App review: Virtualized bystander CPR training

Each year, 475,000 Americans die from cardiac arrest, according to the American Heart Association (AHA). More than 350,000 cardiac arrests, nearly 75 percent, occur outside of the hospital. Ninety percent of those who experience an out-of-hospital cardiac arrest die. However, studies show that almost 45 percent of those who experience an out-of-hospital cardiac arrest survive when a bystander administers CPR. Unfortunately, only about 46 percent of those suffering from an out-of-hospital cardiac arrest received bystander CPR.


Why then, if the studies show that earlier administration of CPR results in better outcomes, is bystander CPR administered less than half the time? It could be related to bystanders not having prior training. They could be fearful of causing more harm if CPR is performed incorrectly. They could be sitting on the sideline waiting for someone else. They could be concerned about spreading or receiving an illness as a result of performing CPR. Or, they could be concerned about the false idea of having mouth-to-mouth contact with a stranger; the current recommendations for layperson CPR are chest compressions only. Whatever the reason(s)—from self-doubt to being grossed out—it is my opinion that we need to help educate bystanders on how to perform CPR in a pinch, should the situation arise.


The more I thought about it, the more I wondered if there were apps designed for laypeople, non-healthcare professionals, that could help train them by virtually placing them in a situation as a potential bystander. I specifically looked at apps that provided a virtual reality (VR) experience. These apps do require some form of device to place your phone into to get the full experience. They can range from a Google Cardboard VR display to any of the multiple plastic devices you can find on Amazon. I used the View-Master VR Headset to review the following five apps.

CPR Training

CPR Training, created by Warp Industries BV, is a free app that requires the user to wear a VR headset. After a brief instructional tutorial, you are “warped” into a scenario at a mall where you witness an elderly man collapse due to cardiac arrest. You are then tasked to select the correct option from a list of at most four options based on the situation.


The application does an excellent job of building the scenario and allows you to look around in all directions. Despite the excellent VR, the overall experience was rather clunky. Scenarios would end suddenly without explanation, and there is no education to reinforce or correct mistakes.

Virtual CPR

VirtualCPR does not require a VR headset. Instead, the app, created by Virtualware 2007, places you in a scenario of a virtual body that can perform basic life support. It appears that you can log in if you have an account, but it was not specifically spelled out, nor was there a readily seen help option. I could access the tutorial, which allows you to enter the simulation. The interface was cluttered and didn’t identify labels for the given options. The tutorial took you through step-by-step as to what needed to be performed on the simulator.


It gamified the basic life support procedures and scored you on how well your compressions were, calculated by percent ineffective compressions versus percent effective compressions, response time. It was quite basic, and I was rather disappointed I couldn't get into the actual app to try the scenarios.


There were few customizations during the scenario you could select. For example, if your compressions were ineffective, you could turn on the metronome that plays The Bee Gees’ hit song “Staying Alive” to sync your compressions to the rhythm. It was OK, but I still felt there could be an app that provided a better experience for the layperson.

VR Clinic

The app VR Clinic, created by Mad development Co, gave me more of what I was looking for. Like the others, this app is also free. Once you download the app on your phone, you can choose which scenario you want: adult, child, or infant. The scenarios include one-person rescue, two-person rescue, and choking.


The application educates you by having you watch a virtual movie/scenario first. You then move onto the “testing” option, which lets you pick the appropriate step from floating options based on the current situation. It then scores you and reviews any mistakes or missteps.


You are also given the option to use the app with or without a VR helmet. The VR helmet offers an immersive experience. You can look all around the setting you are in. The situations tend to be more of a choose your own adventure but could be a useful option to prepare laypeople. It is the only app I used that offered scenarios for children or infants.

Virtual Rescue Hero and Virtual Rescue Mobile

These two apps are variations of each other. Both were created by VR Lab BV for Zoll. Both require a VR helmet, and they take you through a scenario of being outside an office building when someone collapses. Where the two apps diverge is the approach to how they present the scenario:
The Virtual Rescue Hero presents the scenario as a virtual movie. You float over the bystander who is performing compressions and utilizing the Zoll automated external defibrillator (AED). The AED provides you a metronome to keep your compressions in sync. It also tells you if your compressions are ineffective and need to push harder.

The Virtual Rescue Mobile puts you in the shoes of the bystander. You can actually place your hands on a sofa cushion as you look down on the virtual patient and perform chest compressions. As you are performing the chest compressions, you can actually see the chest rise and fall on the patient.


Granted these apps are an advertisement for Zoll AEDs, they provide a good sense of immersion and interaction I would expect the average bystander to have in real-life.


Many of the apps were good in terms of providing basic information and placing bystanders in clinical scenarios to recognize, activate, and begin the chain of survival. I feel the Zoll apps and the VR Clinic would be a good place for laypeople to start. These apps can help build confidence so if they were in that scenario, they could potentially change an outcome of out-of-hospital cardiac arrest.


These apps are still not a replacement for basic CPR certification but hopefully they would encourage laypeople to take action if the opportunity presents itself. Something these apps could do better with regards to bystander CPR is to be more current with the AHA’s recommendations.


With AEDs more ubiquitous in public settings, I would hope that these apps could empower laypeople to take it upon themselves to administer CPR and save a life instead of watching helplessly and waiting for someone else. Time is muscle!

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Negotiating your contracts: Hidden pitfalls and traps

Negotiating and reviewing contracts is probably one of the more unnerving task physicians face. That’s good! Your subconscious is sending you “danger” signals. You simply need to channel this emotion into action to protect yourself.


Sales representatives are very good at selling the benefits of their company’s product to you and your practice, with emphasis on how these benefits outweigh the cost. Essentially, the sales meeting is all about what happens if everything goes as planned. You should never agree to the deal as presented until you are provided a contract and understand the terms thoroughly. The contract spells out what happens when things go wrong. Keep the following in mind before you sign any contract.

Sales personnel will tell you anything to make a sale.

That’s what they do. Watch for it and remember that the contract is what you are bound by. When you receive the contract, read it carefully to note where the contract deviates from the sales pitch and to determine which of three possible types of contracts you have been handed: “A”, “B” and “C”. “A” is very favorable to you. “B” is fair and balanced–so much so that you honestly can’t tell which side drafted it. “C” is only favorable to the seller. These are full of one-sided indemnity clauses, penalties, restrictive covenants, and other legal results which were never negotiated.


Under contract law, a contract is enforceable unless it is illegal or violates public policy. That means, “if you sign it, you are stuck with it, unless your lawyer can get you out.” There are consumer protection laws, but litigating them is very expensive. Retain a lawyer to review a contract before you sign it. After you sign it, all we can do is read it to you, and tell you what you have done to yourself.

Do not be swayed by promises of cost savings.

For every business need, there is a solution that is cheaper, quicker, and has disaster written all over it. Large, well-capitalized companies often offer the best services or products but cost more than smaller competitors and are less likely to negotiate contracts. This leaves plenty of room for startups of all stripes to attempt to undercut the industry leader. Smaller companies may negotiate but are more likely to present a “C” contract, because they are undercapitalized and can’t afford liability when things go wrong. So, they write liability out of the contract.

Beta testing is code for “we don’t know what we are doing but are hoping for the best.”

Watch out for signs a startup or small vendor is trying their product to see if it works. It means they don’t really know and can’t really say if it works. This also means you are the test case. Ask for references and check them.

Beware lockout provisions.

When you sign a contract for billing and EHR systems, in a very real sense, the vendor controls your access to the life blood of your practice. Many software as a service (SaaS) agreements often allow for a “lockout” if you don’t pay, for any reason. You must make sure that you have a right to your data in a usable form no matter why the contract is terminated.

Keep bona fide purchasers in mind.

In many cases, you, the simple purchaser, may be asked to sign more than just an SaaS contract. The vendor may produce a finance contract, which is a type of negotiable instrument, called a “promissory note.” Under the promissory note, you become not only a purchaser, but also a debtor, who promises to pay the payee the total obligation under the SaaS contract. This can have very negative consequences because you may be required to pay the note, even if the SaaS doesn’t work. Even if the SaaS vendor is the payee, the note will usually be sold to a bank or finance company unrelated to the vendor. When that happens, the bank or finance company is considered a bona fide purchaser if it pays value to purchase the note without knowledge of any defenses or reasons why the note might not be owed, such as the product is defective. This means you still must pay the bona fide purchaser note even if the product failed, the same as if you had paid cash up front. Your only recourse is against the vendor. And that is where the “disclaimer of warranties” in a “C” contract will become a real problem.


In conclusion, no matter how well the sales presentation might have gone, always remember these final words, “I need to see the contract before I decide,” and you are well on your way to successfully negotiating the entire transaction.

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6 back office billing strategies

The front desk staff is essential for checking in patients, collecting copays, and verifying insurance. But there’s more to the story, and out of sight doesn’t mean out of mind. Much of the heavy lifting for billing and collections is done in the back office, so it’s even more important to have a deep bench of talent, says Tammie Olson, manager and coding and compliance strategist at Management Resource Group.

In this two-part series, Olson, who works at the Ocean Springs, Miss., firm, offers financial management and support services for the healthcare community. She shares six ways to get your back office team to bring their best game to your billing and collections efforts. Click here to see her suggestions for the front office.


Train select employees to set up payment plans. Often, the front desk will discover the need to set up a payment plan with self-pay patients or patients with an outstanding balance. But the actual arrangement is made by the back office staff. It’s crucial these plans be consistent and fair for all patients. You need to have one or two people in your back office who know how to correctly set up plans. Training back office staff will also alleviate the pressure on the front desk to make decisions about waiving payments—or let their emotions clout their decision-making.


Reconcile encounter forms and bill claims daily. If there are any questions about the services rendered, seek clarification from the provider. Your billers should be knowledgeable about appropriate modifiers and when to use them. Make sure your billers are submitting clean claims.

Clean claims get paid the first time around and stand up to a potential audit.

Analyze insurance denials and develop processes to reduce them. Is there misuse of modifiers? Are denials related to medical necessity? Outdated codes? If you make the effort to track the denials and see where you’re making mistakes, the time spent will be rewarded with higher and prompter payments. Similarly, have processes in place for correcting and refiling denied claims in a timely manner.


Follow up on accounts receivable daily. Run insurance aging reports and review anything more than 60 days old. You may have to call the payer in some cases, but most claims pay within 21 to 30 days of submission. If this is not the case, you need to investigate what’s going on.


Conduct patient flow analyses regularly. Time is money, and anytime there is a patient flow problem, it costs the practice. The office manager or practice manager should analyze patient flow for all services provided, find problems, and identify ways to streamline the processes. For example, you might perform a patient flow study. This will tell you how long it takes patients to complete the check-in process and be placed in the exam room. This will help you track and streamline processes at the front desk. A shorter check-in process can improve patient satisfaction and help keep providers from falling behind schedule.


Designate one person to follow-up on patient balances. Your front office is making sure patients are aware of their balances. Someone in the back needs to be tasked with calling the patients and asking for payments. Many practices outsource this responsibility. It’s less important who makes the calls so long as follow-ups are conducted on an ongoing and regular basis.


When the back office takes these tasks seriously, processes proceed more smoothly throughout the practice. When that happens, your bottom-line will see a bump in revenue. That’s a bonus for everyone in the practice.

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App Review: MDCalc

One of the tools a physician uses every day is a calculator. No, not just the simple ones that are used to add, subtract, multiply, and divide. These are medical calculators that help healthcare providers make critical decisions based on likelihood and evidence.


In a perfect world, these clinical tools would be a standard electronic health record (EHR) tool to provide meaningful use to both providers and the patients they are caring for. But alas, they are not. Next to my stethoscope, my smartphone is the most important tool I carry with me. When I pick up my smartphone to use a medical calculator tool, my go-to app is MDCalc.


MDCalc is the brainchild of two emergency physicians: Joe Habboushe, MD, MBA, and Graham Walker, MD. Since 2005, they have provided registered users free access to hundreds of clinical calculators from multiple specialties. In 2016, they released their mobile application for both Android and iOS platforms.


If you have used their website, the app will look quite familiar. The green banner on white background with black text and pops of yellow provide a clean interface. There is a large search bar at the top. A notification bell icon to the right of the search bar indicates any updates to current calculators or new additions. Beneath the search are four icons: Favorites, Recent, My Specialty, and All.


As its name suggests, Favorites are where you can quickly reference calculators that you have saved using the star icon. Recent shows the last 10 calculators you used. My Specialty is determined when you register and select your practice specialty. Once selected, those calculators are pre-populated. And then there is All, which gives you access to the entire library regardless of specialty.


Once you select a formula, such as Well’s Score for PE, it quickly displays that calculator. The title of the calculator appears at the top along with four secondary navigation tabs:


Calculator- The default display is the actual tool where you click on the appropriate criteria. Once you fill in the options, the result will be displayed at the bottom in a large green box. The calculator option has a local navigation with three useful tabs to select from: When to Use, Pearls/Pitfalls, and Why Use. The When to Use option provides a brief description of the tool and its utility. Pearls and Pitfalls provide doctors information with considerations for using this tool, and Why Use explains to doctors what the test validated.


Next Steps- provides information as to what needs to happen after doctors have calculated the score and also gives some critical action steps not to miss.


Evidence- provides facts and figures, links to the original or primary research, and links to the validation journal article.


Creator- provides a quick professional biography of the calculator. For example, Phil Wells, MD, MSc, speaks to the use of his scores in the app and his opinion on testing in medicine for MDCalc. Note: not every calculator has this information.


MDCalc is one of my essential apps, and I tend to use it frequently during an Emergency Department shift. This app is quick and responsive, and the interface is uncluttered. I find the most useful option to be the Next Steps tab that details an action plan. I have not used any other calculator with anything remotely comparable. Next Steps can be a lifesaver, no pun intended.


It’s also nice to have the option to review the primary research article and the validation articles. Though the app may have access to more than 300 calculators, they do not have them all. I have found some in other medical calculator apps that I would like to have. Fortunately, MDCalc is updated frequently, and users can easily submit a request to consider adding a missing calculator.


Overall, for the price of just registering, MDCalc is the most robust evidence-based medical calculator available. If you haven’t tried it, I encourage you to run, not walk, and sign up.

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