Diabetes Practice Options, July 2012

OPTIONSDIABETES PRACTICE

™

Improving Patient Care Through Increased Practice Efficiency

Visit www.DiabetesOptions.net to view our digital edition and for more practice options information.

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The Physicians' Foundation

www.physiciansfoundation.org

JULY 2012

EDITORIAL

3 | DIABETES STRATEGYGroup Visits Improve Clinical Outcomes for Diabetes Patients

6 | CAPITAL IDEASFlexibility Is Crucial to Meeting Physicians’ Long-Term Wealth-Building Goals: Part II

11 | TOOLSImplement Social Media Into Your Medical Practice to Reach Current, Potential Patients

14 | HEALTH CARE TRENDSOnline Patient-Relationship Management Platforms Streamline Office Functions

Several months ago my wife and I both had back-to-back dental procedures, unsuc-cessful root canals followed by an extraction. We both were given prescriptions forthree days of a strong painkiller.

There is increasing concern about the widespread recreational abuse of painkillers byteens and young adults as well as recent reports about the dangers adults encounter whenprescribed painkillers for painful disorders or following surgery. It’s frightening to readsome of the more recent information about teen prescription pill abuse. In some parts ofthe country, prescription painkillers are the drugs of choice for young adolescents. In fact,the average age of first use of painkillers for recreation is 12.5 years. Where I live, the police estimate that 75% of all crime is related to prescription pain med-

ication abuse. A recent survey of students in two local high schools documented a 100%increase in the recreational use of prescription pills during the past two years.In my community, the recreational pill of choice is Percodan 30 mg, known as “Perc-30s,”

CONTRIBUTOR

Neil Baum, MD

Tightening the Lid on Prescription PainkillersBy Michael Bihari, MD, contributing editor

Page 3

IN THIS ISSUE

Neil Baum, MDUrologistNew Orleans

Daniel BeckhamPresidentThe Beckham Co.Bluffton, S.C.Physician and Hospital ConsultantsWhitefish Bay, Wis.

Nathan KaufmanPresidentThe Kaufman GroupDivision of Superior Consultant Co. Inc.Physician and Hospital ConsultantsSan Diego

Peter R. Kongstvedt, MDP.R. Kongstvedt, LLCMcLean, Va.

John W. McDanielPresident and CEO Peak Performance Physicians, LLCNew Orleans

Jacque Sokolov, MDChairmanSokolov, Sokolov, BurgessScottsdale, Ariz.

This newsletter is published by Premier Healthcare Resource, Inc., Morristown, N.J.

© Copyright strictly reserved. This newsletter may not be reproduced in whole or in part without the written permission of PremierHealthcare Resource, Inc. The advice and opinions in this publication are not necessarily those of the editor, advisory board, publishingstaff, or the views of Premier Healthcare Resource, Inc., but instead are exclusively the opinions of the authors. Readers are urged toseek individual counsel and advice for their unique experiences.

EditorRev DiCerto845/[email protected]

Art DirectorMeridith Feldman

PublisherPremier Healthcare Resource, Inc.150 Washington St.Morristown, NJ 07960973/682-9003; Fax: 973/682-9077 [email protected]

EDITORIAL

EDITORIAL BOARD

with a street value of $30 to $50 dependingon supply. In many communities, demandhas led to an increase in crime, most notablyhouse break-ins and armed robbery. The Centers for Disease Control and

Prevention (CDC) is urging physicians to bemore judicious when writing a prescriptionfor a narcotic painkiller. Recent studies linkthese medications to sleep apnea, reducedhormone production, and in seniors anincreased risk of falls and hip fractures. Long-term use of narcotic medications in people

with chronic pain may create a psychologicaldependence that mirrors addiction.Federal, state, and local governments have

been working to decrease the availability ofthese medications for recreational use. TheOffice of National Drug Control Policy hasfunded more than 1,000 community coali-tions dedicated to preventing teen substanceabuse. Also, the Drug Enforcement Agencyhas sponsored periodic NationalPrescription Drug Take-Back Days that offerpeople a place to safely dispose of unwantedmedications. In the past 18 months morethan 1.2 million pounds of unwanted drugshave been removed from circulation. To withhold appropriate pain medication

is poor medical practice. However, we mustbe careful not to use powerful drugs if they are not needed. My wife and I both took over-the-counter medications for several days following our dental proce-dures. When I have hip surgery, I’ll need a morphine drip. �

STAFF

2 Practice Options/July 2012

More information is available atwww.DiabetesOptions.net

Michael Bihari, MD

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Group visits for diabetespatients, in which patientsreceive a brief, one-on-one

medical visit in addition to self-man-agement education in a group setting,are being adopted by primary carepractices seeking new ways to enhancecare quality and efficiency. “The 15minutes allotted for a typical primarycare visit are insufficient to address allof the care needs of a patient with acomplex condition such as diabetes,”says Robert E. Burke, DNP, RN, FNP-BC, LAc, an adjunct clinical professorin the College of Health Professions atPace University’s Lienhard School ofNursing and a family nurse practition-er at Montefiore Medical Center inNew York City. “Group visits allowpatients with diabetes to receive med-ical care, medication reconciliation,diabetes education, and peer supportduring one extended visit.” “Whether patients are newly diag-

nosed or have been living with diabetesfor a long time, they often feel veryalone and overwhelmed by the lifestylechanges they need to make,” saysSummer Peregrin, PharmD, an ambu-latory clinical pharmacist in the familymedicine clinic and the director of thefirst-year pharmacy residency program

at St. Joseph’s Hospital and MedicalCenter in Phoenix. “In group visits,patients can talk with other patientsand share their best practices and ideas.Through this process, they becomemore motivated with regard to diabetesself-management. The group settingcan prompt greater individual engage-ment in health.”

Evaluating BenefitsA growing body of research suggeststhat diabetes group visits are associatedwith better patient outcomes, lowerhealth care utilization, and improvedprovider efficiency. Burke co-authoreda literature review with policy implica-tions on group visits for adults withtype 2 diabetes that was published inthe January 2012 issue of Health Affairs.This review revealed that studies fromthe United States, Italy and Germanysupport several benefits of group visits,including better glycemic control.“Group visits are associated with a low-ering of hemoglobin A1c that lasts fortwo years, as reported by U.S. studies,to as long as five years in internationalstudies,” he says. Other positive out-comes identified by Burke and his col-leagues include lower systolic bloodpressure; fewer hospitalizations, emer-

gency room visits, and specialist visits;improved diabetes knowledge andhealth behaviors; greater patient andprovider satisfaction; and productivitybenefits for physicians and otherproviders. “While we have never formally

tracked outcomes, we do find that ameaningful percentage of group visitpatients improve their health overtime,” says Peregrin, who helps run dia-betes group visits. Furthermore, patientsatisfaction with group visits is usuallyhigh. “We get incredible feedback fromour patients.” “The primary care physicians in our

practice expressed an interest in a teamapproach that would allow more inten-sive management of diabetes patients;the group visit model just seemed to fitour needs,” says Lucille R. Ferrara,EdD, MBA, RN, FNP-BC, an assistantprofessor and the director of the familynurse practitioner program at theLienhard School of Nursing at PaceUniversity. A nurse practitioner,Ferrara runs diabetes group visits at afamily qualified health center in theBronx, N.Y. “Patients often express how much

they enjoy the group interaction,”Ferrara says. “When I review medicalcharts, I find that many of our groupvisit patients are making changes totheir lifestyles and improving adher-ence to dietary recommendations andmedications, leading to better bloodglucose control.”Ferrara notes that group visits are an

efficient way to provide care. “We see between eight and 10 patients in atwo-hour timeframe,” she says. “If wesaw these patients one-on-one, wecould not provide the same level ofeducation.”Burke emphasizes that peer support

may be a critical factor in promptingbetter outcomes. “People with chronicconditions find it challenging to manage the myriad expectations ofpatient care,” he says. “Peer support canhelp motivate them to make thelifestyle changes required to improve

Practice Options/July 2012 3

DIABETES STRATEGY

Group Visits Improve Clinical Outcomes for Diabetes Patients

DIABETES STRATEGY

their health. While providers oftenempathize and make strong connec-tions with patients, patients feel validated when they can relate toanother person’s struggles with self-management. Group visit patients gain strength from peers and can learn real-life strategiesthat are often more practicalthan what the doctor can recommend.”

Dividing TimeGroup visits are incorporatedinto practices in a variety ofways. “In some instances, thegroup visit replaces the one-on-one physician medical visit, butin other cases the group visits supple-ment the medical visit,” says Burke.According to Burke’s literature review,clinician participants typically includea physician, a nurse practitioner and/ora pharmacist. Brief one-on-one visitswith patients include a physical exami-nation, blood glucose testing, diagnos-tic testing, medication reconciliation,and vaccinations, and can occur eitherbefore, during, or after the group ses-sion. Other team members—nurses, med-

ical assistants, diabetes educators,nutritionists, mental health profession-als, social workers, and others—help

facilitate the educational component ofthe group visit or offer patients one-on-one assistance with specific problems.Group size varies from three to 30patients, and visit duration ranges from60 minutes to three hours. Groups maymeet weekly, monthly or quarterly.

Peregrin’s clinic has been holdinggroup visits for about five years. Thepractice hosts two groups, on the sec-ond Monday afternoon and the secondTuesday morning of every month.Groups have a maximum of 15 patientseach, and visits run two and a halfhours. During the first hour, patientsrotate for brief individual visits with aresident physician (in the presence ofan attending physician) and withPeregrin, while the remainder of thegroup chats in a conference room orwatches a video. During the medicalportion of the visit, the physician takesthe patient’s vital signs, checks blood

glucose, performs a foot exam, andreviews the patient’s medical record toensure there are no gaps in care.Peregrin performs medication recon-ciliation, talks with the patient aboutadherence issues, and addresses chal-lenges. “I also work with the physician

to determine if any medica-tion adjustments should bemade,” she explains. “The res-ident physician can authorizethe medication adjustmentand then will follow up withthe patient’s primary caredoctor.” The remaining time is facil-

itated by a second residentphysician, who covers topics

such as basic diabetes information,exercise, nutrition, and living with dia-betes. “The resident offers a small pre-sentation, but then opens the meetingrelatively quickly for patient discus-sion,” says Peregrin. “Patients ask ques-tions and contribute ideas, while thephysician serves as the moderator.”

Supplementing Physician CareGroup visits supplement, rather thanreplace, the typical one-on-one physi-cian office visit patients schedule everythree to six months. If patients requireextra support related to medicationmanagement, they can make an


Lucille R. Ferrara, EdD, MBA, RN, FNP-BC, who runs diabetesgroup visits at a family qualified health center in the Bronx,N.Y., counsels clinicians who are interested in developing

group visits in their own practices to first conduct a careful assess-ment of staffing capacity. “The availability of personnel will havea huge impact on the practice’s ability to conduct group visits suc-cessfully,” she says. “In addition, practices should spend a signifi-cant amount of time in the planning phase; actual implementa-tion is not very difficult if the process and content of the group vis-its are planned carefully.” Robert E. Burke, DNP, RN, FNP-BC, LAc, who co-authored a lit-

erature review in the January 2012 issue of Health Affairs includ-

ing policy implications on group visits for adults with type 2 diabetes, says other tips for success include scheduling group vis-its at times that are convenient for patients, using well provenstrategies for behavior change such as motivational interviewing,and involving a facilitator who is knowledgeable about groupdynamics.Leveraging existing resources about group visit design is also

advisable; tools and resources are available from the AmericanAcademy of Family Physicians (http://tinyurl.com/d2fy6hg), theInstitute for Healthcare Improvement (http://tinyurl.com/cgy6dca),and Group Health Cooperative (http://tinyurl.com/cu7jhtk).

—DJN

SCHEDULING GROUP DIABETES VISITS ISEASY WITH PROPER PREPARATION, TOOLS

“A group could easily be run by a nurse, nurse practitioner or

diabetes educator.”—Summer Peregrin, PharmD, St. Joseph’s Hospital

and Medical Center, Phoenix, Az.


appointment to meet with Peregrinone-on-one. “Physicians tell patients about the

group, but patients must sign up them-selves,” Peregrin says. “Originally, wehad physicians sign their patients up,but the no-show rate was very high.”The clinic also provides written infor-mation about the group visits in thelobby area. The group visits in Ferrara’s practice

include approximately 10 patients andare facilitated by herself, adiabetes nurse educator, ahealth educator, and a mentalhealth provider. “Our prac-tice’s providers identify dia-betes patients who requireintensive management andinvite them to participate,”she explains. Each groupmeets for three sessions oversix weeks. At the beginning of each visit, a

nurse takes each patient’s vital signsand performs a finger-stick blood glu-cose test. Then the diabetes educatorand the health educator talk to patientsin a group about their current experi-ences, challenges, and topics of interest.During the first session, the clinicianshelp each patient develop realistic self-management goals; the second andthird sessions focus educational topicsbased participants’ expressed interests.At the end of each session, each patientmeets with Ferrara individually for abrief medical visit. “Because we have

covered so much during the group por-tion of the session, these medical visitsare focused largely on medicationadjustments, prescription renewals,and other specific needs,” says Ferrara.“Patients have already had about 90minutes of discussion on topics thatthey normally would ask during a one-on-one provider visit.”After each group visit, Ferrara sends

a progress report about the medicalportion of the group visit—including

care provided and topics of discus-sion—to each patient’s primary careprovider.

Keeping Patients EngagedPeregrin says group visits are a reason-able strategy for physicians in commu-nity practice. “A group could easily berun by a nurse, nurse practitioner ordiabetes educator,” she says. “Althoughthere is a brief medical care compo-nent, education is the primary purposeof the visit.”An important factor contributing to

group visit success is the full participa-

tion of all stakeholders. “Stakeholdersinclude patients and families, clinicproviders, staff and administrators, and the community,” Burke says.“Including all relevant stakeholders inthe decision to hold group visits and,later, in group visit design leads to fullengagement in a program that willmeet the needs of the populationserved.” Including the right number of

patients is important. “The number ofpatients should be highenough so that the group hasan energetic dynamic and theeffort is financially viable, butnot so high that group man-agement becomes unwieldy,”Peregrin notes. A big challenge of group vis-

its is the no-show rate. Toreduce no-shows, bothPeregrin and Ferrara say their

practices contact patients by telephoneprior to each visit as a reminder. Another challenge can be keeping

the group on track. “We develop veryspecific notes regarding what topicsand points we want to cover duringeach visit,” says Peregrin. “The groupmoderator must be vigilant in keepingpatients on the topic of diabetes. Ifpatients have additional questions orissues they want to address, we invitethem to stay after the group to talk witha clinician.” �—Reported and written by Deborah J.Neveleff, in North Potomac, Md.

A growing body of research suggeststhat diabetes group visits are associ-ated with better patient outcomes,lower health care utilization, and

improved provider efficiency.

PRACTICES CAN BILL FOR CERTAIN DIABETES GROUP VISITS

Practices offering group visits for diabetes patients thatinclude a one-on-one medical care component can bill forthe visit.

“Practices are reimbursed by billing for each patient using theexisting procedural codes for primary care,” says Robert E. Burke,DNP, RN, FNP-BC, LAc, co-author of a literature review with poli-cy implications on group visits for adults with type 2 diabetes inthe January 2012 issue of Health Affairs. “The financial benefitfor group visits may be stronger in capitated systems because

providers can see more patients in a given timeframe and effi-ciently provide patient education.”“We bill our group visits using the code 99214, reflecting a

level 4 follow-up visit,” explains Summer Peregrin, PharmD, anambulatory clinical pharmacist in the family medicine clinic and atSt. Joseph’s Hospital and Medical Center in Phoenix who helpsrun diabetes group visits. “Although a clinical pharmacist and sev-eral physicians are involved, the visits are cost effective as long asa sufficient number of patients participate.” —DJN

T he first part of this two-part arti-cle looked at two key elementsaround which any physician’s

wealth plan should build flexibility:changes in your income and changes intax rates. In part II we will examinechanges in financial markets, in yourliability situation, and in your health.

Diversify ProperlyIn discussing financial markets, we arereferring to more than a small sample ofthe stock market in the United States,such as the Dow 30 or the S&P 500indices. Physicians should understandthat there is volatility in all of the secu-rities, commodities, real estate, andother asset marketplaces all over theworld. Values rise and fall in all assetclasses. A Nobel Prize was developedaround the concept of constructinginvestment portfolios that minimizethis type of risk and maximize returns.This concept is called “diversification”or “asset allocation.” Savvy doctor investors understand

that portfolio diversification is a keyconsideration to reducing some of therisk of loss in a portfolio. In historicallyvolatile markets, mitigation of lossis not a luxury, it is a necessity.Many investors who thought theywere adequately diversified lostalmost half of their portfolio valuein 2008 and 2009. These investorswere diversified within the stockmarket, with holdings in varioussectors. What they suffered wasmarket risk. As the entire market camecrashing down, so did all investorswithin the market. A flexible wealthplan requires better planning.Diversification need not be limited to

securities like traditional stock andbond investments or bank deposits.Proper diversification, especially in avolatile market like today’s, must also be

spread across investment classes andnot just within a class. A balance ofdomestic and foreign securities, realestate, small businesses, commodities,and other alternative investmentswould be much less risky than holding

the majority of your investments in realestate and securities, which is whatmost doctors do.

Non-Traditional InvestingA popular strategy among physicians isto take advantage of different invest-ment programs that are not traded on apublic exchange like the New York

Stock Exchange, such as non-tradedreal estate investment trusts, leasingfunds, and oil and gas drilling pro-grams. There are pros and cons for eachtype of offering. Non-traded programs offer a certain

level of stability. Most of theseprograms are sold at a flat priceper share during the offeringperiod. Their performance isnot correlated with any particu-lar market or index, makingthem an additional form ofdiversification. Holding non-correlated offerings can help

reduce the extent to which a traditionalportfolio is vulnerable to market volatil-ity. They should be an additional alloca-tion in your portfolio, not a substitutefor proper allocation.One of the advantages of a non-trad-

ed offering is also a disadvantage. Thereis typically no market for shares of theseprograms. Investors are expected to

CAPITAL IDEASFlexibility Is Crucial to Meeting Physicians’ Long-Term Wealth-Building Goals: Part IIBy David B. Mandell, JD, MBA, and Jason M. O’Dell, MS, CWM

Continued on page 10


Data show that the likelihood ofincurring a significant long-termdisability is much higher than

that of dying prematurely.

David Mandell, JD, MBA, is an attorney, author of five books for doctors, and principal of the financial consulting firm OJM Group(www.ojmgroup.com). Jason M. O’Dell, MS, CWM is also an author ofmultiple books for physicians and a principal of OJM Group. To reachthem, or to obtain a free (plus $5 shipping and handling) copy of theirbook For Doctors Only: A Guide to Working Less and Building More, call877-656-4362.

hang onto the security for the life of the investment, which can be as long asfour to 10 years. As a result your invest-ment may be relatively illiquid. In addition, these programs are not with-out risk. You could invest in an oil andgas drilling program that finds no oil.You will receive a tax deduction, butyou may not get much of your initialinvestment back. Like any other invest-ment class, some offerings are moreaggressive than others, and none makeany guarantee about future perfor-mance. The bottom line is that truewealth plan flexibility dictates a diversi-fication plan that may or may notinvolve alternative asset classes ornon-traded assets.

Insuring Your HealthAnother option many physiciansoverlook to their detriment is acash value life insurance policywhere their policy’s investmentperformance is tied to a marketindex, such as the S&P 500, but wherethe insurance company provides a guar-anteed minimum return. The guaranteeis only as strong as the insurance com-pany itself, which is why using a com-pany with a 100-year track record orlonger is crucial. You can use such a pol-icy to truly participate in the years ofpositive returns of the index and haveprotection against the years of negativereturns. This asset is significantlyunder-utilized by physicians.Physicians know that a person’s

health is the most important element in

his or her life. Being in good health is ablessing and can allow you be more pro-ductive—allowing you to create morewealth and to share it, enjoy it, andeven give it away. Poor health can keepyou from practicing medicine and earn-ing a living, and can even lead to pre-mature death—which can be financial-ly devastating to your family. It is cru-cial that a conservative wealth planbuild flexibility around potentialchanges in a physician’s health.It is important to secure the proper

types of insurance to shield your abilityto earn income as a doctor. There aretwo important types of insurance to

consider: one that provides you with aregular income stream if you becomedisabled and one that provides yourheirs with financial protection whenyou die. These are disability insuranceand life insurance.If you are concerned only about your

ability to meet your financial goals andhave no financial dependents, then dis-ability insurance may be the only cover-age on which to focus. Data show thatthe likelihood of incurring a significantlong-term disability is much higherthan that of dying prematurely.

Nonetheless, in our experience, mostphysicians are under-insured for dis-ability, and are staking all of their finan-cial goals on their ability to avoidbecoming disabled. This is not a risk wecounsel our clients to take. Many doctors also remain under-

insured because they believe they can-not get more than $10,000 or $15,000monthly coverage, even though theirincome is well above these limits.However, the disability insurance mar-ket for physicians has loosened in thelast few years. Physicians who are stillunder-insured and believe they cannotqualify for more protection should con-

tact a financial adviser.There are many different types

of life insurance products—fromterm to cash value, from wholelife to private placement. It isimportant to be sure that whatev-er product you use, you have ade-quate coverage given yourincome, debt, assets, family situa-

tion, tax rate, state of residency, andgoals. As you can imagine, this requiresa case-by-case analysis by a qualifiedadviser.Because risk and uncertainty are so

prevalent over the long term, flexibilityis a crucial element of a conservative yetcreative wealth plan. In formulating awealth plan, a physician should consultwith a financial adviser on ways to buildflexibility around possible changes inincome, in tax rates, in financial mar-kets, in his or her liability situation, andin his or her health. �


CAPITAL IDEAS

Any planning designed to shield a physician’s wealth from alawsuit claimant, creditor, or soon-to-be ex-spouse is typi-cally not effective if implemented after he or she has notice

of a threat. Asset protection planning must be put into placebefore there is a problem.Clients want to maintain ownership and control of their assets,

and access to them, at times when there is no liability threat lurk-ing. Fortunately, with comprehensive asset protection planning,utilizing exempt assets, legal tools, insurance, and proper owner-

ship forms, these goals can usually be accomplished. It is possibleto build flexibility into your planning by using tools that will shieldyour wealth when you have liability threats, but allow you own-ership, control, and access to that wealth when the coast is clear.In fact, if such planning can be combined with corporate structureand tax planning at a medical practice, we often can find ways toprovide asset protection that, in effect, pays the doctor hand-somely each year, since the tax savings gained from such planningcan far outweigh its costs. —DM, JMO

PROPER LIABILITY PLANNING OFFERS MORE THAN JUST PROTECTION

Continued from page 6

Many investors who thought they were adequately diversifiedlost almost half of their portfolio

value in 2008 and 2009.


In 2000, I electronically converted mythree-color, tri-fold brochure into atemplated website for my practice.

Now having a Web presence, I was com-fortable that I could cruise intothe twenty-first century with thisnew technology. Little did Iknow that this was only the beginning of my Internetexperience. At first I thought social media

was only for teenagers or foradults who wanted to locate theirhigh school classmates. Now I realizewhat a powerful marketing tool socialmedia is. I have made an effort to har-ness this technology to increase mycommunication with existing patients

as well as to attract new patients to mypractice.

Start With a BlogThere are four major social mediavenues to consider: Facebook, YouTube,Twitter, and blogging. I suggest thatdoctors beginning to develop a socialmedia presence start with blogging.Blogging is free; the only expense isyour time. It can be done reasonably

quickly and allows a physician to com-municate with his or her existingpatients and potential new patients. A blog is a website maintained

through regular entries (posts).

Whereas a traditional website providesone-way communication between apractice and visitors, a blog allows view-ers and visitors to make comments andallows the physician to respond to theircomments. This creates dialog betweenexisting patients and potential newpatients that is difficult to achieve on awebsite. There are several sites that will host

your blogs. I selected wordpress.com,since The Social Media Bible by RonSafko recommended it. Others includeMovable Type (www.movabletype.com), LiveJournal (www.livejournal.com), Blogger.com, and GoingOn.com.Wordpress.com has a ten-step tutorial(www.youtube.com/watch?gl=US&hl=hi&v=MWYi4_COZMU) that provideseasy-to-follow steps to creating a blog,entering content, and publishing yourmaterial.I suggest a three-step formula for cre-

ating a blog post. First, develop a hookto capture the attention of viewers. Nextcraft a relevant message that your view-ers can identify with. Issue a call toaction to motivate viewers to connect toyour website or contact your practice tofind solutions to their medical prob-lems.Social media experts emphasize that

to be successful in social media, andparticularly with blogging, it is neces-sary to post a minimum of once a week.You will motivate visitors to return ifyour blog is updated regularly.

Grabbing AttentionI suggest that you open a blogpost with a startling analogy, sim-ile, statistic or metaphor to grabthe attention of the reader. If youare writing about prostate cancer,for example, you might beginwith the statistic that nearly40,000 men die each year ofprostate cancer, which is the

capacity of a small football stadium.You can also try to incorporate humorin your blogs.You can also tell a compelling story

about a recent patient without using hisor her name, mentioning how you iden-

TOOLSImplement Social Media Into Your Medical Practice to Reach Current, Potential PatientsBy Neil Baum, MD

Twitter now reaches some 800 million search queries

per day. That’s over 24 billionsearches per month.

Neil Baum, MD, is a physician inNew Orleans and the author of Social Media for the Health-care Professional, GreenbranchPublishing.

tified a problem, made a diagnosis, andsolved the problem. Try posting open-ended questions and comments, placedat the end of the blog. Such questionsmotivate readers to respond and start adialog between your practice andpotential new patients. After you develop your blog, the blog

site’s analytics can provide you withinformation on the number of viewersyou have, how long they are spendingon your blog site, and how many ofthem are connecting to your website.This information can be used to tweakyour blogs and identify whatis working and what is notand then make neededchanges.

Making FriendsThe fastest-growing demo-graphic of Facebook users isages 35-55, with users over 55coming in a close second.Fifty percent of Facebookusers access the site everyday. The average Facebook user has 130friends. Facebook users have a personal pro-

file, which has as much information asyou care to share along with photos,videos, and links to websites that youfind interesting. This information isonly accessible to people you haveadded as friends. Being friended ismutual; it is not possible to accessanother user’s profile without provid-ing access to yours. For this reason,

some professionals do not provideaccess to their patients and clients.Remember, even if you don’t post any-thing inappropriate, if an old friendposts a drunken college photo of you, itis there for everyone to see.This fear should not limit your use of

Facebook in a professional manner. Forone, you can group your friends intodifferent lists and restrict access toinformation through the privacy set-tings. Another way to avoid inappro-priate Facebook contact is to create aprofessional page. Formerly known as

“Fan Pages,” these provide much of the function that personal pages do,without providing access to personalinformation.A Facebook professional page can

serve as a powerful marketing tool.You’ll find that more and more of yourpatients are using Facebook, with theaverage user spending over 20 minutesper day logged into the site. With a pro-fessional page, you are forming anonline club. Starting a professional

page is free and very quick and easy todo. Once it is set up, invite patients andothers to “like” you on Facebook. It isnot necessary to be signed intoFacebook to access a professional page.They are searched and cataloged byGoogle, providing another source ofvisibility to your practice.When you post to the “wall” of your

professional page, which is the mainforum, your post will also be seen onthe walls of your fans, where they canbe seen by all their friends as well. Ifyou are introducing a new service to

your practice and you post acomment about it on yourpractice’s page, it will poten-tially be seen by your fans andmany of their friends. Youcan also have your blog postsand videos automaticallypopulate your professionalpage. Facebook gives a practice

the ability to share informa-tion with current and

prospective patients. Everyone whojoins your professional page will fallinto one of three categories: they eitherhad an interest in you in the past, cur-rently are interested, or feel that theywill have an interest in the future.Provide them with pertinent informa-tion, and stay in front of them on theirFacebook walls.

Posting VideosYouTube enables users to post unique


Wayne Gretzky, one of the greatest hockey players of alltime, said, “I don’t skate to where the puck is or wherethe puck has been; I skate to where the puck is going to

be.” Social media is where the patients are going to be today andwhere they will be tomorrow.So who is using social media? Just a decade ago the Mayo

Clinic used standard marketing techniques such as radio, TV, andprint to attract new patients. Today Mayo makes use of Facebook,Twitter, YouTube, podcasts, and blogging. The clinic even hasdeveloped a Center for Social Media to focus on social media for

the institutions in Rochester, Jacksonville, and Phoenix. If socialmedia is good for the Mayo Clinic, then it must be useful for otherpractices to embrace.Social media allows smaller practices to compete with much

larger practices with huge marketing budgets. With very littleexpense small practices, even solo practices, can develop a socialmedia presence that can rival what the large group practices andeven the multi-specialty group practices like the Mayo Clinic andthe Cleveland Clinic are able to build.

—NB

TOOLS

SOCIAL MEDIA: A VIABLE STRATEGY FOR ATTRACTING NEW PATIENTS

Most medical practices will be considering the use of social mediamarketing in the near future. Thesetools can be used to educate your

existing patients as well as to attractnew patients to your practice.


video content, from 30 seconds to 30minutes long, and allow anyone who isinterested to access that content.Others who are interested in a poster’stopics can subscribe to and recom-mend content to their friends. Millionsof people access YouTubevideos through their com-puters, cell phones, iPads,and televisions. YouTube has become the

most popular video-sharingplatform on the Internet. It isnow used as a search engineby many who want to clickplay to hear and see theinformation they are inter-ested in. It has become thethird most popular search engine and,for that reason, is vitally important toanyone who wants to have an onlinepresence.The cost of uploading to YouTube is

small, with a potentially explosive ben-efit. To broadcast yourself, all you needis a video camera, or you can use thevideo on your iPad or iPhone. Once a video has been created, it can

be used in multiple ways. It can beuploaded to YouTube and other videosites. Websites also exist that willupload a video for you to multiplevideo sites. TubeMogul (www.tube-mogul.com) is a free distribution site.Another distribution site, TrafficGeyser (http://trafficgeyser. com), is apaid service.Video can also be added to blog posts

and embedded on your website. Googleand other search engines love video.

Your video should be titled in a way thatoptimizes how it is indexed by thesearch engines. You can add keywordsto further optimize the video posting.Once you have created a presence on

Facebook and YouTube, you need to

start attracting followers. Be sure yourreceptionist mentions to new patientsthat you have information on YouTubeabout their condition and that newpatients should view the videos beforemaking their first appointment. Thereceptionist should also mention thatthe practice or the doctor has aFacebook site and encourage them tofollow it. You can add links on yourwebsite to your YouTube, Facebook,and blog sites.

Reaching MillionsTwitter is a platform used for micro-blogging. Each “tweet” is limited to 140characters including spaces and punc-tuation. The idea is to follow others youare interested in, and for others to fol-low you. Using Twitter is like being at acocktail party and hearing pieces ofpotentially interesting conversations.

When an overheard thought catchesyour ear and sounds interestingenough, you tune in and listen to whatthe person is saying. When you’veheard enough, you walk over, meet theperson, and begin a relationship.

Twitter works the same way,but it is done on your comput-er or smart phone.This new technology has

been adopted in record num-bers. Twitter now reachessome 800 million searchqueries per day. That’s over 24billion searches per month.Since April 2010, Twittersearches have increased 33%.It is the fastest-growing search

engine in the United States. Physicianswho ignore it do so at a cost—poten-tially losing patients.Most medical professionals and their

staff devote little or no time to tweet-ing. By using a simple tool called RDFsite summary (RSS), you can tie yourblog posts, Facebook posts, and tweetstogether so that when you post a greatblog you are simultaneously posting onFacebook and tweeting.Most medical practices will be con-

sidering the use of social media mar-keting in the near future. These toolscan be used to educate your existingpatients as well as to attract newpatients to your practice. They allowthe practice to enhance its interactionwith established and new patients. It isinexpensive and worth the time andeffort to create a presence on Facebookand YouTube. �

When using social media to communicate with current andpotential future patients, it is important to have titles thatwill capture visitors’ attention. People often base

their decision on whether to read your blog or view your video,and subsequently connect to your website, on just the title you’vegiven it. An effective title is like a billboard: Drivers on the highwayhave seconds to read it and decide if they will stop at the

restaurant, buy the product, or get the phone number and call formore information. I once titled a blog post “Urinary Incontinence: Diagnosis and

Treatment.” This post received few responses. However, when Ichanged the title to “Urinary Incontinence: You Don’t Have toDepend on Depends,” I received nearly 1,000 responses. A differ-ent, more dynamic title made all the difference. —NB

TITLES ARE TERRIFIC WHEN POSTING SOCIAL MEDIA CONTENT

Social media experts emphasize that tobe successful in social media, and par-ticularly with blogging, it is necessaryto post a minimum of once a week.

You will motivate visitors to return ifyour blog is updated regularly.


Asea change is taking place with-in the health care system. Thefee-for-service reimbursement

model is being replaced with a value-and outcome-based model of reim-bursement in which unnecessary healthcare procedures, tests, and hospitaliza-tions are penalized rather than reward-ed, according to a recent article inForbes magazine (http://tinyurl.com/6nxf6tn). This evolving treatmentmodel is the byproduct of the new ageof accountable care, and it is based onthe premise that patient-centered care ismore effective than billing-centeredcare. In recent years, a number of tech-nological platforms have been devel-oped to facilitate patient-relationshipmanagement, with the goal of cultivat-ing this desirable patient-centricapproach, while saving physicians timeand money.

Facilitating CommunicationAvado, Inc. (www.avado.com), aBellevue, Washington-based healthinformation technology firm,is one of several companiesoffering a cloud-based patient-relationship management soft-ware system that eliminatespaper, makes workflows fasterand more efficient, and savesvaluable provider time. Thesystem saves at least 1.5 hoursper day, and “maybe even moreif I sat down and measured itout,” says Gerry L. Tolbert,MD, a family physician fromBurlington, Ky. Tolbert has been usingAvado’s patient-relationship manage-ment software since January 2012,when he first started his private prac-tice, Total Access Physicians, PSC, con-sisting of two physicians and a regis-tered nurse, with no office manager orreceptionist.

“We were looking into medicalrecords systems, and we wanted some-thing that could serve as a stopgap untilwe got something more robust,” saysTolbert. “Avado covered everything wewere looking for. We were planning on

having three different pieces of soft-ware, but this does everything in one.It’s a messaging portal, it’s a place wherepatients can go to see their own infor-mation and take control of their ownhealth care, and it’s also a place where Ican push out my education messageand get preventive care to a lot of peoplewithout much effort.”

The Avado system offers the follow-ing services, which can be integratedwith a practice’s current electronichealth record (EHR): • Patient portal• Forms library/creator

• Electronic medical chart• Online scheduling• Marketing website• Broadcast communicationSome of these services

(secure messaging, broadcast-ing messages, and setting up awebsite and Web portal) arefree to clinicians; moreadvanced features (onlinescheduling, forms library/cre-ator, and the electronic medical

chart) are available for a fee of$100/month per clinician. Patients canaccess all of their medical informationand use the patient portal for free.The patient communication portal is

the most used function in Tolbert’spractice, he says. Most of his patientsopt to use the messaging, a secure fea-ture that alerts patients and doctors via

HEALTH CARE TRENDSOnline Patient-Relationship Management Platforms Streamline Office Functions

Continued on page 18

“If you were to take all of yourpatients and do all of the appropri-ate preventive counseling, it wouldtake 10 hours a day, because you’dbe duplicating so many things.”

— Gerry L. Tolbert, MD, Burlington, Ky.


e-mail when a new message has comethrough the portal. “It’s not like I haveto actively go into Avado and seek outthose messages,” says Tolbert. This fea-ture is different from the messagingoffered in most EHR systems, whichhave no reminders or e-mail alerts, andin which users must be logged into thesystem to know whether they havereceived a new message.Tolbert has used the patient portal to

track his diabetes patients’ blood sugar.Patients can enter their glucose read-ings through the portal, and Tolbert canview them in real time. In addi-tion, reminders can be set upfor patients to check theirblood sugar and blood pres-sure. Patients can record exer-cise minutes and weight, whichis particularly useful for thosepatients with congestive heartfailure.

Saving Time“It’s a great way to interact with patientsregularly without having to have themin the office every three weeks, or con-stantly being on the phone,” Tolbert

says. “For patients, they don’t have tokeep track of things for long periods oftime, and risk possibly losing the paperthey wrote the information down on, orforgetting to bring it with them to theiroffice visit. They can do it right on thecomputer, and it works to get both of usthat information. It gives me and mypatients a visual representation of howwell they’re doing at taking care ofthemselves.”Although his patients have greater

access to him via the patient portal,Tolbert has found that this avenue of

communication saves him time ratherthan taking up additional time. “I don’thave to stop what I’m doing and devotetime to a phone call,” he says. “I respondon my time, or even while I’m doingsomething else, which is very handy. It

has definitely cut down on the amountof work that I would be doing other-wise.”The system’s “broadcast messages”

feature allows physicians to send mes-sages to all patients or targeted sub-groups simultaneously. Patients can betagged according to disease state, gen-der, or age, for example, so they canreceive information that is most rele-vant to them. Tolbert considers this fea-ture handy, and uses it on a regularbasis. “What I’ve been using it for main-ly is [to send out] basic patient news on

topics such as weight manage-ment, general health, and pre-ventive care. For example,when the flu shot was due, Ipushed out information topatients informing them that itwas flu season and time to getthe shot, along with a link to anarticle on the dangers of flu and

the benefits of the flu shot.“If you were to take all of your

patients and do all of the appropriatepreventive counseling, it would take 10hours a day, because you’d be duplicat-ing so many things,” Tolbert continues.

HEALTH CARE TRENDS

“I have a feeling [this managementsystem] is going to be one of those things that becomes priceless,” says Tolbert.

The American Medical Association (AMA) notes that manypatients like having online access to their medical informa-tion, and that such access can lead to improvements in

the delivery of health care. The December 29, 2011 issue ofamednews.com profiles the OpenNotes project, a pilot run byHarvard Medical School researchers at several health care orga-nizations that measured the effect of revealing the content ofdoctors’ notes to their patients. The results of this program, pub-lished in the December 2011 issue of the Annals of InternalMedicine, indicated that patients widely supported the idea andthought it would be beneficial to their health. A total of 37,856 patients, 110 participating physicians, and 63

nonparticipating doctors provided their impressions on how openclinical notes would affect them. Up to 97% of patients, up to81% of participating physicians, and up to 33% of nonpartici-pating physicians were in favor of open notes. Those participantswho were opposed to the idea feared that open notes would con-fuse patients and influence what physicians would and would notwrite.

However, the majority of physicians who participated in thepilot program witnessed its success. “The patients loved it, and ithad absolutely no impact on me really at all,” said David Ives,MD, an internist and infectious diseases physician at Beth IsraelDeaconess Medical Center in Boston, Ma. Ives provided an exam-ple demonstrating the positive effects such a program could have.One of his patients, upon seeing the word “overweight” in hermedical chart, was motivated to lose 10 pounds without any ver-bal provocation. This example dovetails with a finding that 90%of patients said open notes would make them feel more in con-trol of their health care.The AMA reported equally impressive results from a similar

pilot program at MD Anderson Cancer Center in Houston, Tex.This program reported that despite physicians’ fears aboutincreased workload and patient anxiety resulting from open med-ical records, few complaints have been made since the programbegan more than two years ago. The complete article on theOpenNotes project can be viewed at http://tinyurl.com/cvqzt9r.

—SC

ACCESS TO PHYSICIANS’ NOTES BENEFITS PATIENTS, REPORT INDICATES

Continued from page 14


“With the broadcast, you can send amessage that says a lot of those things. Ifyou have diabetes, you need to makesure you’re checking your feet or yourblood sugar once a day. Or if you haveheart disease, you need to make surethat you’re taking care of your heart,and you’re getting your cho-lesterol checked. Things likethat, that you’re saying fivetimes a day, you can push outto people and have them seethat on a regular basis, so youdon’t have to say it every timethey walk through the door.You can reinforce it, ratherthan giving the whole speechabout why it’s important. That saves aton of time.”Implementation of the system

required a minimal amount of effort,Tolbert says. Avado was up and runningin just three days. It would have takeneven less time had he not wanted to cus-tomize his own forms, he adds. “Yousign up and create your front page,” hesays. “If you just want it to be function-al and look good, within about 10 min-utes you could have a pretty goodsetup.”

Accommodating All UsersTolbert created the landing page, andworked on his forms. To save time herecommends that physicians imple-menting such a tool know beforehandwhich forms they want to convert to the

electronic format. Although Tolbert istechnologically savvy and was able towork fairly independently on the devel-opment, Avado offers support via anonline tech support team, as well as arepresentative. “The user interface is very user-

friendly,” says Tolbert. “The programitself has some pretty good tools, andthere are some tip links that give youstraightforward information. They havea lot of boilerplate forms if you justwant to use those. But if you want tomodify them or create your own forms,you can. They walked me through andshowed me how to use the interface thefirst time around, just to see if it wassomething I’d be interested in. “They’re adding things weekly to

make this as user-friendly and feature-rich as possible,” he says. “It’s a work inprogress, but it’s a work in progress thatis very user-centric. Physicians usingthis system can make decisions abouthow they want it to work and customizeit how they would like, and the compa-ny does a good job of working with

them to do that.”The patient population at Total

Access Physicians, PSC ranges “fromcradle to grave,” says Tolbert. Withinthis diverse population, he has foundthat patients between the ages of 18 and50 adapt best to this technology. “Above

50, it’s a little bit trickier,” hesays. “There are exceptions tothat rule, of course, but ifyou’re not Internet savvy, itmay not be as straightforwardto get in and see things assome older folks might like. Alot of our older patients don’teven have e-mail addresses.You have to be aware of who

your audience is. If they’re in the com-fort zone of using computers, they likethis technology. They like being able tosend messages securely; they like to seetheir labs; they like being able to fill outforms one time instead of 10 times.”“This system has streamlined com-

munications greatly, because it’s one place to go for messaging, ratherthan nine e-mail addresses,” Tolbertsays. “It has definitely improved thespeed with which people fill out forms.As far as return-on-investment, I thinkwe’re probably at the break-even pointright now. Once we have our full number of patients, I have a feeling it’sgoing to be one of those things thatbecomes priceless.” �—Reported and written by Stacy Clapp, inOrangeburg, N.Y.

“It’s a great way to interact withpatients regularly without having tohave them in the office every threeweeks, or constantly being on the

phone,” Tolbert says.

ONLINE PATIENT-RELATIONSHIP PORTALSSAVE PHYSICIANS, PATIENTS TIME AND HASSLE

Online patient-relationship management software, such asAvado (www.avado.com), enables a practice’s patients toschedule appointments, message physicians, and receive

educational messages and reminders through a secure online por-tal. Such systems often enable patients to fill out required formsonline, rather than spending time on them in the waiting room,saving time for both physicians and patients.“You can create your own forms,” says Burlington, Ky.-based

family physician Gerry L. Tolbert, MD, who has been using Avado

since January 2012. “For example, we have our own customizedpatient contract, or you can use the system’s templates. The bestpart is that, when patients enter their basic demographic informa-tion to sign up, that flows over into the other forms automatically.Patients spend a lot of time in the waiting room filling out forms.Before adopting this system, we would schedule an appointmentfor 2:45 pm and the patient wouldn’t make it back to the roomuntil 3:15 pm because they were filling out paperwork. This hasdefinitely made that a lot less of a hassle.” —SC

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July 2012

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Diabetes Practice Options, July 2012