NJAOPS Journal

Winter 2010 Vol 10.1

medical mythology

Separating Fact From Fiction in

the age oF evidence-BaSed medicine

Banking on EHR Stimulus Funds? Implement Early

Don’t Quietly Accept Silent PPOs

Physician-Friendly Tips to Trim Taxes

Winter 2009_NJO Journal (AROC) 1/11/10 12:46 PM Page A

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THE JOURNAL | WINTER 20102

TABLE OF CONTENTS THE JOURNAL Editorial and Executive Staffs

Executive Editor Robert W. Bowen Managing Editor Bonnie Smolen

Contributors Laurie A. Clark Timothy L. Hoover Michael S. Lewis Mark E. Manigan Deborah R. Mathis Executive Officers President Alan Carr, DO President-elect Lee Ann Van Houten-Sauter, DO Vice President Antonios Tsompanidis, DO Treasurer Karen Kowalenko, DO Secretary John LaRatta, DO Immediate Past President Susan Volpicella-Levy, DO

NJAOPS Staff Executive Director Robert W. Bowen Business Manager Alice Alexander Director, Exhibit Services Kristen Bowen Director, Medical Education Lila Cleaver Director, Marketing & Communications Bonnie Smolen Office Manager Diana Lennon

The Journal is the official magazine of the New JerseyAssociation of Osteopathic Physicians and Surgeons(NJAOPS). NJAOPS is the sixth largest state affiliate ofthe American Osteopathic Association. NJAOPS representsthe interests of more than 3,600 active osteopathic physicians, residents, interns and medical students. Founded in 1901,NJAOPS is one of the most active medical associations in New Jersey with 12 county societies.

Opinions expressed in The Journal are those of authorsor speakers and do not necessarily reflect viewpoints orofficial policy of NJAOPS or the institutions with whichthe authors are affiliated, unless expressly noted.

NJAOPS/The Journal is not responsible for any statementsmade by any contributor. Although all advertising isexpected to conform to ethical medical standards,acceptance does not imply endorsement by this publication.

The appearance of advertising in The Journal is not anNJAOPS guarantee or endorsement of product or service,or the claims made for the product or service by theadvertiser. When NJAOPS has endorsed a product or program it will be expressly noted.

All advertising contracts, insertion orders, inquiries, correspondence, and editorial copy should be mailed to:The Journal (attention: Executive Editor), NJAOPS, OneDistribution Way, Suite 201, Monmouth Junction, NJ08852-3001. Telephone: 732-940-9000.

The Journal editorial staff reserves the right to edit all articlesand letters to the editor on the basis of content or length.

The Journal (ISSN 0892-0249) is published quarterly (January,April, July, and October) from the executive and editorial officesat NJAOPS headquarters in Monmouth Junction, New Jersey.Periodical postage paid at Princeton, New Jersey, and additionalmailing offices.

POSTMASTER, please send address changes to The Journalof the New Jersey Association of Osteopathic Physiciansand Surgeons, One Distribution Way, Suite 201,Monmouth Junction, NJ 08852-3001.

Subscription to The Journal is included in NJAOPS membership dues. Non-member subscription is $25.

Designed and printed in the USA by Mastergraphx, Monmouth Junction, New Jersey.

The Journal is printed on environmentally friendly paper. Byusing products with the FSC label you are supporting the growthof responsible forest management worldwide.

AROC 2010 .........................................................................Back CoverBC Szerlip Insurance Agency .............................................................15Brach Eichler, LLC .............................................................................21Conventus Inter-Insurance Exchange ...................................................9Cowan Gunteski & Co.......................................................................23NJOEF, Friends of the Foundation........................................................4HealthCare Institute of New Jersey............................Inside Front CoverNJ PURE ..........................................................................................1, 3Pellittieri Rabstein & Altman..............................................................24PNC Bank............................................................................................5Princeton Insurance .............................................................................7Professional Liability Insurance Group of South Jersey.........................6ProMutual Group.......................................................Inside Back CoverUniversity Services Sleep Diagnostic & Treatment Centers ................17Upright MRI of Cherry Hill ................................................................13Woodland Group, The.......................................................................19

Classified Ads ....................................................................................23

President’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4NJAOPS President Alan D. Carr, DO, reports on membership, the upcoming NJOEF fund-raising event and his role as a member of Gov.-elect Chris Christie’s transition team.

From the Executive Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Executive Director Robert W. Bowen introduces the new NJAOPS Legislative AlertCenter, which makes it easy for you to communicate with your legislators and takeaction on issues affecting the profession.

Capital Views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Government Affairs and Legislative Counsel Laurie Clark provides a wrap-up of the stateelection results and the changes in leadership in Trenton.

Medical Myths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10In this quarter’s cover feature, Stephen Kabel, DO, uses evidence-based medicine toseparate medical fact from fiction, dispelling some long-held beliefs that can adverselyaffect patient outcomes.

Banking on EHR Stimulus Funds? . . . . . . . . . . . . . . . . . . . . . . . . . . .17Thinking of installing electronic health record technology? Get started now, experts say,if you want to take full advantage of the federal government’s financial incentives.

Managing Malpractice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Medical liability insurance expert Timothy Hoover explains the steps you should considerto maximize your risk protection if you were formerly insured by the MIIX insurance group.

Legal Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Health law specialist Mark Manigan provides insights into silent PPOs and vigilant stepsyou and your staff can take to deter them.

The Professional Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Medical practice management experts Deborah R. Mathis, CPA, CHBC, and Michael S.Lewis, MBA, FACMPE, offer physician-friendly strategies for reducing your tax burden.

Member News & Classifieds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24NJAOPS shares member achievements, welcomes this quarter's new members, and highlights medical employment opportunities

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PRESIDENT’S MESSAGE

Alan D. Carr, DO

Looking Forward to a New Year of Successes

As we move into a new calendaryear, I’m pleased to report thatNJAOPS continues to perform well.

Although membership is a few percentagepoints off of record levels set in 2008, theoverwhelming majority of memberscontinue to appreciate the need tochampion the profession and havecontinued their memberships. Our effortsover the past several years to increasenon-dues revenue—about 77% of revenuein 2009—have also provided benefits toNJAOPS during uncertain economic times.All of this has enabled us to providequality member benefits and services, andmaintain a financially strong organization.This is the best way for us to approach thechallenges that may await in 2010.

Supporting Osteopathic EducationIt was my pleasure to join Murray Matez,

DO, chairman of the New JerseyOsteopathic Education Foundation(NJOEF), on the UMDNJ-School ofOsteopathic Medicine campus for theannual student scholarship luncheon. Itwas rewarding to hear the appreciationexpressed to NJOEF for its support. It ismy hope that NJOEF will be able tocontinue to support the students in ourosteopathic medical schools for manyyears to come. To that end, NJAOPS hasalready started working with TomPapastamelos, DO, on the annual Friendsof the Foundation fund-raising event insupport of NJOEF scholarships. We’ve seta goal to double the funds raised last year.Make plans now to join us at SofiaRestaurant in Margate for an exceptionaldining experience on April 15, a few shortmiles from Bally’s where AROC activitieswill be underway.

I encourage those attending AROC andanyone who lives or practices in the area to keep this evening open. We areasking pharmaceutical reps not to holdpromotional dinners that night but insteadto join us for the event.

Visiting Our MembersDuring my tenure as president, I’vecome to the conclusion that the GPSmust have been created for associationpresidents. With a goal of visiting all ofthe county district societies at leastonce, I was able to attend dinners inMorris, Burlington, Atlantic, Cape Mayand Camden counties during the pastseveral weeks. I hope to reach thoseremaining on my list by April.

Tackling Medical IssuesIn my fall column I recommended that all NJAOPS members take on the role ofadvocate for your patients and your practice.Shortly after writing that column, I washonored to be appointed to Gov.-elect ChrisChristie’s transition sub-committee on healthcare, one of only four physicians named tothe entire transition team. Beginning in earlyDecember, we met almost nightly in personor by teleconference until our committee’sreport was due in mid-December. I willalways make the interests of physicians andtheir patients a top priority as we tackleimportant medical issues. The committeealso enjoyed the added benefit of havingNJAOPS legal counsel Mark Manigan, Esq.,serving on the team.

Congratulating One of Our OwnFinally, NJAOPS will have the honor ofnominating one of our own, Martin Levine,DO, as president-elect of the AmericanOsteopathic Association this summer at the annual AOA House of Delegates inChicago. While you’ll soon be receiving a letter with additional information, Iwanted to take this opportunity tocongratulate him on his upcomingnomination and wish him the best as hecontinues to provide important leadershipfor our profession on a national level. Iknow that everyone in our association joins me in supporting Dr. Levine. �

Alan D. Carr, DO, is the 2009–2010president of NJAOPS. He is a board-certified anesthesiologist specializing inpain management.

Friends of the Foundation Evening at SofiaYou are cordially invited to attend the

Join us for a relaxing evening of gourmet

Mediterranean cuisine in a one-of-a-kind

atmosphere. This special fund-raising event

for the New Jersey Osteopathic Education

Foundation (NJOEF) is generously under-

written, so 100% of proceeds support

scholarships for osteopathic medical

students. Tickets are $25 each for medical

students, $50 each for NJAOPS members

and their spouses, and $100 each for non-

members. Champion the next generation

of osteopathic physicians and surgeons by

attending and giving to this worthy cause.

Reserve your tickets online today at

www.njosteo.com/aroc.

Questions? Call 732-940-9000, ext. 306.

Thursday, April 15 6:30 p.m.Sofia Restaurant, Margate, New Jersey

�




FROM THE EXECUTIVE DIRECTOR

Robert W. Bowen

Pull Up a Chair at the Advocacy Table

N JAOPS President-elect Lee Ann VanHouten-Sauter, DO, and Iparticipated in the AOA Advocacy

Summit in Phoenix, Ariz., sponsored byPfizer just before Thanksgiving. It was avaluable weekend with helpful presentationsand useful interaction with leaders fromother AOA affiliate organizations. Designedto be both instructive and informative, theprogram underscored how very differentmedicine has become since many NJAOPSmembers graduated from medical school.

The entire advocacy initiative was summedup in one presenter’s comment: “If you’renot at the table, you’re probably on themenu.” How can I convince you of theabsolute truth of that statement?

You’d be amazed at who is completelycomfortable making policy on thephysician–patient relationship with no

input from physicians. Medical insurancecompanies, lawyers and corporations all doit. A thoughtful person may question howthey can produce high-quality legislationwithout input from those directly involved.The answer: They can’t and often don’t.

One of the features of the new NJAOPS Website (www.njosteo.com) that offers the mostbenefit to physicians is the Government tab.New this fall, our Legislative Alert Centertracks more than 100 bills that have beenintroduced in the legislature that could havean impact on health care. Every bill titleincludes a link to the complete bill for yourreview. Also available is an easy andconvenient email system that enables you tocommunicate directly with the appropriatelegislators, usually those from your district.

Another feature is the Legislative Alert thatgoes out to members by email when a

particularly important bill is pending.Recently, an alert was sent regarding theAssignment of Benefits bill that wouldrequire medical insurance companies topay the physician directly when assignedby the patient. Currently insurers have the option, and some elect to send thereimbursement to the patient, requiring thephysician to collect.

During committee hearings earlier this year, one corporate representative said that preventing physicians from collecting their reimbursement from patients is a cost-containment measure. Seriously, the reasoning goes that if out-of-networkphysicians are regularly unable to collecttheir fees from patients after care is provided,then they will be compelled to join themanaged-care network, which will reducefuture healthcare costs. The position beingpromoted is that patients stiffing physicianson their fees is good for health care and isan appropriate mechanism to control costs.Do you find that testimony odd? Troubling?Outrageous? Do you have another point ofview for your elected officials? What’skeeping you from sharing it?

We have been participating in the hearingsand speaking individually with legislatorssince the bill was developed. What has beenmissing from this effort and others like it is anoutpouring from physicians, their practicesand in some instances their patients. Takingjust a few minutes to communicate directlywith legislators can make the differencebetween a bill passing or not. And throughour Web site we’ve made it easier than everto have an effective voice in the discussion.

Despite being outmanned and outspent inour political activities in Trenton, NJAOPScontinues to not only hold its own but makeprogress. Our goal for 2010 is to let the voicesof our members be heard. Will we bringspecific bills to your attention and suggestan appropriate response? We will. But youknow what matters most to you and whereyour passions lie. This grassroots initiative wasdeveloped so you can communicate whatyou want, when you want, to whom youwant. It’s not a question of whether legislationwill be debated and enacted; it’s only aquestion of whether you will be participating.

Pull up a chair. �

Robert W. Bowen is the executive directorof NJAOPS.

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CAPITAL VIEWS

Laurie A. Clark

New Legislative Session Begins

Now that the election is over, here is what the results mean for osteopathic medicine. For

the first time since 2001, we will have a governor who is not in the same party as the legislative majority. This, in and of itself, will provide a dramatic contrast from the past gubernatorialterm. The majority of the issues affectingosteopathic medicine are legislative in nature, and essentially, the playersremain the same despite that there will be significant leadership changes in both houses. NJAOPS will begin thenew legislative session with a strong,bipartisan working relationship with the Legislature.

As we begin 2010, there is no doubt thatour state will face many hardships. Mostof the challenges will be related to themanagement of the state’s fiscal crisis.Legislative and gubernatorial activity will

be focused on solving budgetaryproblems, both long and short term, forthe first half of 2010 and beyond.NJAOPS will continue to employ pastsuccessful strategies and to work withour knowledgeable leadership andmembership to develop new andinnovative models for these challenginglegislative times.

New Leaders NamedGov.-elect Chris Christie’s first order of business was to name key transitionleaders and committee members,including NJAOPS President Alan Carr,DO, and legal counsel Mark Manigan,Esq., both of whom were named to the transition team’s healthcaresubcommittee. Congratulations to Dr.Carr and Mr. Manigan.

Gov.-elect Christie also named DavidSamson, a Republican who was Gov. Jim McGreevey’s attorney general, aschairman of the transition team, inaddition to naming members of thetransition sub-committees on correctionsand homeland security, energy and

utilities, environmental protection,healthcare, human services and childrenand families, law and public safety andtransportation. These sub-committeesconducted a top-to-bottom review oftheir respective government departmentsand agencies. The new governor’sdecisions will include appointments of the cabinet as well as many boards,commissions and authorities. Ourassociation looks forward to workingwith Gov.-elect Christie and his chosen representatives.

The state Legislature formallyreorganized on January 12. Shortly afterthe November elections, the New JerseySenate and Assembly Democratic andRepublican caucuses chose the leaders ofthe 214th Legislature.

Sen. Stephen Sweeney (D-Gloucester) wasselected Senate president. Sen. Barbara

Buono (D-Middlesex) was chosen asSenate majority leader and Sen. Nia Gill(D-Essex) was chosen Senate president protempore. The Assembly DemocraticCaucus chose Assemblywoman SheilaOliver (D-Essex) to serve as Assemblyspeaker and Assemblyman Joseph Cryan(D-Union) was chosen as Assemblymajority leader.

The Senate Republicans unanimouslysupported Sen. Tom Kean (R-Union) forSenate Republican leader. The membersof the Senate Republican leadership teamare Deputy Republican Leader DianeAllen (R-Burlington), Republican BudgetOfficer Anthony Bucco (R-Morris),Republican Conference Leader RobertSinger (R-Ocean), Deputy RepublicanConference Leader Christopher “Kip”Bateman (R-Somerset) and RepublicanWhip Kevin O'Toole (R-Bergen).

Lame-Duck Session Brings ActionBefore Gov.-elect Christie takes office onJan. 19, the legislative session got intenseas legislators had the chance to act on billsthat further Gov. Corzine’s unfinished goals

before the end of the Governor’s term. Thelame-duck session ended January 11.

NJAOPS worked to achieve passage ofsome significant legislation before the endof the 213th legislative session.

One of our key priorities was the VoluntaryPatient Assignment of Benefits Bill (S-114/A-132). This important legislationrequires health insurers to forwardreimbursement for medical care directly tophysicians when a patient decides tovoluntarily execute an assignment ofbenefits. The bill passed the Senate by avote of 37-0 in June 2008, but then stalledin the Assembly Financial Institutions andInsurance Committee.

During the post-election period, weconducted a grassroots campaign toengage our membership in the fight topass this bill. We firmly believe thatwithout this legislation patient access tocare is compromised. We will continue towage this battle as well as others thatcontinue to confront the ability topractice osteopathic medicine in the214th legislative session. The completelame-duck session results and our goalsfor the new session will be reported inthe next issue.

Please visit the Legislative Alert Center atwww.njosteo.com to view our legislativealerts and priorities. The Legislative AlertCenter allows you to easily get involved inthe process by sending emails to yourlegislators in one simple step. The letter isalready written for you. You just fill in yourname and press send.

New Law Affecting HealthcareOn Nov. 20, Gov. Corzine signed into law Bill S-2550 /A-3799, which permits aphysician to issue up to three prescriptionsauthorizing the patient to receive up to a90-day supply of a Schedule II controlleddangerous substance under certain specific conditions. The new law (PL 2009, Chapter 165) will take effecton March 1, 2010. �

Laurie A. Clark is NJAOPS’ governmentaffairs and legislative counsel. She is alsopresident of LegisServe.

NJAOPS will begin the 214th legislative session with a strong,bipartisan working relationship with the Legislature.


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THE JOURNAL | WINTER 201010 THE JOURNAL | WINTER 201010

Medical myths are much like this story.They are the things we have been taught or told that are just plain wrong. Like theproverbial apple that keeps the doctoraway, they are bits of information that arepassed down from generation to generationand become entrenched over time.

How Are Myths Created? During our training, we take the words ofthe faculty and attending physicians as

gospel. Senior residents guide and educateus in the mysteries of medicine. Once inpractice, we look to colleagues for thatwhich we do not know ourselves. Journalsbecome our bibles. Their articles are ourlaw. The research we choose to believeconfirms our own biases.

Why do the myths become difficult todispel? Family physician Robert Flaherty,MD, said they were “particularly persuasive

pearls of punditry.”1 It holds that these mythsgain favor because “they have the ring oftruth, the aura of wisdom and the flavor oflogic.” As busy practicing physicians, wehave little time to fact-check everything. Wesuffer from a kind of knowledge inertia inthat we mostly practice what we learned inmedical school and residency supplementedby experiential learning.

It’s not that we don’t question what we’velearned. But when we do, we tend to fallback on three common responses:2

� The plausible theory model. This holdsthat if something makes sense, it mustbe true. So if we know that a vitamin-Adeficiency may cause blindness then itstands to reason that eating carrots,which are high in vitamin A, would begood for your eyes.

� The lazy model. If it sounds like it ought to work (plausible theory), and it’seasy to do, then do it. Sliding scale insulinis a good example of this. It’s easy, but asI’ll show later, it doesn’t work.

� Dogma. If the experts say it’s so, it mustbe true. For many of us, the writtenword is given great weight. If it’s

medical

mythology

Separating Fact From Fiction in

the age oF evidence-BaSed medicine By Stephen Kabel, DO

A young boy walking through a field in the Scottish countrysidebecomes trapped in a muddy bog and is unable to free himself. Anearby farmer hears his cries and rescues him. The boy’s father, a

nobleman, returns the next day and wants to reward the kind farmer forsaving his son. The farmer tells him he too has a son, a bright lad but,alas, the farmer does not have the money for a formal education. Thenobleman promises to pay for the boy’s education. The years pass andthe nobleman’s son becomes deathly ill. He is treated with a new wonderdrug: penicillin. He survives and goes on to be a successful politician,leading his country out of its darkest hours in World War II and becominga national hero. That man was none other than Winston Churchill. The young boy who went on to school was Alexander Fleming—the manwho discovered penicillin. And now for the rest of the story… pure bunk.Nice story but it never happened. It is just another myth told enoughtimes that people believe it.

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THE JOURNAL | WINTER 2010 11

printed in a major medical journal, webelieve it. We tend to not challengeauthors who overstate or magnify themeaning of their results.

As we have entered an age of evidence-based medicine, these common responsesno longer suffice. We are expected to usethe most current and best evidence inmaking decisions about the daily care ofour patients. Not only do our patientsexpect it, but insurers and healthpolicymakers expect it as well. If we do not learn from the research and insist onkeeping faith in the myths, we end upsacrificing quality care because even themost experienced clinician is nothingwithout evidence, just like the best evidenceis worthless without clinical experience.

Tales from “Old Wives”Some medical myths are no more than oldwives’ tales. It’s the type of informationpatients cite when seeking simple answersto questions about general well-being.“Doctor, tell my son to stop eating Frenchfries so his skin will clear up,” or “I havebad eyesight because I hate to eat myveggies.” These myths usually do no harm,and the truth behind them may beamusing. Let’s start with those carrotsmentioned in the plausible theory model.

Myth: Carrots are good for your eyesight.Truth:While high in vitamin A (and vitaminA deficiency may cause blindness), carrotshave no special effect on eyesight. A typicalwestern diet provides sufficient vitamin A.Where did the myth originate? It was adisinformation campaign by the Royal AirForce during World War II to explain theeffectiveness of their night fighter pilots. Theactual classified explanation was the newinvention RADAR.

Myth: Taste buds have specific areas ofresidence on the tongue.Truth: Many claim that the tongue hasspecific areas of taste: bitter on the tip andsweet on the sides, etc. It is a misconception.All taste buds can sense all tastes. Someare just more sensitive to specific tastes.The myth is owed to a poor translation ofthe original German study.

Myth: Drink eight glasses of water per day.Truth: This dates back to a 1796 German textin which the Surgeon General to the King ofPrussia, who was still vibrant at the age of 80,said the king had “contracted the habit ofdrinking seven-to-eight glasses” of cold waterdaily. In 1900, the New York Evangelistpublished an article, citing a Dr. Vinton, whichsaid one needed to ingest eight glasses ofwater per day and four times as much wateras food. The same article also said that it wasdangerous for young girls to get their feet wetand that their brains were soft like jelly.

By 1920, the popular press ran numerousarticles exhorting people to drink six to

eight glasses of water per day, a goalpropounded by none other than CharlesAtlas. (Who could doubt the original Mr.America?) In 1945, the Institute ofMedicine’s Food and Nutrition Boardrecommended that “a suitable allowance ofwater for adults is 2.5 liters daily.” Whatthe press missed was the last sentence ofthe report that read, “Most of this quantityis contained in prepared foods.”

There is no scientific evidence for drinkingeight glasses of water per day. Animal andplant cells are mostly water, and our foodprovides most of the water we need. Thirstdrives the rest.

Myth: Chocolate and greasy foods cause pimples.Truth: No published trial has shown apositive concordance between chocolateor greasy foods and the exacerbation of acne.

Debunking the MythsThere is another degree of medical myth.These myths are more onerous becausethey can inadvertently sabotage patientoutcomes, offer false hope or causeneedless testing and worry in patients.Some will surprise you and much willchallenge what you believe. Before you seeyour next patient, ask yourself if you knowthe truth behind the following myths.

Antibiotics and Oral ContraceptivesWe’ve all been told that antibiotics can decrease the effectiveness of oralcontraceptive pills (OCP). However the pharmacokinetic evidence3 does not support this. OCP drug levels are unchanged by penicillins,fluoroquinolones, tetracyclines, co-trimoxazole, metronidazole,cephalosporins, azithromycin or

clarithromycin. Only rifampin was shownto lower OCP levels.

Axillary TemperaturesMany falsely believe that rectaltemperature can be accurately presumedby adding 1 degree C to an axillarytemperature in children. The truth is that inchildren temperature at the axilla does notsufficiently agree with rectal temperaturesto be relied on in clinical situations whereaccurate measurement is important.4

Pernicious Anemia and Parenteral B12There is a belief that the lack of intrinsicfactor in patients with pernicious anemiamakes oral absorption of B12 impossible.The truth is that while severe B12 deficiencyinitially requires parenteral therapy toacutely increase levels, long-term treatmentmay be successfully accomplished withhigh-dose oral B12 (2000 mcg/d).5 Adequatelevels will be maintained via osmosis. Oral B12 is safer and less expensive thanparenteral therapy. A four-month supply of 500-mcg pills (about 500 pills) isapproximately $8 at Walmart.

Penicillin Allergy and CephalosporinsMany physicians won’t give cephalosporinsto patients with severe penicillin allergies,believing there is a 10% cross-reactivity.However, no study has shown a trueincrease in cephalosporin allergy as a classin penicillin-allergic patients over baselinecephalosporin allergy rates. The relationshipis strongest when the cephalosporin sidechain is closest to penicillin in structure(first-generation cephalosporin only andonly for those with an IgE type reaction).6Second-, third- and fourth-generationcephalosporins are safe. Penicillin has afive-member ring; cephalosporin a six-member ring. Penicillin degrades into astable ring and cephalosporin does not.Cross-reactivity is unlikely as confirmed by monoclonal antibody testing.7

Why the 10% myth? When cephalosporinswere introduced in the 1960s, there werefrequent reactions in previously penicillin-allergic patients. Initial studies showed upto a 10% incidence. However, these studieswere flawed. Until 1982, penicillin wascommercially produced using cephalosporinmold.8 Subsequent studies have shown therate to be exceedingly low and anaphylaxisrare.9 Second-, third- and fourth-generationcephalosporins show no cross-reactivity.10

Disease Screening What is effective screening and what is theevidence? What is more important, disease-specific or overall mortality? (Refer to Table1 on page 13 for the World HealthOrganization (WHO) criteria for screening.)Black et al.11 found that while disease-specific mortality may be the standard forreporting mortality benefit, it does notnecessarily correlate with a significantbenefit in all cause mortality. It leaves one

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to wonder, is disease screening trulyhelping patients or just changing thediagnosis on their death certificates?Following are thoughts on some commonscreenings in use today.

� Cervical Cancer Screening—There have been no random controlled trials (RCT)performed. Since the advent of PAPsmears and the observed overalldecrease in cervical cancer mortality, ithas been considered unethical to do aplacebo-controlled trial. Therefore, datais not available to thoroughly addressthe issue.

� Lung Cancer Screening—No published RCT has shown a mortality benefit. Nostudy has yet been able to surmount thelead-time bias or length-time bias.Some studies on chest X-rays haveshown an increase in mortality withscreening. The ongoing Prostate, Lung,Colon and Ovarian (PLCO) CancerScreening Trial may provide valuableinformation in the near future.

� Prostate Cancer Screening—No well-conducted placebo-controlled RCTsthat have controlled for lead/length-time bias have shown any survivaladvantage to prostate-specific antigen(PSA), digital rectal examination (DRE)or combination screening. Current U.S.Preventive Services Task Force(USPSTF) and Canadian Task Force onPeriodic Health Examination (CTFPHE)recommendations do not supportroutine screening. The AmericanMedical Association (AMA), AmericanCollege of Physicians (ACP) andAmerican Academy of FamilyPhysicians (AAFP) currentlyrecommend discussing prostate cancerscreening with special attention toaddressing the risks, benefits,complications and uncertainties.

Two studies published in the last yearhave shed some new light on thesubject. The PLCO Cancer ScreeningTrial12 enrolled 76,693 men over eightyears. They were randomized toscreening by PSA and DRE versususual care. After seven to ten years,the prostate cancer death rate waslow and did not differ between thetwo groups. However, a significantnumber of subjects in the usual carearm received PSA testing, thustempering its relevance.

A more appropriate study would be toinclude a placebo arm. The EuropeanRandomized Study of Screening forProstate Cancer13 did just that byenrolling 182,000 European men ages50 to 74 starting in 1990. Subjects wererandomized to either a PSA every fouryears or no screening. They determinedthat screening led to a 20% decrease in

prostate cancer mortality but with ahigh rate of overdiagnosis. Biopsy of anabnormal PSA had a positive predictivevalue (PPV)=28%. The number neededto treat (NNT) showed that 1,410 menhad to be screened to detect 48 extracancers to prevent one death fromprostate cancer. Overall mortality wasnot reported and the decrease inprostate cancer mortality was notevident until 10 years after screening.

� Colon Cancer Screening—Only one well-conducted large RCT, theMinnesota Colon Cancer ControlStudy,14 has been reported. It looked atfecal occult blood testing only andshowed a 33% reduction in coloncancer deaths but no decrease inoverall mortality. Most of the diseaseburden was in the extreme elderly, andit was not powered or designed to lookat just 50- to 60-year-olds. There havebeen no published RCTs withcolonoscopy or flexible sigmoidoscopy.Most have used historical controls orpretest estimates of disease.

� Breast Cancer Screening—No topic in cancer screening has probably had somuch controversy as screening forbreast cancer. The literature is awash inpoorly conducted studies. There issome evidence of benefit in womenbetween 50 and 60 years of age. NoRCT has studied just women older than60. Only one study looked just atwomen between the ages of 40 and 49.That study, the Canadian NationalBreast Cancer Screening Study(CNBCSS), had two arms. CNBCSS I15enrolled women between 40 and 49and randomized them tomammography (M) plus clinical breastexam (CBE) or usual care. CNBCSS II16randomized women 50 to 59 toM+CBE versus CBE alone. Both armsshowed a small benefit in detectingsmaller, early-stage node-negativecancers. Neither arm showed a disease-specific or overall mortality benefit. A16-year follow-up study17 showed nochange in the CNBCSS II results.

The results of the CNBCSS I and IIshould not be surprising in thatductal carcinoma in situ (DCIS),which was rare prior to massscreenings, now accounts for almost30% of all diagnosed breast cancers18and is not even truly a breast cancerbut rather a precancerous lesion.However, 20 years of excising DCIShas not led to a reduction in invasivebreast cancer.19

Two Danish researchers (Olsen andGotzsche) touched off a firestorm when they published an editorial inThe Lancet in 2001.20 They foundmethodological flaws in almost all

Learning the Language of Medical Literature One of the biggest stumbling blocks tounderstanding medical research is thelanguage. Here are some of the terms youneed know to understand medical literature.

Absolute Risk (AR): The arithmetic differencebetween two measurements. Treatment ‘X’decreases incidence of disease ‘A’ from 3%to 2%=1% absolute reduction.

Relative Risk (RR): The percent change inwhat is measured. Treatment ‘X’ decreasesincidence of disease ‘A’ from 3% to2%=1% ; 1/3= 33% relative reduction.

Number Needed to Treat (NNT): Thenumber of people who would be neededto treat to provide the beneficial outcometo one person. It is defined as thereciprocal of the Absolute Risk (1/AR).

Confidence Interval (CI): The range of valuesfor which you are reasonably certain; the trueresult lies to some arbitrary standard, usuallyset at 95%. A trial will often report a specificresult followed by a CI. The result is a pointspecific number regurgitated by somemathematical equation, usually a linearregression analysis. However, the true resultis actually somewhere within the CI range. Atrial’s author may show two comparatorswith a 10% difference and cite this as apositive result proving their hypothesis.However, if the CIs overlap, they haveactually failed to disprove the null hypothesis(that there is no difference). A simpleexample is to flip a coin 10 times. If you getsix heads and four tails, your study says theodds of getting heads are 60%, which we allknow is incorrect. The way to shrink the CI isto increase the enrollment and lower theerror margin. Flip the coin a million times.Casinos make a fortune on this principle.

P Value: The probability that your observedresults are not due to random chance. Themedical research field has generallyaccepted P=0.05 (5%) as being significant.

Lead-Time Bias: The bias that occurs whena condition is diagnosed earlier but thepatient’s outcome does not change.Screening test ‘Y’ diagnoses fatal disease onJune 1 and patient dies January 1. Withoutscreening test ‘Y’, same patient would havepresented December 1 with diseasesymptoms and still died January 1. Literaturereports test ‘Y’ lengthens life by 6 months.

Length-Time Bias: The bias that occurswhen the disease being studied is nothomogeneous and the study takes place(i.e. enrolls patients) over time. Moreaggressive forms of the disease are selectedout of the study, as participants cannothave the disease at entry, thus biasing theresults to more benign forms of the disease.

Note: Lead- and length-time bias are thehardest to grasp. While their basic definitionis fairly simple, their application is difficult.It is tremendously hard to compensate forthem when designing a trial. Authors andeditors tend to downplay them and readerstend to ignore them. They can causesubstantial biases when the studied disease isheterogeneous like many cancers (e.g.,prostate and breast cancer). �



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breast cancer screening studies. Theydeemed only the two Canadian studiesand one Swedish study of acceptablequality—all of which found no benefitto screening. The USPSTF disagreed.They felt the flaws cited were notserious enough to warrant exclusionfrom a pooled analysis (meta-analysis).They felt justified in their thenrecommendation of fair evidence tosupport screening 50- to 60-year-oldwomen, weaker evidence for screening40- to 49-year-olds and 60- to 69-year-olds and that screening should ceaseby age 75.

Most recently, the USPSTF has revisedits guidelines.21 It no longer recommendsbreast cancer screening for women in their 40s. It also indicates thatmammography should be performedbiennially (not annually) in womenbetween ages 50 and 60. Screeningshould cease at age 74, and CBE is no longer considered a usefulscreening test.

The Problem with Meta-AnalysisA problem in the literature and the medicalcommunity at large is a misunderstandingof the usefulness of meta-analyses. Toomany people accept their results as realresearch and do not understand a meta-analysis’ limitations. A meta-analysis pools

the results of multiple small heterogeneousstudies in the hopes of forming a largerstudy population to increase the power todetect small changes not readily apparentin the original studies or to magnify theirsignificance. They are notoriously subjectto biases that are extremely difficult tocontrol for. They cannot provideinformation to guide clinical practice. Theycan only help you decide how to designthe RCT to directly answer the question.Too often a meta-analysis suggests atreatment is either helpful or harmful onlyto be disproved upon direct study (e.g.,vitamin E, magnesium and rosiglitazone incoronary artery disease).

Statistics and PerceptionLet’s say I propose three novel treatmentsfor coronary vascular (CV) disease. The firstresults in a 41% relative risk (RR) reductionin CV deaths and a 31% RR reduction inCV events. Is Treatment One worthwhile?Treatment Two results in a 3.5% absoluterisk (AR) reduction in CV deaths and an8.6% AR decrease in CV events. Wouldyou recommend Treatment Two to yourpatients? Treatment Three’s NNT requiresyou to treat 29 people for six years toprevent one CV death and 11.5 peoplefor six years to prevent one CV event. Itcosts $209,000 to prevent one death and$84,000 to prevent one event. Would you recommend Treatment Three? All

Table 1

three results represent the same thing and are the results of the seminalScandinavian Simvastatin Survival Study(4S) Trial,22 the study that is thecornerstone of statin therapy.

WHO Screening Criteria The condition should...

� Be an important health problem

� Have an accepted treatment� Have available facilities for diagnosis and treatment� Have a recognizable latent or early symptomatic phase� Have a suitable test or examination acceptable to the population� Have a natural history including an adequatlely understood development from latent to declared disease � Have an agreed-upon policy on whom to treat� Be cost effective (ie, cost of screening in relation to expenditures as a whole)� Be a continuous process for a population



OsteoporosisThe incidence of osteoporosis in womenolder than 60 is 13%–20%. Fifty percent ofwomen older than 50 will haveosteopenia23 and a 50-year-old woman hasa 40% chance of experiencing anosteoporotic fracture in her lifetime.24Bisphosphonates (e.g., alendronate) canreduce this risk by 50%.25 The USPSTFrecommends screening of all women at age65 or by age 60 if risk factors are present.Treatment is recommended if the T-scoreby bone mineral density (BMD) testing isgreater than -2.5 standard deviations (SD)below that of the young female mean or ifthere is a fragility fracture. The NationalOsteoporosis Foundation (NOF)recommends treatment if the T-score >-2.0SD or >-1.5 SD if risk factors present.

However, 82% of postmenopausal womenwith a new fracture had BMD in theosteopenic range. Only 45% would havebeen identified by the more lenient NOFcriteria. The NOF, in collaboration withmultiple medical societies and the NIH,also stated that dual energy X-rayabsorptiometry (DEXA) scanning shouldonly be offered if the patient would bewilling to undergo treatment forosteoporosis. Screening is worthless if youare not going to treat the disease, so youmust have a full discussion with the patientregarding treatment options and their risksand benefits before you order the test.

Osteoporosis is a disease that meets all ofthe WHO criteria for an effective screeningprocess. So, what is the “mything link”?First, under the most optimistic results, ifyou screen 10,000 women between ages65 and 69, the NNT to prevent one hipfracture in five years is 731.26 Second is themachines themselves. All current DEXAscanners use proprietary software toestablish their nomograms, and machinesfrom different manufacturers can givedivergent results27 of up to 15%.

How do you monitor patients? There is noconsensus and little to guide you. There are

no published RCTs. “Expert” opinionrecommends rechecking in two to threeyears, but what’s the evidence for thisrecommendation? DEXA scans are highlysusceptible to random variability.28 Theleast significant change is the percent ofchange that is unlikely due to precisionerror of the test and is arbitrarily set at<5%. It is calculated as 2.8 times theprecision error of the test on a givenmachine (supplied by the manufacturer)and test site. In expert centers, theprecision error is approximately 2%.Therefore, changes of <5.6% (2.8 X 2) maybe due to precision error alone.Additionally, outcome studies show apositive result with bisphosphonatesregardless of subsequent BMD.

Given the proprietary nature of thenomograms, the patient must be recheckedon the same scanner and with the samesoftware. This is a difficult propositiongiven insurance limitations, facilityupgrades, etc. Also, given the variableshape of bone and the subtle nature of themeasurement, the patient must berechecked in the exact same position, avirtual impossibility. And, even if youcould control for the above, you stillcannot interpret the results. If the BMDincreases, good. If you find no change oreven a loss in BMD, the loss may havebeen even larger without treatment. Somepatients regain BMD with subsequenttesting even if treatment is unchanged.

“Expert” opinion is that treatment shouldnot be changed if there is an apparent lossof BMD at the first monitoring period. Thisseems at odds with the recommendation toretest. Why retest if it won’t change thetreatment? This violates the dictum that oneshould only order a test to confirm orrefute a diagnosis, if in doubt, or if it willaffect the treatment—neither of whichapplies here. No studies have shown anybenefit to add-on therapy. What if yourpatient is osteopenic? Should you recheckyearly? The answer is no. Bone loss rarelyexceeds 1% per year at the hip, so it would

take 10 years to lose a full point in the T-score. However, BMD may fall faster inthe first five years of menopause. Howclose you are to the treatment guidelineswould determine when you should retest.

DiabetesShould tight control be the goal in Type IIdiabetics, and should we aim for nearnormal hemoglobin A1c (HgA1c) levels?The 2004 National Committee for QualityAssurance (NCQA) in their Bridges toExcellence Program established a goal ofHgA1c<7.0% in 50% or more of aphysician’s patients. The 2006 NCQAraised the standard to HgA1c<7.0% in alldiabetics. This became the new criteria forthe Healthcare Effectiveness Data andInformation Set (HEDIS), the tool used byhealth plans to measure performance onimportant dimensions of care and service.Prior to 2006, it was 9.0%

What’s the evidence? The 1998 UKProspective Diabetes Study (UKPDS)29compared metformin with conventionaltreatment or intensive treatment with asulfonylurea agent or insulin. No benefit wasfound for any single macrovascular endpointfor any treatment arm. Only metforminlowered retinopathy (microvascular disease)and reduced the aggregated macrovascularendpoints; all cause mortality and stroke.NNT over 10 yrs=20 (CI=10-500, 95%).Intensive treatment actually showed a highermorbidity and mortality. A 20-year follow-upstudy30 showed that the results werediminished but were still positive formetformin only.

The ACCORD Trial31 published in 2008randomized 10,251 patients to eitherintensive treatment (HgA1c<6.0) or standardcare (HgA1c=7.0–7.9). The primary outcomewas nonfatal myocardial infarction (MI),nonfatal cerebrovascular accident (CVA) ordeath from any cardiovascular (CV) cause.The trial was stopped early at 3.5 yearsbecause of a 22% excess all-cause mortalityin the intensive treatment arm. The intensivetreatment arm also saw a higher rate of

Current USPSTF Screening Guidelines

AAA One-time screening in men 65–75 if smoked >10 cigarettes in lifetime

Chlamydia Screen all sexually active women age <24, older women if at risk

Lipids Screen all men >35 (20–35 if at risk) and women >45 (20–45 if at risk). screen at 5-year intervals

Diabetes Screen only if sustained BP>135/80

Hypertension Screen all >18 every two years

Tobacco Screen all

Immunizations Screen all and apply all age-appropriate vaccinations

Colon Cancer Screen at age 50–75 or 10 years before age of first degree with CRC, whichever is earlier

Breast Cancer Screen every 2 years from 50–60, stop at age 74

Table 2



significant hypoglycemia and weight gain.There were no differences in the primaryoutcomes between treatment arms. Theproblem with the study? Hazard Ratio(HR)=1.22; 95% CI, 1.01–1.46. The HRshows a 22% increased death rate, but the CIalmost crossed 1.0; therefore, it almost didn’tdisprove the null hypothesis. The primaryoutcome showed no difference, but the p value=0.16, so there was a 16% chancethat their results were due to random chance.

Additionally, 91% of patients in theintensive arm received rosiglitazone whileonly 56% did so in the standard arm. Thereis ongoing debate as to whether drugs inrosiglitazone’s class increase mortality ontheir own. Plus 77% in the intensivetreatment group received insulin while only55% in the standard treatment arm did so.

So what can we say? Currently, there isno well-conducted RCT that shows amajor benefit in lowering HgA1c<8.0–9.0% in regard to macrovascular diseasein Type II diabetes mellitus. Intensivetreatment is probably detrimental andmetformin is the only glucose-loweringagent consistently shown to help withmicrovascular disease.

Sliding Scale Insulin (SSI)SSI was first described by E.P. Joslin32 in1934 and was based on urine glucosemonitoring. There is no standardization inschedules, with most physicians learning itin residency as taught by senior residents. Ithas traditionally been scheduled every fourto six hours without regard to meals. Whyis it still in use? Tradition, it’s easy to use,straightforward and it makes you feel likeyou are doing something. What’s theevidence? An RCT33 evaluating basal/bolus(mealtime) insulin regimen showed superiorglycemic control compared with SSI. SSIhas no literature to support its use. Fifty-twotrials from 1966–2003 in a Medline search34

failed to find even one positive study. Infact, SSI was described as nonsensical 45years ago.35 In 2008, Hirsch36 said:

SSI is a relic of past generations ofineffective and potentially dangerousglucose management that is not evidencedbased and does not attempt to mimicnormal physiology.… Medical professionalsdo not use sliding scale penicillin for feveror sliding scale oxygen for pulmonaryedema. It is time to discontinue amusementpark diabetes therapy so that decades fromnow, clinicians are still not trying to abolishan illogical treatment.

The Routine Physical ExamThe precise origin of the routine physicalexam is unknown, but it is often traced tothe British physician Horace Dobell37 whosaid in 1861:

I wish, then, to propose as the only meansby which to reach the evil and obtain the

good, that there should be instituted, as acustom, a system of periodicalexamination, to which all persons shouldsubmit themselves.

He advocated an exhaustive history, ameticulous physical examination and useof laboratory tests. How did it gainacceptance into modern medical practice?The Metropolitan Life Insurance Companyevaluated the physical examination in themid-1800s. By the turn of the century, itfound that those who had an annual physicalhad lower death rates.38 In 1915, it found a28% reduction in mortality and up to 53%with five-year follow up. Thus, by doingphysicals, it could increase returns by over200%. Not a bad return on investment.

There are two problems with this logicfrom a medical perspective. First, theseexams were geared to weed out poorinsurance risks, not treat disease. Second,early statistics did not take into accountconfounders. People who could afford lifeinsurance or annual physicals were better offsocioeconomically (i.e., better food, housing,sanitation, etc.) and thus lived longer. Itwasn’t the physicals that helped them.

In the 1920s, corporations took an interestin assuring the health of their executives,and the “executive physical” came intovogue. By the 1940s, there were clinicsdevoted to them at private institutions andmajor academic centers. The famousGreenbrier Clinic is an example. It offereda three-day extensive examinationperforming just about everything in themedical armamentarium.

With the advent of World War II and wagefreezes, companies offered healthinsurance as a way to lure scarce workers.Health insurers competed for business byoffering executive physicals to thebusinesses purchasing plans. In the 1950s,with the labor movement at its zenith,unions felt that if it was good enough forthe bosses, it should be good enough forthem. And thus, the routine physicalentered into health insurance coverage forall. And why not? Remember the threemodels of why myths gain acceptance?

1. The plausible theory model: It makes sense.

2. The lazy model: It ought to work and it’s easy to do (no ECGs, MRIs or colonoscopies to do back then).

3. Dogma: If the experts say it’s so, it mustbe so.

The AMA endorsed the routine physical in1922, wholly basing their endorsement onthe objectives of the physical examinationwithout any proof of its benefit. Physiciansreadily adopted it. After all, we got paid toperform physicals and they were easy to

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do. By the 1960s, the concept of theroutine physical was broadly accepted byall parties to include insurers, physicians,employers and the public.

Again, what is the evidence? Two majorstudies initiated in the 1960s—Kaiser39 with10,000 participants in 1964 and the South-East London Screening Study Group40 in1967 with 7,000 participants—bothshowed that a routine comprehensiveannual physical examination had no effecton healthcare utilization and overallmortality. Their findings led to three majorreassessments: an exhaustive review of theliterature by Frame and Carlson (1975),CTFPHE (1976) and USPSTF (1984). Allthree recommended against the routinephysical and only supported those screeningservices for which a benefit could be

proven. A minimalist approach was thenadvocated by the ACP41 and AMA42. (Referto Table 2 on page 14 for the currentUSPSTF guidelines.)

So if it’s not beneficial, why do it? Patientshave come to expect it. It may help buildtrust. There may be unmeasured psychosocialbenefits to the patient: osteopathicallyspeaking, the proverbial “laying on of thehands.” It may serve as protected time toaddress all those preventative measures andscreenings that otherwise would not fit intothe seven-minute sick visit.

ConclusionMy father, Sander Kabel, DO, once told meafter he recertified in Family Practice thesecond time, “Stephen, the questions neverchange, just the answers.” The goal of this

article is to encourage you to questionwhat you have been taught. Before youtreat, ask yourself, does the evidencesupport my typical protocol? Do notblindly accept treatments of the past astreatments for the present. Keep an openmind. Know the evidence. Critically readand question the literature before decidingwhether a belief you stand by is medicalmyth or just plain good medicine. �

A general internist practicing in Delran, NJ, Stephen Kabel, DO, is president of theBulington County Society of OsteopathicPhysicians and Surgeons and a member ofthe NJAOPS Board of Directors. He is alsoa peer reviewer for Annals of InternalMedicine and “The Prescriber's Letter” as well as a contibuting editor for “ThePrescriber's Letter.”

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6. Mayorga C et al., Cephalosporin allergy. N Engl J Med. 2002 Jan 31;346(5):380-1.

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13. Schroder FH, et al., Screening and Prostate Cancer Mortality in a RandomizedEuropean Study. New England Journal ofMedicine 2009, 360(13):1320-28.

14. Jorgensen OD et al., A randomised study of screening for colorectal cancer usingfaecal occult blood testing: results after 13years and seven biennial screening rounds.Gut 2002; 50: 29-3215. CMAJ 1992; 147:1459-76.

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detection and death rates among womenaged 40 to 49 years. Can Med Assoc J. 1992;147: 1459–98.

16. Miller AB et al., Canadian national breast screening study: 2. Breast cancer detection and death rates among women aged 50 to 59 years.Can Med Assoc J. 1992; 147: 1477–88.

17. Miller AB et al., The Canadian National Breast Screening Study-1: breast cancermortality after 11 to 16 years of follow-up. Arandomized screening trial of mammographyin women age 40 to 49 years. Ann InternMed 2002, 137(5 Part 1):305-312.

18. Esserman L; Shieh Y; Thompsom I, RethinkingScreening for Breast and Prostate Cancer.JAMA 2009; 302(15): 1685-1692.

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on Screening for Breast Cancer withMammography. Lancet 2001;358 (9290);1340-1342.

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22. Sacandinavian Simvastatin Survival Study (4S). Randomized trial of cholesterollowering in 4444 patients with coronaryheart disease. Lancet 1994;344:1383-1389.

23. Guzman I, et al. Prevalence of Osteopenia and Osteoporosis assessed byDensitometry in Postmenopausal Women.Ginecol Obstet Mex 2003; 71: 225-232.

24. Riggs BL, Melton LJ. The Worldwide Problem of Osteoporosis: Insights Affordedby Epidemiology. Bone 1995; Nov; 17 (5Supp): 505S-511S.

25. Nelson H et al., Screening for postmenopausal osteoporosis: A review of theevidence for the U.S. preventive services taskforce. Ann Intern Med 2002, 137: 529-541.

26. IBID27. IBID28. Cummings SR et al., Clinical use of bone

densitometry: scientific review. JAMA.2002;288(15):1889–1897.

29. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucosecontrol with metformin on complications inoverweight patients with type 2 diabetes(UKPDS 34). Lancet 1998;352:854-65.

30. Holman RR et al., 10-year follow-up of intensive glucose control in type 2 diabetes.N Engl J Med. 2008; 359 (15):1577–1589.

31. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects ofintensive glucose lowering in type 2diabetes. N Engl J Med 2008;358:2545-59.

32. Joslin EP, A Diabetic Manual for the Mutual Use of Doctors and Patients, Phila,PA: Lea & Febiger, 1934: 108.

33. Umpierrez G; et al. Randomized Study of Basal-Bolus Insulin Therapy in theInpatient Management of Patients with Type2 Diabetes (RABBIT 2 Trial)Diabetes Care2007; 30(9): 2181-2186.

34. Browning L A, Dumo P, Sliding scale insulin: an antiquated approach to glycemiccontrol in hospitalized patients. Am J HealthSyst Pharm 2004. 611611–1614.

35. Robbins L, Let's Get the Sliding Scale Out of Medicine. Med Rec Ann. 1963 Sep;56:201.

36. Hirsch I, Sliding Scale InsulinTime to Stop Sliding. JAMA 2009; 301(2): 213-214.

37. Dobell, H, Lectures on the Germs and Vestiges of Disease, and on the Prevention ofthe Invasion and Fatality of Disease byPeriodical Examination, Churchill, 1861:142-63.

38. Knight A. The value of the periodic examinations of life insurance policy-holders. Proceedings of the Association ofLife Insurance Medical Directors of America.1921-22; 8:25.

39. Dales LG et al, Multiphasic checkup evaluation study, 3. Outpatient clinicutilization,. hospitalization, and mortalityexperience after seven years. Prev Med.1973; 2:221-35.

40. The South-East London Screening Study Group. A controlled trial of multiphasicscreening in middle-age: results of the south-east London screening study. Int J Epidemiol.1977;6:357–363.

41. Periodic health examination: a guide for designing individualized preventive healthcare in the asymptomatic patients. MedicalPractice Committee, American College ofPhysicians. Ann Intern Med. 1981;95:729-32.

42. Medical evaluation of healthy persons. Council on Scientific Affairs. JAMA. 1983;249:1626-32.



Implement Early for Maximum Incentive Payments

Physicians looking to benefit fromthousands of dollars in stimulus fundsfor installing an electronic health

record (EHR) system just got the gift ofextra time but should still get the ballrolling now, EHR industry experts say.

Included in the economic recovery act thatPresident Obama signed in February 2009,the stimulus law provides up to $44,000 inMedicare incentive payments to physicians,hospitals and other eligible professionalswho install a certified EHR system andbecome “meaningful” users, explainedCharles Jarvis, vice president of HealthcareServices and Government Relations atNextGen, an EHR software developer. Butmany physicians have been hesitant toinstall systems, awaiting the regulationsthat would set the standards forcertification and a definition of“meaningful” use.

Those regulations came on Dec. 30, whenthe Centers for Medicare and MedicaidServices (CMS) released its anxiously-awaited proposal on the definition ofmeaningful use and also extended thedeadlines by which physicians must becomemeaningful users to qualify for the funding.The new rules give physicians another year—until 2012— to qualify for the fullfunding. In addition, the release of proposedregulations that set the standards for EHRcertification offers physicians some addedconfidence when they purchase a system.The rules now enter a public commentperiod with a final ruling expected in mid-2010. Despite the extra time, industryexperts say it’s important that practices lookfor an EHR system right away.

“It takes a good three months to select theright system, another three months to get itinstalled and another six months to learnhow to use it effectively,” Jarvis said.“That’s why it’s very important for physiciansto begin their selection process now.”

According to the new timeline set by CMS,incentive payments will equal up to 75%of Medicare allowable charges for coveredservices up to a maximum payment of$18,000 in 2011 for early adopters, withyearly payments of up to $12,000, $8,000,$4,000 and $2,000 continuing through2015, for a total of $44,000. Likewise,adopters who meet meaningful use criteriastarting in 2012 will receive paymentsthrough 2016. Those who becomemeaningful users in 2013 can qualify forup to $39,000 over 4 years; for those whowait until 2014, maximum payments arereduced to $24,000 over three years. There

are no payments to those who first becomemeaningful users in 2015 or later. Forphysicians who provide services in a healthprofessional shortage area (HPSA) asdefined by the CMS, incentive paymentswould be increased by 10%.

To qualify for the incentives, physicians must:

� Use an EHR system that is certified.The Certification Commission forHealth Information Technology, anonprofit group that certifies EHRsystems, has already begun certifyingsystems based on preliminary standardsproposed by the federal Office of theNational Coordinator for HealthInformation Technology (ONC-HIT).To find certified products, visitwww.cchit.org/products.

� Use electronic prescribing. CMSalready offers incentives for physicianswho e-prescribe, but e-prescribing willbe mandatory to also qualify for theadditional bonuses in the stimuluspackage. Additionally, e-prescribing

offers a layer of protection to bothphysician and patient, said RobertGabriel, president and CEO ofMicrowize Technology, an EHRreseller. “With e-prescribing you areable to know if other physicians aregiving medications that contradict with

Continued on page 24

By Bonnie Smolen

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The legacy of the fall of the MIIXinsurance company is about to winddown as the final date to file medical

malpractice claims with its liquidator, theNew Jersey Property Liability InsuranceGuaranty Association (NJPLIGA) rapidlyapproaches. So now is the time to considersteps to protect yourself if you werepreviously covered by MIIX.

MIIX—once one of the largest medicalmalpractice insurers in New Jersey insuringalmost 40 percent of the state’s physicians—closed its doors in 2002 after reporting losses

of more than $200 million over 15 months.The state Department of Banking andInsurance (DOBI) filed a court order for theliquidation of MIIX, setting April 9, 2009, asthe cutoff date to file claims against thecompany. A subsequent court request byDOBI extended that date another year to April9, 2010, but another reprieve is not assured.

After April 9, NJPLIGA will no longer acceptnew claims filed against physicians formerlyinsured by MIIX. On that date, the $300,000NJPLIGA limit of protection is also set to expirefor any new suit filed by patients treated whilea physician was insured by MIIX.

Any physician who was covered by MIIXshould make it a top priority to acquire gapinsurance. This can be done at a minimalcost now but if you wait or worse, donothing, you open yourself up to the risk ofuninsured liability. Remember, without anextension of NJPLIGA, after April 9 anyclaim payments and attorney fees fromactions by patients during the time youwere covered by MIIX will come out ofyour pocket.

Are You At Risk?Many physicians tell me that they can’timagine anything coming back to hauntthem from so long ago. After all, MIIXcanceled its last policy in 2003. While it’slikely that by now the majority of allpotential malpractice events have been

reported, what remains are those rare butsometimes large claims that will bediscovered long after treatment.

You are especially at risk if your practiceincluded pediatric patients or providedother care with the possibility of latentdeveloping complications. Keep in mindthat even a simple missed diagnosis (one ofthe leading causes of all malpractice claims)may not manifest itself until long after theinitial treatment. For instance, a claimalleging failure to diagnose cancer of thelung, colon, cervix, prostate or breast could

all fit this category. Mass torts related tomedications that were withdrawn, such asVioxx, Lymerix, Entex, FenFen and Baycol,have been known to come back to hauntunsuspecting physicians long after theirrelationship with a patient has ended. Andeven a frivolous claim will require theexpense of an attorney for defense.

It does happen, and it’s not just about newlyfiled claims either. Old existing claims canstill present danger. Not long ago, I had aradiologist client who was only recentlyincluded in an ongoing 10-year-old suitinvolving a birth defect. The OB/GYNphysician had exhausted her insurancelimits, leaving no source of recovery. Theinclusion of “John Doe” defendants in thesuit enabled the plaintiff attorney to namethis shocked radiologist as the sole remainingdefendant, bringing him into this case longafter the fact. So ask yourself this question:“On how many old peds or OB charts withbad outcomes am I listed as the primary carephysician or referring physician?” Remembertoo, the New Jersey statute of limitations onreporting such events is very lenient, and nophysician should be overly comforted by itstwo-year cutoff. The two-year period startsonly after the injury is discovered, not at thetreatment date.

Free or Affordable Coverage To me, the tragic part of this story is thefact that insurance against uninsured MIIX

claims is readily available and affordable.In fact, if a suspected adverse event isreported before April 9 to NJPLIGA, theprotection, including full defense costs, isfree. At the very least, every past MIIX-insured physician who has not insured thisgap should spend a few minutes loggingany patients with severe adverse outcomesseen during the MIIX years of coverage.This log should accompany a letter toNJPLIGA so that if a suit does arise afterApril 9, some protection is available. Thefiling of such incidents usually will noteffect future malpractice premiums, andthey are not data bank reportable. So thedownside to reporting is minimalcompared with the potential benefit. Askilled malpractice agent can providevaluable assistance in this effort.

New MIIX claims continue to be reportedto NJPLIGA. The cost has been steadilydecreasing, but time is running out.Fortunately, the leading New Jerseymalpractice insurers have all steppedforward to offer MIIX gap insurance withlimits of at least $1 million. With the gapinsurance, you get higher limits thanNJPLIGA’s $300,000 limit, plus all of therights and services of a policyholderincluding the consent to settle. The onlyrestriction is that you must purchase coveragefrom the same company that currently insuresyour professional liability. There is noindependent market for MIIX gap coverage.

Request a QuoteYou will be surprised at how inexpensiveMIIX gap coverage can be. Consider thatthe cost to hire an attorney for even afrivolous claim could be ten times thepremium of this insurance. At that cost, itis an important product in your arsenal ofinsurance protection. Every agent has anobligation to their physicians who wereformerly insured by MIIX to offer thiscoverage. So ask them now about MIIXgap insurance before this opportunityslips away. �

Timothy L. Hoover, CPCU, is theHealthcare Practice Leader with theWoodland Group. He can be contacted at [email protected] or 973-300-4216.

MANAGING MALPRACTICE

Timothy L. Hoover, CPCU

Last Chance to Cover MIIX Claims

I had a radiologist client who was only recently included in an on-going 10-year-old suit involving a birth defect. The OB/GYN physicianhad exhausted her insurance limits, leaving no source of recovery.


When it comes

to malpractice insurance,

you don’t have the luxury

to practice getting it right.

We Protect. You Prosper.



LEGAL PERSPECTIVES

Mark E. Manigan

Don’t Quietly Accept Silent PPOs

The use of silent preferred providerorganizations (PPOs) is on the riseagain, according to recent health

industry publications. Silent PPOs have thepotential to redirect millions of dollars outof the hands of physicians, impacting bothpatient and doctor. This makes it importantto understand how silent PPOs work and toknow how to handle them when youencounter one.

Silent PPOs (also known as ghost PPOs orblind PPOs) are payer arrangements thatexpect access to discounted medical feeswithout providing the physician with thereferral incentives associated with atraditional PPO or HMO. Generally, in amanaged care contract, PPO discounts areoffered to practices in exchange for higherpatient volume from the PPO.

Here’s how it works. A patient elects toobtain treatment from a physician whodoes not participate in his or her primaryPPO network. Because the physician is outof network, the patient expects to pay ahigher non-discounted fee for the service.After performing the services, the physicianbills the patient’s insurance. Upon receiptof the physician’s bill, the insurance companyre-prices the physician’s charges to reflectthe lower rates that the physician acceptsfrom a PPO in which he or she doesparticipate. This figure is obtained from adatabase purchased from the participatingPPO. The payer then issues an Explanationof Benefits (EOB) to the physician thatstates its payment reflects the physician’s“usual and customary” rates.

In some cases, the practice inadvertentlyaccepts the payer’s payment. In other cases,the physician knowingly accepts paymentchoosing to avoid the administrative hasslesand inefficient use of administrativeresources. The participating PPO (the sellerof the discounted information) and thepayer (the silent PPO) ultimately share thedifference between what is paid and whatthe payer would have paid without thediscount information at the expense of thephysician. The physician often has to makeup for the lost revenue by raising rates,thereby affecting patients’ access to care.

Proposed Rules Offer Some ProtectionRecently, both the courts and variouslegislatures have been dealing with theissue of silent PPOs. In at least one case, afederal grand jury issued a mail and wirefraud indictment against a firm thatimproperly brokered PPO discounts. Inaddition, at least some state legislaturesdisagree with silent PPO practices,responding with legislation specificallydirected at silent PPOs.

In New Jersey, the legislature has twiceintroduced a bill to outlaw silent PPOs.However, the Preferred Provider ProtectionAct has never gotten through committee tobe voted on by the entire legislature. On amore positive note, the New JerseyDepartment of Banking and Insurance hasrecently proposed regulations that wouldbar “all products” clauses in managed carecontracts. “All products” clauses refer to acommon contracting ploy in which a payeror PPO network asks a physician to sign acontract agreeing to a significant discountfor its enrollees and its affiliates for all ofthe organization’s products. These clausesoften have language providing for use ofsilent PPO.

Protect Your PracticeDespite the lack of legislation to protectphysicians against this practice, it ispossible to avoid falling victim to silentPPOs by taking a few simple precautions:

1. Start with your contract.Make sure you negotiate a solidcontract with managed care companies.Advocate for a provision in youragreement that bars the sale ordistribution of agreed-upon discountrates. You can also require that the PPOnotify you of any new payers joining itsnetwork and add a provision thatallows for cancellation for unacceptablenewcomers or if the network drasticallyexpands or contracts.

You want to also pay special attentionto the definitions of contract terms suchas “payer,” “plan” and “member(s).”You need to ensure these termsspecifically designate who is meant. For

instance, the term “members” shouldbe defined as the member of themanaged care company you arecontracting with only.

2. Request ID cards.Physicians can obtain additionalprotection against silent PPOs byrequesting that the PPO issueidentification cards to its members.The ID should clearly state the PPO’sidentity, logo and a contact number orURL. Patient insurance identificationcards should be copied by officeadministrators upon every visit andlogos should be noted before servicesare rendered.

3. Check your EOBs.Practice managers should performperiodic audits of EOBs to check fordiscounted reimbursements and toidentify these insurance practices.

4. Get help from an expert.You may wish to obtain the advice oflegal counsel in negotiating managedcare agreements to reduce exposure toand losses from silent PPOs. An expertcan also help you develop an officepolicy to help identify inappropriatereimbursements from silent PPOs andmitigate losses.

If you encounter issues related to a silent PPO, notify NJAOPS. Yoursituation is likely not isolated. Bycommunicating with the association, you help us assess the scope of thesituation so we can take appropriatesteps to assist you and others.

Silent PPOs raise numerous issues forphysicians, hospitals, licensed ASCs andsurgical practices. Above all else, you mustmaintain oversight of your patient networkand continue to track payer reimbursements.Doing so will help your practice develop areputation for vigilance, thereby deterringsilent PPOs. �

Mark E. Manigan is a member of BrachEichler’s Health Law Practice Group,NJAOPS’ general counsel.


A Beacon for Success

Clients have long come to

rely on Brach Eichler for

guidance in navigating the

dynamic changes of the

health care industry.

Our health law attorneys

have provided representation

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recognize emerging and evolving trends

within the health care industry and

interpret those realities into successful

business outcomes.

Todd C. Brower [email protected]

Lani M. Dornfeld [email protected]

Burton L. Eichler [email protected]

John D. Fanburg [email protected]

Joseph M. Gorrell [email protected]

Carol Grelecki [email protected]

Kevin M. Lastorino [email protected]

Debra C. Lienhardt [email protected]

Mark E. Manigan [email protected]

Richard Robins [email protected]

Jenny Carroll [email protected]

Deborah Cmielewski [email protected]

Eric Gross [email protected]

Rita Jennings [email protected]

Leonard Lipsky [email protected]

Isai Senthil [email protected]

Edward Yun [email protected]



Why should physicians be left inthe dust when it comes tostimulating the economy? With

rising costs in just about every majorexpense in a medical practice, physiciansneed a stimulus package to sustain currentincome levels. While you may not be ableto do much about cost increases, you cancreate your own stimulus by takingadvantage of every possible tax benefit for2009. Implementing just a few of thefollowing strategies may help reduce yourtax burden and boost cash flow.

Don’t Pay More Than NecessaryFor 2009, qualified individuals with smallbusinesses may be eligible to reduce theirestimated taxes to meet IRS safe-harborthresholds. To qualify, you must meet thefollowing two criteria:

� More than 50% of your gross income must come from a business that had fewer than 500 employees in 2008, and� Your adjusted gross income (AGI) in 2008 must have been less than $500,000 ($250,000 for married filing separately in 2009).

The required annual estimated taxpayments for 2009 must be the lesser ofeither 90% of your 2008 tax as reportedon your tax return or 90% of your 2009

tax liability. This is a significant reductionover previous rules that required a safeharbor of the lesser of either 110% of theprior year tax or 100% of the current yeartax liability.

Illustration: Dr. Jones had a federal taxliability in 2008 of $44,000. Under priorrules, Dr. Jones would have to pay 110%of last year’s tax ($48,400), for estimatedtaxes in 2009. Under the new safeharbor, Dr. Jones could pay only 90% of the prior year tax ($39,600).Thisrepresents a reduction in estimated taxesof $8,800.

Deduct Small Business ExpensesIf your practice is considering a majorpurchase such as an electronic health record(EHR) system or medical equipment in2009, you may be eligible for a deductionof the entire cost of the asset in the currentyear. For tax years that begin in 2009, themaximum deduction that may be allowedunder Section 179 is $250,000 forqualifying purchases up to $800,000. Thisdeduction will phase out dollar-for-dollar forany qualifying purchases over $800,000.Eligible property generally consists oftangible property, such as furniture,machinery and equipment, or off-the-shelfcomputer software.

Illustration: Dr. Smith’s medical practicehas a taxable profit of $200,000 in 2009.Dr. Smith purchases computer equipmentand software for his EHR system in 2009totaling $150,000. Dr. Smith is able to takea Section 179 deduction, reducing histaxable income to $50,000.

Maximize Retirement Plan ContributionsIt is important to remember that you haveuntil the filing deadline of the business taxreturn (including extensions) to fund yourretirement plan while receiving the benefit ofthe deduction in the current year. Thismeans that you are able to take a deductionfor your retirement plan contribution on your2009 tax return and defer the funding of the

contribution until the 2010 filing deadline.You may want to consider deferring thepayment of the retirement benefits until thefiling deadline, even if your practice has thefunds available. This would allow you toinvest the cash in an interest-bearing accountor toward the growth of your business.

The following limits apply to the mostcommon types of retirement plans utilizedby physicians in their medical practice:

� Maximum elective deferral for 401(k) plans increases to $16,500 ($22,000 forindividuals age 50 or over)

� Maximum contributions to a qualified, defined contribution plan increase to $49,000

� Maximum SIMPLE salary deferral limit is $11,500 ($14,000 for individuals age50 or over)

� Maximum annual IRA contribution is $5,000 ($6,000 for individuals age 50 or over)

Make Use of New NOL Law On November 6, President Obama signedthe Worker, Homeownership and BusinessAssistance Act of 2009. A significant provisionin this act extends the “carryback” period onyour net operating loss (NOL). A net operatingloss generally represents the excess ofbusiness deductions (computed with certainmodifications) over gross income. Previoustax law allowed you to offset incomereported up to two years prior with a NOLfrom the current tax year. The new provisionallows most taxpayers to make an election toincrease the NOL carryback period from twoyears to a maximum of five years. The amountof the NOL carryback is limited to 50% of thetaxpayer’s taxable income for that year.

Illustration: Infinity Family Medicine, PA,has a $100,000 net operating loss for thetax year ending December 31, 2009. In2004, Infinity had taxable income of$80,000. Infinity may elect to carry backthe $100,000 NOL to the 2004 tax year tooffset a maximum of $40,000 (50% of$80,000) taxable income for that period.

While physicians may not be able to standin line with Wall Street for governmentbailouts, it is possible to create economicstimulus by implementing these strategies.Patient deductibles and insurance planchanges cause many practices to strugglewith cash flow during the first quarter. It isimportant not to compound this with asignificant tax burden in April. Schedule ameeting with your tax advisor to see if theseoptions are a good fit for your practice. �

Deborah R. Mathis, CPA, CHBC, isShareholder/Director and Michael S.Lewis, MBA, FACMPE, is Director,Healthcare Services Group for Cowan,Gunteski & Co. They can be reached at732-349-6880.

THE PROFESSIONAL PRACTICE

Deborah R. Mathis, CPA, CHBCMichael S. Lewis, MBA, FACMPE

Physician-Friendly Tips to Trim Taxes

While physicians may not be able to stand in line with WallStreet for government bailouts, it is possible to create economicstimulus by implementing these strategies.



MEMBER NEWS & CLASSIFIEDS

AchievementsNJAOPS is proud to announce the followingaward earned by our member.

� Lesly D’Ambola, DO, medical director of the Latino Health Initiative at SaintLuke’s Catholic Medical Services inCamden, recently received the UnsungHero Award from the Campbell SoupFoundation for her selfless dedicationto her patients. The Latino HealthInitiative, which provides care to over1,400 patients, focuses on controllingdiabetes and its complications.

New MembersNJAOPS is pleased to welcome the followingphysicians into new membership this quarter.

Active Members� Paul Keshishian, DO

Family Practice, Rochelle Park

� Elizabeth Raleigh, DO Family Practice, Lawrenceville

� Brett Rosenthal, DOInternal Medicine, Cherry Hill

Intern, Resident and Fellow Membership� Max Benanti, DO

Surgery Intern, UMDNJ–SOM, Stratford

� Devin Flaherty, DOSurgery Resident, UMDNJ–SOM, Stratford

� Yehuda Michelov, DOOrthopedics Intern, UMDNJ–SOM, Cherry Hill

Life MembershipNJAOPS is proud to welcome the followingphysicians into life membership.

� Frank DeGennaro, DOFamily Practice (Retired), Jackson

� Robert Hevert, DOFamily Practice, Westfield

� Howard Waronker, DOFamily Practice (Retired), Brigantine

� S. Alan Weinstein, DOFamily Practice, Sea Bright

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Electromyography Testing. Please fax resume to 732-404-1556.

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manipulative treatment are essential.Candidates must be certified inOsteopathic Family Practice and

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Family Practitioners SoughtSouthern Jersey Family Medical Centers,serving the communities of Atlantic,

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FAMILY PRACTITIONERS. We currentlyhave openings in our primary care healthcenters for qualified providers who shareour mission of providing quality care. Please fax CVs to 609-567-9647,

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Physician SoughtSouth Jersey practice seeks a PhysicalMedicine and Rehabilitation Physician

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Physician SoughtBusy South Jersey practice seekinggeneral, family, or internal medicinephysician with interest in learning andperforming simple pain management

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Practices for SaleTwo, long-established medical practices

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Jack Goldstein, DO.



Continued from page 17

what you are giving. It will stop you ifyou are prescribing something that apatient is allergic to, and it will stop theabuse of prescriptions by patients.”

� Use a system that shares data with other systems and offers quality reporting. A CMS incentive program also already exists for quality reporting and something similar will be required for the stimulus bonuses.

� Show you know the system. Havingthe system in place is not enough.Physicians will have to show that theyare actually using it in a way that is“meaningful.” “They are looking forphysicians to utilize their systems in arobust manner,” explained StevieDavidson, CEO and founder of HealthInformatics Consulting. According to theproposal released in December,physicians will need to show that theyare able to extract data from the system,that they are using the data in their dailypatient care and that they are using thesystem for quality reporting.

A “Basic Foundation” for CareThe goal of the incentives is to encouragebroad adoption of the health IT, accordingto the ONC-HIT. Physicians who remaincommitted to their paper records may beputting off the inevitable, EHR expertscautioned. In the future, it won’t be onlythe federal government that is looking for

EHR, but health insurance companies willas well, experts said.

“Positive reform in any industry can onlyoccur by having a basic foundation inplace,” says Andrew L. Carricarte,president and CEO of IOS Health Systems,Inc., one of the first systems to earnpreliminary certification by CCHIT. “Thisfoundation for healthcare is the adoption ofelectronic health records, which results inimproved quality of care and a progressivelowering of costs. The EHR system is a toolthat enables physicians and patients tobetter access, diagnose, collaborate andcommunicate at a much higher efficiencyand effectiveness than ever before.”

To further the goal of broad use, Medicarepayment adjustments will be imposed onphysicians who are not meaningful EHRusers beginning in 2015.

Above all else, experts say you should find asystem that works best for the way yourpractice works and plan for a learning curve. NJAOPS President-elect Lee Ann VanHouten-Sauter, DO, considered sixdifferent systems before deciding on onefor her family practice in Williamstown.

“You need to go to a physician’s office andwatch them use it,” Dr. Van Houten-Sauterurged. “The in-office demos [given by thesales reps] are all about the same, but untilyou really use it, you don’t have a goodunderstanding of how it works and willaffect your routine.”

Practice ResourcesVisit www.njosteo.com/practice for alisting of HPSAs in New Jersey, an e-prescribing incentive fact sheet, toaccess an overview of the PhysicianQuality Reporting Initiative and for thelatest resources on CMS incentives.

Once the system is selected and installed,your work doesn’t end there, cautionedDr. Van Houten-Sauter, who had hersystem installed about a year ago.Transferring the old data into its newelectronic format takes time, she said.She hired an assistant office manager inpreparation for the transition to electronicrecords and added part-time help to scanthe existing paper records. She built intoher day the extra time needed to transitionrecords. If she used to see four to fivepatients an hour, during the transitionshe would only see two to three. Sheput in plenty of weekends during thetransition as well, she said. While someof her associates were still using paper,she “bit the bullet” and vowed to notwrite anything in an effort to become anexpert in the system. She prodded herassociates until they too had turned intheir pens for a keyboard.

“Now it’s hard to understand how I even didit on paper,” she said. “It’s all a learningcurve. You pick up a different skill as you go,and you teach each other along the way.” �

Bonnie Smolen is director of Communicationsand Marketing for NJAOPS.


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Robin VoorheesThe NIA GroupSomerset, NJ – 800-669-6330

Eileen YuenBollinger InsuranceShort Hills, NJ – 800-350-8005

Chris ZuccariniCornerstone Professional Liability ConsultantsRadnor, PA – 800-508-1355

101 Arch Street, Boston, Massachusetts 02110 | 1.800.225.6168 | www.promutualgroup.com



April 14 17, 2010 Bally’s Atlantic City– •

The largest physician conventionand exhibition in New Jersey

Atlantic Regional Osteopathic Convention

AROC20 01

Business of Medicine

Geriatrics

End-of-Life Care

Infectious Disease

Internal Medicine

NeurobehavioralDisorders

OMM

Radiology

Risk Management

Surgery

Also...

Alumni Events

American Red CrossBlood Drive

Basic Life SupportRecertificationfor Clinicians

RelicensureRequirements for

Florida & Pennsylvania

Practice Managers’Seminars

732-940-9000njosteo.com

Register

online today at

for early bird

rates!www.njosteo.com


Documents

NJAOPS Journal