02.2015
A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
www.aad.org
Dermatologists
profile
the specialty’s
data needs 20
+
04 Coding
09 Research
11 Legal Issues
18 Practice Management
41 Academy News
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in this issue
from the editor
DEAR READERS,
February is known for its quaint
story about a groundhog.
W
e all know the plot, especially here in the north. The presence
or absence of his shadow is supposed to predict information
about the remaining duration of the winter. Punxsutawney,
Pennsylvania is the location of today’s famed groundhog
named Phil with forecasting talent, although it is a tradition that began
in the ancient world. And for those of us in the colder parts of the U.S.
who are often anxious to see the cold, snowy days come to an end,
this in essence predicts what will be in store for the rest of the winter
season. I’ve been struck in Philadelphia that the groundhog almost always sees his shadow,
and disappointingly the winter soldiers on. I suspect though that it is the rare person who
doesn’t take note of the data point.
This brings me to the piece in Derm World that I’d like to highlight — about data, and the
Academy’s plan to create a dermatology data platform. This proposed platform will answer
questions that appeal to the scientist in each of us. Following in the path of some of the other
specialty societies, the leaders of our Academy have realized that it is imperative that we collect and own data. While insurance companies have their own data stores, their agendas and
missions vary significantly from ours and therefore we need to own our own. The hope, of
course, is that it will assist us in providing proof of the value of our services, something that
will become increasingly necessary. Some derms have expressed the concern that it will be
used against us, but Dr. Oliver Wisco reassures us when he tells us that “we have to get out
of the mindset that data is about grading.” It has the potential to guide us whether we think it
will or not. Dr. Teisberg aptly notes that “What you measure will be what improves, so measure what really matters to the patient.” Understanding what patients think of the outcome of
our treatments will teach us how to make them better. It is exciting to think that the Academy
will be aiding us in this way. Read our piece, and see if you agree.
Speaking of data, you will also want to take a look at the Answers in Practice piece on
the penalties coming out of CMS. One percent here and 2 percent there — boy, after a while
these penalties certainly add up! We thought that standing back and taking a look at the overall picture might be useful to many. With only 30 percent of derms complying with meaningful use, Rachna Chaudhari from the AAD tells us that it is not too late to reconsider and
take steps to comply with the federal programs. Otherwise you might begin to feel like that
guy in the Groundhog Day movie, stuck in the time warp of the day. With additional penalties
taken each year caring for the 65+ crowd may get more and more challenging. Hope that the
numbers inspire a few of you.
Well, I know what I will do if the groundhog sees his shadow on that day that is halfway between solstice and equinox…stream Groundhog Day and enjoy the laughs! That will
brighten things up. Hope you do the same!
Enjoy your reading.
VOL. 25 NO. 2 | FEBRUARY 2015
PRESIDENT
Brett Coldiron, MD
EXECUTIVE DIRECTOR
Elaine Weiss, JD
PUBLISHER
Lara Lowery
EDITOR
Katie Domanowski
MANAGING EDITOR
Richard Nelson, MS
ASSISTANT MANAGING EDITOR
Victoria Houghton, MPA
DESIGN MANAGER
Ed Wantuch
EDITORIAL DESIGNER
Theresa Oloier
DESIGN TEAM
Nicole Torling
ADVERTISING SPECIALIST
Carrie Parratt
PHYSICIAN EDITOR
Abby Van Voorhees, MD
PHYSICIAN REVIEWER
Barbara Mathes, MD
CONTRIBUTING WRITERS
Diane Donofrio Angelucci
Rachna Chaudhari
Terri D’Arrigo
Susan Jackson
Clifford Lober, MD, JD
Alexander Miller, MD
Victoria Pasko
Morris Stemp, MBA
Beverly Wachtel
EDITORIAL ADVISORS
Lakshi Aldredge, MSN, ANP-BC
Annie Chiu, MD
Jeffrey Dover, MD
Rosalie Elenitsas, MD
John Harris, MD, PhD
Chad Hivnor, MD
Sylvia Hsu, MD
Risa Jampel, MD
Michel McDonald, MD
Christen Mowad, MD
Robert Sidbury, MD
Oliver Wisco, DO
Printed in U.S.A. Copyright © 2015 by the
American Academy of Dermatology Association
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Phone: (847) 330-0230 Fax: (847) 330-0050
MISSION STATEMENT: Dermatology World is
published monthly by the American Academy
of Dermatology Association. Through insightful
analysis of the trends that affect them, it provides
members with a trusted, inside source for
balanced news and information about managing
their practice, understanding legislative and
regulatory issues, and incorporating clinical and
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Dermatology World® (ISSN 10602445) is
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2 DERMATOLOGY WORLD // February 2015
ABBY S. VAN VOORHEES, MD, PHYSICIAN EDITOR
www.aad.org/dw
02.2015
A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
features
www.aad.org
depts
02
FROM THE EDITOR
04
CRACKING THE CODE
Flap, or not?
“How do we
switch from a
strategy around
volume to one 20
of value?”
06
ROUNDS
Medical license portability.
09
ACTA ERUDITORUM
Can better access to
dermatologists improve
melanoma prognosis?
11
COVER STORY
LEGALLY SPEAKING
Dermatologists profile the specialty’s data needs
Do you have a duty to warn
a third party?
DEMONSTRATING QUALITY
BY VICTORIA HOUGHTON
28
ITCHING FOR RELIEF
Dermatologists take aim at pruritus
BY DIANE DONOFRIO ANGELUCCI
34
BUILDING AN OFFICE CULTURE
THAT WORKS
Physician-practice manager partnership is key
BY TERRI D’ARRIGO
14
TECHNICALLY SPEAKING
How to choose tech
solutions to maximize
productivity and improve
patient care.
18
ANSWERS IN PRACTICE
Keeping track of all those
penalties.
40
FROM THE PRESIDENT
41
ACADEMY UPDATE
2014 AM&P Excel Bronze
Award, Design Excellence
2011, 2012, 2013, and 2014
Graphic Design USA Award –
Cover/Feature Design.
2014 Graphic Design USA
American Web Design Award
Advisory Board
resolutions sought, more.
44
FACTS AT YOUR
FINGERTIPS
2013 HOW InHOWse
Design Award –
Cover/Feature Design
2011 Ozzie Silver Award,
Best Redesign:
Association/Non-profit.
2014 Eddie Honorable
Mention, Association/
Non-profit video
Modest increase would
keep AAD’s dues lower
than many similar
organizations.
DERMATOLOGY WORLD // February 2015 3
cracking the code
BY ALEXANDER MILLER, MD
Flap, or not?
ALEXANDER MILLER, MD, addresses important coding and documentation
questions each month in Cracking the Code. Dr. Miller, who is in private
practice in Yorba Linda, California, represents the American Academy of
Dermatology on the AMA-CPT® Advisory Committee.
You repair a large surgical defect with bilateral M-plasties. Do you bill for an
adjacent tissue rearrangement (flap)?
Adjacent tissue transfer or rearrangement (flap) codes are defined in the
CPT as including Z-plasty, W-plasty, V-Y plasty, rotation flap, random island
flap, and advancement flap. An M-plasty does not rearrange any tissue or
move any tissue about. It results from a redirection of the lines of closure
from a straight linear pattern to essentially two backcuts formed at the distal
incision end(s) to shorten the closure length. The excised tissue edges are then
approximated side-to-side. Nothing is advanced or transposed, and the apex
of the M-plasty where it intersects the central line of closure is not advanced
or repositioned. It remains in place. Consequently, in an M-plasty, unlike that
in a Z-plasty or W-plasty, there is no tissue transfer/advancement or rearrangement. In conclusion, an M-plasty does not qualify for the adjacent tissue
transfer/rearrangement CPT code series 14000 - 14061. In the above example
one would bill for the appropriate level of complexity of linear reconstruction,
most commonly with an intermediate (layered) or complex (extensive undermining) repair code.
For the purpose of optimizing tissue alignment and cosmetic appeal one
may excise standing cones of skin adjacent to a central surgical defect in an
opposing offset fashion, undermine the edges, and suture the site shut. This
type of closure results in a curvilinear or S-plasty pattern. Although such a
repair generates a wiggly pattern, it is a variation on a straight linear closure,
as there is no true advancement or rearrangement of tissue, regardless of the
degree of undermining done to facilitate tissue motion. This repair qualifies
only for intermediate or complex repair CPT coding.
In arrangements where CPT coding is determined by anyone other than
the service provider (such as by in-office billers, facility billers, or outside
coders) the biller must be presented with appropriate supporting chart data in
order to generate CPT codes that reflect the work done. Similarly, in situations
where the electronic health record prompts code selection, the chart input
must be optimized for logical code choices. Thus, for flap repairs the recorded
data must satisfy the flap definition requirements, and should specify the
4 DERMATOLOGY WORLD // February 2015
location and the area of the defect plus
that of the raised flap. Diagrammatic and
photographic illustrations of a surgery
can help justify both the appropriateness and legitimacy of what was done.
This can prove useful in chart audit
situations. Tracking insurer reimbursement patterns and any chart documentation requests may reveal an individual
insurer’s peculiar requirements, such as
for justifications in the patient record for
why a flap was chosen over a linear repair.
Integrating such data into the patient
record may help to prevent payment rejections and the expenses of appeals and
delays in payment. A quirky consequence
of electronic billing is that some insurers will subsequently request a surgical
report when Mohs surgery is done with
a reconstruction. When expecting such a
consequence, proactively paper billing on
a CMS-1500 form with an attached surgical report will streamline reimbursement.
Example 1: A patient presents to you with
an upper lip vertically banded scar that
pulls up on the vermilion margin. You
do a narrow fusiform excision of the scar
and then depress the still somewhat elevated lip margin with a Z-plasty. You bill
for the 1.2 cm excision with CPT 11442
and for the flap repair with CPT 14060.
Answer: Incorrect. Only the Z-plasty flap
repair is billable, as the adjacent tissue rearrangement codes include the primary excision. (CPT Assistant, July 2008, p. 5).
Example 2: In the process of repairing
an ear lobule rim defect linearly you do a
Z-plasty across the lobule’s edge in order
to reconstitute the rim’s convexity and to
avoid notching. You bill CPT 14060.
Answer: Correct. As an adjacent tissue rearrangement was done as part of the repair,
one is justified in billing for the appropriately
done Z-plasty.
www.aad.org/dw
coding tips
Example 3: You broadly undermine
the cheek adjacent to a large defect,
advance the edges, and excise the
resulting standing cones, generating
a curvilinear closure line conforming
to the skin tension lines. The insurer
audits your chart and adjusts your
billing from an adjacent tissue rearrangement code to a complex repair.
Answer: Correct. The chart record
shows that broad undermining and
a linear repair were done. The CPT
specifically states: “Undermining alone
of adjacent tissues to achieve closure,
without additional incisions, does not
constitute adjacent tissue transfer, see
complex repair codes 13100-13160.” The
additional incisions needed to excise
standing cones of tissue do not generate
adjacent tissue transfer or rearrangement.
Example 4: Following an excision
of a basal cell carcinoma on the arm
you close the 2.7 cm-wide surgical
defect with an intradermal pursestring suture. As you undermined
broadly beyond the defect’s edges
in order to mobilize tissue you bill
CPT 11603 for the malignant excision and CPT 13121 for the complex
repair. Although the tissue edges are
concentrically advanced centrally, the
procedure does meet the definition of
a flap closure.
Answer: Correct. Since extensive
undermining was necessary to mobilize
the wound edges, both an excision and
a complex repair code are appropriate.
If a purse-string suture were done with
minimal to no undermining, only a malignant excision code, CPT 11603, would
be applicable. The February 2007 CPT
Assistant defines a simple excision as,
“…includes simple (non-layered) closure
when performed.” A typical purse-string
closure consists of a single, continuous
cutaneous suture layer.
Example 5: Following a Mohs surgical
excision of a squamous cell carcinoma located on the dorsal hand you
reduce the 1.7 cm diameter defect
with a purse-string closure and then
further approximate the skin edges
with several vertical interrupted nylon
stitches. You bill for the Mohs surgery and CPT 12041 for the layered
(intermediate) repair.
Answer: Incorrect. Intermediate
repair requires deeper layered closure
of subcutaneous tissue and superficial
(non-muscle) fascia in addition to
epidermal-dermal skin closure. In the
above example both suturing techniques
approximate the same epidermaldermal skin layers, such that only the
simple repair criterion, CPT 12001, is
met despite the use of two distinct suturing modalities. Similarly, if one repairs a
non-undermined defect with a combination of horizontal mattress and simple
interrupted exteriorized sutures, only a
simple repair definition is fulfilled. dw
No XS needed if codes aren’t mutually exclusive
THE NEW XE, XS, XP, AND XU MODIFIERS that CMS began using this year to supplement modifier 59 will change a lot
of things for dermatologists. They will not, however, change the list of Correct Coding Initiative edits that govern the
use of modifiers.
In our November 2014 Cracking the Code, we presented an example of XS modifier use that would have been
correct…if the two biopsies being billed were on the mutually exclusive list. As they were not, no XS modifier is necessary. The corrected example appears below. The full article, with the correction, is available at www.aad.org/dw/
monthly/2014/november/the-59-modifier-modified.
Example 3: You destroy multiple penile condyloma acuminata with liquid nitrogen and biopsy an unrelated cheek lesion suspicious for basal cell carcinoma on a Medicare patient. You bill CPT 54056 for the destruction of condylomas
and 11100-XS for the cheek biopsy.
Answer: Incorrect: These two codes are not mutually exclusive by CCI edits, and they both can be billed together without any
modifier. In a slightly different circumstance, a lip biopsy and a cheek biopsy at the same visit, use of the XS modifier would be
required: CPT 40490 for the lip biopsy and 11000-XS for a cheek biopsy. The difference: 40490 and 11100 are on the mutually
exclusive list and a modifier is required to indicate that they represent two separate services. dw
DERMATOLOGY WORLD // February 2015 5
rounds
news in brief
Federation of State
Medical Boards addresses
medical license portability
STATE NEWS ROUNDUP
A
s a result of the Affordable Care Act, the demand for health care has increased. In order to provide care to
an increased patient population, many physicians are looking to expand their practices across state lines.
Current state licensing requirements can make this complicated. But many states are expected to address
medical license portability this year.
To provide a model framework for license portability, the Federation of State Medical Boards (FSMB) developed
an Interstate Medical Licensure Compact in September 2014 which — if adopted by state legislatures — would allow for expedited licensure to physicians interested in practicing in multiple states, without requiring changes to the
states’ laws that govern the practice of medicine, or the state medical boards’ regulatory authority.
Additionally, the Compact stipulates that the practice of medicine occurs where the patient is located at the
time of the physician-patient encounter. Therefore, the physician would be required to be under the state medical
board jurisdiction where the patient is located. State medical boards that participate in the Compact would retain
the authority to impose an adverse action against a license to practice medicine in that state issued to a physician
through the procedures in the Compact. Participation in the Compact would be on a voluntary basis for both physicians and state boards of medicine.
The American Academy of Dermatology Association (AADA) supports the Compact and will be working with
state medical societies and state dermatologic societies to pass legislation in 2015 that would implement it. For
more information, or to find out how your state can get involved, email Victoria Pasko at vpasko@aad.org.
STATE ACCESS TO INNOVATIVE MEDICINE COALITION TACKLES PRESCRIPTION DRUG COSTS
The AADA has joined the State Access to Innovative Medicine (SAIM) coalition — a group of patient advocacy
organizations, physician groups, and industry members dedicated to decreasing barriers to patient access to prescription medications. The coalition’s advocacy efforts will focus on legislation that caps out-of-pocket prescription
medication costs and limits the use of step therapy and drug tiering. Other members of the coalition include the
Leukemia and Lymphoma Society, National Psoriasis Foundation, Lupus Foundation, Arthritis Foundation, Coalition of State Rheumatology Organizations, Celgene, Genentech, and Pfizer. The SAIM coalition will collaborate
when possible on advocacy efforts and will serve as a resource to the AADA as it pursues this issue at the state and
federal level. – VICTORIA PASKO dw
6 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
NEW
FOR THE TREATMENT OF COMEDONAL AND INFLAMMATORY ACNE
For more information,
please visit www.OnextonGel.com
INDICATION
ONEXTON (clindamycin phosphate and benzoyl
peroxide) Gel, 1.2%/3.75% is indicated for
the topical treatment of acne vulgaris in
patients 12 years of age or older.
IMPORTANT SAFETY INFORMATION
• ONEXTON Gel is contraindicated in patients
with a known hypersensitivity to clindamycin,
benzoyl peroxide, any component of the
formulation or lincomycin.
• ONEXTON Gel is contraindicated in patients
with a history of regional enteritis, ulcerative
colitis, or antibiotic-associated colitis.
• Diarrhea, bloody diarrhea, and colitis
(including pseudomembranous colitis) have
been reported with the use of topical or
systemic clindamycin. ONEXTON Gel should
be discontinued if significant diarrhea occurs.
• Orally and parenterally administered
clindamycin has been associated with severe
colitis, which may result in death.
• Anaphylaxis, as well as other allergic
•
•
•
•
reactions leading to hospitalizations, has been
reported in postmarketing use of products
containing clindamycin/benzoyl peroxide.
If a patient develops symptoms of an allergic
reaction such as swelling and shortness of
breath, they should be instructed to
discontinue use and contact a physician
immediately.
The most common local adverse reactions
experienced by patients in clinical trials were
burning sensation, contact dermatitis, pruritus
and rash. All occurred in <0.5% of patients.
ONEXTON Gel should not be used in
combination with erythromycin-containing
products because of its clindamycin
component.
Patients should be advised to avoid contact
with the eyes or mucous membranes.
Patients should avoid exposure to natural
sunlight and avoid artificial sunlight
(tanning beds or UVA/B treatment)
while using ONEXTON Gel.
Please see Brief Summary of Prescribing Information on the following page.
Except as otherwise indicated, all product names, slogans, and other marks
are trademarks of the Valeant family of companies.
© 2014 Valeant Pharmaceuticals North America LLC. DM/ONX/14/0026
BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION
Neuromuscular Blocking Agents
This Brief Summary does not include all the information needed to use ONEXTON
Gel safely and effectively. See full prescribing information for ONEXTON Gel.
Clindamycin has been shown to have neuromuscular blocking properties that may
enhance the action of other neuromuscular blocking agents. ONEXTON Gel should be
used with caution in patients receiving such agents.
ONEXTON™ (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/3.75%, for
topical use
Initial U.S. Approval: 2000
CONTRAINDICATIONS
Hypersensitivity
ONEXTON Gel is contraindicated in those individuals who have shown hypersensitivity
to clindamycin, benzoyl peroxide, any components of the formulation, or lincomycin.
Anaphylaxis, as well as allergic reactions leading to hospitalization, has been reported
in postmarketing use with ONEXTON Gel [see Adverse Reactions]
WARNINGS AND PRECAUTIONS
Colitis/Enteritis
Systemic absorption of clindamycin has been demonstrated following topical use of
clindamycin. Diarrhea, bloody diarrhea, and colitis (including pseudomembranous
colitis) have been reported with the use of topical and systemic clindamycin. If
significant diarrhea occurs, ONEXTON Gel should be discontinued.
Severe colitis has occurred following oral and parenteral administration of
clindamycin with an onset of up to several weeks following cessation of therapy.
Antiperistaltic agents such as opiates and diphenoxylate with atropine may prolong
and/or worsen severe colitis. Severe colitis may result in death.
Studies indicate toxin(s) produced by Clostridia is one primary cause of antibiotic-associated
colitis. The colitis is usually characterized by severe persistent diarrhea and severe abdominal
cramps and may be associated with the passage of blood and mucus. Stool cultures for
Clostridium difficile and stool assay for C. difficile toxin may be helpful diagnostically.
Ultraviolet Light and Environmental Exposure
Minimize sun exposure (including use of tanning beds or sun lamps) following drug
application [see Nonclinical Toxicology].
ADVERSE REACTIONS
The following adverse reaction is described in more detail in the Warnings and
Precautions section of the label:
Colitis [see Warnings and Precautions].
Table 1: Local Skin Reactions - Percent of Subjects with Symptoms Present.
Results from the Phase 3 Trial of ONEXTON Gel 1.2%/3.75% (N = 243)
Before Treatment
(Baseline)
Maximum During
Treatment
End of Treatment
(Week 12)
Mild Mod.* Severe
Mild Mod.* Severe
Mild Mod.* Severe
Erythema
20
6
0
28
5
<1
15
2
0
Scaling
10
1
0
19
3
0
10
<1
0
Itching
14
3
<1
15
3
0
7
2
0
Burning
5
<1
<1
7
1
<1
3
<1
0
Stinging
5
<1
0
7
0
<1
3
0
<1
*Mod. = Moderate
Postmarketing Experience
Because postmarketing adverse reactions are reported voluntarily from a population
of uncertain size, it is not always possible to reliably estimate their frequency or
establish a causal relationship to drug exposure.
Anaphylaxis, as well as allergic reactions leading to hospitalizations, has been reported
in postmarketing use of products containing clindamycin phosphate/benzoyl peroxide.
DRUG INTERACTIONS
Erythromycin
Avoid using ONEXTON Gel in combination with topical or oral erythromycincontaining products due to its clindamycin component. In vitro studies have shown
antagonism between erythromycin and clindamycin. The clinical significance of this in
vitro antagonism is not known.
Concomitant Topical Medications
Concomitant topical acne therapy should be used with caution since a possible
cumulative irritancy effect may occur, especially with the use of peeling, desquamating,
or abrasive agents. If irritancy or dermatitis occurs, reduce frequency of application
or temporarily interrupt treatment and resume once the irritation subsides. Treatment
should be discontinued if the irritation persists.
Nursing Mothers
It is not known whether clindamycin is excreted in human milk after topical application
of ONEXTON Gel. However, orally and parenterally administered clindamycin has been
reported to appear in breast milk. Because of the potential for serious adverse reactions
in nursing infants, a decision should be made whether to use ONEXTON Gel while
nursing, taking into account the importance of the drug to the mother.
Pediatric Use
Safety and effectiveness of ONEXTON Gel in pediatric patients under the age of 12
have not been evaluated.
Geriatric Use
Clinical trials of ONEXTON Gel did not include sufficient numbers of subjects aged 65
and older to determine whether they respond differently from younger subjects.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity, mutagenicity and impairment of fertility testing of ONEXTON Gel have
not been performed.
Benzoyl peroxide has been shown to be a tumor promoter and progression agent in
a number of animal studies. Benzoyl peroxide in acetone at doses of 5 and 10 mg
administered topically twice per week for 20 weeks induced skin tumors in transgenic
Tg.AC mice. The clinical significance of this is unknown.
Carcinogenicity studies have been conducted with a gel formulation containing
1% clindamycin and 5% benzoyl peroxide. In a 2-year dermal carcinogenicity study in
mice, treatment with the gel formulation at doses of 900, 2700, and 15000 mg/kg/day
(1.8, 5.4, and 30 times amount of clindamycin and 2.4, 7.2, and 40 times amount of
benzoyl peroxide in the highest recommended adult human dose of 2.5 g ONEXTON Gel
based on mg/m2, respectively) did not cause any increase in tumors. However, topical
treatment with a different gel formulation containing 1% clindamycin and 5% benzoyl
peroxide at doses of 100, 500, and 2000 mg/kg/day caused a dose-dependent increase in
the incidence of keratoacanthoma at the treated skin site of male rats in a 2-year dermal
carcinogenicity study in rats. In an oral (gavage) carcinogenicity study in rats, treatment
with the gel formulation at doses of 300, 900 and 3000 mg/kg/day (1.2, 3.6, and 12
times amount of clindamycin and 1.6, 4.8, and 16 times amount of benzoyl peroxide
in the highest recommended adult human dose of 2.5 g ONEXTON Gel based on mg/
m2, respectively) for up to 97 weeks did not cause any increase in tumors. In a 52-week
dermal photocarcinogenicity study in hairless mice, (40 weeks of treatment followed by
12 weeks of observation), the median time to onset of skin tumor formation decreased
and the number of tumors per mouse increased relative to controls following chronic
concurrent topical administration of the higher concentration benzoyl peroxide formulation
(5000 and 10000 mg/kg/day, 5 days/week) and exposure to ultraviolet radiation.
Clindamycin phosphate was not genotoxic in the human lymphocyte chromosome
aberration assay. Benzoyl peroxide has been found to cause DNA strand breaks in a variety
of mammalian cell types, to be mutagenic in S. typhimurium tests by some but not all
investigators, and to cause sister chromatid exchanges in Chinese hamster ovary cells.
Fertility studies have not been performed with ONEXTON Gel or benzoyl peroxide,
but fertility and mating ability have been studied with clindamycin. Fertility studies in
rats treated orally with up to 300 mg/kg/day of clindamycin (approximately 120 times
the amount of clindamycin in the highest recommended adult human dose of 2.5 g
ONEXTON Gel, based on mg/m2) revealed no effects on fertility or mating ability.
PATIENT COUNSELING INFORMATION
See FDA-approved patient labeling (Patient Information).
Distributed by:
Valeant Pharmaceuticals North America LLC, Bridgewater, NJ 08807
Manufactured by:
Contract Pharmaceuticals Limited Mississauga, Ontario, Canada L5N 6L6
U.S. Patents 5,733,886 and 8,288,434
Issued 11/2014
9389300
DM/ONX/14/0031(1)
S:9.75”
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction
rates observed in clinical trials of a drug cannot be directly compared to rates observed in
the clinical trials of another drug and may not reflect the rates observed in clinical practice.
These adverse reactions occurred in less than 0.5% of subjects treated with ONEXTON
Gel: burning sensation (0.4%); contact dermatitis (0.4%); pruritus (0.4%); and rash (0.4%).
During the clinical trial, subjects were assessed for local cutaneous signs and
symptoms of erythema, scaling, itching, burning and stinging. Most local skin reactions
either were the same as baseline or increased and peaked around week 4 and were
near or improved from baseline levels by week 12. The percentage of subjects that had
symptoms present before treatment (at baseline), during treatment, and the percent
with symptoms present at week 12 are shown in Table 1.
USE IN SPECIFIC POPULATIONS
Pregnancy
Pregnancy Category C.
There are no adequate and well-controlled studies in pregnant women treated with
ONEXTON Gel. ONEXTON Gel should be used during pregnancy only if the potential
benefit justifies the potential risk to the fetus.
Animal reproductive/developmental toxicity studies have not been conducted with
ONEXTON Gel or benzoyl peroxide. Developmental toxicity studies of clindamycin
performed in rats and mice using oral doses of up to 600 mg/kg/day (240 and 120
times amount of clindamycin in the highest recommended adult human dose based
on mg/m2, respectively) or subcutaneous doses of up to 200 mg/kg/day (80 and 40
times the amount of clindamycin in the highest recommended adult human dose
based on mg/m2, respectively) revealed no evidence of teratogenicity.
research in practice
Can better access
to dermatologists
improve melanoma
prognosis?
IN THIS MONTH’S ACTA ERUDITORUM COLUMN,
Physician Editor Abby S. Van Voorhees, MD, talks with Dr. David
Moreno-Ramirez about his recent Journal of the American
Academy of Dermatology article, “The role of accessibility policies
and other determinants of health care provision in the initial
prognosis of malignant melanoma: A cross-sectional study.”
acta eruditorum
Q&A
DR. VAN VOORHEES: Dermatologists
around the world have been involved in
trying to identify those with melanomas as
early as possible. Your study looks at the
benefits of these efforts in Spain. Tell us
what you have discovered.
DR. MORENO-RAMIREZ: The TEDIMEL
project has shown that interventions
aimed at improving melanoma patients’
ability to access dermatology units have the
greatest impact on the early diagnosis of
malignant melanoma.
Those primary care centers with direct
referrals have shown a greater frequency
of early diagnosis of malignant melanoma
(Tis-T1).
In our region, several policies aimed at
this goal have been implemented over the
last decade. TEDIMEL has shown us how
these policies have contributed to changing
the trends in melanoma diagnosis in just
10 years.
In 2004, the regional government
launched a “15-day rule” for skin cancer
patients. This obliged skin cancer and
melanoma units to enable direct and
fast referral systems to achieve the goal
of a diagnosis within 15 days. That effort
explained the significant change in early
diagnoses after 2004, as observed in
TEDIMEL.
DR. VAN VOORHEES: What kinds of trends
did you find? Were there an increasing
number of cases of melanoma identified?
If so, by how much? Were there changes
in the mean age at which patients were
diagnosed? Was there the expected male/
female ratio? Was there a shift in the
percentage of cases that were diagnosed at
a later stage?
DERMATOLOGY WORLD // February 2015 9
acta eruditorum continued
DR. MORENO-RAMIREZ: Over the
study period, the total number of
melanoma cases increased by 78
percent. Luckily, this change was
mainly due to the increase in the
diagnosis of in situ and T1 malignant
melanomas. The increasing
frequency of thin malignant
melanoma had been noticed in
recent years in our melanoma clinics,
and it has been confirmed by the
TEDIMEL study.
In terms of age, an increased
incidence of melanoma in younger
subsets has been suggested.
However, during the study period,
TEDIMEL failed to show a significant
change in the frequency of malignant
melanoma in those aged zero to
29 years. A slight increase was
observed, between 5 percent and
12 percent, but it did not reach
statistical significance. By contrast,
a significantly higher frequency of
malignant melanoma was observed
in women (54 percent vs 46 percent);
however, this was balanced by the
greater likelihood of early diagnosed
malignant melanoma that was
observed in women.
DR. VAN VOORHEES: Were there
other differences between sites that
were important? What impact on the
prognosis did these approaches have
and how significant were they?
DR. MORENO-RAMIREZ: Actually,
the only relevant difference between
the participating centers was the
availability of well-established, fasttrack referral systems between
10 DERMATOLOGY WORLD // February 2015
research in practice
primary care and melanoma
clinics. It was this availability that
led these centers to have a greater
likelihood of identifying melanoma
in its earlier stages, that is, at a noninvasive or a very thinly invasive
stage (T1). These fast-track referral
systems involved any procedure or
intervention that allowed patients
with suspected melanoma to have
a specialized consultation within
two weeks. And what we consider
even more remarkable is that this
change was achieved in various
ways, from immediate letter referrals
with no previous appointment to
teledermatology-based screenings
of suspicious lesions at the primary
care center. So, I would stress that
the type of intervention launched was
not as important as the final results
achieved: the shortening of delays to
see a dermatologist.
Other indicators of health care
provision that might be major
determinants of health outcomes,
such as the ratio of dermatologists
per capita, the complexity of the
hospital, among others, failed to
show any direct role in the early
diagnosis of malignant melanoma.
However, these variables might have
served as confounding factors, or
might simply not be as powerful.
group found relevant results in a
rather short period of time from an
epidemiological point of view, the
impact of health care interventions
in terms of final outcomes such
as survival need much longer
study periods. Nonetheless, in the
meantime the results obtained
through TEDIMEL can be considered
a good starting point for policy
makers.
DR. VAN VOORHEES: If there is one
thing that you feel should be learned
from this paper to facilitate the care
of those with melanoma what would
it be?
DR. MORENO-RAMIREZ: The easier
access is to a dermatologist, the
better the prognosis is for malignant
melanoma. It sounds basic and even
simple, but it necessarily involves
dermatologists and policy makers
working together. This has been the
experience at our region for the last
decade. dw
DR. MORENO-RAMIREZ is clinical director of
the dermatology unit at Hospital Universitario
Virgen Macarena in Seville, Spain. His article
appeared in the September 2014 issue of the
Journal of the American Academy of Dermatology.
J Am Acad Dermatol 2014;71(3):507-515.doi:
http://dx.doi.org/10.1016/j.jaad.2014.04.049.
DR. VAN VOORHEES: What were the
limitations of this study?
DR. MORENO-RAMIREZ: The main
limitation is its retrospective nature,
and probably the lack of a survival
analysis. However, although our
www.aad.org/dw
legally speaking
legal issues
BY CLIFFORD WARREN LOBER, MD, JD
Do you have a
duty to warn a
third party?
EVERY MONTH, DERMATOLOGY WORLD covers legal
issues in “Legally Speaking.” Clifford Warren Lober,
MD, JD, presents legal dilemmas in dermatology
every other month. He is a dermatologist in practice
in Florida and a partner in the law firm Lober, Brown,
and Lober.
I
t’s a beautiful winter day when Bryan’s
receptionist bursts into his office. She
tells him that Sandy, one of his dermatology clients, is on the phone with an
urgent problem. Bryan picks up the phone
and begins the conversation.
Bryan: Sandy, how are you? It’s been a
while since we spoke.
Sandy: Bryan, I have a real problem. I just
finished removing a skin cancer from one
of my patients. During the procedure,
she told me that she was aware that her
husband was “fooling around” and that
she has “had enough.” She swore that the
next time he does it she is going to kill
him with the gun kept in her bedroom
nightstand. She was absolutely livid when
she told me this and I truly believe that she
will do so. Should I warn her husband? Do
I need to report this to the police? What
should I do? I have never been in this position before.
Bryan: The issue here is whether you can
or must violate the patient’s confidentiality, which is inherent and expected in the
doctor-patient relationship, to protect her
husband. One of the few times state laws
make an exception to the duty of confidentiality is when there is a credible threat of
violence against another person. States
and even localities within states vary in
whether, and if so to whom, they permit
you to disclose this information. When it is
permitted, however, there must be a clearly
identifiable intended victim and an imminent, credible expectation that the patient
is capable of and truly intends to commit
the violent act. In this case the patient has
clearly identified the circumstances under
which she will shoot her husband and has
the means and intent to do so.
DERMATOLOGY WORLD // February 2015 11
legally speaking continued
Sandy: You said there are differences
in whether I can or need to disclose
this information. What do you mean?
Bryan: Some jurisdictions impose
a duty to warn the potential victim.
This duty permits you to contact the
intended victim and tell them of the
foreseeable danger. The duty to warn
may be mandatory, meaning that
you must warn the intended victim,
or merely permissive, in which case
you have the option of warning the
intended victim. The duty to warn
always necessitates violating the
patient’s confidentiality.
Other jurisdictions impose a different requirement, called the duty
to protect, which allows or requires
that you take action to protect the
intended victim, such as notifying the
police. Like the duty to inform, the
duty to protect may be either mandatory or simply permissive. Sometimes
it may be possible to take action to
protect an intended victim without
breaching the patient’s confidentiality, such as by committing a patient
with a psychiatric issue to a mental
health facility.
Sandy: Do all states have a duty to
inform or a duty to protect? How do I
know which applies to me?
Bryan: No! Surprisingly, some states
and jurisdictions have neither a duty
to warn nor a duty to protect third
parties. They give you no protection
if you violate the patient’s confidentiality. Therefore, I have to check the
laws in our jurisdiction before telling
you how to proceed. There is another
wrinkle, however.
12 DERMATOLOGY WORLD // February 2015
legal issues
KEY POINTS:
1 State and local jurisdictions vary in whether they permit or
require you to warn a potential victim of foreseeable violence.
2 There must be a clearly identifiable victim and an imminent,
credible expectation that the patient is capable of and truly
intends to commit violence.
3 Some jurisdictions impose a duty to warn potential victims. This
may be permissive or mandatory, thus allowing or requiring you
to contact and notify the intended victim.
4 Other states and jurisdictions have a duty to protect, which is
either permissive or mandatory, permitting or mandating that you
take affirmative steps to protect the third party.
5 If the duty to warn or protect the intended victim in your
jurisdiction is limited by statute to mental health and/or social
workers, it may offer no protection to dermatologists.
Sandy: What’s that?
Bryan: The laws that permit health
care personnel to breach a patient’s
confidentiality to protect a third party
are frequently limited in scope to
mental health professionals, such as
psychiatrists or psychologists, and/or
social workers. If the laws are strictly
limited to those professionals, they
may offer no protection to you as a
dermatologist.
law and get back to you as quickly as
possible.
Sandy: Okay, Bryan. I will wait to hear
from you. Thank you again for your
help.
If you have any suggestions for topics to
be discussed in this column, please email
them to me at loberc@gmail.com. See
the February 2013 issue of Dermatology
World for disclaimers.
Sandy: What about my ethical duty to
protect the patient’s husband? I really
think he is in danger.
Bryan: I am certain that you feel
morally obligated to act. Nevertheless,
if neither our state nor local jurisdiction recognizes a duty to inform or
protect the patient’s husband, the
patient may take legal action against
you if you violate her confidentiality. I
will check the relevant state and local
www.aad.org/dw
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DERMW2015CA
technically speaking
BY MORRIS W. STEMP, CPA, MBA, CPHIMS, AND BEVERLY WACHTEL
How to choose
tech solutions to
maximize
productivity and
improve
patient care
EVERY OTHER MONTH, DERMATOLOGY
WORLD covers technology issues in
“Technically Speaking.” This month’s
author, Morris W. Stemp, is the CEO
of Stemp Systems Group, a Health IT
solutions provider in New York City.
Wachtel is the marketing manager at
Stemp Systems. Stemp earned the designation of Certified Professional
in Health care Information and Management Systems (CPHIMS) in 2010,
joining an elite group of only 1,500 professionals worldwide to earn this
certification.
M
edical practices don’t have computers and
diagnostic equipment in the office because the
doctors and staff love technology. They have
this technology because it is required to take
care of patients, run the office more efficiently, and get
paid faster. There are many technologies and options
available. Choosing the optimal solution can enhance
the lives of the doctors and staff, and create an enjoyable
patient experience. Choosing the wrong solution can be
very frustrating, inefficient, and costly. Even more costly
is the time and money to move from the wrong solution
to the right solution (a task unfortunately performed at
some point by almost 50 percent of EHR users). So how
do you choose?
The most central technology at any medical practice
is the EHR including the practice management (PM)
module. As you probably already know, a good part of a
physician’s and staff’s work day revolves around using
this technology, and using an EHR changes a practice’s
entire workflow. You’ll find more information about
choosing a dermatology-specific EHR, and technology
which integrates with it, in the sidebar.
CHOOSING THE RIGHT TECH SOLUTION
Given all the complexity and options, how do you
choose the right tech solutions? While there are many
choices to address some needs, you’ll find that there
are very few choices for others. While cost will always
be a consideration, a system that is easier to use will
lead to greater productivity and be less costly over time.
THE STEPS OF THE PROCESS
1 Understand your needs
It may seem obvious, but before you even consider a
technology solution, you need to understand and document the problem you are trying to solve. Frequently,
our clients know they have an issue but have difficulty
articulating and documenting the details and nuances of
the issue. This documentation is critical to convey your
needs to possible solutions vendors and to evaluate the
degree to which the solutions meet your needs.
2 Create an evaluation team
The staff members who eventually use the solution
are the best group to be involved in both documenting
the need and evaluating the solutions. You’ll also have
more cooperation from the staff in implementing the
chosen solution if they have input into making the
decision.
3 Learn the options
Researching the available technology options that
might meet your needs is the next step. Searching the
14 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
tech tips
Internet, contacting vendors, attending
dermatology and health IT conferences, as
well as speaking with colleagues and with
IT consultants, will expand your awareness
of all the options and reveal a range of pricing. Gaining this awareness will also lead to
further refinement of your needs.
4 Set a budget
Now that you have an idea of the possibilities and range of costs, you can set your
budget and refine your choices to those that
fit within your budget. Be sure to consider
not only the cost of the software and hardware alone, but also the cost of implementation, training, maintenance, and support.
Do you have the funds available or will
you consider financing the solution? If the
purchase cost is substantial, you should
discuss the income tax issues regarding
purchasing and financing the equipment
with your accountant.
5 Write a request for proposal
When choosing an expensive technology
solution such as an EHR, prepare a request
for proposal (RFP) for each vendor you are
seriously considering. This document tells
the vendor about your practice and your
priorities in choosing a solution. By submitting an RFP with blanks for the vendor
to fill in answers, you will be able to do a
side-by-side comparison of solutions from
different vendors. The RFP should include
the following information.
 Your practice information – size, location, computer hardware and network
information and any product you currently use for the same purpose.
 Your practice’s goals for functionality –
prioritized
 Request for vendor information – history, number of employees (for sales/
support/research and development, and
management), financial statements,
product history, list of current dermatology users of that product that are
similar in size to your practice
 Request for product information – how
it performs your prioritized functions,
other functions it performs, software
versions and release dates
 Hardware and network requirements to
use their product
 Maintenance and support provided and
related costs
 Training provided (included and for additional cost)
 Details of a proposed implementation plan
 Integration and interface capabilities
 Proposed costs and payment schedule
Warranties
 Sample contract
6 Select vendors to consider
Compare the RFPs and select the vendors
of a few products you would seriously
consider. If choosing an EHR, consider
vendors that have EHR systems that are
specific to dermatology, integrate with the
other products you want to use, and have
favorable ratings.
7 Schedule a demonstration
Invite the vendors to come to your office to
demonstrate functionality and workflow of
the technology. (Some technologies have
online demos, but it is preferable to have
in-person demos for a system as pervasive
as an EHR or PM system.)
When vetting an EHR, look at the
layout of the screens. Does the design of
the screens make the steps to document a
dermatology visit intuitive? Does the EHR
have the option to draw on the screen (with
your finger or stylus)? Does the design
enable you to easily input data, construct
queries, and create reports so that the EHR
will be more useful than a paper record?
How many clicks does it take for each visit?
Extra clicks take more time, so make sure
the next steps flow and the screens are easily accessible. Is the EHR easy to use on a
laptop, tablet, or smartphone?
Provide the vendor with scenarios to
find out if the product meets those needs or
can be customized. Ask the vendor about
integration with other systems. Which practice management software integrates with
their EHR? Is the EHR part of a suite which
includes the PM system?
Be sure to let staff participate in vendor
demos to see if the EHR meets their needs
as well, since they will be using different
functions of the software. Everyone who
will be using the system should have input,
including clerks, medical assistants, nurses,
and doctors. There needs to be buy-in from
the whole team to ensure that implementation of the EHR will be successful.
Ask about training and support for the
product. If you are replacing your EHR, ask
about moving the data into the new system,
or creating an interface to allow you to access data from your old system.
Upon moving to a new system, it’s important to consider what you are going to do
with your old system and if you still need access to it. If the old system is a cloud-hosted
system, maybe you can negotiate a lower rate
since you will no longer be actively using it?
If the old software is running on some old
server, do you expect that server to be stable
until you no longer need access to your old
software? It may be possible to move the old
system into a hosted environment where the
system can be kept alive so you can access it.
8 Check references
Check with other physician users and ask
each the same questions about the solutions you’re considering. Compare their
practice with your own. Inquire about their
usage, the training and support they’ve received, the hardware that was required, how
the product was implemented, and their
satisfaction rating. Also check references
with IT consultants. Then do the same type
of side-by-side comparison of the responses.
You might even consider asking the
vendor for references to practices that were
using their system but are no longer using
it. Speak with those practices to find out
why they switched away from the system
you’re considering.
9 Visit other practices that use the
solution you’re considering
If you don’t know of other dermatology
practices the same size as yours that are
using the solutions you’re considering, visit
the practices recommended by the vendor.
Recognize that the vendor will only choose
practices that are happy with their product,
but it will give you the opportunity to see the
product being used in an office environment.
Pair a doctor from your office with a doctor
who uses the product, and pair a practice
manager with a practice manager, to observe
DERMATOLOGY WORLD // February 2015 15
technically speaking continued
the workflow. Watch how the product is used
and ask questions about how the technology
functions. Ask about their experience working with the vendor including the training,
updates, and support provided. This is especially important in choosing an EHR since
the EHR is a game-changer for your practice.
Be sure to take notes.
10 Rank the vendors
One of the most difficult aspects of evaluating
possible solutions is determining which solution does the best job of meeting your needs.
Rank the vendors using the results of
the product demo and references, based on
how they meet your goals and priorities.
Consider not only functionality and cost,
but also the implementation, training, sup-
port, how the product is maintained, and
the long-term viability of the vendor.
If the solution you are considering has a
lot of features to compare, it is a good idea
to develop an evaluation matrix. For the
columns list the goals you want to meet by
using technology, and for the rows list the
names of the technology solutions. You’ll
find more criteria as you do your research,
and then you can ask the vendors whether
(and how) their product meets those needs.
11 Select a solution
Compare your notes from the office visits
to your notes from the demos and the
RFPs. Select the best, and the second best,
solution for your needs. If you are not
happy dealing with your first choice when
negotiating your contract, you’ll be ready to
proceed with your second choice.
12 Negotiate a contract
Your contract is just as important as the
technology you choose.
Most EHR vendors offer standardized
contracts with some negotiable terms, but
some will not negotiate terms. It is a good
idea to consult an experienced attorney for
help with contract negotiations. The Office
of the National Coordinator for Health
Information Technology has a guide that
explains key contract terminology and how
it may impact a physician’s practice. We
strongly recommend that you read it.
Ask for a trial period and escape clause.
Also, review the terms of the training: find
TECHNOLOGY DESIGNED FOR DERMATOLOGY
EHR AND PRACTICE MANAGEMENT
The electronic health record is an
electronic version of the patient
chart, including the medical history,
demographics, progress notes,
problems and medications. The
practice management portion of the
EHR manages appointment scheduling,
secure messaging, reporting, document
management, and billing.
Some of the features which make
an EHR specific to the practice of
dermatology include:
• Dermatology and cosmetic surgery
specific templates (such as acne,
psoriasis, lesions, rosacea, and
cancer screenings)
• Dermatology workflow
management
• Dermatology-specific procedure
and diagnosis codes
• Dermatology-specific clinical
decision support
• Graphics of each area of the body on
which to identify the location of and
draw the dermatologic condition
• Ability to store before and after
photos of patients
• Ability to draw directly on photos to
demonstrate location of treatment
using touch-screen or digital pen
16 DERMATOLOGY WORLD // February 2015
With so many EHR choices, it will be
helpful to follow a very comprehensive
selection process like the one
described in the main article.
You’ll want to make sure you’re happy
with the EHR that you’re using before you
start focusing on add-ons and integrated
technologies. Make sure that the EHR
you choose can be configured to access
your local Health Information Exchange
to comply with the HIE requirements
of meaningful use. In addition, make
sure that the solution will enable you to
transition smoothly to ICD-10.
DERMATOLOGY SOLUTIONS THAT INTEGRATE
WITH EHR
There are many technology options that
integrate with EHR systems. Data only
has to be updated in one application
and the changes are automatically
made in the integrated systems.
Integration benefits the practice by
increasing efficiency and reducing
errors due to manual entry of data.
Patient Portal
One of the requirements of meaningful
use is patient engagement. Engaging
patients with secure communication
through a patient portal can also
save your practice time. The portal
enables patients to schedule and view
appointments, receive communications
from your office, and access portions
of the patient’s medical record. Most
EHR systems offer a cloud-hosted
patient portal. There are also nonproduct specific portals which may
integrate with your EHR such as
Omedix, InteliChart, and Updox.
Dictation
Many physicians like to use dictation
services to document their notes
instead of typing and clicking through
their EHR. Dragon Medical by Nuance
is the top selling transcription
software for health care. Many EHR
systems integrate with Dragon for
documentation of notes and even for
navigating around the system.
E-prescribing
E-prescribing is built into most EHRs.
For physicians not using an EHR,
standalone options are available
through Surescripts, MDToolbox,
DrFirst’s Rcopia, and the National
ePrescribing Patient Safety Initiative.
Surescripts is an e-prescribing network
which covers more than 90 percent of
U.S. pharmacies. (MPR discontinued its
ePrescribing service effective August
2014. Refills can be transferred to
another e-prescribing service).
www.aad.org/dw
tech tips
out how much training is included in the
price and how much it costs for additional
training later.
SKIPPING SOME STEPS
It is clear that some of these steps are
not necessary for every technology
solution you purchase. If you are the
only one using the technology, you
don’t need to create an evaluation team
to choose it. There may only be one
reputable vendor for the solution you
want, so the RFP may not be relevant.
You may simply decide to use the same
technology your favorite colleague uses
or that you were exposed to in medical
school.
Clinical decision support
Clinical decision support (CDS) is
interactive software used at point of
care that works with the clinician’s
knowledge to assist in diagnosis and
analysis of patient specific data. It
is built into most EHR systems. A
standalone version for dermatology,
available on desktop, smartphones,
and tablets, is VisualDx.
Laboratory platforms
Instead of receiving your lab and
pathology results by fax and having
to manually file them in the patient
charts, you can save time by having
the results transmitted electronically
from the lab and attached to the
patient record in the EHR. All of the
major medical laboratories set up
integrations with EHRs, including
Quest, Labcorp, Sunrise, and Shiel.
Photo storage
Storing and accessing photos is
essential for dermatology. Options were
discussed in the October 2012 Technically
Speaking column; see www.aad.org/dw/
monthly/2012/october/dermatologistshave-options-for-storing-and-accessingphotos-in-their-records.
Informed consent
Integrating informed consent into your
technology process helps to limit your
liability. This was discussed in the
ASSESSING THE SOLUTIONS YOU’RE CONSIDERING
If you’ve prepared a matrix to compare
products, you’ll find it is relatively easy to
see which solutions have which features.
Evaluate which features are most important
to you, and eliminate the products that
don’t have those features. Then, as you do
your side-by-side comparison, decide which
remaining features are more important to
you and move the products that have those
features to the top of the list.
GETTING THE MOST OUT OF YOUR IT
When you choose a technology solution,
you want to make sure that the technology helps you improve productivity. To get
the most out of your IT, you will want to
October 2014 issue; see www.aad.org/
dw/monthly/2014/october/informedconsent-how-technology-can-improvethe-process.
HIPAA-compliant communication
There are many HIPAA-compliant
methods of communication that you
can use to collaborate on patient
care such as text-like applications,
encrypted email, and e-fax. Options
can be found in the June 2014 issue;
see www.aad.org/dw/monthly/2014/
june/hipaa-compliant-ways-tocommunicate-with-other-doctors.
Cloud storage
Sometimes it is helpful to work on
documents with patient information
outside of the office, or in collaboration
with another provider who is not in the
same location as you. Using a HIPAAcompliant cloud-storage solution will
enable this process, as discussed in
the February 2014 issue; see www.aad.
org/dw/monthly/2014/february/usingthe-cloud-for-data-storage.
Smartphone apps
Your smartphone can be used in
many ways to improve productivity in
your dermatology office. If you do use
smartphone apps for clinical care, ensure
that your mobile phone is password
encrypted and download a remote wipe
app such as Find My iPhone.
make sure that the technology solutions
work together and that you know how to
use them. So it boils down to integrations
and training. If the product integrates
with your EHR, the information gathered
and produced by that technology will
move directly into the patient records in
the EHR, eliminating the need for data
entry, which saves time and improves
accuracy. With more training, you’ll know
how to use more of the features of the
product and the most efficient way to use
it. Both will lead to improved productivity, accomplishing your goals of taking
care of patients, running the office more
efficiently, and ultimately, getting paid
faster. dw
There are skin scanner solutions
that turn your smartphone into a
dermatoscope, like the DermLite and
the Handyscope, and imaging apps that
associate patient metadata with the
image like the tKDerm Touch. (See the
October 2012 issue at www.aad.org/dw/
monthly/2012/october/dermatologistshave-options-for-storing-andaccessing-photos-in-their-records.)
If you’re looking for easy access to
information, there are also apps
you can use on your smartphone or
computer to access online materials,
like Medscape for research and
Epocrates for drug reference.
Many of the hundreds of dermatology
smartphone apps are designed for
patients. If you decide to use them,
check the ratings; most are not rated
well. One that we like that is patient
centered is ZocDoc. Potential patients,
who download ZocDoc for free, use it
to look up doctors in the area who take
their insurance, and book appointments.
Physicians pay a flat fee of $300 per
month for a listing and the app syncs
with the PM scheduling system. The
cool thing about it is that the app tracks
cancellations, enabling patients to book
appointments in those slots.
DERMATOLOGY WORLD // February 2015 17
answers in practice
BY RACHNA CHAUDHARI
Keeping track
of all those
penalties
EACH MONTH, DERMATOLOGY WORLD tackles issues “in practice”
for dermatologists. This month Rachna Chaudhari, the Academy’s
practice management manager, offers tips on an area she
commonly receives questions about from members.
D
ermatologists are well aware that they
face penalties from the Centers for
Medicare and Medicaid Services (CMS) if
they do not comply with various quality
reporting programs including meaningful use
(MU), the Physician Quality Reporting System
(PQRS), and the value-based modifier (VBM).
However, due to the confusing regulatory
language surrounding these programs, many
dermatologists are not aware that these penalties are cumulative and add up to much larger
percentages than they originally thought. In
fact, the Medical Group Management Association (MGMA) recently released results from its
Physician Practice Assessment: Medicare Quality Reporting Programs survey that showed
over 70 percent of physician practices rated
Medicare’s quality reporting requirements as
“very” or “extremely” complex. Additionally,
more than 83 percent of respondents believed
the current Medicare quality reporting programs did not enhance quality of patient care;
the vast majority of respondents, and probably
most physicians, would support streamlining
all of these programs into one quality reporting
program that would standardize reporting.
In order to fully comprehend how much of
your Medicare Part B revenue is at stake with
these quality reporting programs, you need to
know how each program is administered and
reported. Each program is outlined in the summary below.
MEANINGFUL USE
The MU program was created by Congress
in 2009 to encourage physicians to adopt
electronic health records (EHRs). MU requires
that physicians complete a series of measures
to show that they are utilizing their certified
EHR in a quality manner, such as performing
electronic prescribing, documenting medications in the electronic chart, and implementing a patient portal. All of the measures and
guidelines are outlined on the AAD website at
www.aad.org/meaningfuluse.
Physicians who choose to not report in
this program will face a 1 percent penalty in
2015. If you did not participate in the program
between 2011-2014, you should check your Explanation of Benefits (EOB) statement to see
the 1 percent penalty. Additionally, if you did
18 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
management insights
not participate in the electronic prescribing program through CMS in 2012 or
2013, you will see an additional 1 percent
penalty on your EOB. The e-prescribing
penalty will end after 2015 while the MU
penalty will increase by one percentage point every year to a maximum of 5
percent.
PQRS
PQRS was created by Congress in 2006
to foster quality measurement amongst
medical providers. The program, which
initially offered bonus payments to those
who participated, now requires providers
to report on a series of quality measures
to avoid penalties on their Medicare Part B
revenue. If you did not report in the PQRS
program in 2013, you should review your
current EOB to see if you are receiving a
1.5 percent penalty. (You probably are.) The
penalty increases to 2 percent in 2016 and
continues at 2 percent for every subsequent year. Each year of reporting to PQRS
serves to avoid the penalty two years in
the future. (New providers are assessed on
a shorter timeline.) Dermatologists have
several specialty-specific quality measures
to report on including measures related
to melanoma, psoriasis, and biopsies. For
more information on measure specifications and reporting guidelines, see www.
aad.org/qrs.
VALUE-BASED MODIFIER
The value-based modifier (VBM) was created through the Affordable Care Act (ACA)
to begin value-based payments to providers
for Medicare services. It will either raise or
lower Medicare provider reimbursement
based on their cost compared to other
providers in the same geographic area and
quality data from the PQRS program; nonparticipants in PQRS will automatically
see VBM-based payment reductions. The
program begins in 2016 for group practices with 10 or more eligible providers and
will affect their pay by up to 2 percent that
year. Practices with less than 10 providers
or solo practitioners will be subject to the
value-based modifier beginning in 2017.
PENALTY SUMMARY
For 1-9 provider practice
Year
EHR
PQRS
VBM
Total
2015
1%
1.5%
0%
2.5%
2016
2%
2%
0%
4%
2017
3%
2%
2%
7%
2018
4%*
2%
TBD**
6% + VBM
2019
5%*
2%
TBD**
7% + VBM
*EHR penalty will rise to 5% if less than 75% of all Medicare providers are participating in meaningful use by 2017.
**Scheduled to be announced in final rule for 2016 Medicare fee schedule.
For 10+ provider practice
Year
EHR
PQRS
VBM
Total
2015
1%
1.5%
0%
2.5%
2016
2%
2%
2%
6%
2017
3%
2%
Up to 4%
Up to 9%
2018
4%*
2%
TBD**
6% + VBM
2019
5%*
2%
TBD**
7% + VBM
*EHR penalty will rise to 5% if less than 75% of all Medicare providers are participating in meaningful use by 2017.
**Scheduled to be announced in final rule for 2016 Medicare fee schedule.
If you are part of a group practice of
10 or more providers, you would have had
to participate in either the PQRS Group
Practice Reporting Option (GPRO) or had
at least 50 percent of your individual providers in the practice participate in PQRS
in 2014 to avoid the 2 percent penalty in
2016. If your group practice successfully
participated in PQRS in 2014 and you are
deemed a high quality/low cost provider,
you could obtain an incentive up to 2
percent of your Medicare Part B allowed
charges in 2016. To determine if your
practice meets these criteria, CMS will
release a Quality and Resource Use Report
(QRUR) in Summer of 2015 that will detail
quality and cost performance data. You can
view your QRUR from 2014 by logging
in at https://portal.cms.gov/wps/portal/
unauthportal/home/. In 2015, you would
have to continue participating in PQRS,
however your group practice could still
face a penalty of up to 4 percent in 2017
if you are deemed a low quality/high cost
provider through the QRUR.
If you are a solo practitioner or part of
a group practice with less than 10 providers, you must report in the PQRS program
in 2015 to avoid the value-based modifier
penalty of 2 percent in 2017. You could
also obtain an incentive of up to 2 percent
if you are deemed a high quality/low cost
provider through your QRUR report; however solo practitioners and group practices
of less than 10 providers will be subject
to greater penalties in 2018 even if they
continue to participate in PQRS but are
found to be low quality/high cost providers
through QRUR.
For more information on how the VBM
is calculated, visit www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
PhysicianFeedbackProgram/ValueBasedPaymentModifier.html. dw
DERMATOLOGY WORLD // February 2015 19
Dermatologists
profile
the specialty’s
data needs
20
DERMATOLOGYWORLD
WORLD////February
February2015
2015
20
DERMATOLOGY
www.aad.org/dw
www.aad.org/dw
BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR
D
ermatology patients are keenly aware
of the unique value of the specialty’s
care. According to a 2001 study in
the Archives of Dermatology, patients
have confidence in their primary care
physician to care for their skin disease.
However, they have more confidence in
the care provided by their dermatologist
(Arch Dermatol. 2001 Jan;137(1):25-9). Yet
as health care evolves from a volumebased, fee-for-service model, physicians
are being asked to prove their worth
beyond anecdotal evidence.
Given this new environment, experts are
beginning to think that data collection
is no longer a luxury, but a necessity.
“People are starting to understand the
imperative of having a strategy around
value,” said Elizabeth O. Teisberg, PhD —
author and professor at the >>
DERMATOLOGY WORLD // February 2015 21
Dartmouth Center for Health Care Delivery Science
— at a recent forum on demonstrating value in
health care. “So how do we switch from a strategy
around volume to one of value?” To Dr. Teisberg
and many in dermatology, the answer to that
question lies in the development of data registries
that measure patient outcomes and physician
performance. “Dermatology is a specialty that few
people truly understand,” said Oliver Wisco, DO, a
member of the Academy’s Ad Hoc Task Force on
Data Collection Platform and Registries. “I see a
data collection system as a way to define our role as
specialists.”
However, as a specialty that collectively
treats up to 3,000 skin diseases, the continued
process of determining data collection priorities
will prove daunting. “We need to decide what to
collect and what requires standardization,” Dr.
Wisco said. “The development of a standardized
way to grade a disease — or the features that lead
to a certain grading system — needs to occur
within the different subspecialty groups within
our specialty.” The Ad Hoc Task Force on Data
Collection Platform and Registries has been charged
with investigating the data collection options for
members, recommending action toward platform
development, and advising on functionality to
best serve dermatologists’ data needs. So far, the
task force has gleaned some clarity on what the
specialty’s specific data needs are, and where the
Academy could potentially start when building out
this platform, which has been named DataDerm™.
HONING IN ON DISEASE
To many, a natural first step in developing a data
registry would be to focus on care for specific
diseases. “As a specialty, skin cancer is one of the
crucial areas of what we do that we have to own — I
think we have the most comprehensive training to
best care for skin cancer patients,” Dr. Wisco said.
“Defining what we do and why we do it well, and
what we should improve upon, is where we should
start first.” Joel Gelfand, MD, MSCE, a member
of the Academy’s Research Agenda Committee,
agrees and believes that some of the most common
dermatologic diseases — psoriasis, eczema,
and acne — are the logical places to start. At the
University of Pennsylvania, Dr. Gelfand developed
the Dermatology Clinical Effectiveness Research
Network (DCERN), the first U.S.-based independent
dermatology registry, to review data on more than
1,800 patients across the country with moderate
to severe psoriasis to benchmark his patients’
22 DERMATOLOGY WORLD // February 2015
treatment outcomes. The registry was initiated
through an NIH “Challenge Grant” targeting
an Institute of Medicine priority to determine
the comparative effectiveness of treatments for
moderate to severe psoriasis. “DCERN data allows
us to determine achievable goals for psoriasis
patients, be they physician-reported, such as
percent of patients being clear or almost clear, or
patient-reported, such as percent of patients having
minimal quality of life impairment based on the
Dermatology Life Quality Index survey. Say, for
example, the national average of being clear or
almost clear on drug ‘X’ is about 50 percent. If in
my practice it’s 30 percent, I might think something
is wrong,” Dr. Gelfand said. Dr. Gelfand measures
how thick, scaly, and red his patients’ plaques are,
logging and following up on these data points over
time. “I can show patients how they’re doing over
time and we can make treatment decisions based on
this objective data. The goal would be to help people
identify what the norms of good control are so we
could all have quality improvement.”
According to James Cavan, president and chief
operating officer of Corrona, LLC, which collects
data across several disease areas, the breadth
and depth of the collected data points will vary
depending on the nature of the disease and the
treatments. CORRONA was founded in 2000 to
advance medical research and improve the quality
of patient care by observing the effects of biologic
agents in the treatment of rheumatoid arthritis,
psoriatic arthritis, and spondyloarthritis, and is
also launching a Psoriasis Registry in collaboration
with the National Psoriasis Foundation. CORRONA
has collected thousands of data points from
multiple private and academic sites on over
42,000 rheumatic disease patients. After the
data are analyzed by independent academicians
and statisticians, employed by medical centers or
universities, CORRONA will provide the aggregated
tables and data to subscribers — both industry and
research facilities — with general observations
about the effects of a particular biologic agent on
these patients.
CREATING PATIENT VALUE
While focusing on disease and treatment outcomes
could be a first step in developing a registry,
experts argue that gathering information on
disease treatments is only a fraction of what a
data collection system could do. “This will not
be a registry in terms of just thinking about it
as a disease-specific registry,” said James Taylor,
www.aad.org/dw
S
C
E
N
V
I
R
O
N
M
E
N
T
A
L
Many specialty groups and disease-based organizations have dipped their toes into the data
registry realm in recent years. While the conditions and data points may differ, the goal of
each registry represents a shared desire to improve care.
N
Organization
American
College of
Cardiology
American
Consortium of
Academy of
Rheumatology
Ophthalmology Researchers of
North America, Inc.
Dermatology
Clinical
Effectiveness
Research
Network
American
College of
Rheumatology
Crohn’s
and Colitis
Foundation of
America
American
Academy
of
Dermatology
Name of
registry
NCDR™
(National
Cardiovascular
Data Registry)
– Includes six
hospital-based
registries and
one outpatient
registry.
IRIS™ Registry
(Intelligent
Research in
Sight)
CORRONA™
(Consortium of
Rheumatology
Researchers of
North America,
Inc.)
Dermatology
Clinical
Effectiveness
Research
Network
RISE
(Rheumatology
Informatics
System for
Effectiveness
Registry)
CCFA
Partners
Current:
AAD Quality
Reporting
System (QRS)
Established
1998
2014
2000
2009
Currently in
beta-testing
mode – expected
completion fall
2015.
Started as a
pilot in 2010
2011 (QRS)
Goal(s)
Promote
practice
innovations
and achieve
clinical
excellence.
1.Improve the
quality of eye
care.
2.Support
pay-forperformance
reporting.
3.Support MOC.
4.Provide infrastructure
for clinical
research.
Utilize
observational
research of
patients with
rheumatoid
arthritis, psoriatic
arthritis,
spondyloarthritis,
and psoriasis
when they have
meaningful
exposure to
biologic agents.
Perform scientifically sound
clinical research
critical to advancing the care
of dermatologic
disorders. Help
physicians
make treatment
decisions and
improve the
quality of care
for moderate to
severe psoriasis
patients.
Assist members
in practice
improvement,
local population
management,
and participation
in national
quality
programs.
Improve the
quality of life
for patients
living with
inflammatory
bowel disease
(IBD) through
research and
education.
QRS
facilitates
member and
approved
members’
non-physician
clinicians to
participate in
CMS PQRS.
User(s)
ACC hospitals AAO members
and physicians
Physicians at
CORRONAapproved sites.
DCERN
members
ACR members
Patients
with Crohn’s
Disease and
ulcerative
colitis.
AAD
members
and approved
members’
non-physician
clinicians
By the
numbers
Used by 2,400
hospitals
and 1,000
outpatient
providers and
includes 18
million patient
records.
Collected
more than
110,000 patient
years of data
representing
about 42,000
patients.
Data on over
1800 patients
with moderate
to severe
psoriasis
collected. 11
published
studies in JAMA
Dermatology and
JAAD.
Currently in
beta-testing
mode with
50 practices;
have collected
300,000 patient
encounters.
13,000
patients
enrolled; have
produced
about 25
abstracts and
12 papers.
Has recorded
data on more
than 396,000
patient
encounters.
98 percent
of users
who submit
data via QRS
successfully
qualify
for CMS
incentives.
As of
September
2014: 5,000
physicians
registered;
includes 10
million patient
encounters
from 3.85
million unique
patients.
Future:
DataDerm™
DERMATOLOGY WORLD // February 2015 23
MD, co-chair of the Ad Hoc Task Force on Data
Collection Platform and Registries. “The Academy
envisions an expanded data platform that will collect
electronic data from members nationwide for
external reporting requirements, specialty advocacy,
maintenance of certification, quality improvement,
and related programs. The whole purpose is to have
good outcomes and outstanding patient care. The
patient is at the center of this.”
By collecting patient-reported outcomes,
physicians will be able to improve the value of the
care from the patient’s perspective. Dr. Gelfand
can think of a number of patients who he thought
were doing well based on the outcomes data he was
collecting. However, “I’ve had people whose qualityof-life scores were really not good,” Dr. Gelfand
said. Those results prompted Dr. Gelfand to discuss
changing therapies with the patient. “The more data
The Martini Klinik attributes its ability to
develop flexible and innovative therapies to several
key factors. The clinic maintains that its surgeons
have years of expertise in the field of prostate
cancer and as such, that cumulative experience
and knowledge can lead to high-quality care and
innovative therapy development. Additionally,
because the clinic is located at the University
Medical Center Hamburg-Eppendorf, the clinic’s
physicians and its patients benefit from the readily
available expertise of other specialists throughout
the hospital. This “network competence” includes
not only the regular use of pathologists and
oncologists to help develop necessary follow-up
treatments, but psychologists to provide follow-up
support to the patients as well.
On average, one year after prostate surgery,
roughly 75 percent of German patients report erectile
dysfunction (ED).
However, as a result
of this specialized
and comprehensive
The more data we have to make good treatment
care, at Martini
only 34.7 percent of
decisions the better off our patients will be.
patients experience
ED. On average,
incontinence after
one year of surgery is
we have to make good treatment decisions the better 43.3 percent; at Martini it’s 6.5 percent. “Physicians
off our patients will be.”
have to get at what really matters for the patient with
While the prospect of evaluating each patient’s
a specific disease, beyond survival,” Dr. Teisberg
quality-of-life may seem like an overwhelming
said. “What you measure will be what improves, so
endeavor, Dr. Teisberg maintains that for specific
measure what really matters to the patient.”
patient populations, the breadth of these data
REFINING CARE
points may prove thinner than one thinks. “Value
By identifying both disease-based and patientis created at the level of the individual patient
defined outcomes, physicians may find that they are
but structured around common conditions,” Dr.
Teisberg said. “Think about organizing solutions for altering their clinical care. “If I want to understand
how my practice is doing in general, I need to figure
segments of patients with similar needs.” According
out how I am doing in making people’s quality of
to Dr. Teisberg, at the Prostate Cancer Clinic at the
life improve,” Dr. Gelfand said. “For the patients
Martini Klinik in Germany, physicians capture not
who aren’t doing well, how can I serve them better?”
only survival rates, but also functional outcomes
However, individual benchmarking may make some
that the patients are most worried about: impotence
uneasy. “We have to get out of the mindset that
and incontinence. Because patients have defined
data is about grading. Data is not about grading,”
these needs as highly important, surgeons at the
Dr. Wisco said. “Data is about understanding your
Martini Klinik make it a priority to ensure that
patient population and how to improve the care that
the neurovascular area for continence and erectile
they receive.” Additionally, according to Dr. Wisco,
function remains intact during surgery. After the
the value of data collection is not just to prove that
surgery, staff at Martini collects data around these
the specialty does its job well. “This is a system
patient-defined outcomes one week, three months,
that we can use to show the rest of the medical
and every year after the treatment so physicians
community that we are striving for better care,
can evaluate their care and tweak treatments
better access, and better patient outcomes.”
accordingly.
24 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
Benchmarking care was one of the primary
reasons that the American Academy of
Ophthalmology (AAO) developed the IRIS™
registry (Intelligent Research in Sight). According
to Michael Chiang, MD, chair of the AAO’s Medical
Information Technology Committee, there are
several goals with IRIS, but the number-one benefit
of this platform is to improve the quality of eye
care. IRIS was developed in 2012 and launched in
March 2014. Since then, IRIS has registered 5,000
AAO physicians who have logged 3.85 million
unique patients and 10 million patient visits in the
system. “In terms of quality improvements, I think
ophthalmologists just want to do a good job taking
care of patients,” Dr. Chiang said. “The premise of
the registry is that by providing a mechanism to do
that, ophthalmologists can individually benchmark
how they’re doing and identify what they’re doing
well and how they can be better.”
STREAMLINING REPORTING REQUIREMENTS
In addition to improving the quality of the
physician’s care and the value of that care
to patients, Dr. Taylor said that DataDerm
will continue to support members regarding
the reporting requirements already in place.
Specifically, Dr. Taylor believes that information
gathered for DataDerm will be used for MOC selfassessment and quality improvement activities.
“MOC is not going to go away so we need to come
up with further ways for members to evaluate their
own practices and then meet the requirements for
MOC,” Dr. Taylor said.
Additionally, physicians are now required to
report quality measures through the Centers for
Medicare and Medicaid Services’ (CMS) Medicare
Physician Quality Reporting System (PQRS), or
face a payment reduction. While physicians who
reported quality measures in 2014 were eligible for
an incentive payment of 0.5 percent of their total
Medicare Part B allowed charges, physicians who
haven’t reported will endure a 2 percent payment
reduction, assessed in 2016. According to Dr.
Taylor, having more measures to report that are
developed by the Academy should make it easier
for physicians to avoid future payment reductions,
and a centralized data registry could help in the
development of these measures. “CMS expanded
the number of measures that we’re required to
report from three to nine and we don’t have nine
dermatology-specific measures,” Dr. Taylor said.
According to Brent Moody, MD, a member of the
AAD Health Care Finance Committee, CMS and
a number of other programs are looking to the
specialties to determine what their quality measures
should be. “They are admitting that they cannot
be the arbiter who determines quality practices
for a particular specialty,” Dr. Moody said. “They
invited the provider community to come up with
meaningful measures for those providers and that
type of practice.”
ADVOCATING FOR THE SPECIALTY’S WORTH
In addition to reporting demands, dermatology is
facing unprecedented challenges to cut costs from
the legislative, regulatory, and private payer arenas.
Given these pressures, physicians are finding it
more difficult to retain fair value for the services
they provide. Experts argue that data is paramount
in showcasing value with key policymakers, because
data drives many of the decisions being made about
health care today. Without these data, the value of
the specialty may be determined elsewhere. “We are
in a situation where the data is already out there and
it’s being analyzed and acted upon, but the quality
of that data right now is poor,” Dr. Moody said.
Howard Rogers, MD, another member of the
AAD Health Care Finance Committee, explains.
“Insurance companies don’t have their own data
regarding either the quality or cost-effectiveness
of physicians. So in lieu of setting up in-house
data, most insurers have gone to third-party
private corporations that provide them with data.”
According to Dr. Rogers, these third parties analyze
the cost of claims data within individual episodes of
care. The physician who was paid the most during
that episode becomes the party deemed responsible
for that episode. As a result, that physician is
assigned a cost or quality index which ranks the
physician with their peers. “The episodes of care
are not well-differentiated in terms of severity and
there are no good measures at this point on severity.
A small superficial skin cancer in the leg will be
compared to a large one on the nose, which may
require more resources,” Dr. Rogers said. “In terms
of outcomes, there’s no ability for the insurance
companies or the people providing the episode of
care to decide what the outcome was — whether the
skin cancer was cured, there was a good cosmetic
result, or the patient had significant side effects
or complications from the surgery. All of these
measures provided to the insurance companies are
based solely on cost.”
As a result, Dr. Rogers argues that a central
dermatology data platform could provide the
missing pieces in payers’ value equations. “The
DERMATOLOGY WORLD // February 2015 25
data could tell us a lot about the severity of our
patients and tell us how well we do in terms of
diagnosing patients. It’s going to really indicate why
certain patients are more severe. If we’re saying that
dermatologists are the experts in skin disease and
that we’re getting better outcomes, we’ll need to
prove that. The only way to prove that is to have the
data.”
now a revenue stream for the College. That allows
us to support advocacy and other programs.”
However, perhaps a more daunting obstacle
lies with the feasibility of collecting these data.
“One of the challenges going forward is to handle
this electronically with minimal effort on the part
of the members to report their data,” Dr. Taylor
said. “The idea would be that we would collect data
directly from electronic records so there would be
DATA COLLECTION CHALLENGES
little direct involvement required on the part of the
While there may be no shortage of physicians
physicians. The challenge would be dealing with the
who believe that a concerted data collection effort
EHR vendors in terms of pushing or pulling data
could help the specialty demonstrate its value,
from the electronic records and interfacing with our
many remain concerned about the administrative
registry vendor to get the data.”
and financial burdens that an undertaking of this
Dr. Brindis reiterates that one of the most
magnitude could have on physicians and their
important considerations when developing a
practices. To help pay for the development of a data
successful data registry is ensuring that the
registry and practice management tools and for
administrative load on physicians does not
interfere with work
flow. “With the
Pinnacle registry,
we developed a tool
Data drives many of the decisions
that is agnostic to
all EHR software
being made about health care today.
vendors and literally
pulls data out of the
patients’ encounter
and populates the
other advocacy activities, the Academy’s Board of
data fields. You don’t have to have a staff person
Directors is asking members to approve a one-time
separately enter data in a Web-based database; the
$50 dues increase starting in 2016, followed by a
data are auto-populated from the encounter.” Once
cost-of-living increase to sustain and maintain these
the ACC collects and collates these data — roughly
efforts in 2017 and beyond, which the Board of
60 to 80 data points for any given measure — the
Directors can forgo if deemed unnecessary (see p.
physician will then receive a report on how they
44). The cost-of-living increase will be taken from a
fared compared to their peers on that particular
national index, which has averaged 2.5 percent over
measure.
the past 10 years.
Regardless of these challenges and concerns
According to Ralph Brindis, MD, former
about the burden of a data registry, many in
president of the American College of Cardiology
dermatology believe that physicians can no longer
(ACC) and current board member of the ACC’s
sit idle while others make decisions about the future
National Cardiovascular Data Registry (NCDR™),
of the profession and its patients. “If you think
the initial investment up front may be a difficult
you’re great, how do you know you’re great? If we
pill to swallow. However, the value of the data will
say that we’re the best at doing what we do, how do
far exceed the costs. NCDR started in 1998 and has
we know?” Dr. Wisco said. “We’re in an era of health
since developed six hospital-based registries and one care where we simply can’t use anecdotal evidence.
physician registry, called Pinnacle. “It started out as
We have to be more specific in what we do. We have
a $1 million investment for the College and people
to have data collection systems because it’s crucial to
were concerned that it was going to be a waste of
our patients and there are limited funds for what we
money and wasn’t going to be successful. It was
do. But ultimately it’s really what’s right.” dw
actually nicknamed ‘the black hole,’” Dr. Brindis
recalls. Since then, the NCDR registries have grown
into a $35 million a year enterprise for ACC through
outsourced contracts with research centers. “It’s
26 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
Registration and Housing is open!
Join us in San Francisco and experience an array of dermatologic educational sessions like no other!
• Sharpen your skills with over 360 sessions covering the latest in dermatology
• Enjoy full access to the high-energy exhibit floor as hundreds of exhibitors showcase the latest
products and services
• Network with colleagues from across the globe and build valuable professional relationships
• Discover new and innovative research at the electronic poster exhibits
And while in San Francisco, check out:
• The Golden Gate Bridge – experience the views of San Francisco’s most famous landmark
• Cable Cars – take a ride on the world’s last manually operated cable car system
• Pier 39 – home to more than 100 shops and restaurants, an aquarium, and the famous sea lions
• Museums – from Modern Art to Walt Disney, explore all the different museums that
San Francisco has to offer
Discounted rate expires February 11 at 12 p.m. (CT)!
Advance registration closes March 11 at 12 p.m. (CT)
Visit www.aad.org/AM15
for more information!
Dermatologists take aim at pruritus
28 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
BY DIANE DONOFRIO ANGELUCCI, CONTRIBUTING WRITER
P
ruritus has emerged as a leading research target since the
2012 American Academy of Dermatology (AAD) Research
Agenda Consensus Conference. Gathering thought leaders in dermatology and representatives from specialty societies,
patient advocacy groups, regulatory agencies, and insurance companies, the meeting focused on identifying areas of research that
need to be addressed within dermatology, said Henry Lim, MD, who
is chair of the Research Agenda Committee and the C.S. Livingood
Chair and chairman of the department of dermatology at Henry
Ford Hospital in Detroit. Although the AAD is not a funding agency,
its activities can help move these initiatives forward, he said.
“At that meeting it became very apparent that there was a wide gap
in understanding about pruritus and definitely a lack of treatments
to address chronic conditions,” said Julie Block, chief executive officer of the National Eczema Association, who was president of the
Coalition of Skin Diseases at that time. >>
DERMATOLOGY WORLD // February 2015 29
Pruritus is a common symptom among
dermatology patients. “It’s one of the biggest
problems that patients have,” said Ethan Lerner,
MD, PhD, associate professor of dermatology at
Massachusetts General Hospital. Patients may have
an inflammatory skin disease such as psoriasis or
eczema or systemic conditions such as kidney or
liver disease. “Those don’t necessarily come to the
attention of the dermatologist unless they’re referred
by someone else because they don’t really have spots
on their skin for the most part,” Dr. Lerner continued.
Although dermatologists’ knowledge of itch has
been limited, along with their ability to help affected
patients, that situation is changing. “I think that
nowadays we are more capable and understanding
what is behind itch, so we can help our patients,”
said Gil Yosipovitch, MD, professor and chair of the
department of dermatology at Temple University in
Philadelphia; director of the Temple Itch Center; and
author of Living With Itch: A Patient’s Guide.
EXAMINING ITCH
Pruritus can significantly impair patients’ quality of
life, leading to sleep disturbances, mental health issues,
and other difficulties (see sidebar). Furthermore, the
incidence of pruritus increases with age.
Kini and colleagues reported in Archives of
Dermatology in 2011 (147:1153-1156) that chronic itch
affects patients’ quality of life similarly to chronic
pain, based on a study of 73 patients with chronic
pruritus and 138 patients with chronic pain.
“Many dermatologic conditions have itch as a
central symptom, if not being the most debilitating
symptom in that context,” said Brian Kim, MD,
MTR, assistant professor of medicine in the division
of dermatology at Washington University School of
Medicine in St. Louis and its Center for the Study
of Itch. “A good example would be eczema or atopic
dermatitis, but… there’s also a number of people who
have itch with no clear cause and this is actually quite
frequent.”
Previously, experts believed that that the same
pathways that mediate pain might also mediate itch
and, therefore, blocking all neural pathways might
alleviate itch. “I think the most explosive move
forward has been in the last several years with the
identification of itch-specific receptors on sensory
neurons,” Dr. Kim said. Such discoveries have
provided evidence that itch is a distinct pathway from
pain — not just a mild form of pain, he said.
MEASURING ITCH
One challenge in investigating itch is the lack of
specific assessment tools. “We have multiple scales
30 DERMATOLOGY WORLD // February 2015
that have been used by various investigators, but there
is no standardized measurement that everybody can
agree upon that can be utilized in clinical studies and
in presenting data to the FDA,” Dr. Lim said.
The AAD Pruritus Workgroup is developing a
standardized measurement that can be validated, Dr.
Lim said. If accepted by the FDA, it could be used
by the pharmaceutical industry when developing
medications, he said.
The Temple Itch Center uses a numeric visual
analog similar to the pain analog commonly used,
where patients are asked about the severity of itch on
a scale of 0 to 10. “Patients can say, ‘I have horrible
itch,’ but you want to get some kind of quantitative
assessment,” said Dr. Yosipovitch, who founded the
multispecialty International Forum for the Study of
Itch in 2005 to promote better understanding of itch.
He has also found the visual analog scale helpful
when using electronic health records.
A 2012 prospective study published in Acta
Dermato-Venereologica reported that a visual analog
scale, numerical rating scale, and verbal rating scale
were highly reliable (92:502–507).
Although some studies have investigated pruritus
by assessing the number of scratch marks, people
can have severe itch without scratch marks, Dr.
Yosipovitch said.
TREATING PRURITUS
Because there are many types of itch, no single
treatment fits all cases.
“I think that if you don’t have any treatments in
your armamentarium that are universally effective, you
tend to shy away from managing it,” Dr. Kim said.
In addition, the broad nature of the condition
makes it difficult to address. “It’s hard for us as
clinicians to even understand what itch really is. If
you contrast that to, say, psoriasis, where we see it,
we can biopsy it, the pathologist will confirm the
diagnosis, and now we have treatments for psoriasis
that are quite targeted,” Dr. Kim said.
“There are some specific targets that we look
into. First of all, most of the itch in chronic itch is
not mediated by histamine, which was the classical
prototype,” Dr. Yosipovitch said. “Antihistamines are
the most commonly used medications because these
are the only ones approved by the FDA.” However, the
effects of antihistamines are limited.
Topical treatments target skin receptors, such as
the transient receptor potential (TRP) ion channels or
TRPVI and TRPA1 associated with the itch of eczema,
Dr. Yosipovitch said. He reported on treatments for
chronic pruritus with Jeffrey Bernhard, MD, in the
April 25, 2013, issue of the New England Journal of
www.aad.org/dw
Medicine (368:1625-1634). Topical menthol or cooling
may help reduce itch through other TRP channels.
For itch with dry skin, the upper layers of stratum
corneum are damaged; this may be relieved by certain
moisturizers, he said.
Compounds such as capsaicin and a combination
of lidocaine and prilocaine with amitriptyline and
ketamine target the ion channels, Dr. Yosipovitch
said.
Additional topical agents such as strontium and
pramoxine numb the nerve fibers and reduce itch.
“Most of them work on these ion channels,” Dr.
Yosipovitch said.
In addition, dermatologists also turn to systemic
medications to treat the neural system. “The common
pathway of all itches is transfer of nerve fibers to
the spinal cord and up to the brain,” Dr. Yosipovitch
said. “The concept of reducing itch by mechanisms
of drugs that work on the neural system is extremely
important.”
However, dermatologists may be less comfortable
prescribing drugs that affect the neural system
because they usually don’t deal with the neural
system, Dr. Yosipovitch said.
In cases of central sensitization, patients may
develop a chronic itch that no longer is simply in
ITCH’S IMPACT
Patients with severe pruritus often endure constant
itching that significantly impairs their quality of life.
“Just imagine if you had mosquito bites or poison
ivy covering a large portion of your body 24/7 and
there was no end in sight to the itching,” said Julie
Block, chief executive officer of the National Eczema
Association.
“The prospect of that is completely unimaginable,
but that’s life for the more severe eczema patients,”
she said. “Sleep deprivation is probably one of
the greatest overall impacts of itch. What follows
from that are depression, anxiety, low self-esteem,
relationship issues, and isolation.”
“I would say that the majority of chronic itch patients
will tell you that in the evening and at night the itches
intensify,” said Gil Yosipovitch, MD, professor and
chair of the department of dermatology at Temple
University in Philadelphia; director of the Temple
Itch Center; and author of Living With Itch: A Patient’s
Guide. “It causes significant impairment of quality
of life, and it’s a vicious circle,” Dr. Yosipovitch said.
“The more you lack sleep, the more you’re itchy.
You’re more depressed. It has an effect on mood. It
has an effect on self-esteem.” In extreme cases, he
said, the effects can lead to suicide.
Furthermore, Block explained, severe itch in children
leads to sleep deprivation and impacts the entire
family. Loss of sleep leads to social and academic
problems for the child and challenges for parents and
siblings who also have lost sleep and are anxious and
worried about the affected child.
Despite patients’ struggles, some physicians may
not even ask them about the itch, Block said. “One,
because there is no standardized tool to assess
it, and two, because there are limited therapies to
address it,” she said.
Patients may go to great lengths to find a clinician who
can provide relief of itch. “I’ve treated a lot of other
conditions in the past, but half my patients are coming
from hours away, driving from six hours away, flying
in from the coast and I’m in St. Louis,” said Brian
Kim, MD, MTR, assistant professor of medicine in
the division of dermatology at Washington University
School of Medicine in St. Louis and its Center for the
Study of Itch. “I think that’s very striking.”
Block is thrilled that the American Academy of
Dermatology has prioritized this area of research.
“We have a lot of catching up to do — there’s a gap in
understanding, research, and treatments,” she said.
“At last count, there were 22 drugs in development
listed on clinicaltrials.gov for atopic dermatitis,”
Block said. “Just a few short years ago that listing
was practically blank. There are a couple of
compounds on the list specifically targeting itch. We
are entering a new decade for eczema care — we
have a lot of hope!”
DERMATOLOGY WORLD // February 2015 31
the skin, Dr. Lerner said. “So the neural networks
or nervous system is trained to think, correctly
or incorrectly, that there’s an itch, and when that
happens, putting something on the skin isn’t going
to help so much,” he continued. For example, chronic
conditions like notalgia paresthetica and brachioradial
pruritus have neuropathic origins.
In chronic itch patients, hypersensitization
phenomenon is common. Nerves react even to nonitchy stimuli, in which case some dermatologists may
use medications that target the neural system. “Some
of these drugs, such as gabapentin or pregabalin, are
given for neuropathic pain and hypersensitization
of pain, and they have the same effect for itch,” Dr.
Yosipovitch said.
In addition, Dr. Yosipovitch and his colleagues
also use mirtazapine, a neuroepinephrine and
selective serotonin inhibitor, which he discussed
with Tejesh Patel, MD, in Expert Opinion on
Pharmacotherapy (2010;11:1673-1682). “It reduces itch,
not specifically, but it reduces that sensitization, and
it enables the patients to sleep better and have less
itch at night,” he said. “Sometimes the combination
of it with gabapentin and pregabalin is even better.”
Mu-opioid antagonists may reduce chronic itch in
some cases, but results have not been consistent in
uremic patients. However, nalfurafine hydrochloride,
a kappa-opioid agonist, was approved in Japan but is
not available in the U.S. It is given to patients with
uremic pruritus who are receiving hemodialysis.
Dr. Yosipovitch has prescribed butorphanol, a
mu-opioid antagonist and kappa-opioid agonist,
in an inhaled form for intractable itch. He and
Aerlyn Dawn, MD, reported on this in the Journal
of the American Academy of Dermatology in 2006
(54:527-531). However, this is another drug type that
dermatologists are not accustomed to prescribing.
In addition, researchers are exploring the use of
botulinum toxin for pruritus, injecting it locally, Dr.
Lerner said.
In treating severe pruritus, clinicians often
tell patients not to scratch, but this is a powerful
compulsion in patients with itch. In addition,
researchers have found that scratching an itch targets
brain areas associated with reward, Dr. Yosipovitch
said. If researchers could mimic the same brain
response with future medications, they may be able to
reduce itch, he said.
included some speakers who are not dermatologists
because there is a lot of research and there are a lot
of activities that are going on outside of dermatology
in research on pruritus,” he said. (This year’s session
will take place Saturday, March 21 from 2 to 5 p.m. in
room 2014 of the Moscone Center.)
Researchers continue to focus on treatments
that will target the specific pathways associated with
itch. “There’s so much understanding now about the
pathways involved in itch, and some of that learned
from work that’s done in the pain field, that I’m truly
optimistic that we will have targeted therapies,” Dr.
Lerner said.
“We have a very interdisciplinary program, and
what we’re finding now is that when we do combine
all of our skill sets and our techniques and our
technologies, we’re able to do things that we never
really thought of before,” Dr. Kim said.
“I think we’ve had the tools to do this for a while
now,” Dr. Kim said. “It’s just that people have not
really looked at itch as a distinct discipline, disease,
and if you don’t conceptualize it that way, it’s really
difficult to tackle the problem.”
Although treatments for conditions such as
eczema and psoriasis block the inflammation, it is not
known whether symptoms improve because the drugs
broadly inhibit the inflammation or the itch itself.
“That has yet to be determined, but I think in some
respect we could see some things in the next five
years,” Dr. Kim said. “I think other areas are going to
take longer because it’s such an uncharted frontier in
terms of research.”
Despite these efforts, however, it is unlikely
that researchers will develop a universal treatment
to relieve pruritus. “Not all itch is equal,” Dr.
Yosipovitch said. “Chronic pain could be from a lot of
causes and the same with chronic itch.”
Financial disclosures: Dr. Yosipovitch is a member of
the scientific advisory boards of Creabilis, Cosmoderm,
Trevi Therapeutics, Tigeract, and the National Eczema
Association. He served as a consultant for Eli Lilly,
Celgene, and Allergen. His research has been funded
by GSK Stiefel, LEO Foundation, and the National
Institutes of Health. Dr. Lerner is supported in part by a
research grant from LEO Pharma. Dr. Lim and Dr. Kim
have no financial interests related to their comments. dw
FUTURE PERSPECTIVES
Recognizing the importance of addressing pruritus,
the AAD now presents a session on the condition
during its Annual Meeting, Dr. Lim said. “We have
32 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
INTRODUCING
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The new Webinar All-Access Pass provides the ability to participate in all of the 2015
live webinars, and the flexibility to train and watch these seven webinars “on demand”
wherever and whenever is convenient. Best of all, you don’t have to spend a fortune —
the Webinar All-Access Pass costs $599!
To see a listing of webinars scheduled in 2015 visit www.aad.org/webinars.
Webinar All-Access Pass:$599
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Visit www.aad.org/store to purchase
Copyright © 2015 American Academy of Dermatology. All rights reserved.
BUILDING
AN OFFICE CULTURE
THAT WORKS
Physician-practice manager partnership is key
34 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
BY TERRI D’ARRIGO, CONTRIBUTING WRITER
O
ffice culture: It sounds like one of those corporate terms
bandied about companies like Microsoft. But a good office
culture — one where employees are enthusiastic about
their work and performing at their absolute best — is essential to
any dermatologist’s practice.
“If employees are happy at work, they focus their energies on the
task at hand, that of patient care, and that makes patients happy.
If you create a culture that is extraordinarily pleasing to patients, it
builds your business. Patients tell friends and family, and you will
get external referrals,” said Victor J. Marks, MD, associate in the
department of dermatology at Geisinger Health System in Danville,
Pennsylvania. “It will also draw the kinds of employees you want as
your office becomes known as the place to work.”
Culture derives from the vision of the practice and what clinicians
and staff do to achieve that vision, Dr. Marks said. “It’s the way
you do things, meaning behavior as opposed to attitude, which is
what you think. If your vision is to have people walking out of your
practice feeling like they’ve never been treated so well, think about
what behaviors are necessary of the people working there to lead
to that.”
Once there is a vision for the practice, a blend of strong management, appropriate staffing, and clear communication will produce
a thriving office that will not only achieve that vision, but enable the
practice to change and grow. >>
DERMATOLOGY WORLD // February 2015 35
BUILDING
AN OFFICE CULTURE
THAT WORKS
HIRE THE RIGHT PRACTICE MANAGER
Perhaps the most important hiring decision
dermatologists can make as practice owners concerns
practice managers, said Ali Hendi, MD, clinical
assistant professor of dermatology at Georgetown
University Hospital in Washington, D.C., and a Mohs
surgeon in solo practice.
“The practice manager is the eyes and ears of the
doctors and practice owners,” Dr. Hendi said. “That
person is in a position of leadership and has to have
the right personality and ability to see what is going on
in the office, what the morale is like, and what can be
done to elevate it.”
Dr. Hendi added that trustworthiness is crucial in a
practice manager because that person will be a partner
in maintaining the practice’s financial health. “Do
your due diligence when you hire someone you don’t
already have a relationship with. Trust gradually, and
go by the old saying of ‘trust but verify.’”
Dr. Marks encourages dermatologists to interview
prospective practice managers with the goal of finding
out how they would behave on the job.
“Ask questions that deal with real-life situations,
such as how the person would deal with a coworker
who was caught stealing or an employee with a
negative attitude who brings the whole group down,”
Dr. Marks said.
Dermatologists should look for a practice
manager who shares their work ethic but whose
approach is complementary, said Leslie C. Gray,
MD, of the Dermatology Center of Atlanta, a
comprehensive medical, surgical, and cosmetic
practice. “It’s like getting married. You have to know
yourself, and the better you know yourself, the better
you can choose.”
Dr. Gray said her partnership with practice manager
Melinda Lomax, CMOM, CPCD, works because Lomax
has the room to voice a differing opinion.
PERSONALITY GOES A LONG WAY
Even with the best of intentions, hiring a practice manager can be a matter of trial and error. For Jonathan S.
Weiss, MD, and the other dermatologists at Gwinnett Dermatology, PC, and Gwinnett Clinical Research Center,
Inc., in Snellville, Georgia, the third time was the charm. First one practice manager, then another crumbled
under the pressure of seeing the practice through expansion and technological advancement.
“We had a couple of practice managers who were very controlling,” Dr. Weiss said. “We had a front office
manager, a clinical coordinator, and staff who worked out of three offices. The practice managers managed so
tightly that those people felt powerless.”
For example, one practice manager, though a hard worker, had a tendency to get bogged down in procedure,
particularly in matters of technology.
“Whenever someone took on a minor project, she would produce a 25- to 50-page manual that was virtually
unreadable and want it followed to a T. She wanted a level of attention that led to angst among the staff,” Dr.
Weiss said.
When the time came to update the practice management system and convert paper charts to electronic
medical records (EMR), Dr. Weiss and the other dermatologists knew that such micromanagement simply
wouldn’t work.
“We wanted someone with a calm demeanor who could bring focus to the practice,” Dr. Weiss said. “We
needed someone who knew how to build and grow and could delegate, but who would maintain a managerial
role and take on huge tasks.”
Enter Randy Haviland, CPA, CMPE, experienced practice administrator. A year prior to implementing an EMR,
he chose a practice management system that would integrate with the practice’s chosen EMR system. He
then negotiated a good deal with the EMR vendor, and learned what kind of training would be necessary for
36 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
“I’m the visionary and she’s the detail person,
and when I come up with 12 different ways we
can do something, she tells me what’s reasonable.
She’s strong enough to say she doesn’t agree,” Dr.
Gray said. “The practice manager needs to be able
to work independently. If they have the experience
and they mesh with your practice, respect their
knowledge.”
HIRE THE RIGHT STAFF
Thoroughly screening candidates for the skills and
experience a practice needs seems like a no-brainer,
but dermatologists and practice managers would be
wise to look for a winning disposition, Dr. Hendi said.
“You can teach people skills and train them on the
technical aspects of the job, but you can’t change their
personalities,” Dr. Hendi said. “If you want an upbeat
office, you’ll need an upbeat staff. A negative person
only poisons the well.”
Dr. Hendi’s office manager, Bobbie Warren, noted
the impact a staff member’s personality can have on
patient care. “When patients come here, they know
they have cancer. They can be anxious, so we need a
calming presence. Type A, high-strung, or loud people
don’t do well here.”
At the Dermatology Center of Atlanta, Lomax
uses the Gary Smalley Personality Types Inventory
(http://smalley.cc/images/Personality-Test.pdf),
which categorizes workers according to various traits
such as confidence, spontaneity, sensitivity, and
predictability.
“We found that it’s a good way of determining
what someone’s strengths may be — as leader,
someone with empathy, or someone who is detailoriented, and we look for certain traits for certain
positions,” Lomax said.
Current staff members have an opportunity to
interview job candidates, as well. “New hires work
the staff. Ultimately, he designed a training plan that broke the practice into teams, taking into account each
person’s personality and tech savvy and urging the dermatologists to take ownership of the transition.
“He imbued the dermatologists with the idea that we had to take on the transition personally, and invest
ourselves in the process,” Dr. Weiss said. “He impressed upon us that the doctors really had to be the ones to
drive it.”
Haviland admits there were challenges, but also surprises.
“There were some generational aspects to address. The senior partner was in his early 70s, and the youngest
was in her 30s,” Haviland said, noting that it’s not uncommon for seniors to resist the transition to EMR after
using paper charts for so long. “But our eldest partner is probably the best adapter.”
There were also logistical challenges, as the best laid plans went awry. The staff wanted a trainer on-site on
the first day the system was installed, but because of scheduling conflicts, the trainer couldn’t be there for two
weeks.
“That actually ended up working in our favor,” Haviland said. “We struggled the first week, but by the time the
trainers came in, we knew what to ask them.”
As a result, when the system went live, the practice did not lose any money in collections, and the entire
transition was complete within three months, at which time the practice qualified for the Centers for Medicare
and Medicaid Services’ incentives for meaningful use.
“We really got an optimal return on Randy,” Dr. Weiss said. “He spent a few months organizing it on two or
three hours of sleep a night, and he drove us along. A change of this scope can be daunting, but when you have
a manager who does advance work and stays calm, it makes everything easier.”
DERMATOLOGY WORLD // February 2015 37
BUILDING
AN OFFICE CULTURE
THAT WORKS
with other employees when they first come on board
so they can learn [the ropes] and pick up good habits,
and we know our employees don’t want to work with
people who just wouldn’t get it,” Dr. Gray said.
Once good employees are in place, a practice
should do whatever is necessary to retain them,
said Shannon Page, practice administrator for
New England Dermatology and Laser Center,
a comprehensive practice that serves western
Massachusetts, northern Connecticut, and southern
Vermont.
“The most important aspect in an office culture is
support for employees,” Page said. “I’m referring to
training support, because if they are comfortable and
knowledgeable, it shows. But they also need resource
support so they have [what they need] to ensure they
are successful; and management support such as
feedback and praise, and the feeling they can openly
go to management with any concerns or issues.”
asked to do this so they can describe procedures to the
patients more accurately.”
Practice managers should be flexible, Page said.
“I am ready, at any time, to jump in and help any
employee. They know this, and they appreciate it.
Leading this way leaves no room for anyone to hesitate
or complain about jumping in to help others.”
COMMUNICATE
The key to a well-adjusted, smoothly run office is
communication. It ensures that everyone knows
what his or her role is and it allows leadership to nip
problems in the bud, said Dr. Martin, who makes
it a point to speak to her practice manager, April G.
Mulkey, CMOM, at least twice a day.
“We have a brief meeting at the beginning and end
of each clinic day, and she fills me in on what is going on
in the office,” Dr. Martin said. “I know how scheduling
went, any patient issues that have arisen, whether
someone was out with a
sick child, all of the day’s
events.”
Dr. Martin added
It starts with leadership
that she maintains
an open-door policy
and the dermatologists are the leaders.
not only because she
wants everyone to feel
comfortable speaking
to her, but because she
LEAD BY EXAMPLE
needs to trust that they’ll handle issues as they arise.
As leaders, dermatologists and practice managers set
“You can’t do all things at all times, and you have to be
the tone for a practice, and they should be aware of
comfortable delegating. A lot goes on every day in human
how even the smallest actions can affect the staff, said
resources or billing, and I trust my managers to handle it,
Elizabeth S. Martin, MD, of Pure Dermatology and
but they need to tell me about it,” Dr. Martin said.
Aesthetics, PC, which specializes in medical, surgical,
Clear communication extends to the patients, as
pediatric, and cosmetic dermatology in Hoover,
well. At Pure Dermatology and Aesthetics, staff informs
Alabama.
patients if the dermatologists are running more than 30
“My staff told me they knew what kind of day
minutes late and offer patients the option of waiting or
we would have by the cadence of my footsteps
rescheduling.
when I arrived. It opened my eyes to how unspoken
“The patients love it because they have a choice,
interactions can have an impact on the atmosphere of
and the employees appreciate it, especially at the front
the office,” Dr. Martin said.
desk, because the patients won’t be staring them down,”
Dr. Hendi stressed the importance of enthusiasm.
Mulkey said.
“It starts with leadership and the dermatologists are
At Dr. Hendi’s practice, staff gleans important
the leaders. If you don’t like what you do and you are
information from patient satisfaction surveys.
grumpy throughout the day, it rubs off on staff and
“We look for trends and if we see something that
the patients.”
needs work, we address it at one of our regular staff
New non-clinical staff at Dr. Hendi’s practice
meetings,” Warren said.
scrub up and shadow him during procedures, a form
of education that Warren said is vital.
REMEMBER THE DETAILS
“Sometimes you need to see what goes on in the
When creating an office culture, the little things mean a
surgery room to understand why the practice is set
lot: a staff member’s choice of words or attire, the décor,
up the way it is, why we bill a certain way, and so on,”
even television programming in the waiting room.
Warren said. “Most of our employees have actually
38 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
run slides of artwork,” Warren said. “We don’t show
news on our televisions. We don’t need our patients’
blood pressure going up.”
At Pure Dermatology and Aesthetics, administrative
and clinical staff have different dress codes.
“We don’t put administrative, front office, or back
office staff in scrubs. It’s too confusing to the patients,”
Mulkey said.
Mulkey encourages dermatologists to remember
that a practice is a business. “Patients are customers,
and these details help keep them satisfied and the
business running,” she said. “When dermatology
patients make appointments, they are usually not
dealing with an urgent condition. They can take their
time and decide who to see. It’s a choice, and you
want them to choose you.” dw
VISIA®
Dr. Marks encourages dermatologists to think of
every point of contact a patient has with the practice —
from the initial request for an appointment, through
registration, examination, and follow-up care — and to
lay out specifically how interactions should go along the
way.
“Behaviors can be scripted and specified in your
cultural documents. You can script how your nursing
assistants greet patients in the waiting room, and put
reminders at the front desk for answering the phones,”
Dr. Marks said.
The physical layout of an office can help prepare
patients for their examinations or procedures, said
Warren, Dr. Hendi’s office manager.
“Our suites are spa-like, with calming colors. We
offer snacks to patients who will be here all day, and we
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from the president
academy perspective
BY BRETT COLDIRON, MD
Health care
is changing
rapidly — will
dermatology
keep pace?
D
riving down the interstate, you’d be hard-pressed to miss the dozens of billboards advertising quick and cheap tele-health dermatology services. Think
back to the last time you went into your local pharmacy or grocery store — I’d
be willing to bet that there was a health clinic inside that store. Haven’t noticed any
of these signs or clinics? You will soon.
Recent trends in health care indicate that venture capitalists are starting to see
medicine as the new cash cow, as patients look for cheaper and more convenient
methods to receive health services. For example, although the retail clinics’ share of
patient visits is a small portion of total health-provider visits in the U.S., according
to a 2012 Health Affairs study (31(9):2123-2129), visits to these clinics increased from
1.49 million in 2007 to 5.97 million in 2009. Imagine how many visits will take
place in 2015!
However, the question remains: when our patients text a photo of their ailment
to one of these companies or visit their local grocery store for a diagnosis on a rash,
are they seeing a dermatologist? The companies that are funding these endeavors are
likely utilizing non-physician providers to fill the patients’ need for convenience and
to keep immediate costs down. As a result, patients will continue to support these
systems, and insurers will delight in the theoretically reduced price tag. However, if
this commoditization of medicine becomes the norm rather than the alternative, the
quality of health care could suffer.
We know, in addition to convenience, that patients value quality and safety. The
American Medical Association conducted a survey of patients, and found that 91 percent of respondents believe that a physician’s years of medical education and training
are vital to optimal patient care, especially in the event of a complication or medical emergency. We also know that patients value our dermatologic services. I have
written before that — according to a study conducted by the Mayo Clinic — access to
dermatology is an important indicator of patient satisfaction. However, because many
patients are now required to pay high deductibles out of pocket either way, they’re
more inclined to utilize quick clinics and telemedicine.
40 DERMATOLOGY WORLD // February 2015
Additionally, while some patients may
be cured of their skin disease by these new
means, many won’t, and they will eventually find their way back to a dermatologist.
As a result, the total cost of their treatment
will be higher because it will require more
physician visits, more useless or even
harmful medications, and likely more
biopsies. Finally, because consumers and
insurance companies are buying into this
market-driven system of health care, one
has to wonder if the metrics for evaluating
a physician’s worth will change as well.
Will we soon be graded on our availability instead of our clinical acumen? If the
marketplace becomes the primary driver of
how we define value within our health care
system, this may be the case.
The majority of our specialty is made
up of solo practitioners or physicians in
small practices. Inevitably, that means
that by default we are business people.
However, I would bet major odds that most
of us didn’t go into medicine because we
wanted to open a business, or because
money was our primary goal. Unfortunately, there are many entities entering
the health care arena because they see it
as such. Dermatologists are valuable as
we possess a wealth of knowledge and we
add value to the system in terms of quality
and cost. But we are up against a powerful force. We can’t sit back and watch as
we are taken out of the system. We are
cost effective, we are the experts in skin
disease, and we provide incomparable care.
Physicians’ paramount concern is quality
of patient care while venture capitalists are
interested only in making a profit. I call on
all members to continue to remind payers
and consumers of this fact. It is incumbent
upon us to be advocates for, and protectors of, our patients in the face of purely
profit-driven medicine. We cannot let the
marketplace advances discount the value
that our specialty offers our patients, both
in cost effectiveness and quality. dw
www.aad.org/dw
news + events
Academy Advisory
Board invites
members to submit
policy resolutions
academy update
DATEBOOK
WHAT’S COMING UP
T
he Academy’s Advisory Board (AB) invites all AAD members as well as state, local,
and specialty dermatology groups to submit proposed AAD/A policy resolutions on
issues of interest and/or concern. The AB convenes every year at the AAD Annual
Meeting to deliberate on issues of importance to individual practitioners and propose new policies on those issues to the Academy’s Board of Directors for consideration.
If there is an issue of interest and/or concern, now is your opportunity to submit a resolution from which an official Academy position might arise. To view the Academy’s current
position statements visit www.aad.org/Forms/Policies/ps.aspx.
To ensure full consideration, all resolutions must be received by Feb. 27. The author
and/or their AB representative must be present at the Reference Committee Hearing on
Friday, March 20, at 2 p.m. (PT) at the Academy’s 73rd Annual Meeting in San Francisco,
to introduce and discuss the resolution. The full AB will vote on resolutions on March 22.
Even if you do not submit a resolution, all members are invited to attend the Reference
Committee Hearing to be a part of this influential debate. For general questions, or to
obtain a template resolution form or submit a resolution, contact Ashley Cook at acook@
aad.org by Feb. 27. – ASHLEY COOK
2015 Annual Meeting registration and housing still available
REGISTER NOW at the discounted registration rates to attend the Academy’s 73rd Annual
Meeting in San Francisco, being held March 20-24, by registering online at www.aad.org/
AM15. Online registration and housing is now open. Discounted registration rates will
apply until Feb. 11 at 12 p.m. (CT). After this date and time standard registration rates will
apply.
Guest rooms are being held at several major hotels in San Francisco at AAD discounted
meeting rates available only to those who book through the AAD. For a current listing of
official AAD hotels, visit www.aad.org/AM15. Hotel reservations must be made online in
conjunction with registration for the meeting. More information is available on the Academy website and in the 2015 Annual Meeting Advance Program.
You can add a donation as you register for the Annual Meeting. Be a part of the Academy’s efforts to create a world without skin cancer by contributing to SPOT Skin Cancer™,
or help support a unique summer camp opportunity for young patients by giving to Camp
Discovery. – SUSAN JACKSON dw
DERMATOLOGY WORLD // February 2015 41
classifieds
PROFESSIONAL OPPORTUNITIES
Central Florida Dermatology and Skin Cancer Center (CFD) is seeking an ACMS fellowship trained
Mohs Surgeon and/or a BE/BC General Dermatologist. We are also looking for qualified ARNPs
who have dermatology experience. CFD is located in Winter Haven, FL. Winter Haven is the
home of Legoland and is also known as the Chain of Lakes area. Winter Haven offers the suburb
experience with quick access to Tampa, Orlando, and the beach.
Interested parties, who want to join a busy and successful practice, can submit resumes/CVs to
our Practice Manager, Dan Lackey, at Daniel@centralfldermatology.com or call 863.293.2147
for more information. Please visit us on the web at www.centralfldermatology.com.
Manchester & Wolfeboro, NH
APDerm® is a vibrant, growing practice of clinically accomplished and patient-focused dermatologists who practice in a community distinguished as among the best places to live on the east coast/
Boston area.
We are seeking a full or part-time dermatologist/Mohs surgeon to join our group of twelve
board certified dermatologists in a professionally run practice with dermatopathology lab, Mohs
surgery and medical aesthetics. This opportunity would allow a highly qualified dermatologist/
Mohs surgeon to practice with excellent support staff in a collegial practice in our Manchester and
Wolfeboro, New Hampshire offices with competitive salary, benefits and opportunity for practice
ownership. For more information, please contact: Glenn Smith, MHA, Administrator and Chief
Operating Officer, at (978) 849-7501 or email gsmith@apderm.com.
Meriter Medical Group, a 125-physician multispecialty group in Madison,
Wisconsin, is actively recruiting a BC/BE Dermatologist.
• Join two experienced colleagues in a busy and established practice
•Flexible practice model includes general medical dermatology, procedural
dermatology, cosmetics dermatology and opportunity for some Mohs
• Excellent supportive, collaborative and collegial team environment
• Top recipient of “Best Companies to Work For” by In-Business Madison magazine
•Scenic Madison is home to the University of Wisconsin-Madison and the State
Capital, and consistently ranks as one of the top places in the country to live,
work, and play!
For more information about this excellent opportunity, please contact our recruiter
Susan Shurilla at (800) 528-8286, ext. 4114, or susan.shurilla@stratummed.com.
PORTERVILLE, CALIFORNIA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
MONTROSE, COLORADO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
BOULDER, COLORADO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
GROTON, CONNECTICUT
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
42 DERMATOLOGY WORLD // February 2015
OCALA, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
SANFORD, NORTH CAROLINA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
TAMPA, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
BOUNTIFUL, UTAH
Associate Opportunity. Contact
Karey, (866) 488-4100 or www.
MyDermGroup.com.
WEST PALM BEACH, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
MOHS SURGEON
Multiple Part Time Opportunities
CHICAGO, ILLINOIS
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
ANN ARBOR, MICHIGAN
MEDICAL DERMATOLOGY FELLOWSHIP
1 – 2 years experience in management of complex medical dermatology patients in both private practice
and teaching clinic. Biologics,
immunsuppressants, immunomodulators, clinical trials. PGY 5/6. Send
CV & 2 LOR to: David Fivenson, MD,
fivensondermatology@comcast.net.
SANTA FE, NEW MEXICO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
NEW YORK
FT/PT BC/BE dermatologist needed
to join as associate. Excellent opportunity to join busy Plastic Surgery solo
practice on LI. Forward CV to
Job4cosmeticsurgery@gmail.com.
HICKORY, NORTH CAROLINA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
Montrose, CO 1-2 days/mo
Enfield, CT
2-3 days/mo
Groton, CT
1-2 days/mo
Tampa, FL
1-2 days/mo
Reno, NV
1-2 days/mo
Hickory, NC 1-2 days/mo
Sanford, NC 2-3 days/mo
Bountiful, UT 3-4 days/mo
Contact Karey, (866) 488-4100 or
www.MyDermGroup.com.
PRACTICES FOR SALE
TEXAS
Well-established , small, solo medical
dermatology practice in south Dallas
suburb. Considering retiring for the
right offer that is best for loyal patient
base and excellent staff of two. Contact correspondencecym-practice@
yahoo.com. No brokers please.
We Buy Practices
•Why face the changes in Health
Care alone?
•Sell all or part of your practice
•Succession planning
•Lock in your value now
•Monetization of your practice
•Retiring
Please call Jeff Queen at
(866) 488-4100 or e-mail
WeBuy@MyDermGroup.com
Visit www.MyDermGroup.com
Contact Carrie Parratt at
(847) 240-1770
www.aad.org/dw
ad index
PROFESSIONAL OPPORTUNITIES
We gratefully acknowledge the following advertisers in this issue:
Company Product/Service
Canfield Imaging Systems...................Vectra..................................................... 39
Care Credit...........................................Corporate............................................... 13
Modernizing Medicine.........................EMR...................................................IFC-1
NexTech...............................................EHR....................................................... BC
Valeant Pharmaceuticals....................Onexton................................................ 7-8
Vancouver Derm World Congress.......CME...................................................... IBC
Recruitment Advertising
Adult & Pediatric Dermatology, PC.................................................................... 42
Central Florida Dermatology & Skin Cancer Center......................................... 42
Meriter Medical Group....................................................................................... 42
Northwest Permanente, PC............................................................................... 43
Help Build a Gateway
for Better Health
At Northwest Permanente, P.C., we want every patient we see
to receive the medical care they need to live long and thrive.
We also offer NWP physicians the opportunity to pursue
their personal and professional goals with equal passion
through cross-specialty collaboration and work-life balance.
We invite you to consider this opportunity with our physicianmanaged, multi-specialty group of 1,100 physicians who care
for approximately 500,000 members throughout Oregon and
Southwest Washington.
DERMATOLOGISTS
Portland, Oregon
We’re seeking BC/BE Dermatologists to join our team of 16
Dermatologists. Our Dermatologists have an active practice
with an unusual number of complex cases and opportunities,
if desired, for cosmetic procedures. Ours is a collegial and
stimulating practice in one of the most successful managed
care programs in the country.
Physicians with Northwest Permanente, P.C. receive
competitive salaries in addition to an extensive benefit
package which includes medical, dental, disability and life
insurance; generous retirement plans; vacation, sabbatical
and educational leave; and professional liability coverage.
Physicians are also eligible for Senior Physician and
Shareholder standing after approximately three years with
the group (must be Board Certified by that time).
To submit your CV and learn more about this
opportunity, please visit our website at:
http://physiciancareers.kp.org/nw/ and click on
Physician Career Opportunities. Or call (800) 813-3762
for more information. We are an equal opportunity
employer and value diversity within our organization.
Classified ads are welcomed from dermatologist members of the American
Academy of Dermatology, from dermatology residents of approved training
programs and institutions with which they are affiliated, as well as from
recruitment agencies or organizations that acquire and sell dermatology practices and equipment. Although the AAD assumes the statements being made
in classified advertisements are accurate, the Academy does not investigate the
statements and assumes no liability concerning them. Acceptance of classified
advertising is restricted to professional opportunities available, professional
opportunities wanted, practices for sale, office space available, and equipment
available. The Academy reserves the right to decline, withdraw, or edit advertisements at its discretion. The publisher is not liable for omissions, spelling,
clerical or printer’s errors. For more information about classified advertising,
contact Carrie Parratt at cparratt@aad.org or visit www.aad.org/recruitmentopportunities.
FOR DISPLAY ADVERTISING INFORMATION, CONTACT:
Ascend Integrated Media, Publisher’s Representatives
Bridget Blaney (Companies A-D and Q-R)
Email: bblaney@ascendintegratedmedia.com
Phone: (773) 259-2825
Cathleen Gorby (Companies E-L and S-T)
Email: cgorby@ascendintegratedmedia.com
Phone: (913) 780-6923
Maureen Mauer (Companies M-P and Tu-Z)
Email: mmauer@ascendintegratedmedia.com
Phone: (913) 780-6633
ADVERTISING STATEMENT:
The American Academy of Dermatology and AAD Association does
not guarantee, warrant, or endorse any product or service advertised
in this publication, nor does it guarantee any claim made by the
manufacturer of such product or service.
Northwest Permanente, P.C.,
Physicians and Surgeons
EOE
THE AD INDEX IS PROVIDED AS A COURTESY TO OUR ADVERTISERS. THE PUBLISHER IS NOT
LIABLE FOR OMISSIONS OR SPELLING ERRORS.
DERMATOLOGY WORLD // February 2015 43
facts at your fingertips
data on display
MODEST INCREASE WOULD KEEP AAD’S DUES LOWER
THAN MANY SIMILAR ORGANIZATIONS
T
he AAD is asking members to approve a two-part dues increase on its spring ballot: a $50 increase starting in 2016 followed by cost-ofliving adjustments annually thereafter (which the Board of Directors can forgo if deemed unnecessary).
The additional funding will be used to launch an ongoing, multi-pronged effort that includes:
• a dermatology-owned data platform to demonstrate the quality of care, outcomes, and performance measures within the specialty;
• practice tools that help dermatologists determine their practice value within the health care system; and
• a robust data-driven communication plan to ensure payers and policymakers understand the value dermatologists bring to patients.
The chart below shows how the AAD’s current dues ($750 for fellows) compare with several other medical organizations in 2015. The
organizations were chosen because their dues pay for a similar suite of benefits. The Academy is in the middle of the pack in terms of dues, a
position it would retain if the increase is approved. – RICHARD NELSON dw
Comparison of dues against other organizations in 2015
$1500
$1,274
$925
$895
$890
$770
$750
$683
$665
$600
$900
$900
$615
DUES AMOUNT
$1200
$451
$300
0
y
et
ci ns
So eo
an rg
ic u
er tic S
y
m
Am las
de
P
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of
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h
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an u
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ic S
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at s
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so eo
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an g
ic lo
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s
As
44 DERMATOLOGY WORLD // February 2015
www.aad.org/dw
WCD2015 is presented under the auspices of the
International League of Dermatological Societies.
The ILDS has 157 national and international member
organizations including the AAD, ASDS, and SID.
Approved for
AMA Physician
’s
Recognition Aw
ard
Category 1
CME CreditTM
A TRULY UNIQUE
GLOBAL DERMATOLOGY
EXPERIENCE
THE WORLD’S LONGESTRUNNING DERMATOLOGY
CONGRESS
A FRIENDLY AND
STUNNINGLY BEAUTIFUL
HOST CITY
PHOTO COURTESY OF TOURISM VANCOUVER
SO MUCH TO SEE AND DO
IN VANCOUVER
Over 200 sessions, 1,500 speakers
and 3,500 abstracts—all in
ONE great meeting!
www.derm2015.org