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16 Mar 2018

PLS Announcement: Now licensing all mid-levels. Physician Assistants, Nurse Practitioners, etc.

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Physician Licensing Service is pleased to announce the creation of our mid level team, designed to service the medical licensure needs of Physician Assistants and Nurse Practitioners(APRN).

Over the last 20+ years, we have provided time management services for working medical professionals. Time is a resource that is very coveted in modernity and our business model has been designed to keep working medical professionals focused on what makes them successful. Tens of thousands of our clients have chosen to hire out the 20+ hours of mindless phone calls and paperwork necessary to acquire a medical license in any given state.



THIS NEW SERVICE for Physician Assistants and Nurse Practitioners is now available in all 50 states in the United States for a one time low cost fee. For details on timeframes and costs associated please contact our Business Director, Tony Hendricks, at 801-449-9196 or



Call or email us to find out what we can do to save you time and money through our new mid level service offering.

05 Mar 2018

Can Telemedicine Be Both Cost Efficient and High Quality?

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Health insurance companies are encouraging patients to turn to apps and virtual visits to save time and money, but some patients end up not getting the care they need.

Erica Jensen, with her 5-month-old daughter, Charlee Jaques, by her side, video conferenced with her doctor, Dr. Marie McDonnell, from her mother’s home in Wilmington, Mass., on March 15, 2016.(DINA RUDICK/THE BOSTON GLOBE VIA GETTY IMAGES)


LAST MONTH, JENNIFER McMurrain of Bartlesville, Oklahoma, didn’t go to the doctor – she requested one by app. “I had horrible sinus pressure in my head,” she said. “I knew immediately it was a sinus infection and to get over it I’d need a round of antibiotics and prednisone.” So McMurrain relied on Teladoc, a telemedicine provider that partners with Aetna, her insurance provider. She told the doctor she was asthmatic and that if she didn’t receive treatment, her medical history indicated the infection would settle in her chest.


The doctor refused to help; instead of a prescription, McMurrain got “a lecture on how people use antibiotics too much.” Then she got sicker. The sinus infection moved into her lungs, she missed four days of work, and her husband fell ill as well.


In 2017, Teladoc treated 24 million patients. Ninety-two percent, the company claims, were pleased. Some subscribe to the service directly, but others, like McMurrain, access Teledoc through their health insurance. For providers like Aetna, telemedicine offers cost savings and increased access to care. But some consumers wonder how their insurance companies make sure telemedicine partners provide quality care – and what, if any, accountability measures are in place when they don’t.


At Aetna, Head of Network Product and Telemedicine Strategies David Hildebrand says their Teladoc contract includes “performance guarantees” for hold times, call length, and member satisfaction. He mentions no guarantees regarding standard of care. When it comes to whether physicians have the credentials and experience Teladoc claims, Hildebrand says, “We trust them and contractually they’re obligated.”


This trust has propelled the partnership for seven years. When Aetna chose Teladoc in 2011, the telemedicine provider was one of two on the market. “We found them to be the largest and most experienced at that time,” Hildebrand explains, noting email security practices were also considered.


Today, the American Telemedicine Association says around 200 providers are in operation, but Aetna doesn’t plan to change partners any time soon. While Hildebrand says they “continually look at all available options,” changing providers is difficult for a company of Aetna’s size, especially when long-term vendors become partners.


“Over the years we’ve expanded the offering and the partnership to additional services,” he explains. “We’ve rolled out behavioral health with them. We’ve rolled out dermatology, as well as a caregiver program. And we have the opportunity to partner with them and look at building out new products and services. We look at the data together. We look at the communications to our members together, and try to understand them, and provide information at the right time to them, provide them resources to our customers.”


“We’re really trying to innovate… and look at figuring out where the next evolution of telemedicine will go,” he continues. “And it’s easier to do that when you have an incumbent that is as much invested in supporting your members as you are.”


“We’re happy with the partnership that we have; our customers are happy with it.” he adds. How does he know they’re happy? Teladoc surveys say so.


“We do a follow-up with everybody at 72 hours to see if they’ve gotten better or if they needed to go see another provider,” explains Teladoc CEO Jason Gorevic, specifying that everybody really does mean everybody. “Every consumer gets at least an electronic follow up after 72 hours.” That’s where the 92 percent pleased statistic comes from.


That’s what’s supposed to happen, but in reality, everyone doesn’t receive a survey. McMurrain didn’t. Neither did fellow Aetna customer Kim Guthrie of Olney, Texas, who called Teladoc last month with a urinary tract infection. “The doctor told me within three minutes that she couldn’t treat me,” Guthrie says. “She said I needed to go to my regular doctor.”


After refusing service, Teladoc next refused to issue a refund. “It’s just very frustrating,” Guthrie adds, explaining that, as a teacher, she has a fixed income. “Teladoc makes money either way,” she continues, adding that she thinks “they are screwing people over.”


“Obviously, I can’t respond to an individual case without looking into it, but I’m happy to,” Gorevic responded after being asked about Guthrie and others’ claims.


While patients like Guthrie and McMurrain end up having to pay for both a Teladoc consultation and a visit to their regular doctor, Gorevic says financial savings are one of telemedicine’s big draws. The exact amount charged varies by plan, but he says the typical Teladoc appointment costs insurance companies “about $45. That contrasts to about $120 to $125 for a typical office visit, somewhere in the neighborhood of $175 for an urgent care visit, and north of $1,000 for an emergency room visit.” Overall, Teladoc-funded studies show each call saves providers an average of $472.


While Teladoc does keep Aetna’s costs down, Hildebrand says customers aren’t required to see teledoctors before or instead of their primary care physicians: “We don’t have a benefit plan that says they need to use this service before they do something else. It is set up there [for] convenience, to provide access, and allow them to access the service when they feel it’s most important to them.” He does, however, note telemedicine services are priced “at a lower cost share to try to encourage utilization.”


This holds true industry-wide. Oscar Health customers can access the insurance provider’s Doctor on Call service, which directs to Teladoc and other vendors, for free. UnitedHealthcare works with Doctor on Demand and American Well. UnitedHealthcare Director of Communications Lynne High says, “The total cost of a visit is under $50, with the member’s portion of the cost determined by their benefit design.”


“Consumers throughout their entire lives are shifting to the on demand economy, whether it’s booking travel or shopping for groceries or buying shoes,” Teladoc’s Gorevic says, adding “healthcare fits right in with the rest of the economy. Consumers see this as a more-convenient, more-timely way to get care. It also happens to be a more cost-effective way to get care.”


But no matter how cost-effective care gets, providing it – and addressing people’s health concerns – isn’t as simple as buying milk. Khan Shoieb, head of communications for Oscar Health, says when a customer experiences a problem due to quality of care, employees “direct the member to address their concerns specifically with Teladoc” as opposed to Oscar, stressing that Oscar and Teladoc “are two separate entities.” Hildebrand says Aetna’s contract with Teladoc outlines processes for escalation and issue resolution, but open communication is important, especially from people like McMurrain and Guthrie, who don’t make it into Teladoc’s surveys..


“If there’s a problem,” Hildebrand says, “we would want to know about it and address it right away.”


Original By Terena Bell, Contributor – – Feb. 27, 2018, at 3:41 p.m.

Reposted by Physician Licensing Service

23 Feb 2018

Taking the Telemedicine Leap

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In October 2012, Medicare began rewarding hospitals that provide high-quality care for their patients through the Hospital Value-Based Purchasing (VBP) Program. Under VBP, hospitals are paid for inpatient acute care services based on quality of care — not the volume of services they provide.  To this end, a hospital’s Total Performance Score (TPS) and unplanned readmissions are significantly and inversely related to readmission rates.



These new payment models have driven hospitals to evaluate the variables that might impact the readmissions of their patients. One of the most common discharge locations for hospitalized patients are Skilled Nursing Facilities (SNFs). In some communities, this increased scrutiny has revealed that facilities that are not providing services adequate to prevent readmissions, which results in those facilities no longer being a preferred referral source.




Beginning on October 1, 2018, the SNF VBP Program will begin to reward (or penalize) SNFs for 2017 performance by offering incentive payments for the quality of care they deliver to Medicare patients. In this new environment, SNFs across the nation are now – more than ever — seeking creative ways to utilize telemedicine to distinguish themselves with their hospital partners and deliver a higher level of care to their patients by treating them in place, thereby avoiding hospital transfers.



Telemedicine is growing at a rapid pace, and the number of patients using telehealth services will rise to seven million in 2018, up from less than 350,000 in 2013. Broadly defined, telemedicine is the monitoring, diagnosing and treating of patients from a distance using technology. Recent technological advances, particularly during the past 10 years, have enabled medical providers at many levels to be virtually at the bedside like never before.



Telemedicine has been proven to deliver results across a variety of settings with definitive measurables such as length of stay, readmissions, emergency room visits and improved access to caregivers.  However, to achieve positive results and reap the benefits, consideration should be given to several factors.



Key considerations


As SNFs assess the value of telemedicine at their individual facilities, here are areas they ought to consider before taking the leap:



  • How does this service fit into our overall strategy of patient care? A good telemedicine program can make patients and families more comfortable and confident in the care at the facility level. It is beneficial to take into consideration if this will be used to attract new patients. The program should retain patients at the facility, avoiding costly and uncomfortable ambulance trips and Emergency Department visits. Also, it’s best to determine if the results achieved will be used to maintain preferred provider status. The support given to the nursing staff can result in less stress and turnover. It’s important that the organization articulate the reason for adopting a new service and can support both its installation and usage.


  • How will this integrate with current workflow? As with any new program, an important factor to consider with any telemedicine implementation is how it fits within an existing workflow. Ideal telemedicine solutions should enhance and support the care already being delivered, not create one-off processes that required additional staff time.


  • What is the status of the facility’s wireless internet capability? Facilities will need to ensure that they have enough bandwidth to implement the types of telemedicine services they are considering. This can be as simple as adding some new access points or range extenders as well as if more complex solutions might be required. The wireless capability should be assessed in tandem with the telemedicine service provider.  The equipment proposed by the telemedicine provider can have an important impact on the necessary upgrades.


  • How much additional staff training will the service require? It is important to understand what the training costs are in terms of dollars as well as the time needed for educating staff and attending physicians on how the telemedicine solution will be used. Is the proposed equipment so complex that the nursing team might struggle with engaging the telemedicine physicians?


  • Is there reporting available to measure the results of the service? How can metrics be accessed and communicated to the facility leadership and in what format? Is there a customer service group that works to enable satisfaction and results after the initial launch of the service? Assuring that the telemedicine provider is prepared to measure and meet the SNF administrative needs are critical success factors.



Measuring the Impact



For SNFs moving forward with telemedicine services, they will find the best successes by understanding their baseline data and setting clear objectives for the program.  Important baseline elements to track before and after the service installation are:


  1. The typical length of stay for a patient


  1. Number of patients who return to the hospital each month



  1. The percent of those who leave and who never return


  1. The percent who return after a hospital stay



  1. The facility Resource Utilization Groups (RUG) Rates

Using this information, the facility can derive the impact on lost revenue.  By comparing the results quarterly to baseline data, the return on investment can be clearly demonstrated.




In a recent study by the TRECS Institute (a non-profit organization dedicated to improving care for seniors while decreasing healthcare cost), during which telemedicine physician services were used, both a dramatic improvement in the quality of patient care delivered as well as a significant financial benefit were reported: in many instances of hospital admissions/readmissions were averted. Additionally, results revealed positive increases in net revenue for the study facility, which significantly exceeded the cost of the telemedicine provider’s services, thereby improving both top- and bottom-line financial performance for the SNF.



Mary Jo Gorman, Chief Executive Officer, TripleCare

Physician Licensing Service
February 23, 2018









Implementing a successful telemedicine solution is a smart and affordable way to stay in preferred provider networks, increase facility census, reduce hospital readmissions, make room for happier residents and their families and ensure more confident staff members are part of the team.


Go ahead and take the leap; it may just be what helps you stay afloat amid the changing healthcare waters.



Mary Jo Gorman, M.D, is chief executive officer of TripleCare, a leading high-acuity telemedicine services provider to skilled nursing facilities throughout the U.S. She can be reached at


30 Jan 2018

Enhanced Interstate Nurse Licensure Compact Implemented

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Published on Medscape by Troy Brown, RN – January 25, 2018

Republished by Physician Licensing Service


The National Council of State Boards of Nursing (NCSBN) has added new requirements to the Nurse Licensure Compact, an interstate agreement that allows nurses to practice in multiple states with one license.



The Enhanced Nurse Licensure Compact (eNLC) adds state and federal criminal background checks, restricts licensure for nurses with felony convictions, and standardizes licensure requirements among participating states. The implementation date for the eNLC was January 19, 2018.



“Although these nurses may skip the licensing process in the eNLC states, they still must follow the laws and nurse practice act of each state where a patient is located. The eNLC affects registered nurses and licensed practical or licensed vocational nurses; it does not apply to advanced practice nurses,” healthcare attorney Carolyn Buppert, MSN, JD, writes in an article for Medscape Medical News published November 1, 2017.



Maryland signed the original NLC into law in 2000. It enables registered nurses and licensed practical/vocational nurses licensed in one compact state to practice in other compact states without having to obtain an additional license. Advanced practice nurses are not included in the compact.



Proponents of the compact say it enables nurses to provide direct nursing care and telenursing services to patients located across the United States without having to obtain multiple licenses. The compact also facilitates the movement of nurses across state borders to provide care during disasters and reduces licensing burdens for nurses who live in areas that border two or more states.



The enhanced version adds the requirement of a criminal background check (state and federal) at the time of initial licensure and restricts nurses from obtaining a multistate license if they have ever been convicted of a felony. In addition, the eNLC requires compact states to adopt the NCSBN’s Uniform Licensure Requirements, which “establish consistent standards for initial, endorsement, renewal and reinstatement licensure needed,” according to the American Nurses Association.



“Nurses who had a multistate license as of July 20, 2017, will not need to meet these requirements and will be grandfathered in under whatever requirements they met at the time of their application. However, if they move to another state, they will be subject to the requirements of the eNLC,” Buppert explains.



To date, 29 states have enacted eNLC legislation: Idaho, Montana, North Dakota, South Dakota, Nebraska, Wyoming, Utah, Colorado, Arizona, New Mexico, Texas, Oklahoma, Missouri, Iowa, Arkansas, Wisconsin, Kentucky, Tennessee, Mississippi, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Delaware, Maryland, New Hampshire, and Maine.



eNLC legislation is pending in Vermont, Massachusetts, Michigan, Indiana, Illinois, and New Jersey. That legislation must be signed by the states’ governors after advancing through the states’ legislatures.



Nurses in good standing whose declared primary state of residence is a compact state are eligible to practice nursing in any of the other compact states; however, they are only allowed to have one license. As with drivers’ licenses, nurses who change their state of residence must obtain a new license in the new state and surrender the former multistate license.



Nurses whose primary states of residence are noncompact states are not eligible for a compact license, according to the NCSBN.

24 Jan 2018

23 Tips for Starting and Running a Private Practice

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Original story by: Nathan Wei, MD – June 06, 2017 –

Reposted by Physician Licensing Service



During my 4 years of medical school, 4 years of residency, and 2 years of fellowship, not once did I receive any type of exposure to how to run a business.



I suppose it didn’t matter to those who were going to stay in academic medicine. However, for those of us who elected to go into private practice, it was an incomplete education.



In my 30-plus years of private practice, I’ve had ups and downs. I have had victories as well as ignominious defeats. So for those of us in the trenches, and on the basis of my experiences, I’d like to provide a few pointers on how to start—and run—a successful practice:



  1. Formulate a business plan. This should be heavily weighted on the numbers—meaning the economics of what it takes to operate a private practice.



  1. Create a USP, or “unique selling proposition.” This is a brief statement of why someone should see you as opposed to somebody else. You should not use such words as “quality” and “service.” I have yet to see somebody say, “We offer mediocre quality and poor service.” Here are some good examples from the past. When Domino’s first started, their USP was “fresh, hot, pizza delivered in 30 minutes or less or your money back. ” Federal Express’s USP when they first started out was, “When it absolutely, positively has to be there before 10 AM.” A USP is different from a tagline. Taglines often read as stupid; a good USP does not.



  1. Your entire practice needs to be run on systems, and each person in your office should be aware of how these systems work. This will prevent the “Sally knows how to do it, but nobody else does” syndrome.



  1. Be unique yourself, and be unique in how the public see you. People aren’t going to knock down your door just because you’re “he of good doctors.” People such as Dr Phil and Dr Oz may take this a bit too far, but assuming you’re competent at what you do, a public image can’t hurt.



  1. Early on, expect to do grunt work. This means giving talks, meeting and greeting, and doing other things to help make sure people know who you are.



  1. Recurring newsletters and correspondence can be critical. The newsletters should contain news of interest to you and prospective patients. This does not mean the newsletter should be all about what you do. That’s boring. The newsletters should feature a patient and what makes them interesting (with their permission, of course). Perhaps they have an unusual hobby, etc. Maybe include recipes, jokes, or cartoons—anything to increase personal engagement.



  1. Financially speaking, don’t be afraid of going negative. By that, I mean you may need to forgo your initial consultation fee; however, you can make this up on the back end. This will involve your looking at the math.
  2. Make sure your cash flow is gaining. You’ll have to know how to analyze a profit and loss statement, as well as a balance sheet.



  1. Hire wisely. Make sure you have a system in place. Remember, when interviewing a perspective person, it is important to go over the traits that are important for your practice. Also, remember that people will behave the way they behave. In other words, a good question to ask is, “When X happened to you, what did you do about it?” You can predict future behavior by learning about past behavior.



  1. Hire slow, fire fast. This goes not only for employees, but also for patients. Doctors tend to hold onto both employees and patients for much too long. Life is too short to go through that stress.


Technology, Public Relations, and More

  1. Use technology to help make you more efficient. However, do not use technology for technology’s sake. The human touch will always supersede technology when it comes to taking care of patients.



  1. Learn empathy and persuasion strategies. Some may consider these to be manipulative. I certainly do not. You need to gain people’s trust, but not abuse it.



  1. Work very hard on building your reputation, and maintaining it. It only takes a moment for someone to destroy your reputation. This is unfortunate, because your reputation is the most important thing you have when it comes to a successful practice.



  1. Remember this: You are a marketer of what you do; you are not what you do. In other words, it is important to market yourself as the physician of choice. A prospective patient has a lot of different choices. As soon as you understand this important concept, the quicker things will begin to happen. People will seek you out for who you are more than for what you are.



  1. Learn public relations. Here are a few good ways to get good publicity: Do not believe in the old adage that any publicity is good publicity. Bad publicity will sink you very quickly.



  1. Write a book. When you write a book, you can become perceived as an authority—as an expert. It is not difficult to write a book. I have written a number of books over the years, and with all of the self-publishing options nowadays, you do not need Madison Avenue gurus to help you.



  1. Guard your wallet. There will be plenty of people after your bank account. Do not let them have access to it.



  1. Make sure you have a website that contains appealing information as well as an offer. That offer should be a lead-generation offer for more information that will allow you to build your patient database.



  1. Learn how to do video. This way, when people search Google or YouTube, they may find you.



  1. Continue to learn. Learn new techniques that will help your patients. Learn how to do procedures. The fact of the matter is that procedures still pay more than cognitive services. To this end, make yourself unique.



  1. If you must run an ad, that ad must justify its cost. Always have a clearly defined offer.



  1. Reactivate old clients. People’s lives are busy. Believe it or not, you are not at the top of their mind. It helps to remind former patients of who you are. The newsletter helps, but occasionally you may have to reactivate patients who have not returned. This reactivation campaign should be systematized.



  1. Finally, listen to the experts; don’t believe someone who has never run a business. People always have plenty of advice, even if they don’t have skin in the game.


19 Jan 2018

Study: Telemedicine Consults Help Save About $500 Per Patient

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An analysis of the eConsult service finds that doctors using the telemedicine platform for cardiology consults saved about $500 in Medicaid costs per patient over a six-month span.

Source: ThinkStock

By Eric Wicklund – January 17,2018

Reposted by – Physician Licensing Service 

January 17, 2018 – A telemedicine consult platform for cardiology cases saved almost $500 per patient in Medicaid costs over in-person treatments, according to a newly released study.


In what’s being billed as the first published randomized study of the eConsult platform, researchers at Community Health Center and the University of Connecticut Health Center found that the telemedicine platform, which facilitates virtual consults with a specialist, yielded lower mean adjusted total costs of $655 per patient, or lower mean costs of $466 when adjusted for non-normality, compared to those using face-to-face consults over a six-month span.


In addition, the eConsult group reported reduced costs of $81 per patient for outpatient cardiac procedures, as well as improving access to care for underserved patients and reducing the rate of no-shows for providers.


“The results of our analysis show for the first time that when [primary care providers] are given an option to use eConsults for Medicaid beneficiaries, the total costs and the cost of outpatient cardiac tests and procedures at 6 months are significantly lower, by $466 and $81, respectively, compared with the traditional [face-to-face] approach,” the study, highlighted in the January issue of the American Journal of Managed Care, reported.


The study was conducted by a team led by Daren Anderson, MD, CHC’s vice president and chief quality officer and director of the Weitzman Institute, CHC’s research and innovation arm, both based in Middletown, Conn.


“The important findings from this research are that a relatively simple intervention, the use of eConsults to communicate with cardiologists, can improve access to care and reduce the need for face to face consults, all while saving the system money – a win-win for patients and payers,” Anderson said in a press release announcing the study’s results. “The $466 saved per cardiology eConsult demonstrates the economic benefit, while patients who commonly endure long waits for specialists receive timely, high quality care.”


CHC and the Weitzman Institute launched one of the first eConsult pilots in 2015, working with Safety Net Connect, a California-based developer of online care coordination services. Working at first with cardiac care patients, the program routed all specialist referrals from CHC providers through an online system that allows the specialist to review the case online. This includes access to the patient’s medical record and any questions the primary care doctor may have about his/her diagnosis and treatment so far.


Based on that success, CHC and the Weitzman Institute created the Community eConsult Network, a non-profit to manage and run the program, which now includes eConsult services in several states across the country. In 2016, the Centers for Medicare & Medicaid Services approved the program for Medicaid reimbursement.


“With limited specialty providers available to treat Medicaid patients, appointment wait times can be as long as a year, leading to healthcare disparities, higher rates of disability and complications in chronic diseases,” CMS officials said in a 2016 press release. “SNC’s eConsult system has been proven to increase access to timely, cost-effective specialty services for underinsured and underserved patients, many of whom live in rural areas with limited access to specialty care.”


Now those savings are coming into focus.



For their study, Anderson and his colleagues drew data from 235 Medicaid patients receiving face-to-face cardiac care treatment and 134 involved in the eConsult program.


In the eConsult group, 59 were referred for face-to-face consults due to the urgency of their condition or an established relationship with a cardiologist. Of the rest, which

were referred to a reviewing cardiologist on the virtual care platform, 54, or 72 percent, didn’t require a specialty consult and were treated by the PCP, who received some guidance through the eConsult platform.


In the control group, 196 of the 235 patients, or 83 percent, had a face-to-face visit with a cardiologist; of the other 39 patients, 24 were no-shows.


Anderson and his colleagues said the eConsult platform proved itself by enabling PCPs to manage and coordinate care for more of their own patients rather than pass them off to a specialist, while also reducing referral waiting times for those in need of a consult. The primary source of savings, they said, was in a reduction in unnecessary and costly treatments.


Others savings, they said, included transportation and administrative costs incurred by safety-net health centers, some of which “invest significant resources not only in scheduling specialty visits for their patients, but also in providing extra support to help patients overcome financial, transportation, and other logistical barriers to reduce the likelihood of a no-show.”


Not included in the study was the impact on patients. Anderson and his colleagues noted one study undertaken in Canada that found significant costs savings in avoided transportation and lost productivity and wages from taking time off from work.


“These potential benefits associated with the eConsult represent unmeasured but potentially important cost savings that accrued to patients in this study,” they said.


While pointing out the value of the eConsult platform to healthcare providers and their patients, the study also noted that changes need to be made for the program to continue its success.


Anderson and his fellow researchers concluded that the eConsult platform can be valuable to state Medicaid agencies and health systems seeking ways to improve healthcare access for the underserved while reducing costs.


“Policy changes that support the use of eConsults as a new service modality could result in significant savings to the Medicaid program in a relatively short time frame,” they noted. “However, sustaining eConsult programs will require changes in reimbursement policies, either by authorizing payments for eConsults on a fee-for-service basis or by increasing the opportunities for primary care and specialty providers to share in the savings that accrue from more efficient and effective care.”


10 Jan 2018

Clinicians Brace for AI to Transform Medicine

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Artificial intelligence is coming … how will it affect medicine?




The doctor enters and pulls up the electronic medical record. The patient’s history is already there. So is the CT scan. The doctor drags and drops the image, presses the “analyze” button. An actionable diagnosis appears a moment later.


If artificial intelligence (AI) were to one day take over much of clinical practice, as some fear or anticipate — being potentially faster, more reliable, and generally better at certain tasks than humans — clinical decisions may no longer depend on tired eyes, imperfect risk scores, or lagging guidelines. Does that leave a role for physicians as decision-makers? Or will they become like Uber drivers in the age of GPS, just following directions issued from a device?


“GPS is not always precise,” offered Thomas Luscher, MD, a cardiologist at Switzerland’s University Hospital in Zurich, during a recent panel at the American Heart Association (AHA) meeting. “If you’re smart enough you can figure out how false it is.”


That’s the general idea of how things may also go in medicine once AI enters the mainstream. Clinicians today are cautiously optimistic that AI won’t exactly take their jobs. At risk, however, are those whose tasks involve a lot of repetitive tasks, such as looking at scans.


And that’s what automation is good for: processing information in rote, or nearly rote, fashion at high speed and with no issues of distraction or fatigue.


“I tell young people, ‘Don’t become a radiologist. You will be substituted by a machine,'” Luscher said.


Skeptics might point out that automation in medicine is hardly new in 2017. Automated ECG analysis began in the 1970s; computer vision is long established in liquid cytology for analyzing Pap smears; the MelaFind device for screening skin lesions is FDA approved.


Those systems, however, were narrowly focused and to a large extent still rely on human backup. ECG analysis software, for example, makes enough false diagnoses of atrial fibrillation and inappropriate cardiac catheterization laboratory activations that cardiologists generally know not to rely on it for clinical decisions.


What sets AI apart is the growing sophistication enabled by increased computing power and, just as important, the emergence of “Big Data” for training the algorithms.


Earlier this year, an AI system reportedly beat clinicians at recognizing 12 out of 14 arrhythmias and with better sensitivity and specificity. And just a few weeks ago, a computer algorithm outperformed human pathologists in diagnosing cancer metastasis in sentinel lymph node specimens.


The reach of AI is expected to increase as databases grow with the influx of information from wearables, electronic health records, and personal genomics firms as well as conventional sources.


Turning Point


“AI is a critical transformative part of the history of medicine. Medicine is an information system, now firmly so than ever before,” commented Harlan Krumholz, MD, of Yale School of Medicine in New Haven, Connecticut, at the AHA panel, adding that his academic group started hiring mathematicians and people who can code in Python.


“It will find its way into decision support, providing guidance on diagnostic interpretations, assisting in assessing prognosis, enabling better assessments of risks and benefits of particular clinical strategies – and generally spreading expertise. It will be a foundation for precision medicine,” he later told MedPage Today.


“The biggest impact of AI in medicine in the short term will be in the area of pattern recognition and image interpretation. Currently we are limited by human cognitive capabilities, which lead to high miss rates on image interpretation and marked inter and intra-observer variability,” Krumholz said. “We will also be able to extract useful information that is hard to discern with our eyes. Other important areas will center on prediction, with improved means of estimating prognosis – and of complications and risk.”


In addition to its potential for delivering better care, AI will be a democratizer of healthcare wherever it is available, according to Rima Arnaout, MD, a cardiovascular imaging sub-specialist at University of California San Francisco.


“Right now, the big academic medical centers with experienced niche specialists often provide better diagnosis and care for patients with rare or complex conditions. But if models for patient diagnosis and management are trained on data from those experts and made widely available, patients at big academic centers and rural clinics alike will have better access to better care,” she said.


Arnaout and Krumholz are both in the trenches of making AI a reality in medicine, her taking part in the effort to develop image-recognition tools to diagnose disease with higher accuracy and precision than human beings, and him investigating ways that AI may improve patient care and outcomes by identifying high-risk patients — those who may, say, be more likely to be re-admitted to the hospital after a medical procedure.


But to call today’s technology in its infancy would be an understatement.


Joseph Hill, MD, chief of cardiology at UT Southwestern in Dallas, said that he doesn’t know anyone practicing medicine with AI today. “In my world, AI-facilitated interpretation of echocardiograms is on the horizon but likely 10 years from prime time,” he said, predicting that initial uses will likely be in analyzing x-ray images.


It comes down to the technology not being widely available at an affordable cost, said George Welch, MD, a cardiologist at New York’s Manhattan Cardiology. “The cost of that technology will have to come down significantly before any of us are using it on a larger scale.”


Available Now or Soon


One application Welch is following is IBM’s Watson, which is being trained by a coalition o CVf hospitals, ambulatory radiology providers, and imaging technology companies for use in health imaging. Other Watson-enabled projects include WatsonPaths and Watson EMR Assistant, two projects launched in collaboration with the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, the former seeking to make it easier to trace how AI determined the best option for each clinical scenario and the latter designed to highlight the most important information from patient medical records.


Yet another recent AI-based rollout comes from Hitachi and Boston-based Partners Connected Health, which purportedly can predict hospital readmissions within 30 days for patients with heart failure. It identifies patients who would benefit from a special readmission prevention program, saving the healthcare system a substantial number of dollars.


And it’s not just the big names that are putting real effort into this technology: Andreessen Horowitz just created a new $450-million fund to invest in startups developing AI and machine learning for healthcare.


After all is said and done, when AI has been fed enough data and cash, when it moves from infancy to its teenage years, and people are satisfied with its reliability and accessibility, the question remains: will doctors really lose their jobs to a computer?


“This type of capacity will reduce a lot of the roadwork that cardiologists do and will free up our time to spend with patients and create a better connection and bond with patients,” Welch suggested.


“There’s still a role for radiologists — all the machine is doing is giving you a prediction,” said former FDA Commissioner Robert Califf, MD, at the AHA panel. “What do you do with probabilities? There’s a tremendous role for radiologists. This is bringing humanism back to medicine, the interaction with people. The role of the doctor is going to get bigger and bigger.”


For his part, Califf is now employed at Verily, Google’s life sciences division, where he has a hand in Project Baseline. The study continues to recruit for a goal of 10,000 participants who will volunteer massive amounts of their daily health information via wearable technology, surveys, and clinic visits — perfect fodder for feeding to AI, ostensibly.


Yet “AI is not a cure-all for the problems in healthcare,” Arnaout emphasized, adding that “especially with respect to supervised learning, an AI tool is only as good as the data you train it with. The medical community needs to be very careful in curating training data for these models, providing high-quality data that represents all ages, genders, races, ethnicities, and patient conditions.”


“If we don’t do this, we can allow some dangerous biases about our patients and diseases to get baked right into our systems of care,” she warned


  • by Nicole Lou,Contributing Writer, MedPage Today – December 26, 2017
  • article reposted by Physician Licensing Service – January 10, 2018
22 Dec 2017

BEST YEAR of PRODUCTION in 20 years at Physician Licensing Service

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12 Dec 2017

Walgreens makes telemedicine deal with NewYork-Presbyterian for Duane Reade stores

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The telemedicine services will rely on software and kiosks from AmericanWell.


Walgreens has embarked on a deal with NewYork-Presbyterian health system to provide non-emergency telemedicine services at drugstore retailer Duane Reade stores around New York City, starting with a branch on Wall Street with plans to roll out to other branches in Manhattan, Brooklyn, and Queens. It marks the first time Walgreens has collaborated with a local healthcare provider to deliver its telehealth and digital strategy, a company news release noted.


NewYork-Presbyterian and Walgreens are providing the telemedicine services as part of the NYP OnDemand suite of digital health services. They will be delivered through in-store-kiosks at $99 per visit. The kiosks are provided by AmericanWell, a company with which NewYork-Presbyterian has an existing partnership, said NewYork-Presbyterian Chief Transformation Officer Dr. Peter Fleischut in a phone interview.


The kiosks are equipped with connected medical devices including a thermometer that measures temperature by swiping the forehead, a blood pressure cuff, and a pulse oximeter that measures the amount of oxygen in the body. A dermascope, which allows the provider to see a high-resolution view of skin conditions, is also available through a Walgreens partnership with Iagnosis, according to the news release. The teledermatology service is referred to as DermatologistOnCall.


The service will also be provided through the Walgreens website as NYP OnDemand Urgent Care. Customers can use it to have a video chat with board-certified emergency medicine doctors.


NewYork-Presbyterian has been piloting the use of telemedicine as a way of triaging walk-in patients at emergency departments through NYP On Demand Express Care. It has been rolled out to four of the hospitals in its network to date: Weil Cornell, Columbia Presbyterian, The Allen Hospital, and Lower Manhattan Hospital. Fleischut said the service has helped it whittle down the duration of emergency room visits from an average of two hours to 30 minutes. Patients who have used the service span 18 to 98 years old, noted Fleischut.


By increasing access points to NY-Presbyterian physicians, the deal with Walgreens allows the hospital to expand access points to the hospital, extending its brand and network reach, adding more patients to its system.  Fleischut also addressed the question of how to help patients who use the service but may have a more urgent condition that can be addressed in the setting of a Duane Reade.


“We find there is more and more need for immediate access to physicians and lot of low acuity needs. That is why we provide these services. If a condition is more severe…we can provide some services virtually and refer some situations onto a specialist or an emergency department,” said Fleischut.


In addition to the in-store kiosks, Walgreens customers in the New York area using the Walgreens website can access NYP OnDemand Urgent Care to video chat with board-certified emergency medicine doctors, the news release said.


Walgreens inked a collaboration deal with MDLive two years ago to offer telemedicine services in its stores around the country.


Asked about the deal, Greg Orr, Walgreens divisional vice president of digital health said in an email that the deal expands Walgreens’s strategy to provide healthcare access for its customers in a convenient way. He noted that it complements an existing collaboration with MDLive, which focuses on general health issues and mental health services.


Telemedicine delivered through kiosks failed for one healthcare startup, HealthSpot, which went out of business  last year. RiteAid purchased its assetsfor just over $1 million. Still, Walgreens and NewYork-Presbyterian have the scale that HealthSpot was never able to achieve, plus they are bringing to bear different telemedicine capabilities.


“We see the kiosks as only part of a larger collaboration between Walgreens and NYP,” Orr said in an email. “Similar to our approach in retail, we believe in the power of omni-channel to connect customers with our brand both inside our stores and digitally to meet them wherever they are.  By collaborating with a well-known health brand like NYP in the New York City market we believe we can maximize convenience for our customers both inside our stores through kiosks as well as online through our digital properties.”


The deal will make Walgreens more competitive with other companies seeking to add on to their healthcare services such as CVS Health, which has entered into a deal to acquire Aetna.


Photo: NewYork-Presbyterian

Re-posted by Physician Licensing Service – Dec 12, 2017

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08 Dec 2017

How to reduce Christmas stress

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“It’s the most wonderful time of the year,” but also a time when stress levels soar. We have put together some top tips to stop stress in its tracks and make the season of goodwill more enjoyable.
stressed woman wearing christmas hat

The holidays can be a time of high stress levels, but managing stress can help you to have a happy and healthy Christmas.


While Christmas is known as “the season to be jolly,” it can be a significant source of stress, pressure, and conflict for many of us. Some people can feel overwhelmed by the excess, expectations, and exchange and become depressed during the holidays.


A lack of time and money, credit card debt, and the pressure of gift giving can often contribute to stress during the holiday season.


Most of us are aware of the adverse effects that stress can have on our body. It can impact our thoughts, feelings, and behaviors, and it can lead to high blood pressureheart diseasediabetes, and obesity if left unchecked.


In fact, research has shown that there is an increase in the occurrence of heart attacks and heart-related deaths during the festive season, which may be due to stress, heavy alcohol consumption, a fatty diet, or all three. Therefore, it is of utmost importance that holiday stress is dealt with — pronto.


With all the cooking, decorating, visiting, and gift giving, the holidays can seem more like trying to meet a high-pressure deadline than a vacation. So, try these Christmas stress-busting strategies to ease the strain and help stress melt away.

1. Limit spending


Money issues are one of the leading causes of stress during the holiday season, according to a pollconducted by the American Psychological Association (APA) in 2004. Recent data collected in the APA’s annual Stress in America survey reflect this finding and report that 62 percent of us feel stressed about money.

woman wearing Christmas hat and shopping

Avoid overspending by setting a budget.


Holiday retail sales in November and December 2017 are expected to increase between 3.6 and 4 percent and total between $678.75 billion to $682 billion, according to the National Retail Federation. These figures are up from $655.8 billion last year.


Gift buying, entertainment, and travel can all fuel financial burden, even for the savviest shoppers. However, here are some steps that you can take to limit financial stress.

Set a budget. First of all, make sure that all your usual expenses are accounted for so that you do not fall short on bills such as rent. Plan for any other spending over the holidays, including any parties you may be hosting or traveling to visit friends or family.

Once these items have been subtracted from your budget, you can then work out how much you can spend on gifts. Being organized and realistic about your budget will help you to ensure that you do not overspend.


Make one financial decision at a time. Make sure that you space spending-related decisions out. Trying to make too many decisions at once can be overwhelming, which can lead to depletion of your willpower and an increased risk of overspending.


Avoid temptation. It is often impossible to steer clear of stores and shopping malls altogether over the festive season, but limiting the time that you spend in these places can also help you to curb your spending.


Manage impulsive spending by taking only the cash you can afford to spend on shopping trips and leaving all credit and debit cards at home.

Recognize how you deal with stress-related money problems. Sometimes, during tough economic moments, individuals turn to smoking, alcohol, gambling, or excessive eating to try to relieve stress. These behaviors can lead to arguments and conflicts between partners and families.


Be mindful and seek help from a healthcare professional if you find that these behaviors are causing you problems.


Keep in mind what is important. Overspending can overshadow the true sentiment of Christmas. If your expense list exceeds your monthly budget, keep in mind that your relationships with friends and family are more important than material objects.


2. Manage expectations

Everyone has an idea in their heads of the perfect holiday, but when reality falls short of the vision, stress can ensue. Try to manage expectations with these simple tips.

Be realistic

family sitting at the table with Christmas dinner

Having a late dinner will not ruin your day.


Despite your grand plans, no event ever runs seamlessly, and this also rings true for holiday celebrations. Rather than accumulating stress along the way from any mishaps that might occur, view these miniature calamities as an opportunity to exercise flexibility and resilience.


Dinner being 30 minutes late, spilling food on your festive outfit, or having a lop-sided tree is not going to ruin your day. Instead, they’ll create fond memories that you can reflect on in years to come.

Help children to be realistic


When children get older and start to become more aware of what they want and what their friends have, parents can feel pressurized to deliver, meet their expectations, and provide them with the perfect presents.

Help your child to create a wishlist that outlines any gifts they desire. Make sure they know that they will not receive everything on the list and highlight anything that is not acceptable or obtainable.

Remind your child that Christmas is about being together, not a list of presents to tick off a list. Planning fun activities that encourage everyone to come together and have fun can create excitement.

Take some time out

Carrying the world on your shoulders and trying to achieve everything alone during the holidays can take its toll on your mind and body.


Enlist some help in accomplishing some of the tasks on your list and take some time out. Destressing can benefit you and the rest of your family. Focus on doing something that you find relaxing to recharge your batteries, such as reading a book, watching a Christmas movie, listening to music, or going for a massage.

3. Avoid overindulging


‘Tis the season for indulgence, and whether it be a festive holiday party or a family dinner, we are surrounded by extravagant foods and alcoholic drinks.

person standing on the scales after eating Christmas food

Allow yourself some holiday treats, but quickly go back to eating healthful foods and doing exercise to avoid weight gain.


Although many of us only gain an extra pound during the holiday period, that extra pound may build up over the coming years and contributeto obesity later in life, according to the National Institutes of Health (NIH).

Excessive stress raises appetite and cravings for sugary and fatty foods, and chronic drinking can further exacerbate stress by raising levels of the stress hormone cortisol.


Dietitians from the University of Missouri in Columbia recommend that families should aim to maintain healthful dietary habits during the holidays in order to avoid weight gain and stress.

  • Eat a healthful diet during the day. Eat some high-protein snacks, such as yogurt or an apple with peanut butter, so that you are not too hungry by the time that dinner arrives.
  • Make simple food swaps. Eat whole-wheat bread instead of white, and brown rice instead of white, to help keep you feeling fuller for longer.
  • Be treat-wise. Enjoy seasonal treats, but try to control portion sizes.


If you do find yourself overindulging, maintain perspective. One day of indulgence will not lead to significant weight gain, as long as you plan to get back on track with healthful food choices and exercise the next day.


4. Go for a walk

The antidote for holiday stress could be just as simple as taking a walk around the block. Researchdemonstrates that physical activity reorganizes the brain in such a way that it reduces its response to stress.

Family walking in the woods

Go out for a walk with the family to decrease stress.


Regular exercise can help to decrease tension and boost and stabilize mood. Furthermore, exercising produces endorphins — natural painkilling chemicals that are released in the brain — that improve your ability to sleep and reduce stress.


Research also shows that if you convince the rest of the family to leave the couch and come along on the walk with you, your stress levels will be reduced even further.


Researchers found that working out in a group reduced stress levels by 26 percent and improved physical, mental, and emotional quality of life.

5. Have some fun

As you decorate the tree or bake festive cookies, forget all the items left on your to-do list and give yourself permission to have fun.

family playing Christmas games

Organize fun activities to boost laughter and reduce stress.


Laughter goes a long way in the fight against stress and could be just what the doctor ordered.


Laughter lightens your mood, stimulates your heart, lungs, and muscles, and also releases endorphins. Laughter also boosts circulation, helps muscles relax, and lessens the physical symptoms that are associated with stress.


Whether your laughter is powered by sidesplitting moments in your favorite movie, jokes at the dinner table, a holiday prank, or an afternoon of fun activities, be sure to include some holiday humor, giggles, and guffaws. Even looking forward to a funny event raises relaxation-inducing hormones and decreases stress hormones.


Finding positive, healthful ways to manage stress could reduce many of the related adverse health consequences. Finding stress-busting techniques that work best for you can enable you to have a stress-free Christmas.

Original Published
Reposted by Physician Licensing Service