? The answers lie somewhere in the middle of the two extremes.
	
	


	
	CBD is one of hundreds of cannabinoids found in the cannabis sativa plant (marijuana and hemp) that does not cause the euphoria or intoxication of its cousin compound, THC.
	
	“CBD binds to different receptors than THC,” says Jack Springer, MD, Fellow at the American College of Emergency Medicine and assistant professor of Emergency Medicine at the Zucker School of Medicine at Hofstra Northwell in San Diego, Calif.
	
	Researchers are only just beginning to understand the endocannabanoid system in the human body, he says, which were only discovered around the 1990s. “Since that time this system has been found to have numerous important functions on the body relating to appetite and energy balance, immune function and nervous system function,” Springer says.
	
	CBD, a phytocannabanoid-deriving from plants-is frequently touted as relieving such conditions as chronic pain and inflammation, anxiety, and sleep issues, says Rosemary Mazanet, MD, PhD, an oncologist and Chief Scientist at Columbia Care, a provider of medical cannabis products in 13 states.
	
	However, when it comes to the evidence, most claims are only anecdotal. Research studies in the U.S. on CBD are still limited.
	
	Mazanet says that many of CBD’s positive effects on these conditions may be placebo, but she does not consider that a bad thing, particularly for issues such as anxiety. “Even if it’s placebo, if people think it’s working for them, that’s good because people take so many benzodiazepenes, which can be addictive over periods of time,” Mazanet says.
	
	Other physicians believe that taking CBD alone is missing the effectiveness of the whole cannabis (marijuana) plant, which includes THC and numerous other cannabanoids, which work together in what is known as an “entourage effect.”
	
	Jordan Tishler, MD, an internist and professor at Harvard Medical School in Brookline, Massachusetts, and president of the Association of Cannabis Specialists, also believes that the benefits the average person is getting from CBD are likely placebo, and that it’s THC that can really treat symptoms. “If you think about the general things cannabis is used for-pain control, nausea suppression, appetite stimulation, treatment of anxiety-that’s all THC… in proper dosing and in proper timing that’s actually working.”
	
	However, any of the compounds of cannabis in isolation have their downsides, even THC, Tishler says. This is evidenced by the failure of a drug called Marinol, released in the 1980s, which was essentially pure THC. “It didn’t work well because most people got so intoxicated that they never achieved the therapeutic value,” Tishler says.
	
	Because both hemp and marijuana were considered illicit substances for so long, research on CBD in the United States has been limited. Thus, there simply isn’t enough convincing scientific evidence yet to back up any specific usage of CBD with one exception. The only FDA approved use for CBD in the U.S., Tishler says, is the FDA approved drug Epidiolex, used to treat seizures associated with Lennox-Gastaut syndrome (LGS) or Dravet syndrome (DS) in patients 2 years of age and older. Even then, it does not work for every patient who takes it.
	
	Tishler says that the dosage of CBD required to bring benefit to the average person is so high-between 600 and 1200 mg of CBD per day-it is also cost prohibitive for many. He estimates CBD costs approximately five cents per milligram, which would make a therapeutic dose of CBD about $80 per person per day. “You need so much CBD to make a dent,” Tishler says.
	
	In an attempt to provide some concrete evidence on effectiveness of CBD and THC, The National Academy of Science Engineering and Medicine released a report in 2017 that found the following:

“Conclusive or substantial evidence” that cannabanoids (not specifically CBD) are effective as antiemetics in the treatment of chemotherapy-induced nausea and vomiting (with oral cannabinoids); and improving patient-reported multiple sclerosis spasticity symptoms (with oral cannabinoids).
	
	“Moderate evidence” that cannabanoids improve short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis (primarily nabiximols).
	
	For everything else, evidence is “limited or inconclusive.”

“The important thing to get across is that nothing is a panacea,” says Springer. “Until we dial in the mechanism of action and can pick apart which cannabinoid is most beneficial for what and can isolate it, we’re not going to know.”
	
	He urges physicians to be cautious about making claims that CBD is definitely going to work for any specific ailment or disease.
	
	While there aren’t a lot of known side effects to CBD other than diarrhea, upset stomach and occasional lightheadedness, Springer says, he feels the marketing of CBD downplays any potential side effects. “Anything you put in your body is going to have an effect. The issue comes down to what form and dose are you taking,” Springer says.
	
	Side effects are also much more likely at higher dosages, which is where Tishler urges caution. “Having CBD at placebo levels is probably not a big deal, but high levels of CBD are probably something we want with some control, or people will get drug interactions.”
	
	


	
	In addition to questions about CBD’s curative claims, there’s some gray area around its legality. There’s an erroneous assumption that marijuana is illegal and hemp is legal, therefore, CBD derived from hemp is assumed to be legal as well. William Garvin, JD, shareholder for the law firm Buchanan, Ingersall, and Rooney in Washington D.C., and co-head of its cannabis group, which handles issues related to the regulation and sale of cannabis, says, “The problem is that marijuana and hemp have the same genus species of plant.”
	
	Thus, he says, hemp has long been lumped in with marijuana, legally speaking, and treated as illegal even though hemp does not contain enough THC to create intoxication. That muddied the legal waters in states where local authorities don’t know the difference between the plants, and has kept even hemp-derived CBD from being legal to buy and sell in every state.
	
	The passage of the 2018 Farm Bill has legalized hemp, and thus hemp-derived CBD, so long as the producer is licensed and in compliance with federal or state agricultural standards.
	
	However, no such federal agricultural program exists yet, Tishler says.
	
	The legalization of hemp may change who is allowed to produce and sell CBD, by requiring more stringent standards, but Garvin thinks that might be a benefit to the consumer by creating more consistent and standardized products.
	
	All of that said, there is often lag time between legislation and law enforcement, so Garvin urges CBD users, “Don’t take [CBD] through airports. Treat it as a product that could have difficult with authorities because you never know which authorities are going to be on board with it and which ones aren’t.”
	
	


	
	Mazanet also cautions that not all CBD products are created equally, or with any consistent manufacturing standards. “When patients buy CBD products over the counter or from the gas station, they have no idea what they’re getting,” she says.
	
	She points to a 2017 study in JAMA where researchers tested 84 CBD products they purchased over the internet from 31 different companies-40 oil products, 20 tinctures, and 20 vaporizations. “Less than half of the products had in them what they said they had in them,” Mazanet says. “There’s really no oversight in what people buy.”
	
	Springer says even dispensaries in states with medical marijuana are not always the most reliable source.
	
	That being said, Mazanet accepts that patients who want CBD products are going to get them, and feels that physicians should try to work with these patients. “The thing that’s most important is that physicians don’t send their patients elsewhere,” she says.
	
	Springer urges physicians to encourage their patients to do their research before purchasing products and to acquaint themselves with quality brands for those patients who are determined to buy them.
	
	Like Mazanet, in the service of keeping rapport with his patients, Springer doesn’t write CBD off entirely because his patients are interested in it. He’s hopeful about research that shows cannabanoids may help to reduce dependence on other drugs, particularly opioids and benzodiazepenes, which can become addictive.
	
	“For people who are opiate dependent or on a medication that has side effects, it’s a no brainer. If they’re willing, they should try to see if it helps,” Springer says.
	
	Tishler is less likely to recommend CBD to his patients, however, (though he does recommend medical marijuana). “I don’t destroy patients’ response to placebo, but I don’t recommend placebo, either,” he says.
	
	He feels it’s more important for doctors to figure out what the patient is trying to treat and focus on whether they need to intervene in some directed fashion. “If someone asks my opinion about [CBD] I’ll tell them it’s not particularly useful,” Tishler says.

What should physicians say to their patients?

The CBD oil trend

Q: I have several colleagues who are getting paid for telehealth services. Is this something that is being reimbursed? If so, how do we bill?

Reimbursement varies between payers, so be sure and check with those in your area to ensure they reimburse for telehealth services prior to performing and billing.

There are several requirements that must be met in order to bill telehealth services.
	
	

An originating site is the location of an eligible Medicare patient at the time the service furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in: 

a county outside of a Metropolitan Statistical Area (MSA) or

A rural Health Professional Shortage Area (HPSA) located in a rural census tract 

Authorized originating sites include physician practices, hospitals, rural health clinics.


	
	Another requirement for telehealth services is the type of practitioners at the distant site who can perform and be reimbursed for covered telehealth services, and those include: Physicians, nurse practitioners, physician assistants, and others.
	
	


	
	You must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site.
	
	In order to indicate that services were performed as telehealth services at a distant site, you need to list Place of Service (POS) 02: Telehealth on the claim.  This is where the services are provided or received, through telehealth telecommunication technology.
	
	


	
	Simply using the appropriate CPT and POS codes sometimes is not enough. Since Medicare and payers are tracking the number of telehealth visits, they require these modifiers for specific situations:

A GT modifier is used for interactive audio and telecommunications system on institutional claims billed under CAH Method II only.

A GQ modifier is used for asynchronous telecommunication system visits (only for Federal telemedicine demonstration programs in Alaska or Hawaii).


	
	Originating sites are paid a facility fee for telehealth services, per HCPCS code Q3014. Bill for the originating site facility fee, which is separately billable, and append the GQ modifier.
	 

Getting paid for telehealth services

When Gary LeRoy, MD, FAAFP, signed on as medical director of a community health center in Dayton, Ohio, it consisted of a single physician and dentist, a nurse practitioner and a handful of other employees housed in a 5,000-square-foot former grocery store.
	
	Today, the center-now known as the East Dayton Community Health Center-bears little resemblance to the facility LeRoy joined 16 years ago, despite being in the same location. For starters, it’s doubled its size by expanding into formerly vacant space in the rear of the building. It now employs two physicians, two nurse practitioners, and nine staff members.
	
	Equally important, the building’s retail-like ambiance has been replaced by a welcoming environment, due in part to the abundant natural lighting provided by skylights. The waiting room has plenty of comfortable furniture for adults and a play area for children.
	
	In addition, LeRoy says, the center improved its efficiency by changing the way patients flow through the building, and created work pods where physicians and support staff can talk without being overheard by patients.
	
	“We basically redesigned the building from the ground up,” recalls LeRoy, now a board member of the American Academy of Family Physicians. “Everybody drew up their wish list of what they wanted to see in the facility. Then we sat with the architect and said, ‘how can we realistically create the components everyone is asking for?’”
	
	As a result of its makeover and expansion, East Dayton now serves about 15,000 patients annually and has been designated a Federally Qualified Health Center. It also hosts community classes on health and stress reduction. “We decided that since we’re a part of the community we should provide services of use to the community,” LeRoy explains.
	
	While East Dayton’s overhaul may have been more extreme than most, it was far from alone in undertaking it. In a 2016 survey by the Medical Group Management Association (MGMA), just over half of respondents said they either remodeled, added space, moved, or made some other change to their practice space in the past two years.
	
	Ken Hertz, FACMPE, principal consultant with the MGMA, says those numbers don’t come as a surprise. “Given the rapidly changing healthcare landscape, practices and physicians are coming to see it’s vital that they continually reinvest in the business by updating their space, changing the aesthetics, introducing new technology and so forth,” Hertz says.
	
	


	
	So what are some of the tell-tale signs that a practice may need a makeover?  They fall into three broad categories, experts say: space, appearance, and productivity. Of these, space-or the lack of it-is usually the most obvious, since it’s readily apparent when a practice can no longer accommodate the needs of its patients and providers.
	
	David Zetter, CHBC, founder and lead consultant of Zetter HealthCare in Mechanicsburg, Penn., cites the example of a client, an urgent care center in an Orlando, Fla. strip mall just outside Disney World.
	
	“Every time I’ve walked in there, the place is packed,” Zetter says. “They’ve got patients standing outside or sitting in their car waiting to be called because there isn’t enough room in the reception area.”
	
	Fortunately, Zetter adds, an adjoining storefront came available that the client plans to buy, even though it’s more room than the center currently requires. “There’s a perfect example where somebody realized, ‘I’ve got to do something about this situation,’ and he’s going to spend a lot of money on it to do it right. But he’s confident, given how busy he is, that he’ll get a return on his investment.”
	
	The need to freshen its appearance, especially in the patient waiting area, is another frequent catalyst of practice makeovers. That’s especially the case, experts note, given that the waiting area is where patients form their first impression of a practice. Worn-out carpeting, lack of comfortable seating, outmoded decor, absence of Wi-Fi, and use of fluorescent lighting are all indicators that some serious remodeling is in order for that space-and likely the rest of the practice as well.

“Put yourself in the patient’s shoes”


	
	Sometimes doctors, even if they own the practice, may not be aware of problems with the waiting room simply because they rarely see it. That’s because in many practices clinicians and staff members use a separate entrance that takes them directly into the work area.
	
	The way to overcome that disconnect, Zetter advises, is to “put yourself in the patient’s shoes. Walk into your reception area, sit in the chairs for a little while and ask yourself, ‘is this where I would want to spend time waiting to see the doctor?’”
	
	Hertz says that in some client practices he holds weekend strategic planning sessions in the waiting room. “I make the docs spend a day or two where their patients sit every day, and I see them walking around going, ‘holy cow,’” he says. “Usually on Monday morning they’re saying to the practice administrator, ‘please get us some new furniture and have the walls painted as soon as possible.’”
	
	Sometimes the signs that changes are needed show up in a practice’s processes and workflow. “If a practice starts seeing its doctors consistently running behind schedule, or patients aren’t ready for them to see in the exam room, that’s a pretty clear indicator that something’s going on,” says Larry Brooks, AIA, principal of Practice Flow Solutions, a medical space planning and consulting firm in Roswell, Ga. “A lot of times it stems from just not having the space to check people in or do a pre-exam workup.”
	
	


	
	Once a practice has decided it needs a makeover, the next step is deciding on the specific changes it wants to make. For a small practice, the process is similar to remodeling a home, Hertz says: the physician-owner and office manager should inspect the practice’s rooms, equipment, and furnishings and make a list of everything they want to see fixed, changed, or disposed of.
	
	For larger practices, experts recommend convening clinicians and staff members by department and soliciting their input. “Ask them, ‘if you could have a new space, what would it look like? What are the things that aren’t working now and what changes would make our patient care better and help support the work that you do?’” Hertz says.
	
	Patient suggestions for improvements can also be helpful, he adds. Some practices he’s worked with survey their patients via phone, e-mail, or regular mail, while others will invite patients to come in person during an evening or weekend to make recommendations.
	
	Regardless of its size, often a practice can get useful ideas just from looking around to see what others are doing, Hertz says. “If the administrator or docs or staff have been to offices they think are fabulous, or have seen pictures in magazines or newspapers, bring them in, put them in a book and keep them as a resource,” he advises.
	
	Advice and suggestions from other practices who’ve undergone the process is also helpful. “Ask colleagues, when they got through with their makeover what were the things where they went, ‘Oh my God, how could I have forgotten about this?’”
	
	While practices will differ in the look they want to achieve depending on their financial constraints and the tastes and desires of owners and staff, experts agree that the goal is to create an ambiance that is up-to-date, comfortable, and inviting. “Nowadays, nobody wants to be in a sterile office environment,” Zetter notes.
	
	Lighting, wall colors, and fixtures are important parts of a makeover, so Zetter advises practices to consult interior design specialists on how to use these to create the look and feel the practice wants.
	
	Reception area amenities and furnishings are similarly crucial in creating a hospitable, patient-friendly atmosphere. For Brooks, the most important element of a good waiting room is having plenty of chairs with armrests, particularly if the practice serves a large number of elderly patients.
	
	“A lot of times you’ll see practices with nice couches and sofas, but it’s hard for an elderly person with back or knee problems to get out of those,” he notes. “Individual chairs with arms allow them to get up and sit down much easier.”


	
	Other conveniences practices should consider include coffee, snacks, carrels for patients to work in while waiting, charging stations for electronic devices, and Wi-Fi. “Even the grandmas and grandpas are texting and e-mailing with their phones these days, so Wi-Fi has almost become a given,” Brooks says.
	
	Experts note that updating a practice’s appearance need not be expensive. Sometimes, Hertz says, putting down new flooring and carpeting, repainting walls, and re-covering furniture can achieve the desired look without spending a great deal of money. He recalls working with a practice in need of a new paint job but whose physician-owner didn’t want to spend money for professional painters.
	
	“I pulled together some of their staff and we got painting equipment and brought in pizza and soda and painted the place ourselves, and it looked like new,” he says.
	
	


	
	When it comes to redesigning for improved productivity, experts say practices should focus on eliminating bottlenecks that slow the movement of patients through the office. A common one, according to Brooks, occurs when receptionists are required to both field phone calls and check in patients, causing backups in the latter process. Another is when doctors have to leave the exam room to get something they need or communicate with another provider or staff person, thereby extending the patient visit.
	
	That issue ties into what Fields calls the “number-one time waster” in a medical practice: walking. During his three decades of time studies, he says, “the amount of time doctors spend walking between exam rooms, or for tasks like taking a chart to a ready rack or finding a staff member to verbally deliver orders is mind-boggling, when you consider the doctor is the highest-paid member of the practice.”
	
	Brooks says practices can alleviate this problem during remodels by “podding” exam rooms-putting them across the corridor from each other rather than stringing them out along a corridor, which causes doctors to have to walk further between them.
	
	Another helpful technique is to place mini work stations near the doctors’ examining rooms. “That way if they want to make some notes or take a phone call between patients they can do it close to their rooms, versus going to their ­office, which might be far away,” he says.
	
	An important issue practices need to consider when planning a makeover is the exam room: designing it to ensure that doctors can maintain patient eye contact while typing in their EHR, and if possible show the patient the information they are entering. “You want to avoid the situation where the patient is talking to the back of the doctor’s head while they’re typing on the other side of the room,” LeRoy says.
	
	Hertz says some practices initially addressed this problem by mounting computer monitors on the walls of exam rooms, thereby allowing doctors to face patients and patients to see what the doctor is typing.
	
	In recent years practices have begun using laptop computers and tablets, which afford much greater flexibility than desktop computers. Some are also providing mobile tables, enabling doctors to wheel the EHR from room to room and position it to
	accommodate the patient.     
	
	An additional exam room feature to keep in mind, Brooks says, is standardization. Designing and supplying them identically means providers don’t have to spend time looking for items they need. “A doctor or staff member should be able to walk into any room, close their eyes and know where everything is, even to the point where they know each drawer has certain things in it,” he says.
	
	


	
	With a practice’s makeover wish list in hand, it’s time to execute the project. If it involves reconfiguring or adding space, an architect is essential. The best way to find one, experts agree, is through old-fashioned word-of-mouth and networking.
	
	“This is where you reach out to colleagues in your community who’ve redesigned their space and ask who they used for the project and what their experience was,” Hertz says. After developing a list of candidates, check references and, if possible, visit other practices to view a candidate’s work first-hand.
	
	Once the architect is on board, he or she will price out the practice’s wish list and work with administrators and doctors to determine which of them are financially and/or technically feasible. The architect will also draw up the plans and assemble the other members of the project team, such as the construction contractor and interior designer. 
	
	For a makeover that’s only cosmetic-a new paint job or flooring, for example-an interior designer alone will usually suffice. While administrators and/or doctors sometimes want to select colors and fabrics themselves, Hertz advises leaving these decisions to design specialists.
	
	“Someone with experience in this area will have a better understanding of the colors, materials and textures needed for the look and feel the practice wants to achieve  for its space,” he says. 
	
	When work gets underway, practices face the challenge of minimizing any disruption and inconvenience to employees and patients while continuing to function. Here, strategies differ depending on the scope of work involved. If the practice is adding space, Brooks says, the typical approach is to build the new space first and move the practice’s operations into it while work is being done on the existing space.
	
	If the practice is just renovating or reconfiguring its existing space, Zetter says, the choices are to work on one section of the office at a time, or have the work done during evenings and weekends.
	
	The latter is usually the best approach when it comes to the waiting room, Brooks says. “I’ve seen a lot of groups close early on Friday and give the contractors over the weekend to do the stuff they just couldn’t get to with patients in the office. That seems to work pretty well,” he says.
	
	Regardless of how the work is scheduled, it’s vital to inform patients and staff about what the practice is doing, why, and how long it’s expected to take. Zetter advises posting floor plans and artist’s renderings in the waiting room and around the practice so everyone can see what the result of the work will be.
	
	“When you’re letting patients and staff know what’s going on, it gets everyone kind of hyped up and creates an atmosphere of excitement,” he says. “That makes noise and disruption easier to take.”

What doctors need to know about revamping their office space to meet consumer demands.

Practice makeover: Designing a modern medical office

“Healthcare’s future: Four policy debates doctors must follow”

. (March 25, 2019 issue) you mentioned the Affordable Care Act, expanding healthcare insurance, prescription drug prices, and changes to accountable care organizations (ACOs) as four areas of healthcare policy that physicians must keep their eyes on.
	
	But, to these four should be added a fifth because it leads to inefficiency and rising costs: the medical liability system. It is deplorable that even though the personal injury lawyers are permitted to hit doctors with unmerited suits, they receive little or no criticism from policymakers.
	
	

 are doctors’ worst nightmares. To ward them off, they order extra tests and consultations. It is impossible to estimate how much these extra tests and consultations raise the cost of care, but doubtless it is considerable.
	
	Even if doctors have acted competently and even if they have trusting relationships with their patients, bad things happen and some patients will sue.
	
	An American Medical Association report in 2017 mentioned that 68 percent of closed claims in 2015 were dismissed or withdrawn, and that of the 7 percent of claims that went to trial, 88 percent were decided in favor of the doctor.
	
	Clearly, there are way too many brought against physicians.
	
	Health courts that operate like workers compensation are a good alternative. Overseen by judges with special training medical liability, they would resolve cases quickly and get compensation to patients in months, not years.
	
	And knowing that there would be fewer unmerited suits, physicians would have peace of mind and be less inclined to order unneeded tests and consultations.

https://www.healthcare.gov/glossary/affordable-care-act/Our readers respond to recent articles.

Your voice: Medical malpractice is a major policy issue;  doctors should pay attention

 (April 10, 2019 issue), I think you should change the title to over/misinformed patients.
	
	Just because someone has access to all the medical information they can read does not mean they are qualified to interpret it. I would argue that patients are not even close to being qualified to interpret the glut of information and misinformation on the internet.
	
	Even though I’m a family practice doctor I could very easily research airplane repair on the internet. Will you fly in my jet? I doubt it. The only thing I can say possibly about the “empowered patient” is that they are good for business. All their research always leads to a self-diagnosis of cancer-which brings them into my office for an accurate diagnosis. Long live the internet.

0610, 2019 Edition

Is your EHR a malpractice risk?

How to build a practice for younger patients

The CBD oil trend

Getting paid for telehealth services

Practice makeover: Designing a modern medical office

Your voice: Medical malpractice is a major policy issue; doctors should pay attention

Your voice: Empowered patients - Are they just misinformed?