By Jose Lopez, Senior Consultant, The Verden Group

In our most recent issue of ViewPoint Magazine, we provided some tips on how to prepare for the reporting requirements and shift to quality payment models under the proposed Medicare Access & CHIP Reauthorization Act (MACRA). MACRA was scheduled to take effect on January 1, 2017. However, after feedback and pressure from most of the professional medical societies and specialty membership organizations, Andy Slavitt, the Acting Administrator for the Centers for Medicare and Medicaid Services (CMS), recently indicated MACRA could be delayed from the proposed January 1 start date.

The final rule for MACRA is not expected to be released until November 1, 2016, only two months prior to the current proposed effective date of January 1, 2017. This would put unbelievable pressure on providers, particularly those in small practices, to scramble to meet the requirements of MACRA in a very short period of time. The Verden Group encourages CMS to delay implementation of MACRA, and for practices to fully understand, prepare for, and implement changes in their workflows to demonstrate the cost effectiveness and high quality of care they provide to their patients.

HIPAA Legal Updates — Breach Reporting Requirements

By Sumita Saxena, Senior Consultant, The Verden Group

There might be some confusion regarding the breach reporting requirements mandated by the Health Insurance Portability and Accountability Act (HIPAA) and further enforced by the Health Information Technology for Economic and Clinical Health (HITECH) Act. A breach is considered any acquisition, access, use or disclosure of Protected Health Information (PHI) which compromises the security or privacy of the PHI. However, if the disclosed PHI has been rendered unusable, unreadable, or indecipherable to unauthorized individuals, an adequate risk assessment may determine that a sufficiently minimal or nonexistent risk is present, thereby excluding the event from the definition of a breach.

The most basic example of a breach occurs when one patient’s records are accidentally sent or disclosed to another patient or individual. While this may seem trivial in a circumstance in which the content disclosed is rather limited, physicians must be aware of how to identify a breach and understand their obligations with respect to reporting.

Every HIPAA breach is reportable; the differentiating factor in reporting is determined based on the number of individuals affected by the event. In instances where fewer than 500 individuals are affected by the breach, practices must maintain a system of logging or otherwise documenting these breaches that occur during the calendar year. Practices must then submit a detailed account of all such events to the Secretary of the U.S. Department of Health and Human Services (HHS), through the HHS Office for Civil Rights, no later than 60 days after the end of the calendar year. Immediate notification to the Office for Civil Rights is required in the event that a breach affects more than 500 individuals.

Recent OIG reports signal an upcoming increase in OCR activity and oversight of HIPAA covered entities, even in the absence of a breach.

On September 29th, the Office of Inspector General (OIG) in the U.S. Department of Health and Human Services (HHS) released two reports which reviewed the successes and shortcoming in the Office for Civil Rights’ (OCR) oversight of Health Insurance Portability and Accountability Act (HIPAA) compliance for covered entities. OCR is responsible for overseeing covered entities’ compliance with the HIPAA standards, which include the Breach Notification Rule, the Privacy Rule and the Security Rule. In one report, the OIG provided conclusions and recommendations from their study on covered entities’ compliance with the HIPAA Privacy Rule, while in the other report, the OIG provided conclusions and recommendations from their investigation of OCR’s follow-up on breaches of patient health information which are reported to OCR. In both studies, the OIG reached some similar conclusions. The guidance provided by these reports should be recognized by providers for what it is: harbingers of OCR’s likely future enforcement activity.

One of the key findings by the OIG likely to have a direct impact on providers: OCR will now proactively audit covered entities to monitor compliance with the Privacy Rule, as opposed to its traditional approach of initiating investigations as a result of complaints or breach reports. The fact that OCR has not been proactively auditing covered entities allows for some level of comfort for covered entities, as there is not a great concern that OCR will conduct an investigation of a covered entity unless a potential breach or violation were reported. It is likely that this will be changing in the very near future, as the OIG has recommended that OCR improve its oversight of covered entities and take a proactive stance, by instituting a permanent audit program, as opposed to OCR’s current reactive posture. In addition, the OIG recommended improving the tracking system which OCR uses to keep records about investigations of covered entities. Such improvements in record-keeping and tracking investigations could mean that OCR will be more likely to impose penalties, as it will be able to more easily determine when covered entities are the subject of multiple investigations.

Regarding the follow-up of breaches, the OIG made some similar recommendations concerning the need for OCR to improve its tracking system. The OIG recommended that OCR more uniformly enter information about breaches, whether large or small, into a searchable database. At present, OCR has largely focused on thoroughly investigating large breaches (e.g. breaches of 500 or more affected individuals) that are reported to it. However, the OIG has now recommended that OCR also track and follow-up on small breaches that are reported to it. This could have a significant impact on providers who may have experienced several small breaches, as it will be more likely that OCR will now closely track and examine covered entities that experience several small breaches. In addition, the OIG recommended that OCR maintain more complete documentation in its database of corrective actions taken by covered entities that experience a breach. Currently, because OCR does not keep thorough records of corrective actions, covered entities may be able to get away with implementing few changes if they experience a breach. Once OCR implements these recommendations to better document corrective actions taken by covered entities, it will place greater scrutiny on these corrective actions to ensure that the covered entities carry out the necessary changes and prevent the occurrence of a similar breach in the future.

It is extremely important for providers to understand how to comply with HIPAA, as well as what to do if they experience a breach. These reports serve to emphasize the importance of compliance and the ways in which OCR will begin to more actively investigate HIPAA compliance. Here at The Verden Group we can offer assistance in reviewing your HIPAA protocols and ensuring you have all the required forms up-to-date and properly disseminated to your patients.



CMS issues Final Rules for Stage 2 and Proposed Rules for Stage 3

By Jose Lopez, Senior Consultant, The Verden Group

On October 6, 2015, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) released the final rules (click here to view) for modifications to Stage 2 and 2015 reporting requirements, as well as proposed rules for the third stage of the Meaningful Use incentive program.

Meaningful Use Stage 2 Changes

As expected, CMS finalized the modifications for the 2015 reporting period and some Stage 2 requirements (see my earlier blog post about details on those anticipated changes). CMS says it is providing a simpler, more flexible set of stage 2 regulations for 2015 through 2017 as the meaningful use regulation era gives way to CMS’s transition to value-based compensation. In summary:

  • The rules also allow for a 90-day reporting period for providers in 2015, and new providers in 2016 and 2017.
  • Many of the measures of personal health engagement have been drastically reduced (patient portal and e-messaging requirements).
  • Clinical quality measures for both hospitals and providers will remain the same.

The Verden Group applauds the relaxation of these measures to reflect the real challenges that practices and hospitals are facing. More than 60% of hospitals and about 90% of physicians have yet to attest to stage 2!

Meaningful Use Stage 3 Measures

In spite of calls from most of the major medical associations to delay the onset of Stage 3, CMS also announced that Stage 3 will go on as planned and will not be delayed. In summary, major provisions pertaining to Stage 3 meaningful use include:

  • There will be 8 objectives for eligible providers and hospitals.
  • In Stage 3, more than 60 percent of the proposed measures require interoperability, up from 33 percent in Stage 2.
  • Public health reporting will include flexible options for measure selection.
  • Clinical Quality Measures (CQM) reporting are aligned with the CMS quality reporting programs.
  • Finalizes the use of application program interfaces that enable the development of new functionalities to build bridges across systems.

In short, CMS is attempting to address the two areas in Stage 3 that have been the primary barriers for successful Stage 2 attestation: interoperability and patient engagement. In 2017, Stage 3 requirements are optional, but providers who opt to start Stage 3 in 2017 will have a 90-day reporting period. Come 2018, all providers must comply with Stage 3 regulations using a certified EHR.

Industry Reaction

Despite a public outcry from the healthcare community to delay the onset due to the lack of successful Stage 2 attestation, Stage 3 is set to begin as an optional requirement for physicians and hospitals in 2017 and a requirement in 2018. The American Medical Association applauded CMS for allowing a hardship exemption for physicians who are unable to attest in 2015 but called the final rule, as a whole, “deeply disappointing.” The American Hospital Association urged CMS to delay the implementation of Stage 3 and focus instead on “ensuring that providers could easily and efficiently share health information to support care delivery and new models of care.” The American College of Cardiology says that the program requirements “remain difficult to implement.”

The final rule for Stage 3 includes a 60-day comment period, which is longer than is typical, suggesting that there may be additional modifications or delays. As such, the political fight to delay the onset of Stage 3 of meaningful use may not be over, and we expect many changes may be coming before the rule is finalized.

A Post-HITECH World

When Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), it essentially sunset the meaningful use payment adjustments (penalties for noncompliance) at the end of 2018. Instead, Congress has called for the establishment of a Merit-Based Incentive Payment System (MIPS), of which the meaningful use program will form one component. CMS will continue to consolidate its current incentive/adjustment programs under the umbrella of MIPS as it further transitions from encounter-based payments to value-based compensation. The Verden Group will continue to monitor industry reaction and comments submitted to CMS on the final Stage 3 rule in order to guide our clients through successful Meaningful Use Attestation and beyond.


Looking Ahead: Meaningful Use Stage 3 Requirements

By Jose Lopez, Senior Consultant, The Verden Group

In my recent blog on the proposed changes to Meaningful Use 2 requirements CMS recognized the barriers providers were facing in meeting the Meaningful Use Stage 2 requirements, and proposed a rule to simplify the Measures and Objectives for 2015 and beyond. CMS clearly heard the complaints from providers that meeting the measures were creating workflow issues. The Verden Group applauds these changes and hope they are approved in their entirety.

Let’s look forward now to what lies beyond meeting the revised Stage 2 requirements in 2015 and 2016, to Stage 3. Following a proposed “optional” year in 2017, all providers will report on the same streamlined definition of Meaningful Use at the Stage 3 level in 2018, regardless of prior participation.

CMS has come out with 8 tentative advanced use objectives for Stage 3 designed to align with national healthcare quality improvement efforts, and to promote interoperability and health information exchange which will focus on the triple aim of reducing costs, improving access and improving quality:

  1. Protect electronic health information
  2. e-Prescribing
  3. Clinical decision support
  4. Computerized provider order entry
  5. Patient electronic access to their data
  6. Coordination of care through patient engagement
  7. Health information exchange
  8. Public health reporting

The specific measures for each objective have yet to be defined but if you think the objectives look like Stage 2, then you would be correct. And as with Stage 2, the most challenging objectives appear to be those where the provider does not have direct control over their outcomes: patient engagement (patient use of portals and e-messaging), health information exchange (by states or other entities), and public health reporting (by states or other entities).

While CMS came under fire in 2014 following the fallout of providers being unable to meet Stage 2 requirements, it is vital that practices continue to advance their use of electronic health information. As Medicare and private payers continue their evolution from fee-for-service to pay-for-performance, data is being used to report on quality outcomes and to differentiate high performing practices to patients.

In closing, it is crucial that providers and provider associations provide feedback when CMS proposes rules for Stage 3 to ensure the data being required isn’t arbitrary (as was the case with Stage 2), but that it meets the intent of the HITECH Act to begin with: reducing costs, improving access, and improving quality.

In our next blog on Meaningful Use, we’ll discuss proper Meaningful Use Attestation documentation and the ugly truth no one wants to hear: CMS plans to audit one in every 20 meaningful use attesters.


By Julie Wood MSc. PCMH CCEPCS_logo_VG

Co-Founder, Patient Centered Solutions LLC

The NCQA is in the process of redesigning not only the initial Patient Centered Medical Home recognition process, but also the renewal process for already recognized practices. The redesigned initial recognition process will be part of the 2017 update to the PCMH Standards, and the updated renewal process is part of a major, ongoing redesign intended to streamline the application.

The current NCQA PCMH Recognition process is highly labor intensive for all involved. The process can take anywhere from six months to two years to complete (depending upon your practice size and number of locations), adding up to a significant investment of your practices resources.

In addition to the sheer amount of work involved, the NCQA application process isn’t an easy one to navigate. For example, there are three different places online where you have to go at various stages during the application:

  1. You’ll first log in to obtain your Standards and to buy the ISS Survey Tool. For this you will need to have a Username and Password for the NCQA Online Store.
  2. Then you’ll need a separate Username and Password for the Application portal where you will complete and submit your application.
  3. Lastly, in order to add documentation to the ISS Survey Tool for submission to the NCQA for grading you’ll need another separate Username and Password.

To make matters more complicated, you can’t pay online right now either—payments are only accepted by phone, fax or check.

In order to address some of this complication, in the spring of this year NCQA started a forum called Ideas4PCMH on their website. Representatives from small and large practices, professional societies, health plans, hospitals, accountable care organizations, community health centers, health IT companies, PCMH Certified Content Experts (CCEs), and State-based agencies gathered to form 17 focus groups tasked with developing new ideas for the redesign of their program logistics.

The PCMH redesign strategy includes four major components:

  1. Provide more guidance to practices through new channels, including live support, online resources and improved customer service;
  2. Introduce a streamlined annual check-in for recognized practices rather than requiring a full documentation review every three years;
  3. Use information generated in the course of daily clinical care to support the recognition process; and,
  4. Redesign the online survey tool to be more user-friendly and efficient.

In the current (2014 Standards) submission process they have already streamlined a few things. For example, the time-consuming process of entering percentages into a box in the ISS survey tool is no longer required for any of the meaningful use reports or the Record Review Workbook.

Under the 2011 Standards NCQA introduced ‘pre-validation’ for EHR’s and Practice Management Systems. Despite streamlining, the work required to get credit for pre-validated points after you have achieved recognition requires the equivalent of an add-on survey. For those of you going through the process now, check with your EMR vendors and if a product was pre-validated under the 2011 Standards, NCQA has cross-walked some of those points to the 2014 Standards. I will add a note of gratitude to the IT companies that do complete the pre-validation process—it is costly and time-consuming for them to do so—making it that much easier for practices submitting to the NCQA with these systems in place, and for us here at The Verden Group/PCS when guiding our clients through the process. Under the 2011 Standards some Vendors had as many as 17-21 points towards the 85 you need for a Level 3 Recognition—a really great step in the right direction.

However, while they help streamline some processes, there is also more work involved under the 2014 Standards than any standards that have come before. There is a requirement to provide annual patient satisfaction results and clinical performance data to them once you have your 2014 Recognition. This is to make sure that practices truly are continuing on the PCMH path and not just submitting (and then promptly dropping!) all of the good practices put in to place through the transition process.

One really exciting step in the right direction is that the NCQA has engaged a digital agency with unique expertise in user experience to help design their new online submission platform. During the next three to five months, the agency will talk to focus groups, participate in internal discussions, and review submitted comments. At the end of this first phase of development, the agency will present a design concept for the online platform that supports the updated PCMH recognition process. Their goal is to approve the final design concept later this year with the intent to build and test it in 2016.

The NCQA states, “We all have the same goal—improving the care people receive, their experiences with health care, and the need to reduce costs.” With regard to this statement, I believe that while the current NCQA PCMH model has introduced many benefits to practices and patient care, it is also true that the time and resources this process takes within a practice is enormous. Every practice that we have taken through the NCQA Recognition process has seen the benefits to documenting processes and overall streamlining of care. No one can argue that the system isn’t improved when you close all of the loops where patients can get lost in the cracks, but the resources it takes to do so cannot be ignored.

Also, having taken practices through the renewal process, I am keenly aware that even though you only have to provide documentation for 11 of the 26 Elements, you had better make sure that you are ready and able to provide documentation for the other 15 Elements as they can come back and ask for it at anytime. Generally, they will allow 3 days to provide the information but we’ve seen some cases where the practice has only been given 24 hours to produce documentation (we appeal those requests, of course!).

Here at the Verden Group/Patient Centered Solutions we are sincerely hoping for a sensible and simplified result from this major redesign.

We encourage you to participate in this discussion by sharing your opinions and ideas with the NCQA at: [email protected]

*A Tip for Practices Recognized under 2014 Standards: Under your quality improvement project, change your clinical measures to new ones once you have reached your goal – continuing at 100% would not be acceptable to NCQA 3 years in a row. They expect to see continuous improvement, not improvements achieved and then simply maintained at that target level. So set your goals small in order that they are both easily achievable and allow for incremental upward progression over the course of the three-year period.

New HCPCS Modifiers Define Subsets of the 59 Modifier

By Jose Lopez, Senior Consultant, The Verden Group

As of January 1, 2015 the Centers for Medicare and Medicaid Services (CMS) established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier. The Modifier -59, which is used to designate a “distinct procedural service”, is the most widely used HCPCS modifier. It is defined for use in a wide variety of circumstances and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. In addition, this modifier is associated with considerable misuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases. The introduction of subset modifiers is designed to reduce improper use of Modifier -59 and help to improve claims processing for providers. The new modifiers (referred to collectively as -X{EPSU} modifiers) are:

  • XE – Separate Encounter, a service that is distinct because it occurred during a separate encounter.
  • XS – Separate Structure, a service that is distinct because it was performed on a separate organ/structure.
  • XP – Separate Practitioner, a service that is distinct because it was performed by a different practitioner.
  • XU – Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual       components of the main service.

CMS will continue to recognize modifier -59 but may selectively require a more specific -X{EPSU} modifier for billing certain codes that are at high risk for incorrect billing. When a specific –X modifier describes the circumstances for reporting both codes it should be reported in lieu of modifier -59. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X {EPSU} modifiers are more selective versions of modifier -59, so it would be incorrect to include both modifiers on the same line. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. For further instructions and implementation of the HCPCS Modifiers -X{EPSU}, check with your Medicare Administrative Contractors (MACs) or Private Payers.

CMS Resources:

The American Academy of Pediatrics Update on Private Payer Implementation of HCPCS Modifiers -X{EPSU}:

Changes to Coding for Brief Emotional/Behavioral Assessments and Developmental Screenings

By Jose Lopez, Senior Consultant, The Verden Group

Effective January 1, 2015, the 96110 code was revised to distinguish it from a new brief emotional/behavioral assessment code 96127. The revision of 906110 clarifies it as an assessment that is focused on identification of childhood and adolescent developmental levels (e.g., fine and gross motor skills, cognitive level, receptive/expressive and pragmatic language abilities, neuropsychological areas [attention, memory, executive functions] and social interaction abilities), rather than behavioral or emotional status, utilizing a standardized instrument.

The new 96127 code is used for brief emotional/behavioral assessment with scoring and documentation using a standardized instrument. This assessment serves as a mechanism to identify emotional and behavioral conditions that previously may have been underestimated and/or undetected in any age population, such as depression screening and attention-deficit/hyperactivity disorder rating scales. This new code was added to differentiate those instruments that look solely or mainly at behavioral and/or emotional issues from developmental screening which are reported with 96110.

A summary of the revision to 96110 and new descriptor for 96127 is as follows:

  • 96110 – Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.
  • 96127 – Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.

A listing of brief emotional/behavioral assessment and developmental screening instruments with their appropriate CPT code is listed in the grid below.


CMS Foregoes Direct Supervision Requirement to Encourage Use of Chronic Care Services

By Sumita Saxena, Senior Consultant, The Verden Group

Medicare will start paying physician practices for chronic care management beginning January 1st, and has carved out an exception to the direct supervision requirement for incident-to-billing, which is often considered difficult to comply with. This change is intended to encourage the effective use of the services according to the 2015 Medicare physician fee schedule regulation published on November 13th.  There are conditions surrounding this new move, including the documentation of a care plan for patients with two or more chronic conditions and the use of interoperable electronic health records.

The American Medical Association (AMA) created new CPT codes for chronic care management in 2013, but CMS instead proposed using HCPCS “G” code. CMS has reconsidered its initial position and will pay physicians for CPT 99490 (chronic care management services, at least 20 minutes of staff time directed by a physician or other qualified health professional, per calendar month). The code is billable for patients who have two or more chronic conditions expected to last at least 12 months or until the death of the patient, if the conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, and “a comprehensive care plan is established, implemented, revised or monitored,” per the regulation.

The new code is both a revenue opportunity and a compliance risk for providers and CMS will be paying attention to how this develops. CMS declined to cover CPT 99487, another chronic care management code, because it doesn’t include face-to-face time with the patient.


To avoid imposing yet a new set of standards for billing management of chronic conditions, CMS stated “it decided to emphasize that certain requirements are inherent in the elements of the existing scope of service for CCM services, and clarify that these must be met in order to bill for CCM services.” They include:

  • Giving patients access to clinicians 24/7 if they have urgent chronic care needs.
  • Managing chronic conditions, including assessment of medical, psychosocial and functional needs, medication reconciliation and review of patient management of medication.
  • Ensuring continuity of care by having patients see the same clinician at successive appointments.
  • Satisfying various documentation requirements. For instance, patients must agree in writing to receive chronic care management services and authorize electronic communication of their medical information with other providers to facilitate care coordination.  Providers must give patients a copy of their care plan and document they received it, and inform patients they can quit receiving chronic care management services at any time.

CMS also eased a regulatory requirement that otherwise could be an obstacle to chronic care management. These services will often be provided by nonphysician practitioners incident-to a physician’s services, which means they can be billed to Medicare under the physician’s provider number at 100% of the fee schedule if they meet certain requirements. Typically, incident-to services have to be provided under the direct supervision of the physician. “Direct supervision” means the physician “must be present in the office suite and be immediately available to provide assistance and direction throughout the service (but does not mean that the supervising physician must be present in the room where the service is furnished),” according to CMS.

That is not always practical in the chronic care management context. With CMS requiring 24/7 patient access to the clinician, CMS recognizes that the physician may not always be available to supervise. CMS created an exception to the incident-to rule, and will require general supervision for chronic care management. General supervision means the services are performed under the physician’s overall control, but he or she doesn’t have to be in the office.


The supervision exception for incident-to billing should reduce noncompliance with the incident-to billing rule. CMS extended the supervision exception to incident-to billing for the non-face-to-face portion of transitional care management services which are hospital oriented. On January 1, 2014 Medicare began paying for two new CPT codes:

  • 99495: Transitional care management including communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity; and face-to-face visit within 14 days of discharge.
  • 99496: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of high complexity; and a face-to-face visit within 7 days of discharge.

The codes for transitional care management are designed to encourage primary care physicians to arrange a visit with patients almost immediately after discharge from the hospital with the intent of improving quality of care and reducing readmissions.

Although physicians can bill Medicare for chronic care management incident to the physician’s services, there are still constraints imposed by state scope-of-practice laws. State laws will preempt Medicare rules if it requires direct supervision.

Providers should not bill Medicare for chronic care management if the care plan is unchanged or requires only minimal change, for example medication adjustment. And while chronic care management can be reported on the same day as an evaluation and management service, clinical staff time cannot be attributed to both visits.

The coverage of chronic care management is also tied to meaningful use compliance. To get paid for chronic care management services in 2015, physicians and nonphysician practitioners must use “EHR technology certified to either the 2011 or 2014 edition(s) of certification criteria to meet the final core capabilities for CCM and to fulfill the CCM scope of service requirements whenever the requirements reference a health or medical record,” per the regulation.

For more information please visit:


Creating a Life Plan

by Susanne Madden

It’s been a while since any of us at Verden have taken the time to add a blog post. Things have been so very busy and the micro-blogging capabilities of Facebook and Twitter have distracted us from this space.

But this topic deserves a little more room. I spend a lot of time here at the Verden Group helping our clients plan for the future. Planning for growth of their practices, planning for succession and sales, planning for mergers or acquisitions – you name it, we help you plan for it.

Recently it struck me that while I am busy planning out the professional and business lives of my clients, I’ve been giving very little thought to my own life. It’s easy to get too busy, work more hours to meet obligations and to prevent being overwhelmed, and generally put life on hold in the process. Many entrepreneurs, executives and small business owners face the same issues. The problem is, most of us don’t pay enough attention until there are serious consequences. We face major fatigue. We burn out. Worst case, we face serious illness and have heart-attacks. . .

So, how is one suppose to manage a busy career and live life more fully, without ending up in the emergency room?  It comes back to planning.

Yesterday, I stumbled across an e-book titled ‘Creating Your Personal Life Plan’ by Michael Hyatt, that really appealed to me. While I have not yet carved out some precious time to implement the tools in the plan, reading through it has motivated me to get started, and has given me some sense of hope that things can be different, if only we can plan for it.

Now, Mr. Hyatt is certainly more religious than I, but don’t let that put you off. The principles seem sound and grounded, to me. And I’m a big believer in ‘process’ as a game-changer. Every time we work through a planning exercise with a client, it is the process of planning that facilitates the changes needed to improve, grow, learn.

It’s time I took my own advice and put myself through the process of planning for life.

You can find more information on the FREE e-book* here:

(*I have no affiliation or business interest with this person or his company)

“If we would only give, just once, the same amount of reflection to what we want to get out of life that we give to the question of what to do with a two weeks’ vacation, we would be startled at our false standards and the aimless procession of our busy days.”
Dorothy Canfield Fisher

Using Evidence-Based Medicine Resources

By Tiffany Lauria

Two recently released reports have brought to light an interesting point regarding evidence based medicine- that it may not be as widely used as thought, or should be.

In a retrospective cohort study of cases submitted to the National Cardiovascular Data Registry-ICD Registry[1] between January 1, 2006, and June 30, 2009, researchers found that out of 111,707 patients, 25,145 received implantable cardioverter-defibrillators (ICDs) that were not recommended by evidence-based guidelines. In other news, a study published in Arthritis Care & Research[2] highlights that physicians treating patients with osteoarthritis (OA) may not be adhering to the recommended guidelines and that clinical practice often diverges from the medical evidence.   

So why the big deal? Simply put, evidence-based medicine works, and not adhering to it on a routine basis puts patients at risk and continues to add increased costs to our already over-burdened system. The patients who had non-evidence based ICDs in the above referenced study experienced a 0.57% risk of in-hospital death, compared to 0.18% in the patients who received an implant following standard approved guidelines. The same group also had an increased risk of post-procedure complications. How does a physician go about explaining this situation to the family of a patient that passed away, despite having clear guidelines to follow?

Ultimately, our healthcare boils down to trusting in our provider’s clinical expertise. Granted, the clinical experience of our provider is often comprehensive and trustworthy-  caring for thousands of patients with the same problems over the years, does tend to make one qualified to judge what works and what doesn’t. However, clinical expertise is largely dependent on staying abreast of new techniques and updated guidelines. It requires that providers know what works and what doesn’t in the national and international population, not just in their patient base over their years of practice. And, while each of us personally may be comfortable with our physician’s clinical judgment, regardless of what the evidence suggests, it is undoubtedly dependent on the provider to justify any decision-making that varies from evidence-based proof.

I certainly don’t make the statement that EBM is in-fallible, or that in all cases it is the right way to go. It is possible to mis-use or over-use the guidelines to the patient’s detriment. Blindly following a ‘proved’ algorithm of care eliminates the very essence of personalized healthcare. All patients are entitled to care that considers the patient as a whole. The EBM guidelines for two different conditions may cancel each other out, or worse yet, do more damage than good. And the personal opinions and circumstances of your patients must be considered. After all, what good is evidence when it can’t (or won’t) be followed? So where clinician training, experience and judgment dovetail with the evidence is where you want your medical practice to be. Without this quadrant of care, the potential for good medicine is lacking.

We can look, however, to the mentioned studies for some ideas on why physicians may be thwarting the evidence. For example, in the ICD study, the number of non-evidence based implants was significantly different according to physician specialty and hospital. Therefore, it is reasonable to conclude that the practicing environment and specialty culture may have a large impact on a provider’s commitment to adhering to recognized guidelines. In addition, the extent in which a facility appropriately enables provider staff to maintain up-to-date knowledge of evidence-based guidelines, by the provision of educational and other resources, is likely to be largely diverse across organizations. As the old saying goes- he that is walking with wise ones, becomes wise. If providers surround themselves with an environment conducive to learning and a culture of evidence-based decision making, then using proven treatment guidelines will become their standard of care. Supplemented, of course, by their years of trusted judgment based on clinical experience in the patient arena.

As medical evidence increasingly becomes more accessible to the general population, providers will have additional reasons for ensuring that their clinical practice remains within the close confines of what has been proven and substantiated. With the advent of the internet, construction worker John Smith need only go to any number of medically oriented websites or patient forums to determine what tests and treatments are routinely prescribed and what is the ‘norm’ for a particular illness or condition. A particularly savvy patient, with persistent researching skills, may ultimately wind up uncovering the specifics of the national guidelines that pertain to their condition…and bring that in to face you, the provider, who may be doing otherwise.

Certainly, no one is advocating for cookie cutter medicine or a one-size-fits-all approach to healthcare. Clinical experience and a provider that is willing to step out of the box in their effort to best treat their patients are more than needed in today’s climate of increasingly complex conditions and new advances. However, the question of why evidence-based medicine is not common practice yet needs to be addressed by providers, facilities and regulators in order to determine the best means of integrating proven care strategies into everyday care. It shouldn’t take a health reform initiative to convince people that making decisions based on evidence, just plain works.

[1] Al-Khatib SM, et al.”Non–evidence-based ICD implantations in the United States” JAMA 2011; 305: 43-49. Retrieved from:

[2] David J. Hunter, Tuhina Neogi, and Marc C. Hochberg. “Quality of Osteoarthritis Management and the Need for Reform in the US.” Arthritis Care and Research; Published Online: June 25, 2010 (DOI: 10.1002/acr.20278); Print Issue Date: January 2011.