Independent or employed, primary care physicians are facing one of the most tumultuous health care environments in decades. As many of the earliest adopters of the concierge medicine model head toward retirement, how can the next generation best realize the opportunity to acquire a financially stable, thriving practice and achieve personal and professional fulfillment? Younger doctors seeking an entry into the rewards of the membership medicine model are increasingly able to find their perfect match by taking the reins from a retiring concierge physician.

The essays below are authored by two physicians who made the decision to purchase a practice from a retiring physician, who explain why the made the choice and how it has benefited their careers.

My route to becoming a concierge physician may not be traditional, but having successfully navigated this life-changing trajectory in 2019, it’s one I would unhesitatingly recommend to fellow travelers — even more so today. I share my experience here because I understand the hesitation many doctors have of making such a significant career and life change and the fear of not succeeding. But two years later, I can look back and see some very evident truths: It was the right move and the right way to accomplish it, and I am so grateful that I was able to launch a thriving independent practice that continues to grow.

This is not a story of sudden and serendipitous good fortune, but one of methodical, thoughtful planning that can be replicated by other physicians. For me, the seeds had been planted long before I encountered a widely respected concierge physician in Delray Beach, not far from my own private practice. I had previously explored making the change to personalized medicine, but an analysis of my practice showed it was not likely to succeed with my current patient panel. Determined to find another way, I was delighted to meet Dr. Bryan Wasserman at a social gathering and learn that he wanted to retire in the next year — but not before he found a successor who would ensure continuous care for his loyal, profoundly older (average age 89) patients with multiple chronic conditions. Stepping into the shoes of this dedicated physician who had built a successful concierge practice by carefully tending to his patients’ needs represented the opportunity I was seeking.

With the help of practice transition experts Specialdocs Consultants, I lined up the other essential members of my team, including a lawyer, an accountant and a lender. The entire process was straightforward and transparent. The numbers for projected income, patient panel and practice expenses clearly showed the potential to realize a return on investment within a year or two of purchase. With the loan in place, I was ready for the next crucial phase.

The eight-month transition process was intentionally gradual, allowing ample time for Dr. Wasserman to personally endorse and introduce me. In the years since he initially launched his practice with Specialdocs, he had developed enormous loyalty and a treasure trove of fond memories among his patients

Together, we took the time needed to let each patient know my commitment to them was as strong and enduring as Dr. Wasserman’s and that they would continue to be incredibly well cared for as a member of my practice. I believe this passing of the baton was vital to the patient retention rate, which ultimately topped 85%.

I also worked with my transition team to encourage my own private practice patients to become members of the new concierge model. The message of highly personalized, preventive care; longer, unhurried appointments; and direct availability to me resonated with all. My membership panel filled up quickly and continues to expand.

There’s a richness in the relationships I have with patients that was impossible to achieve in a traditional model. I now have time to advise, educate and understand the whole patient. The experience has been career- and life-changing.

 is owner of Personalized Medical Care in Delray Beach, Florida.

My rapid journey from employed physician to thriving, independent and joyful concierge doctor

My transition to concierge medicine can be summed up most aptly by the phrase “carpe diem.” Seize the day. Although I had been considering this practice model for some time, a lightning-fast response was needed when the opportunity arose. With the support of a team of experts, my experience acquiring an established concierge practice in San Diego was swift, seamless and sweet.

Initially I cared for patients at my own clinic and then as part of a program to ease patients’ transition from hospital to home. My yearning to return to a practice centered on building relationships with patients became stronger each year, but with it came the realization that traditional fee-for-service models had evolved in exactly the opposite direction. Rushed, impersonal visits had become the unfortunate standard of care. Concierge medicine appeared to present an ideal solution, with a sustainable practice model based on membership fees and a greatly reduced patient panel that allowed individualized care. However, as a hospital-employed physician, I was missing the key to success: long-term relationships with patients.

I was stuck but found my solution when two well-regarded physicians were looking for a successor to purchase their concierge medicine practice in 2018. They had gained a reputation for clinical excellence and the loyalty of hundreds of patients over more than three decades. The only drawback: Just 90 days were given to finalize the acquisition and launch a new practice.

My emotions ran the gamut from fear to excitement. Overriding all was the strong feeling that this was a once-in-a-lifetime opportunity. But I needed to confirm that before making the leap. With the help of Specialdocs Consultants, we used every minute of that whirlwind 90 days to literally pull apart the practice and determine if acquisition was feasible. We considered everything from the current stability of the practice to the growth of the surrounding neighborhood, and we swiftly developed a transition plan. I entered my new life as a concierge doctor thrilled — but well aware of challenges ahead.

The quick ramp up gave me no time to know patients or gain their confidence before taking the reins of the practice. Every patient I saw during the first year was new to me. I am gratified to report a retention rate of more than 90%, and I’ve since added many patients of my own.

At first I frequently heard “that’s not how we used to do things.” But with patience and time, I built trust and reshaped the practice to reflect my vision. In 2020, my husband, Dr. Hector Cardenas, joined me; together, we introduced programs that became treasured offerings.

I wholeheartedly recommend concierge medicine and this unique path to it, with some advice:

Bring in the experts early. I leaned on Specialdocs’ experience and insights throughout the transition process and still do.

Assess the potential for attracting new patients by making sure the practice you acquire is in a growing, vibrant community.

Build in a period of support from the retiring physician to reassure patients that the coming “changing of the guard” is a welcome one.

Care for yourself throughout the process by practicing what you preach to patients: eat well, exercise, get sleep and manage stress. Change is challenging, but this one gives you the chance to practice medicine as you’ve always envisioned.

 is co-owner of Cardenas Internal Medicine
in San Diego.

Articles

How I changed my career and transformed my life by acquiring a concierge practice

The benefits of purchasing a concierge practice

As of early May, about 152 million Americans had received at least one dose of a COVID-19 vaccine and approximately 115 million people were fully vaccinated, according to the Centers for Disease Control and Prevention (CDC).

As the long lines of patients seeking a lifesaving vaccine begin to shorten, the physicians, nurses, pharmacists, medical technicians and other health care professionals who have been working tirelessly to administer all those shots in the arm are bracing for a new threat: liability lawsuits.

Most of the risk of medical malpractice litigation related to COVID-19 vaccines comes from the possibility that staff did not follow their own best practices, and this risk can be greatly reduced by meticulous adherence to procedures.

Here are a few things your medical practice needs to know and prepare for as the public health campaign to quickly administer COVID-19 vaccines spurs a wave of litigation.

The Public Readiness and Emergency Preparedness (PREP) Act provides immunity from legal liability for covered persons who work on the development, testing, manufacturing and distribution of the vaccine (e.g., wholesalers, retailers, repackers, and common and contract carriers), plus those who are authorized to administer or dispense the vaccine.

As part of the public health push to get more people vaccinated quickly, several amendments to the PREP Act have expanded the list of professionals qualified to administer the vaccine. In addition to physicians, physicians’ assistants, nurses and emergency medical technicians, the list now includes dentists, podiatrists, veterinarians, midwives, health care students trained on vaccine injections, recently retired professionals and others.

There is much confusion and uncertainty about whether normal medical malpractice insurance covers litigation related to the COVID-19 vaccines.

If a professional is authorized to administer vaccines, they would be a “qualified person” under the PREP Act’s immunity, so it may be a moot point; however, if a lawsuit is filed against a vaccine administrator, they would still need a defense attorney to file the necessary motions to dismiss while invoking the PREP Act. This costs money. It is anticipated that these types of lawsuits would fall under medical malpractice and/or ordinary negligence, depending on the wording of the complaint. In any event, it would be prudent for a practitioner to have this discussion with their insurance carrier to be sure coverage exists in the event that a lawsuit is filed against them.

Despite the PREP Act’s broad immunity coverage, plaintiffs’ attorneys have already been filing complaints in many jurisdictions to test the waters for possible wins that could set precedent in other venues.

There will also likely be litigation around the one exception to the PREP Act in which liability immunity gets suspended: death or serious physical injury caused by “willful misconduct.” To overcome the willful misconduct hurdle, a plaintiff must show that the vaccine administrator acted intentionally to achieve a wrongful purpose, knowingly without legal or factual justification, and in disregard of a known or obvious risk that is so great as to make it highly probable that the harm will outweigh the benefit — all of which results in serious physical injury or death. Serious injuries include those that are life threatening, permanently impair a body function, permanently damage a body structure or require medical intervention to avoid such permanency.

Even if there are some isolated cases in which serious injury or death can be conclusively tied directly to the administration of a COVID-19 vaccine, those individuals may be eligible to receive compensation through the Countermeasures Injury Compensation Program.

Medical practices must be able to demonstrate that they have fully trained their staff and adopted protocols to carefully follow the CDC’s COVID-19 Vaccine Storage and Handling Toolkit. Those guidelines were developed in collaboration with vaccine manufacturers, scientific studies and public health officials and are revised or updated periodically.

Each practice should write and adopt standard operating procedures for vaccine storage and handling and document the dates of staff training for each person who will be involved in their vaccine program.

It’s also important to look for and adopt updated guidelines from the CDC when they are issued.

The early toolkits didn’t address the importance of maintenance and temperature validation checks to vaccine storage units, for example, but that issue is addressed in the 65-page toolkit released in March.

A faulty seal on the door of a cold storage unit could compromise the potency of the vaccine, and dormitory-style combination refrigerator/freezer units are specifically banned. Practices must only use purpose-built or pharmaceutical-grade units.

As always, the best defense is a good offense. Encourage all staff to have meticulous record-keeping practices and proactively look for opportunities to spot check or conduct double verification of important data or documents.

Something as simple as sloppy handwriting could be problematic in front of a jury. A carelessly scribbled number nine might look like a seven on first glance, for example. If there is ever any doubt, pause, double check and verify.

Should a patient complaint, threat of a lawsuit or litigation occur, ensure that all staff follow protocols for preserving patient charts, check-in and release logs, handwritten notes, notes about verbal conversations, voicemails, emails and other records that will be discoverable. Never alter a record or perform an unscheduled records purge.

Every physician practice should be working proactively with an attorney who is experienced in medical malpractice and liability litigation defense to plan and prepare for possible COVID-19 vaccine litigation.

That preparation should include a comprehensive review of current policies, procedures, staff training, documentation practices and other areas of potential exposure. Having a solid plan in place improves the defensibility of any claim that could arise and allows health care professionals to deal with possible litigation in a more confident way.

James R. Embrey Jr., J.D., is a partner with Hall Booth Smith, P.C. Send your legal questions to medec@mjhlifesciences.com.

What physicians need to know about the risks

COVID-19 vaccines  and medical liability

The flourishing of telehealth in 2020 was driven not just by necessity, but also by a significant loosening of governmental regulations and of reimbursement requirements by payers. Waivers were granted during the public health emergency that allowed the use of traditionally noncompliant communications platforms, such as FaceTime and other consumer-level technologies. Practices have been able to grab most any technology and expect to get paid for the appointment.

Today, both states and payers are already changing their rules and laws rapidly. A good first step for many practices is to wean themselves away from noncompliant communications to immediate implementation of a Health Insurance Portability and Accountability Act-compliant telehealth solution, which will be essential when the public health emergency is terminated.

To ensure that you will continue to be paid for your telehealth services, here are three best practices to be aware of:

Check to see if your state has proposed or passed legislation requiring insurance companies to cover telehealth.

Your local medical societies are often a good source of this information. Several states are already passing regulations regarding telehealth reimbursement requirements. Determine exactly what the regulations are in your state, whom they affect and when they go into effect.

Closely monitor bulletins and announcements regarding telehealth from any insurance payers that your practice accepts.

Payer policies are changing rapidly and unexpectedly. Do not assume that policies that applied in 2020 will continue. Make monitoring of payer policies at least a monthly discipline.

When you verify that a particular patient’s insurance accepts telehealth, determine if the coverage specifies the use of the payer’s approved telehealth vendor only. In that case, appointments conducted on the practice’s telehealth platform may not be covered. In some cases, state telehealth regulations might specify that the telehealth appointment must be allowed to be conducted with the patient’s regular provider, which could supersede the payer’s requirements. However, even if your state has such a requirement, be extra careful in 2021. There may be a gap between the implementation of state requirements and the provider contracts and policies that would postpone application of the state requirements until 2022.

What many providers and their staff may also not realize is that Employee Retirement Income Security Act rules override state laws regarding employer-based plans, so it is not safe to assume that a health plan covers telehealth services under the state-mandated guidelines. Always confirm the specific plan benefits for telehealth, and instruct billing staff to watch for payment discrepancies as the situation with the public health emergency evolves.

Update and clarify your practice’s financial policy regarding collection of copays for telehealth services.

To provide much-needed care during the pandemic, policies regarding collection of copays became very lax in many health care practices. Now is the time to remedy that. A clearly stated practice of collecting patient payments before service, just as would be done if the patient came into the office, should be in place, and practices should not hesitate to reschedule appointments if payments aren’t made. A procedure to maintain a credit card on file simplifies timely payments. Make sure patients receive a copy of your policies so that they know what and how much to expect to pay. When patients are unclear as to the amount owed, they tend to put off paying their health care bills.

There’s no doubt that telehealth is here to stay. Both practitioners and patients have discovered that telehealth is a viable approach to health care delivery. In fact, patients love the convenience of telehealth and now expect it as a delivery option. If a practice doesn’t offer telehealth, patients may go elsewhere. Therefore, it’s critical that independent practices stop considering telehealth a fortunate stopgap and make sure they are laying the groundwork to make telehealth a robust part of their care delivery — and their bottom line.

3 best practices you must implement to stay compliant and collect maximum reimbursement.

How to keep getting paid for telehealth in 2021

Virtually every medical practice relies on technology for some aspect of care, from electronic medical records to billing. The move to bring health care online was meant to make medical care more efficient, but it also made the industry more vulnerable to cyberattacks.

According to a report from the Herjavec Group and Cybersecurity Ventures, ransomware attacks on health care organizations quadrupled between 2017 and 2020, and more than 93% of health care organizations had some kind of data breach over the last few years. Email is a big weak spot when it comes to cybersecurity risks, and email phishing scams exploded during the COVID-19 pandemic, according to the cybersecurity firm KnowBe4. The problem is only expected to get worse, with some experts predicting that cyberattacks will increase fivefold between 2020 and 2021.

These increasing threats have led to the evolution of cyberliability coverage. Like malpractice insurance for cyberattacks, these policies can help offer protection if your practice’s data is breached or taken for ransom. Keep reading to learn what these policies cover, what they cost and why the need for cyberliability insurance is increasing.

Personal health information is protected by federal Health Insurance Portability and Accountability Act of 1996 and, while one might think this increases the privacy of this information, it also increases the risk health care practices face if this information is stolen.

Janel Loud-Mahany, senior vice president of underwriting and policyholder services at Copic, says health care is a prime target for cyberattacks because of the wealth of valuable patient information organizations store, such as birthdates, Social Security numbers and billing information. Copic is a medical liability insurance carrier that specializes in coverage for health care providers and organizations.

“We are seeing increased sophistication of cybercriminals, a growing base of connected devices, increased use of telehealth and human error all contributing to cybersecurity risks that are being exploited,” she says.

Matt Sherman, senior vice president of reinsurance and programs at Tokio Marine HCC-Cyber & Professional Lines Group, says cyberliability insurance began as a matter of privacy protection but has really evolved over the years. Privacy violations from patient records that were exposed by employee error were the main cause of loss, he explains, but now extortion through hacking is the bigger risk.

“What’s changed in the last couple of years is the proliferation of threat actors,” Sherman says. “Hacking is not new, but the business of extorting people for private information is skyrocketing in the last 36 to 48 months, and health care is at the epicenter of that issue.”

This is partly because many health care providers do not have the proper network and system protections needed against malware that infects and locks their systems containing personal patient information. The Health Insurance Portability and Accountability Act and other regulatory frameworks require notification in the event there is exposure of that information. To make matters worse, he says, advanced ransomware and the complexity of health care technology mean that many organizations are behind when it comes to protecting themselves against these threats.

“The systems that small offices are using are not up to the same level as finance and commercial businesses,” Sherman says, adding that the migration to electronic medical records has only made the problem worse.

The COVID-19 pandemic also increased the risk of cybercrime because health care providers had to scramble to transmit information and provide care in new ways, Sherman says. The rush to provide the same care without delay during lockdowns meant that many were doing their work in new ways without much security or preparation, he explains. There was also a rise in scams and hacking of personal devices used for health care work.

Lee Kim, director of privacy and security at Healthcare Information and Management Systems Society North America, agrees that the COVID-19 pandemic has increased problems with cybersecurity, mostly due to the larger perimeter health care organizations created through increased remote work and telehealth.

“Previously, most IT assets and personnel were located within the walls of the hospital,” Kim says. “Now, though, many personnel are working beyond the hospital walls, such as from their homes. Thus, we’re vulnerable since we’re dealing with a lot of fluidity.”

Disruption of IT operations and clinical information systems, destruction of data and patient safety risks — especially in regard to the functioning of medical equipment or devices — are the major concerns when it comes to cyberliability risks in health care. Even worse, breaches can occur undetected for long periods, she adds.

“Many are unaware that their health care organizations are experiencing security incidents,” Kim says. “Being willfully blind will not make the problem any less. Situational awareness and robust defenses are keys to maintaining the fortress.”

Employee negligence is a leading cause of cyberlosses, Loud-Mahany adds, with cybercriminals tricking workers into providing login or credit card information. General awareness and concern about cyberattacks is increasing across the health care industry regardless of hospital or practice size.

Different insurers also provide varying levels of insurance. In many cases, a low limit of coverage may be included as a standard part of a professional liability plan. The dollar amount of coverage may vary, and limits can be increased through add-ons to those policies. The cost to increase coverage is usually based on practice size, using the number of physicians or revenue amounts as a unit of measurement.

Cyberliability insurance plans are often embedded into medical professional liability insurance policies and can include coverage for:

defense costs/fines associated with a data breach;

damage to network assets and interruption expenses;

fines and penalties levied by the Payment Card Industry Data Security Standards Council; and

loss of revenue directly resulting from an adverse media report and/or notification to customers of a security or privacy breach.

While many of the damages that can occur in a cyberattack are covered by these policies, no policy is all-inclusive, Loud-Mahany says. Every policy has exclusions, and it’s important to read the entire policy to understand specific coverage restrictions. Examples of acts that might be excluded from cyberliability plans are intentional crimes and employee sabotage, she explains.

Most cyberliability plans cover a mixture of first- and third-party coverage components, Sherman says. For breach notification, health care organizations may need to hire a lawyer, a breach coach, or even a public relations team. Smaller practices might think this doesn’t cost enough or that their practice isn’t large enough for the insurance cost to be worthwhile, but the entire process is time-consuming and costly.

Sherman says his organization manages more than 2,000 breach events each year and most of those are in the health care industry. Smaller practices might think they have less risk than larger organizations, but he says they are actually the most vulnerable because they are using generic email accounts like Gmail or they lack protection software.

“This leaves health care practices exposed, and the first time you realize this shouldn’t be an actual breach,” Sherman says. Practices then have to figure out how to restore their operations and get back to business as soon as possible.

In cases of extortion, hackers can gain access to an entire system, forcing doctors to lose access to their entire network, Sherman says. You may have to pay a ransom or figure out other ways to restore the system and even look into forensics to recover files.

Even phishing scams have become more sophisticated, Sherman says. Scammers don’t rely on pleas for cash from some overseas stranded royal anymore. Instead, hackers can mimic an organization’s aesthetic and email address to pose as a vendor or provider.

“We all get spam. These hackers are sending out tens of thousands of spoofed emails at a time in hopes that a few make money,” Sherman says. “Add to that the fact that doctors are vulnerable and inclined to make ransom payments.”

Public perception is a big part of this vulnerability, too, Sherman explains. Privacy is a big concern in health care, and patients who feel as though their privacy has been compromised may be hesitant to continue working with an organization.

One big question when it comes to cyberliability insurance is coverage of bodily harm. This could happen when medical operations are hacked and medical devices are affected. Coverage for a device that malfunctions or doesn’t work because of a cybercrime and results in bodily harm to a patient varies by policy, Sherman says. Insurers debate where cyberliability insurance ends and medical malpractice coverage begins.

“Bodily injury is a very gray area,” Sherman says. “We don’t intend to cover anything a medical professional policy would already cover. That’s the evolution of it.”

Other nuances of coverage depend on the policy, too. Sherman says some policies are starting to exclude things like major cyberevents that cause dependent business interruptions. For example, if a state’s power grid were hacked, shutting down power in large areas, a cyberliability policy may exclude problems related to that larger systemic event — even though these disruptions could cost billions in losses.

Costs are a huge factor in cybersecurity and liability plans. While these policies may seem like a big investment on top of other security measures, Loud-Mahany says a 2020 report by IBM/Ponemon Institute revealed that health care has the highest industry cost for data breaches containing personally identifiable customer information. She says analysis of these breaches shows that stolen patient records can cost health care providers about $429 per patient —roughly triple the loss from stolen data in other industries.

“Like other types of insurance, people should look at the resources available to them that help prevent issues from occurring and tools that support efforts to identify and address risks proactively,” Loud-Mahany says. “One of the biggest impacts a cyberissue can have is reputational damage. Good coverage will hopefully mitigate the effects a cyberissue has on your business and a big part of this is having a support team ready to help walk you through the necessary actions that should be taken.”

As the risk and frequency of cybercrimes against health care organizations increase, Loud-Mahany says premium costs are increasing as well.

“In order to increase limits, we’re seeing increased control requirements to prevent and limit the possibility of cyberattacks,” she says.

Many cyberliability policies are sold through other insurance companies as part of a larger medical liability plan, Sherman says. Limits are usually set relatively low, at about $50,000 to $100,000 worth of coverage. The insurance company may then offer additional coverage for an extra fee as a benefit to existing customers, he says. For this reason, health care organizations usually get more bang for the buck when cyberliability coverage is combined with malpractice insurance. But is it enough?

The average security breach may cost a practice between $15,000 and $20,000 to resolve, according to Sherman. In that case, $50,000 to $100,000 in coverage would be enough. An extortion event, on the other hand, can cost hundreds of thousands of dollars. For this reason, some practices may elect to increase their protection — even up to $1 million.

A million-dollar policy used to cost about $1,000 for the year, but increased loss activity in the last few years has driven costs up. Now, Sherman says, a million-dollar policy will cost a smaller practice or hospital about $2,000 per year in annual premiums. A solo physician can expect to pay about $1,000 per year in cyberliability premiums, he says, while larger hospitals can pay up to $10,000 per year.

A key aspect of cyberliability management is education. Just as health insurers are increasingly interested in preventive health care, professional liability insurers who offer cyberliability insurance have an interest in making sure clients have the necessary safeguards in place.

“So many doctors are trained in a very specific profession and don’t know the real danger about how it might affect their practice,” Sherman says. “There is very basic cyberhygiene that all professionals should be practicing.”

Loud-Mahany says Copic offers several tips to help clients prevent ransomware and other security breaches:

Use two-factor authentication for a secure application access.

Deploy spam filtering and email configuration.

Install next-generation anti-virus software that provides behavior-based protection.

In the end, insurance is just a piece of what should be a larger risk mitigation strategy, Sherman says. Practices should also be using protections like two-factor authentication and cloud-based backup software on a regular basis. Tokio Marine HCC offers its clients resources on risk management strategies. Sherman says education focuses on spelling out what could happen, what it could cost a practice, what to do if a practice has been hacked, questions to ask breach consultants and how to change passwords.

“Educating the client base will make a policy more profitable than increasing insurance premiums,”
 he says.

Your practice will at some point be attacked by hackers. Are you prepared for the financial fallout that will follow?

What physicians need to know about cyberliability coverage

Cardiovascular disease remains the leading cause of death and morbidity worldwide, including in the United States.

Randolph P. Martin, M.D., FACC, FASE, FESC, emeritus professor of cardiology at Emory University Healthcare and chief medical officer for Caption Health, notes we live in an obesogenic, salty and sedentary environment, so thinking about preventative cardiology has never been more important than it is today.

“We’re in an environment now where obesity is rampant and becoming an issue for the young and old alike; our diet tends not to be conducive to healthy living, and we’re increasingly sedentary,” he says. “I try to encourage patients, family and friends to live both a heart-healthy and active life, as that will not only decrease their chances of heart attacks and strokes but help them simply feel better and more able to enjoy life.”

Following a healthy lifestyle can help prevent heart disease and the causes of heart disease, such as diabetes and hypertension. Additionally, healthy living helps prevent some significant cancers and may, in fact, help prevent other diseases like dementia and Alzheimer’s.

Internist Vicken Zeitjian, M.D., a cardiovascular fellow at The University of Texas Health Science Center at San Antonio, notes that self-care and making adjustments are a huge part of heart health.

“I recommend all my patients ... adhere to a heart-healthy diet, exercise daily or at least five times per week, aim to reach ideal body weight, ... quit bad habits like smoking and help minimize their comorbidities like treating obstructive sleep apnea, hypertension, hypercholesterolemia and diabetes,” he says.

Arash Bereliani, M.D., FACC, a clinical associate professor of medicine and cardiology at UCLA’s David Geffen School of Medicine and an attending cardiologist at Cedars-Sinai Medical Center in Los Angeles, notes the first step in promoting heart health for patients is to motivate them.

“For some patients, positive reinforcement, such as feeling better and having more energy or living long enough to see their grandchild get married, is effective,” he says. “For others, a negative reinforcement such as ‘If you don’t change your life habits or if you don’t watch your diet, you might need heart surgery soon or you might end up having a stroke’ can do the job.”

Bereliani always gives patients hope that they have a chance to prevent those conditions, adding that it’s vital you don’t cause fear or anxiety.

“I emphasize to them that they should not get scared but, rather, get motivated to take care of themselves,” he says. “The challenge as a physician is to know which tactic to use to make them understand and to motivate them the right way to take steps to take care of their heart health. Using the wrong technique could backfire and either cause more anxiety and fear, which (are) harmful, or might not do anything to change their behavior.”

He recommends that everyone older than 40 have a baseline checkup for underlying heart disease by a cardiologist who is well trained and knowledgeable in the field of prevention and who knows what tests to order.

Then there are the basics, Bereliani explains, like regular exercise, the right diet, stress reduction and a good night’s sleep. Additionally, mild to moderate alcohol consumption for patients who do not have high blood pressure or diabetes or liver disease could be beneficial.

Martin has a three-step blueprint for fostering heart health.

“My first three actions are always to listen, talk and then encourage patients to lead a heart-healthy lifestyle,” he says. “I try to be encouraging (and) sympathetic for how hard it is to do all this and give them ways to go after one thing at a time. I also try to emphasize that these steps aren’t just good for them — (they’re) good for their families, children, loved ones and friends.”

He also points patients to an August 2009 article from the 

 titled “Healthy Living is the Best Revenge,” which highlights that there are no magic pills and that the future of health care really begins with each one of us.

Explaining this to patients is one thing, but getting them to actually make the changes is quite another.

Martin finds that being a motivational listener is effective.

“Just telling a patient what to do often doesn’t help, but listening and showing empathy for how hard all of these things can be to tackle at once can help,” he says. “It’s easier to point out the gaps between where they should be and where they are — and then encourage them to make some lifestyle changes. I also make sure to keep up with my patients a lot and compliment them when they’re making progress.”

One of the key things he encourages his patients to do is know their numbers: blood pressure, weight, waist-hip measurement, cholesterol and blood sugar.

“I keep encouraging my patients. I tell them it’s tough, and we tackle one thing at a time,” Martin says. “If they’re having problems with smoking cessation, then I get them help and resources, like those from the (Centers for Disease Control and Prevention). If they’re having trouble getting active, I tell them to just start walking and give them a regime for that. I also encourage them to check out apps like those recommended by sites like the Mayo Clinic — there are blood pressure apps, stress management apps, heart rate monitor apps and so on.”

A diet rich in fruits, vegetables, high fiber, low cholesterol, monounsaturated fats instead of

saturated fats, and omega-3 fatty acids is ideal for heart health, according to Zeitjian. A Mediterranean diet also reduces the risk of cardiovascular disease.

In Bereliani’s practice, they have a program that enables the team of nurses and assistants to continuously engage with patients via phone calls, Zoom meetings and emails to make sure the patients follow his recommendations.

“Our newsletters and social media also constantly remind our patients the importance of taking care of their heart health by implementing my recommendations,” he says.

And when he realizes a patient is not following his advice, Bereliani sets up an office meeting with them to try to understand the psychology behind their nonadherence.

“Many of these patients have underlying psychological issues such as anxiety, depression or trauma,” he says. “Once I discover their psychological barrier, I either discuss the case with their family, with the permission of the patient of course, and using a team approach, we come up with a plan to address the underlying issue. Once the underlying issue has been addressed, the patient is very likely to start taking care of himself or herself.”

Preventative cardiology is one of the most important aspects of the field. Many cardiovascular

diseases such as coronary artery disease, heart failure and arrhythmias are a result of multifactorial components — principally, lifestyle habits, comorbidities and genetics.

“We can only focus on the first two,” Zeitjian says. “In terms of what you can do, think of the acronym COSHED (cholesterol, overweight, smoking, hypertension and exercise), which literally means ‘hit on the head’ (and) is figuratively what would happen if we do not focus on prevention.”

The new advancements in preventive cardiology have enabled physicians to not only determine one’s current risk of heart disease but to accurately predict one’s future risk of a heart attack or heart disease.

“If the right testing is performed and if the right treatments and prevention are implemented, no one should die of heart disease at least until at a very old age,” Bereliani says. “Unfortunately, many physicians and cardiologists either do not perform the right tests or do not implement the right preventive strategies for their patients. Most cardiologists are very good at treating heart disease when it has already occurred but not very good at preventing heart disease.”

Zeitjian notes that despite the tremendous advancements in the field, primary prevention nearly always results in longevity as opposed to secondary prevention.

“Most of my patients are referred for established cardiovascular disease, and we have medications and procedures (that) can treat them. However, they have increased morbidity and mortality despite our interventions,” he says. “No matter where you stand on the health spectrum, it is never too late to invest in yourself. Prevention can not only prolong life, but improve the quality of your life.”

Boosting patient adherence can enhance outcomes 

Motivating patients to achieve heart health

When it comes to working on behalf of health data interoperability, few people are better qualified than Micky Tripathi, Ph.D., M.P.P., the new head of the Office of the National Coordinator for Health Information Technology (ONC).

Tripathi has spent his career in the health information technology field, most recently as chief alliance officer for Arcadia, a health care data and software company. While there, he served as project manager of the Argonaut Project, an industry collaboration to accelerate the adoption of Fast Healthcare Interoperability Resources (FHIR).

Earlier, Tripathi was president and CEO of the Massachusetts eHealth Collaborative, a nonprofit health IT advisory and clinical data analytics company. Before that, he founded and was CEO of the Indiana Health Information Exchange.

® about his goals as ONC director, especially in the areas of health data interoperability and electronic health record (EHR) usability. The interview has been edited for length and clarity.

 (ME): What are your top priorities for ONC?

I divide them into two categories. One is the immediate priorities with respect to the pandemic, and those are related to trying to help with specific things like improving the scheduling experience that patients have so that vaccination gets easier.

And we’re doing a lot of work in public health. We’re working on an executive order in partnership with the CDC (Centers for Disease Control and Prevention), looking at evaluation of public health systems, evaluating what we’ve learned through the pandemic and then making some recommendations about the future.

Then we have the regular stuff that ONC does — first and foremost being interoperability. We have a couple of dimensions of that. One is information blocking. The applicability date for the (21st Century Cures Act) information blocking rule was April 5, so we’re doing a lot to educate the industry to help it move forward on that.

We also have the Trusted Exchange Framework and Common Agreement, which is the nationwide interoperability governance. The final thing I would add is we’re doing a lot of work in social determinants of health and outcome disparities and how can we think better, deeper, more broadly about how to enable health information technology to identify and help to solve the disparities in health care that exist today.

ME: I don’t usually think of HIT (health information technology) as having a role in that. Can you explain in more detail what form that would take?

Tripathi: The first step to even knowing how we’re doing with respect to health equity and health disparities is to be able to measure it, and you can’t measure it unless you’re capturing the right data so that you’re able to ask, “How am I doing once I stratify according to different demographic characteristics?”

So that’s fundamental to HIT. You’ve got to have that data capture in EHRs and then structure it in a way that you can aggregate it and run the kind of analytics to be able to understand that minority, marginalized, underserved communities are getting disparate care compared to other groups. Then ideally you want to be able to provide decision support or tools back to providers and other frontline people who are using those systems to be able to help them take actions when their areas are identified. So all of those are part of HIT.

ME: I want to go back to the 21st Century Cures Act. ONC has said its initial focus is on the elements in the core data for interoperability, such as transitions of care and clinical information reconciliation. Why focus just on those elements?

Tripathi: Information blocking covers the broader category of information called EHI, or electronic health information, which is (a of piece) of the designated record set, which is defined in HIPAA (Health Insurance Portability and Accountability Act of 1996). That’s what the Cures Act said is EHI, which is basically everything you or I might have in a provider’s office, assuming they use an EHR and whatever has been migrated to an electronic form.

So information blocking covers all of that. We recognize that it’s hard to just flip the switch overnight and say all of that should be made available on demand when we haven’t been doing that. It’s not a common practice, and systems aren’t set up to do it. Provider organizations don’t have workflows for that. We realize it’s a complicated thing to do.

So we said let’s focus at the beginning on what we call the Core Data for Interoperability, which every certified EHR system is already required to be able to generate, either in the form of a continuity-of-care document or soon in a FHIR API (application programming interface). So we said those things are already available because providers are already required to exchange those for transitions of care, for example. So why don’t we start with those, and we’ll call that EHI for the first 18 months; and after that, hopefully everyone is understanding information blocking and the workflows, and then you can open it up. And it also prepares them for how they are going to open it up beyond those data sets.

ME: Pulling back a little to the issue of interoperability generally, on a scale of 0 to 10, with zero being no ability to send data and 10 being the ability to do it as easily as we send regular emails, where would you say our health system falls now?

Tripathi: It depends on what you’re doing and what health system you’re in. For example, if you’re in an academic medical center and you’re on a fully certified EHR system that’s connected to CommonWell or Carequality or a health exchange, that exchange is actually happening in the background already, millions of times a day across the country. And that’s a continuity-of-care document that contains the CDI we were just talking about, which is 24 to 25 data elements. And those are like if you and I sat down and said what do we think are the basic elements that the physician should be able to have access to on any given day for any given patient. You and I would come up with pretty much what’s in the CDI. It’s problems, allergies, meds, dates of encounters, most recent lab results, etc.

So that’s exchanged in those systems today. It doesn’t even require effort. Providers in a large system will see it in the background and often they don’t realize that it’s come in from other places. Similarly, if you’re on any system and you want to do e-prescribing, you can do it pretty much out of the box on most EHR systems in a very automated way that’s familiar now.

On the other hand, if we’re talking about the ability to, in any setting, be able to get a record in almost any place, if you’re on like a small vendor that isn’t connected to one of these nationwide networks, then there’s going to be a gap there because all those systems haven’t adopted the technologies and not all of them are connected to the network.

The last thing I would say is we’re never going to feel like we’re at a 10 because just like when we first got our cell phone, it was pretty primitive but we thought it was the coolest thing in the world. But if we went back now and asked, “Am I satisfied with that?” the answer would be “Absolutely not. It’s terrible.”

It’s the same way today with interoperability. We’re always going to want more. Next it’s going to be what about genetic information? What about algorithms, why don’t we have those? So I don’t want to pretend there aren’t problems and gaps, but I think it depends on the use case.

ME: Doctors often complain that EHRs are designed as billing and coding tools rather than for their ability to improve clinical care. Can ONC do anything to change that?

Tripathi: We’re very sensitive to that, and we completely appreciate that clinician burden from health information technology is a huge issue. We’ve worked on the clinician burden report, and we continue to look at burden issues that come from the HIT itself as well as the things that are pushed through the HIT. One of the things we’ve started to understand as we think about these systems is that a lot of what physicians feel as “burden from the system” (are sometimes) things that organizations are pushing through the system that (physicians) didn’t do before — more documentation requirements, for example. Then the EHR gets blamed for that when it’s actually just a vehicle for things that couldn’t have been done in the paper world and now are being pushed through that system.

So we work a lot with our partners at the Office of (Burden Reduction and Health Informatics) at CMS to try and understand these burden issues and how can we reduce (them) through better usability and through reduction of some of those requirements — because some aren’t really necessary or they are very cumbersome because what naturally happens in these kinds of transitions is you take a paper process and try to ram it through an electronic system it wasn’t designed for. If you said this is an electronic system, we should think of it natively, we could probably take better advantage of the electronic tools that we have.

We do what we can to highlight those through our program on clinician burden. We also have usability as a part of the certification that vendors are supposed to go through. Then we also have things like in the next generation of EHR certification, we are requiring real-world testing rather than just testing in a laboratory, which as we know, just like with drugs, there’s a big difference between testing something in a lab and testing it with people in the real world.

ME: Is there any evidence that EHR vendors are focusing more on usability now than they were five or 10 years ago?

Tripathi: I think there is. There’s a very heterogeneous set of vendors so it’s hard to say this is true for every vendor. But I think vendors have big usability programs, and they have physicians on staff and they have programs (in which) they apply usability science as well as input from physicians who are using the system. An individual may feel frustrated by their system; they may feel like it isn’t usable. That doesn’t necessarily mean there haven’t been usability considerations behind the system. It’s just that it’s a complex system, and it can’t be perfect for everyone.

But I will add two things: Systems don’t get better without people using them and providing feedback. Software engineers sitting in a room by themselves can’t design a perfect system. They need to be able to put those in the field and get constant feedback from users. So as we’re maturing, I think we’re starting to see those systems are better.

The second thing I’d point out is that the whole move toward FHIR APIs, which are now required by ONC regulations, is that you ought to be able with your EHR to download apps and use them on your EHR, just like you do on your phone. And the beauty of an app on your phone is that when you open it, it’s usable in ways that you want it to be.

And that’s what apps in the API world promise as well — that if you’re in your EHR system, you ought to be able to have a set of apps that don’t lock you in to that EHR system. If you have a different way of doing something, you can do it through an app as well. I think that’s a really important part of usability that may not be obvious now to a lot of doctors, but it is coming in the next few years as apps and APIs start to mature.

ME: Does ONC have the ability to nudge EHR manufacturers in that direction and make sure they’re following through?

Tripathi: Absolutely. Our regulations — the information blocking rule and the corresponding EHR certification rule — require that the vendors make available FHIR APIs. And those are supposed to be open APIs so that apps from the outside can connect to them without special effort. And there’s a whole set of provisions that are part of that regulation to make sure that’s a level playing field, so you don’t have vendors trying to close out things that they see as competitive or create too many burdens for a provider to be able to get an app on to their system. There are fixed dates that the vendors are required to meet. And that’s the hope — that we can create platforms you can have apps on of your choosing. And hopefully that makes it a better experience for everyone.

A Q&A with ONC director Micky Tripathi

Bitcoin, Dogecoin, Litecoin: These may sound like collectibles from a video game, but savvy investors have turned these cryptocurrencies into an attractive vehicle for those with an appetite for risk.

In the 12 years since Bitcoin was introduced, these digital currencies have been used for things as varied as buying illicit drugs on the internet to massively overpaying for pizza. Now that companies like Tesla, Inc. and Square, Inc. have amassed hordes of the assets, what started as a project from an anonymous person or group has become the hottest trend in investing.

Although it may seem like a ticket to quick riches, experts warn investors that the young market can be volatile and that some of the actors in the space may have malicious intent.

These assets are essentially a type of decentralized digital money meant to be used over the internet and built on a technology known as blockchain, which is basically an open-source ledger that can easily be read by anyone, according to cryptocurrency trading platform Coinbase. This blockchain is maintained by large server farms called mines that compute millions of math equations to verify transactions in a race against other mines. The first mine to complete the calculations and update the ledger are rewarded with more of the currency, which has made mining an attractive prospect for those with excess computing power available.

Proponents say this decentralized foundation and the open nature of the ledger make cryptocurrency transactions more secure than traditional online payments. The prospect of being able to spend the asset for goods and services adds another layer to its appeal that normal investments can’t compete with.

But many argue that in the race to verify transactions, miners are having an outsized impact on the environment. Bill Gates, the co-founder of Microsoft, told

earlier this year that Bitcoin uses more electricity verifying each transaction than any other method, a severe liability at a time when the public and governments are trying to get serious about combatting climate change.

Zak Killermann, assistant publisher for global financial at Finder, says that first-time cryptocurrency investors should keep in mind this is still a young market undergoing regulatory changes and developments in countries around the world.

reported in March, President Joe Biden’s administration is studying gaps in oversight connected to the fledgling market, citing the wild swings in value Bitcoin saw in the opening months of 2021.

Even though established assets such as stocks have been highly regulated with different classes of stocks for different parties and established criteria and qualifications for brokers, Killermann says the cryptocurrency market is wide open at the moment.

According to Killermann, impending government regulation isn’t something to be feared because it could smooth out some of the wrinkle in cryptocurrency investing.

“I think that in a country like the U.S., it will absolutely help the market if we have more regulations so that banks can get involved,” he says. “It makes it easier to add cryptocurrencies to existing financial systems. And it makes it more clear for regular investors to add cryptocurrencies to the portfolios through existing brokers.”

Killermann recommends first-time investors do their homework and learn as much about the currency they’re looking to invest in before buying into it. He says his website, Finder.com, publishes unbiased explanations of the concepts, players and what coins are available as well as analysis of where they think the market is going. But he says it’s unwise to trust any one source of information when it comes to the fledgling market.

“The market not yet at a place where I feel comfortable pointing to one individual’s advice and saying, this person or this website or this source of information will always be correct,” he says. “So I’d always recommend at least checking two or three places before feeling comfortable with the research that you’ve done.”

Julianne Andrews, MBA, CFP, AIF, senior wealth advisor and senior director at Mercer Advisors Inc., in Atlanta, says that especially after the COVID-19 pandemic prompted some people to eschew paper money, the move to a digital-only currency is likely to come about once regulation catches up to the market. She says cryptocurrencies should fall into the part of an investor’s portfolio allocated for real assets, commodities or real estate — investments that are more volatile.

“Most advisers, if they have an allocation to commodities or real estate in their portfolio, it’s going to be 5% or less. It’s going to be a small allocation,” she says. “So it’s not a big part of the portfolio.”

Most importantly, Andrews recommends that her clients seeking to add cryptocurrencies to their portfolio create a separate account with a set amount of money in it that they’re completely comfortable losing.

The digital assets offer opportunity and risk

Medical Economics July 2021

The benefits of purchasing a concierge practice

COVID-19 vaccines and medical liability

How to keep getting paid for telehealth in 2021

What physicians need to know about cyberliability coverage

Motivating patients to achieve heart health

A Q&A with ONC director Micky Tripathi

Decoding cryptocurrency: A physician investor’s guide

E/M coding: Can you bill multiple same-day visits?

4 areas to address to improve your bottom line

5 things to consider when making a financial plan

The link between financial success and patient satisfaction

Should physicians day-trade stocks?

Investing in the post-COVID stock market

Going the extra mile to make patients feel welcome

Building wealth