Thursday, April 26, 2018

5 Ideas for Managing Physicians' Outside Activities

Almost every physician contract I review contains a provision limiting the physician’s ability to engage in “outside activities,” such as consulting, speaking, outside research, expert witness testimony, or even moonlighting.


However, physician practices rarely go far enough in monitoring their physicians’ outside activities and taking the steps necessary to protect the practice from possible liability, including conflicts of interest that may implicate federal law.

Recently, I worked with a client that permitted its physician-employees to engage in outside activities as long as they “disclosed” such activities to the employer. One physician, who rendered research activities through a separate entity he owned, ended up being subpoenaed in a government investigation. Unfortunately, the practice was also drawn into the investigation and the physician’s counsel was able to make a claim on the practice’s directors and officers liability insurance policy for such outside activities.

For many practices, the above scenario is a real possibility. Physician practices must take the time to evaluate their policies related to “outside activities."

The following are some ideas to consider:

1. Every employment agreement should restrict a physician from engaging in any outside activities without written approval by the employer. Although many physicians (and their counsel) find this unfair, there are many reasons why this is reasonable to require. Simple “notice” of the outside activity is insufficient to protect the practice in most cases and may be deemed to automatically suggest the activity was approved/consented to by the practice, thus implicating the practice’s insurance coverage.

2. The practice should have every physician complete a questionnaire concerning outside affiliations and organizations, at least annually. The practice should work with counsel, taking into account the practice’s specialty, to develop the appropriate questions to include. For example, the questionnaire should inquire whether each physician (or an immediate family member) owns, holds a position with, and receives any payments, royalties or other amounts from an outside healthcare entity unaffiliated with the practice. It is also important to know whether such entity does business directly or indirectly with the practice, particularly as it may relate to pharmaceutical, device and similar companies.

The physician should be required to advise the practice of any changes within 30 days and failure to comply, and/or falsification of responses, should be possible grounds for termination. The information collected from the questionnaire should be closely reviewed by the practice, with counsel as appropriate, to assure that there are no potential legal issues to be addressed (such as Stark self-referrals, Anti-Kickback, Sunshine Act, etc.).

3. Every practice should have a policy advising on the practice’s stance regarding outside activities. For example, the policy might set forth the following: the process for obtaining consent to outside activities; how payments are handled’ the amount/type of insurance required for the outside activity; events that require notice to the practice (i.e. investigation); clarification on intellectual property ownership; a requirement that the practice be indemnified in writing by the physician (and outside entity) related to such outside activity; and a requirement that the physician provide any written agreement with the outside entity for the practice to review.

4. In many cases, practices mandate, as a condition of approval, that the agreement for the outside services incorporate the practice’s own “Terms and Conditions,” as an exhibit. This exhibit then incorporates into the third-party agreement the practice’s desired terms related to indemnification language, intellectual property rights, insurance, control over the physician, etc. I have found this to be an effective approach to protect my clients, but it must be properly done to be sure the practice’s document controls.

5. Make sure the practice has adequate insurance coverage and determine what type of language might be required to minimize risk of a claim being successfully brought for a physician’s outside services. Determine whether each outside activity needs to be specifically excluded from the policy.

Because every practice is different, it is important to evaluate its specific needs and concerns when developing appropriate policies on outside activities. Any time and legal expense required to develop such practice documents are likely to be far less than the possible consequences of failing to so.

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Tuesday, April 24, 2018

Wading through the Quantity—and Quality—of EHR Data

Ninety-five pages and I still couldn’t locate the patient’s phone number. One of my patients was recently admitted to an area hospital which is part of a different health care system and a different EHR. The hospitalization was complicated and lengthy and involved home health care afterwards.


To the credit of the health system, they sent me almost all the information I could want: 95 pages of it.

When I plopped that pile of papers on my desk, it took me back to my third year of medical school during my medicine rotation. That was before EHRs, and every admission required a careful review of the patient’s entire medical record. Those were the days when an echocardiogram result might be buried between a Pap smear and refill request. Since there was an attending physician, senior resident, junior resident, intern, fourth-year medical student, and third-year medical student all on the case, it was less likely that we would all miss a relevant piece of information. For those not part of a teaching program, it was usually the primary care doctor who was admitting and following the patient during a hospital stay, so the patients were often already known well.

Today in clinic I saw a patient who I was concerned was in atrial fibrillation. I asked her daughter if her mom had ever been in atrial fibrillation. The daughter told me it didn’t sound familiar. Back in the day, I would’ve poured over a thick file of medical information (or multiple volumes) looking at all the EKGs to see if it had ever been diagnosed. Now, I just enter “atrial fibrillation” into the search bar and the entire record is scanned in an instant. It’s good we have that type of electronic system because medicine is complex in a way today that it wasn’t when I was a medical student. Part of the complexity is the very presence of an EHR in which the quantity of information is exactly what makes finding the right information so difficult. Part of it is that a faceless colleague across town admitted, cared for, and discharged my patient. It is so much easier, in many ways, to provide good care when you are providing the full spectrum of care. And a final part is that what is missing is what I really need – that three-minute conversation in the doctor’s lounge that summarizes my patient’s clinical situation in a way that no amount of paper or electronic pieces of data ever could.

For my recently discharged patient, I requested a social worker to see her at home. The number listed in our system had been disconnected, so they reached out to me to find out if I had another number. Ah-ha! I had 95 pages of information. Surely, the number would be easy to find. And, the phone number was easy to find on page 3.

Unfortunately, it was the same number we had and was still disconnected. This is how I often feel when facing the EHR – so many pieces of information and still I can’t find the one piece of data I actually need.

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Saturday, April 21, 2018

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An App that Helps Physicians Focus on Wellbeing

As physicians, we tend to care for the wellbeing of others such as our patients or our family members. But we tend to neglect another important person — us. By nature, I believe that is how most of us are hardwired. We’ll get to ourselves in a little bit after I take care of this for so and so and do this for such and such. But honestly how often do you actually return to yourself? Not doing so can lead to stress and burnout.


Aura is an app that claims to target stress, anxiety, and depression. It is a perfect option for people who are looking to increase their daily mindfulness practice by using a simple app. It allows the user to start their day with tailored meditation practices that help them have a positive mindset throughout their day. These can be a short three minute (or seven minute with subscription) guided meditations that will allow users to form a healthy morning and evening routine that helps them live a happier life. If a short meditation isn’t enough, you can listen to relaxing sounds or try the "Mindful Breather" feature, which shows an animated circle that expands and contracts. You need to synchronize your breath to the circle. The home screen also encourages you to write down something you are grateful, which acts as another tool for well being.


It is a great app if you are at the start of focusing on personal wellness. It is not complicated in terms of its interface. It is also great for those who do not have time to meditate. The app provides a short simple meditation a day which might be all that you need.


As you use the app more and become more mindful of the meditations, consistency develops. You can provide the app feedback following each session, as well as on your overall mood and the mindset it helps to create for you. The feedback helps tailor your next meditation session to what you need and want.


Even though there is a subscription model to this app, the free version allows anyone to listen to meditations designed for specific moods anytime of the day. You can also set goals for each day and sync the to Google calendar to monitor your progress.


As I mentioned there are two tiers to the app


There is the Basic Aura app which is free and available for both iOS (Apple) devices and Android devices. The free option provides you:

-3-minute meditations every morning

-Mindful Breather plus reminders

-Nature sounds for unguided meditations

-Gratitude reflections

-Daily goal monitoring with Google Calendar integration

-Personalized meditations


Then there is Aura Premium. This is an in app purchase to the subscription model, which you sign up for. The subscription version can cost $11.99 monthly. There is also an annual subscription offered for $94.99 (which breaks down to $7.92 per month). There is also a lifetime subscription for a whopping $399, which is a one-time purchase. If you look online you may be able to find some special offers like I did. I was able to purchase a lifetime subscription for just $60. Not only do you receive the aforementioned features from the free tier, but you also gain access to

-Unlimited meditations based on your emotions

-3 or 7-minute meditation durations based on your availability and comfort

-Full mood tracking


After using it for some time, it provides me a moment where I begin my day energized and focused. I find as health care providers, we tend to be hypocritical when it come to caring for ourselves. We need to focus on us as much as we focus on those we care for. Let Aura provide you that moment in your day to re-center yourself, re-focus yourself, and rejuvenate mentally in our crazy and hectic worlds.


I give Aura 3 ½ /4 stethoscopes


Pros:

Easily fits into one’s schedule with short sessions

Uses machine learning to customize your meditations

Monitor your progress

Clean, uncluttered interface

iOS and Android compatible

Also compatible for iPads, Apple Watch

Feature packed free tier

Great for beginners


Cons:

To unlock all features, subscription model required

Cost can be prohibitive (look online to find deals, I found a lifetime subscription for $60)


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