Today, it’s all about sexting, COPPA, and children’s online privacy. Who knows what issues we’ll have to face tomorrow?

Helping people stay healthy isn’t easy for physicians. Not only must we abide by a host of science-based rules, guidelines, and best practices that are often open to wide interpretation and must be applied with each patient’s unique situation in mind, we also are bound by labyrinthine state and federal laws and regulations (not to mention all of the third-party payer hoops we have to jump through if we want to get paid for our work).

Physicians must deal with the interface of law and health every day. For example, when we counsel our young teen patients about drinking and driving, we are practicing at that interface. The driving and drinking ages are set by law and when teens do not abide by the law, they are taking unnecessary health risks as well as breaking the law. A technology-focused example of the interface between medicine and the law is sexting. Teens that send risqué photos of themselves via text message run the danger of being labeled as a sex offender (

). This is why education is so important around this issue.

However, the hottest issue at the interface between health and law that is putting our kids at risk is one that most physicians and parents are unfamiliar with: the Children’s Online Privacy Protection Act (COPPA; 

). COPPA was created in 1998 to protect children under age 13 from having their information collected online without parental consent. Websites that fail to comply with COPPA are ï¬ned heavily by the FTC.

When COPPA was developed in 1998, the Internet was in its infancy. The robust evolution of Web 2.0 with the likes of social media sites and blogs has caused the FTC to take a step back and ask if the current COPPA rule is still effective. To that end, a roundtable was convened on June 2, 2010, to discuss COPPA and tease through the many complex issues surrounding children’s online privacy (

www.ftc.gov/bcp/workshops/coppa/index.shtml

). I was one of many experts asked to participate and sat on the “Actual Knowledge” panel, representing the American Academy of Pediatrics.

One of the salient points of COPPA is being able to deï¬ne that a site has what is called “actual knowledge” that a person signing up for a site is 13 or older. Many sites (Facebook for example) clearly state in the terms of service that persons younger than 13 years of age are not allowed to participate on their site. Many sites also have a page or section that allows users to report others whom they suspect are under age 13.

If a child under the age of 13 wishes to sign up for Facebook or other age-restricted websites, that child either has to lie about his or her age, or that child’s parent has to lie about the child’s age. This is unhealthy for the development of the child. If we condone lying in one setting, children may get the message that it is ok and try on that hat in other settings. We need to reinforce that rules and laws apply to the online world too.

Parents often don’t understand that kids under age 13 are incredibly vulnerable to the deceptive ploys of online advertisers and to content that is meant for a much older teen and young adult audience. This isn’t about connecting with friends and family but about keeping kids who are too young to negotiate a complicated social and commerce site away from that site until they have the maturity and social skills needed to stay safe in that online environment. If older teens struggle with the Facebook environment and settings, why in the world would we expose our younger kids to this, especially since we have to lie and break a law to do so?

As experts in kids’ health and development, it’s up to physicians to help parents stay on top of all issues that impact their kids’ lives, and that means being aware of laws like COPPA. We don’t need to be experts in all of the legal nuances, just savvy enough to help keep kids healthy online and ofï¬‚ine. Today, issues such as sexting and COPPA are at the center of the debate on health, technology, and the law. Whatever issues tomorrow may bring, we’ll deal with them as they come and continue to ï¬nd a way to address them during our all-too-brief appointments.

Gwenn Schurgin O’Keeffe, MD, FAAP, (aka “Dr. Gwenn”) is a pediatrician, health journalist, parenting and social media expert, and is CEO and Editor-In-Chief of Pediatrics Now (

), an online health and communications company dedicated to providing reliable information for today’s busy families. She also writes the blog Dr. Gwenn Is In (

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Today, it's all about sexting, COPPA, and children's online privacy. Who knows what issues we'll have to face tomorrow?

Social Media Notebook: The Intersection of Health and the Law 

Do unresolved issues surrounding performance, reliability, and security make data-intensive applications like EHRs poor candidates for the cloud?

The latest buzzword to make the transition from geek to mainstream is “cloud computing.” While I love the image of ï¬‚oating on a cloud as I type on my laptop, the rosy picture painted by cloud-computing supporters doesn’t quite match up with reality.

In practical terms, “cloud computing” means that your software applications and data are housed on a server somewhere on the Internet instead of stored locally on your PC or on a server in your ofï¬ce. Beneï¬ts of cloud computing include the fact that users can avoid some of the capital expenditures usually associated with computer use, because they basically rent a service from a third-party provider, instead of owning the physical infrastructure (servers, software, etc). Thus the phrase “Software as a Service” (SaaS) that is often used in conjunction with cloud computing.

Cloud computing is a hot concept in healthcare technology, with several companies offering cloud-based EHRs. However, I am clearly biased against cloud-based EHRs; my company, Amazing Charts, deploys a client/server EHR model (Allscripts-Mysis MyWay, AthenaHealth, and PracticeFusion are other examples of non-cloud-based EHRs).

Having said that, I believe there are several important issues that must be resolved before practices begin using cloud-based applications and storing their patient data remotely. Although cloud computing and SaaS sound good in theory, the reality is that with this approach (also sometimes referred to as an “on-demand” or “hosted” model), your patient charts and other practice information are only accessible if your Internet connection is working. Can you imagine if your ofï¬ce charts were locked up in a cabinet, and the person with the key was late or out for the day? An Internet service disruption would have signiï¬cant effects on productivity, especially for a paperless practice. I have had issues with my ofï¬ce Internet (goes down, goes slow) far more often than I have experienced a hard drive failure on my PC. Being at the mercy of the Internet—and my Internet Service Provider&mdash;as to whether I’ll have access to my patient records is not something I would personally accept.

Several users of cloud-based EHRs who have subsequently switched to a client/server EHR have told me that, even when the Internet is running ï¬ ne (which, in all fairness, is certainly the norm), they still experience signiï¬ cant delays waiting for screens to refresh when navigating from window to window. While this lag is not that noticeable when browsing the Internet, using a click-intensive EHR that exchanges a lot of data with the database can mean signiï¬ cant time wasted while waiting for screens to load. Users have reported frequent waits of as long as 20 seconds or more for the next window to load with updated information. Many EHRs (whether client/server or cloud-based) already have performance issues due to poor designs that require too many clicks; making users also wait for data to load over the Internet can make an EHR essentially unusable.

There are other potentially troubling issues with storing your patient data in the cloud, the most obvious being privacy. The cloud model is often criticized for the greater ease with which the companies hosting the cloud services can control and monitor (lawfully or unlawfully) data in the system. As physicians entrusted with sensitive patient information, we must be especially vigilant in this area.

Another issue is that your EHR will exist only so long as the vendor supports it. With most client/server software EHRs, if the vendor goes out of business, you can still start up and use your EHR. That is not the case if the data is in the cloud. For example, in June 2002, GE sent a letter to physicians using their Web-based Encounter EHR giving them just three months notice that their EHR would be shut down (read the news article at http://hcp.lv/9t4QfN). Users had to scramble to get their data out of the EHR and to ï¬ nd another system.

I believe that eventually most software applications will be hosted in the cloud. In the meantime, there are still unresolved issues surrounding performance, reliability, and security that make data-intensive applications like EHRs poor candidates for the cloud. Perhaps the most frustrating aspect is that the one clear beneï¬ t that theoretically makes cloud EHRs more appealing than their client/server cousins—the potential for lower costs&mdash;has also yet to be realized. In fact, most EHRs hosted in the cloud still charge ridiculous sums that can result in a doctor actually paying more for use of their cloud-based EHR than they would if owning the software outright.

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI. 

Tech Talk: The Dark Cloud Hanging over Web-based EHRs 

Concierge Medicine: The Beneï¬ts and Drawbacks of Personal Health Care

Featuring several physician experts in practice management and concierge medicine, this activity deï¬nes concierge practice and how it works; explains the differences between cash-only and concierge models; compares the pros and cons of the model for both patients and physicians (not least of which is the concept of being paid up front); reviews what considerations one must make before moving to the concierge model; and explores the legal and ethical issues surrounding this relatively new form of practice. Enter the program title in the search window at 

, click the “go” button, and select “physician” as your profession to access the program.

Health Care Providers Brace for Medicare Audits

Fee:$10 (Massachusetts Medical Society members)/$20 (non-members)

With all states now on board with Medicare’s Recovery Audit Contractors (RACs) program—created as an attempt “to detect and correct administrative and resource waste in the Medicare program”&mdash;physicians are encouraged to participate in this program to learn about the structure of RACs, numerical burdens of RACs, possible ï¬scal and legal consequences of RAC audits, and where potential resources focused on RACs can be found.

The Cash Only Practice: Reinventing an Old Practice Model

Physicians who don’t want to deal with the billing and reimbursement issues that come with a “standard” practice should deï¬nitely participate in this activity, which deï¬nes cash-only practices and how they work. Additionally, the activity differentiates cash-only from concierge practices and explores pros and cons of the former, what to consider before making the switch from standard practice, and “the legal and ethical considerations of a cash only practice in the context of its larger societal impact.” Enter the program title in the search window at 

Designed “to help users avoid denials, save time, and get answers to medical coding questions on a variety of code sets,” this site separates itself from others by performing searches through numerous code sets—including ICD-9-CM vol 1 Diagnosis codes, CPT codes and descriptions, ICD-10-CM/PCS codes and descriptions&mdash;with a single search. The one catch: annual or monthly subscriptions are required, running $334.24 and $29.95, respectively.

Claiming to be the “#1 diagnosis coding website,” this aesthetically unappealing site provides a surprisingly well-organized system for searching for not only ICD-9 codes, but also CPT and HCPCS codes. Users can perform searches for speciï¬c topics, or choose from categories and sub-categories to narrow down the search and pinpoint the exact code they require. Notes are provided throughout to aid in the search.

The American Academy of Professional Coders provides this resource, which allows users to compare ICD-9 codes to ICD-10 codes in an attempt to help in mapping the expansion from 17,000 to roughly 141,000 codes. After entering a code in the search window (ICD-9 or ICD-10), users are presented with the corresponding code from the other set, along with its descriptor. Site visitors are urged to note that the tool only coverts ICD-10-CM codes, not ICD-10-PCS.

Public Policy: Medicare Physician Reimbursement — MGMA

Offered by the Medical Group Management Association, this site serves as a repository of Medicare physician reimbursement news dating back to 2006. News from 2010 covers the 2011 proposed physician fee schedule, the 21% Medicare pay cut, and more. A free registration is required to view most materials.

Pilot Study of Providing Online Care in a Primary Care Setting

Purpose:“To study the use of e-visits in a primary care setting.”

Results:A far-ranging number of conditions were able to be cared for using the online care model, with minimal message exchanges thanks to the use of structured histories. Further, care that was previously provided for free or by nurse triage and subject to malpractice could be documented and billed.

Reimbursement and Value-based Pricing: Stratiï¬ed Cost-effectiveness Analysis may Not Be the Last Word

Purpose:To test the hypothesis that “when manufacturers are price setters, reimbursement or [value-based pricing (VBP)] based on stratiï¬ed cost-effectiveness analysis may not be optimal.”

Results:“Negotiation regarding trade-offs between price and coverage may lead to improved outcomes both for health-care systems and manufacturers compared with processes where coverage is determined conditional simply on stratiï¬ed cost-effectiveness at a given price.”

Saving Billions of Dollars—and Physicians’ Time&mdash;by Streamlining Billing Practices

Authors:Blanchï¬ eld B, Heffernan J, Osgood B, et al.

Purpose:To explore the hypothesis that a “single transparent set of payment rules for multiple payers, a single claim form, and standard rules of submission, among other innovations,  would reduce the burden on the billing ofï¬ces of physician organizations.”Results:This hypothetical model, on a national level, would “translate into $7 billion of savings annually for physician and clinical services. Four hours of professional time per physician and ï¬ve hours of practice support staff time could be saved each week.”

HIPAA 5010/ICD-10 Straight Talk — Planning for 2010 and Beyond

Originally held as a webinar on March 30, 2010, this archived webcast features three experts who discuss what can be learned from other health plan efforts, planning “considerations for addressing ICD-10 compliance,” and addressing the ICD-9/ICD-10 Crosswalk.

ICD-10: Much More than a Regulatory Mandate - Webcast for Providers

This hour-long webcast from May 17, 2010, meant to help providers understand and prepare for ICD-10 compliance, “provides an overview of the requirements and lessons learned from current ICD-10 conversion projects.” Because the transition will be highly complex and may cause signiï¬ cant changes in processes, technology, and staff, the webcast also reviews the best ways to obtain efï¬ cient and effective conversion “and potential process improvements through effective ICD-10 implementation.”

Though written by SoloDoc author AkiFox—with the help of Megan Lewis, MD, a family physician in rural Colorado, and Albert Fuchs, MD, an Internist in Beverly Hills&mdash;back in September 2008, the information still holds true. Using the experience of dining at a restaurant as an analogy for receiving care in a physician’s ofï¬ce, the blog post explains how frustrating it is for physicians to receive reimbursement and why ofï¬ce visits are forced to be handled in such short lengths of time.

A Right Perspective: Doctors Can’t Take 21% Cut from Medicare

Directed at patients, this column from the Memphis Commercial Appeal’s Marilyn Loffel provides a couple analogies that help explain the Medicare reimbursment cut and how it will affect both patients and their physicians—leading to what she says will be many physicians either opting out of Medicare or leaving practice altogether, either way leaving Medicare patients without a doctor. Loffel also encourages readers to contact their representatives in Congress and tell them not to support the cut.

Feature Articles

We searched the Internet for billing and reimbursement resources so you don't have to.

The Net Guide: Billing & Reimbursement

Enter the link codes in the search window above to access these third-party resources.

Consult the resources at this site for information and advice on saving for your child’s college education. Featured are calculators and tools, informative articles, blogs, and interactive search options that help you look up professionals in your geographic region and calculate cost estimates. In the “College 101” tab, learn about 529 savings plans offered on the state level and decide which is right for you. In the tools and calculators section, you can plug in your child’s age to estimate how much you should start saving now and compare saving plan options and view plan ratings. In the community sections, visitors can ï¬nd answers to frequently asked investment questions, visit the message board, and view investor polls.

“The deï¬nitive guide to 529s” has been offering information on college saving plans for at least the past three years. While not the most aesthetically pleasing site, visitors can pretty much ï¬ nd exactly what they’re looking for, whether it’s an overview of 529s, a complete review of 529s available across the country, or information on accessing a personal advisor via phone in your state. Learn about future estimates of how much college will cost when your child is ready to attend.

Search for a wide variety of scholarships that may suit your child’s interests and needs for college.Scholarships are organized by subject/category, including athletic, minority, degree level, by state and by student type. Visitors can read several articles to learn more about the grants, loans, scholarships, and other ï¬nancial aid opportunities. The article “101 Grants You’ve Never Heard of” explains the differences between need-based and merit-based, profession-speciï¬c, and other types of grants. There is also a Financial Aid Blog, which has covered such topics as “iPad in Education,” and “at Harvard, No More Final Exams.”

The “College Savings Plans Network is a national non-proï¬t association dedicated to making college more accessible and affordable for families.” The site’s main goal is to help families “ï¬nd the plan that best meets [their] long-term needs and ï¬nancial goals.” Here, visitors can ï¬nd detailed information on 529 college saving plans, links to publications, informative articles, and a college calculator. Visitors can also check out common questions and answers in four distinct categories: Saving For College with a 529 Plan, 529 Prepaid Plans, Tax Advantages of 529 Plans, and School Admission Financial Aid.

This site is designed to help parents start saving for their children’s college and determine which savings plan may be right for them. Clicking on “Which College Savings Plan is Right for Me?” brings the reader to a page outlining four savings plan options: 529 savings plan, education savings account, UGMA/UTMA account, and taxable account. The page features charts that review the similarities and differences between each plan and answers questions like “What are the contribution limits” and “Where can I use my savings?” Additionally, the site provides answers to frequently asked ï¬nancial aid questions, such as “How Much Financial Aid Should I Plan for in my College Calculations?” Visitors are encouraged to watch the video “Investing in College 529 Plans” that visitors can watch. Visitors have the option of investing with T. Rowe Price as well if they so choose.

This site takes a three-step approach to “demystify the college savings maze:” educate, allocate, and collaborate. Click on the “Educate” tab to access a page of information on college funding, income strategy planning, tax-advantage savings vehicles like 529 plans and UGMA/UTMA, and how to ï¬ nd scholarships, loans, and other options. The “Advice and Tools” section offers savings calculators and 529 plan compasses that can help you determine future costs and compare local state plans. There are also webinars such as “College Savings 101” or “Advanced College Funding Techniques” and a message forum.

Loan Repayment/Forgiveness and Scholarship Programs

The American College of Medical Colleges hosts this database that lists 90 loan and scholarship programs by state, designation (state, federal, federal/state, other), and type (scholarship, repayment, forgiveness). Though many programs do not have specialty requirements, there are a number of programs designed speciï¬cally to attract physicians to the ï¬eld of primary care and rural medicine.

The American Medical Association provides this resource collection “to aid you in your quest for information on various topics such as medical student debt facts and statistics, ï¬nancial aid options, debt management, and loan consolidation.” The site includes information on “the ins and outs of student loan consolidation,” a link to the AMA ï¬nancial aid website, and requirements for deferring student loan payments.

Volunteer for Duty, Armed Services Pays the Way

) scholarship programs offer comprehensive coverage of medicalschool costs, from tuition and fees to books and living expenses. Upon graduation, you will serve as an active duty member of your chosen military branch under a year-for-year repayment plan with the option of extending your tour of duty as long as you see ï¬t. It’s a chance to both graduate debt-free and serve your country.

“Dedicated to improving the health of low-income and minority communities by increasing the representation of minority physicians, educators, researchers, policymakers, and health care administrators in the United States,” National Medical fellowships has awarded more than $39 million to more than 28,000 recipients since 1946. As of this writing, the organization is currently accepting applications for its 2010 GE Medical Scholar and 2010/2011 Need Based Scholarship programs.

Albert W. Dent Graduate Student Scholarship

Open only to minority students in good standing with the American College of Healthcare Executives (ACHE), 20 of these $5,000 scholarships are awarded each year to students in “their ï¬nal year of a healthcare management graduate program.” ACHE also offers a Foster G. McGraw graduate Student Scholarship the winners of which are ineligible to receive the Dent scholarship.

Though the application doesn’t explicitly say that the CAM Scholarship Program is available only to those of Chinese descent, it’s probably a safe bet that that’s the case. To be eligible, one “must be a ï¬rst, second, or third year medical or dental student at a US medical or dental school.” CAM speciï¬cally designates two awards “for students who show merits and also ï¬nancial hardship.”

Pre-medical student members of LMSA can apply for one of 10 scholarships to the Dr. Flowers MCAT online review course, a “six-month personalized” course valued at $595.

Paying for medical school is like taking on a mortgage. The medianamount owed by students in 2008 was $145,000 (public) and $180,000 (private), while nearly a quarter of all graduates accumulated more than $200,000 in debt over the course of their education (

). Thankfully, not everyone is sitting on their hands in the face of this unsustainable dynamic. In the July 2010 issue of the 

American Journal of Obstetrics & Gynecology

), Louis Weinstein, MD and Honor Wolfe, MD proposed “a uniquesolution to solve the pending medical school tuition crisis” called the Strategic Alternative for Funding Education (SAFE). Under this program, “a practicing physician [would] pay for his or her medical school education after completion of residency/fellowship over a 10-year time interval when income will likely be rising. The amount paid yearly is calculated as a percent of the physician’s professional income.” This would begin after a grace period of anywhere fromseven to 12 years, “depending on the length of residency and fellowship.” Though no school has yet adopted this proposal, it’s encouraging to see the healthcare community beginning to challenge the status quo and consider alternate means of ï¬nancing healthcare professionals’ education.

Something tells us that Mt. Sinai School of Medicine is going to receive an inï¬‚ux of applications from history and English majors next year. The 

reports that Mt. Sinai has been quietly admitting “about 35 undergraduates a year [who] study humanities or social sciences instead of the traditional pre-medical school curriculum and maintain a 3.5 grade-point average” since 1987. Dr. Nathan Kase, Mt. Sinai’s Dean for Medical Education and founder of the Humanities and Medicine Program, posits that the standard path to medical school “makes science into an obstacle rather than something that is an insight into the biology of human disease.” In a recent study (

) of 85 students in the program compared “with those of 606 traditionally prepared classmates from the graduating classes of 2004 through 2009,” found that though the humanities students “scored lower on Step 1 of the Medical Licensing Examination…they ranked about the same in honors grades and in the percentage in the top quarter of the class.” Further, “the humanities students were more than twice as likely to train as psychiatrists…and somewhat more likely…to go into primary care ï¬elds, like pediatrics and obstetrics and gynecology. Conversely, they avoid some ï¬elds, like surgical subspecialties and anesthesiology…and were signiï¬cantly more likely than their peers to devote a year to scholarly research.”

When choosing a college or university, how do you know you’re going to get your money’s worth? This article reveals which schools provide the highest and lowest return on your tuition dollar investment.

One popular method of ï¬nancing your child’s college education is to get a second mortgage or an equity loan. Another option is to take out a home equity line of credit. However, college ï¬nance counselors caution that there are pros and cons to both approaches.

Parents looking forward to overwhelming college tuition bills may be able to catch a break by doing research into some of the nation’s low- and no-tuition colleges.

Rules Are Changing for Coverdell Education Savings Accounts

Upcoming changes in the rules governing Coverdells are likely to make them even less attractive, as they will limit both the amount you can contribute as well as the kinds of expenses for which you can make tax-free withdrawals.

Married Couples May Get a Break with New IBR Student Loan Rules

On July 1, two important changes in the Income-Based Repayment (IBR) plan went into effect that may allow more doctors to join the student-loan repayment program and lower monthly payments for married couples.

Editor's Note

We searched the Internet for medical school, college payment, and education financing resources so you don't have to.

Paying for Medical School/College

With possible tax increases looming, what can physicians do to safeguard their hard-earned income?

The federal government has committed more than $11 trillion to bail out the US economy (

). The good news is that only $3 trillion of it has been spent so far. Of course, somebody has to pay for this, and the burden will fall heavily on high-income taxpayers.

Let’s examine facts about the taxes for high-income Americans and corporations, and see how much of this burden will really fall on doctors and similar-earning taxpayers. According to the Internal Revenue Service, more than 140 million tax returns were ï¬ led in 2009 (

). Of these taxpayers, 70 million people pay more than 97% of the total income tax in the United States. That means, the bailouts will cost each of those 70 million taxpayers an average of $157,143.

), a Washington, DC think tank, the tax burden of the top 1% of earners exceeds that of the bottom 95% of earners (

). As a physician, you can expect to be in the top 1% if your adjusted gross income is over $410,000, or in the top 5% if your income exceeds $160,000, according to most recent statistics from the IRS (

). If needed changes to the tax code are not enacted, the top 5% of taxpayers, or 1.4 million people, will be expected to pay for 60.63% of this bailout in taxes, an average of $952,757 per taxpayer (

Corporate tax loopholes and a “progressive” personal income tax structure mean hefty tax bills for high-income earners 

In 2009, Exxon Corp. reported $45 billion in proï¬ts and yet had zero US income-tax liability (

). During the same time period, General Electric Corp. ï¬ led more than 7,000 tax returns in various jurisdictions. GE’s total US tax bill? $0! This was on a global proï¬ t of $10.8 billion (

). Did the ï¬nancial collapse and need for bailouts hurt the incomes of chief executive ofï¬cers of top ï¬nancial institutions? Hardly, if Citigroup Inc.’s CEO, John Havens, is any indication. He received total compensation of $11.3 million in 2009 while his company received $5 billion in bailout funds (

Although many large corporations can get away with paying little or no income tax, the same cannot be said of individual citizens at the top of the income scale. According to the Tax Foundation, the “average” adjusted gross income (AGI) of a member of the top 0.1% of taxpayers is $7.4 million (

). If you are looking for a goal, you should note that it only takes an income of $2,155,365 (the low end of the top 0.1% of earners) to claim a seat within this group. Compare this to the rest of the top 1% of taxpayers. This group has AGI over $410,000, but less than $2.155 million.

Consider this troubling statistic: The rest of the top 1% pay 22.56% as an average income-tax rate, while the top 0.1% of earners pay a lower average tax rate of 21.46%. The group with income between $410,000 and $2.1 million pays more tax as a percentage of income than the group with “average” income of $7.4 million. How can that be? One reason is that higher-income taxpayers often receive better ï¬nancial advice and more careful tax, retirement, and investment planning.

Related Content on Taxes and Tax Policy from Physician’s Money Digest 

Some middle-income taxpayers will lose and some may win under new income tax rates proposed by the Obama administration.

If you can’t get your return ï¬nished by April 15, you can ï¬le IRS Form 4868 to request an automatic extension, which gives you until October 15 to get your act together.

You’ve ï¬ led your tax return and you’re now expecting Uncle Sam to reward you with a nice fat refund check. There are tax advisors who will tell you this isn’t a good thing; that you should tweak your withholding so you don’t get such a big refund. So, what do you do with the cash?

Before too long, your taxes may actually end up even higher 

There has already been passage of legislation with a Medicare surtax of 3.8% on all investment income for taxpayers who earn more than $250,000 (

). The cost of this tax increase is going to vary, based on the amount of your investment income. If you consider that the long-term capital gains tax on investments is only 15% (for now; there has been talk that Congress may allow the Bush-era reductions in capital gains taxes to expire and revert to previous levels), this surtax represents an increase in investment income tax of 25.3%.

If this tax-rate increase on capital gains and dividends comes to pass, it could be as high as 33% of the existing tax rate (if the tax rate increases from 15% to 20%). These two taxes combined could represent an increase in taxes on investments of more than 58%. The dollar impact of this increase will depend on the value of your appreciated assets and income-producing assets (such as real estate, equipment, etc). Needless to say, this tax increase may hurt a little, even for doctors who utilize smart asset-protection strategies, and separate assets from the operating practice.

Right now, the Social Security tax stands at 12.4% for self-employed individuals, but it only applies to the ï¬ rst $106,800 of income. What would happen if Congress successfully legislates away many of the tax beneï¬ ts of S-Corporations (as it attempted to do recently with the American Jobs and Closing Tax Loopholes Act of 2010), and every dollar of income is subject to Medicare’s new 3.8% tax? What happens if the law is changed so that the maximum amount of wages subject to the social security tax is increased from its current cap of $106,800? For doctors making $500,000 to $1 million per year, these hypothetical changes could represent up to $110,000 of additional taxes. The Medicare payment increase alone for a $1 million-earner who currently takes half of his or her income in salary and half in S distribution could be as high as $23,500 per year.

Another possible tax increase that has been discussed is to raise the highest marginal income tax rate back up to 39.6%, from the current 35% (

). This would apply to income of approximately $400,000; for a doctor earning $600,000, this could cost another $9,200 a year. Finally, the estate-tax repeal that was enacted under former President George W. Bush is going to “sunset” on Dec. 31, 2010. This means that if you don’t die this year and lawmakers don’t extend or make the repeal permanent before it expires, all those big nasty estate taxes (up to roughly 55%) are back on the table. Now, assuming you are not interested in dying this year to avoid estate taxes, or to save the time and aggravation of doing income-tax planning, there are some strategies you can implement to prepare for the potential for higher taxes in the coming years.

Yes, you read that correctly. It is crucial to get as much money as possible out of taxable environments and into tax-free environments. This is necessary because it’s extremely likely tax rates are going to have to increase substantially to pay for the bailouts, healthcare reform, and other federal programs that are on the agenda. Here are some examples of ways to accomplish this goal:

If you have the liquid cash available to pay the income tax, convert all of your individual retirement accounts to Roth IRAs in 2010.

If you have property with capital gains (especially gains that are the result of a number of 1031 tax-free exchanges), sell it and pay the taxes now.

If you have appreciated stock of public or private companies, explore ways to sell so you can trigger capital gains taxes in 2010.

Increase the amount of money you invest into tax-free vehicles, such as cash-value life insurance. Under the current tax regime, the beneï¬ts of tax-savings outweigh the costs of the insurance. In a higher-tax environment, the beneï¬ ts will only be enhanced.

Health insurance expenses are 100% tax deductible. Right now, individuals can’t deduct health-related expenses until the costs exceed 7.5% of adjusted gross income. One bill under consideration right now would raise this threshold to 10% of AGI, unless the individual is eligible to take a self-employed health-insurance deduction. For a doctor earning $600,000, the ï¬rst $45,000 to $60,000 of health expenses are not deductible individually, but are 100% deductible through a C-Corporation.

Long-term care insurance is treated like health insurance. While you are in your peak earning years, you can pay these premiums for a limited time (say, over 10 years) and be eligible for a full income-tax deduction while doing so. So beneï¬ts are tax-free, if and when you and your spouse need them. The deductible amounts for long-term care insurance are very low for individuals.

There are ways for a C-Corporation to tax-efï¬ciently purchase life insurance. If you can get a partial deduction for putting money into a vehicle that grows tax free, allows you access to the funds in the policy tax free, and provides some protection for your family, why wouldn’t you do it?

There are tax-saving strategies that exist that allow successful doctors to take annual deductions that can be in the hundreds of thousands of dollars or more under the umbrella of a C-Corporation.

Pay no more tax than absolutely necessary 

On items you’ll eventually be taxed on, no matter what, you want to pay the tax now while rates are still relatively low. But on future income, you need to be smart and maximize tax deductions any place you can. If Congress passes the bill to reduce or eliminate the tax beneï¬ts of S-Corporations, savvy doctors will take advantage of the beneï¬ts offered by C-Corporations (see sidebar).

Not knowing exactly where the tax increases will fall is no excuse for inactivity. In all likelihood, tax rates are going to increase for high earners. By the time tax increases go into effect, it may be too late to act. And if, by some chance, tax rates go down, at least you’ll have invested the time to lower the overall rate of tax you will ultimately have to pay, so there will still be some beneï¬t.

Oh, and the answer to the question posed in the title of this article is a quadrillion (that’s a 1 followed by 15 zeroes). At the rate the national deï¬cit is ballooning, many taxpayers may learn the answer to that question the hard way.

Christopher Jarvis is an MBA with more than 15 years of consulting experience. Carole Foos is a CPA with more than 20 years of experience. They are both part of the consulting ï¬rm, OJM Group (

), with ofï¬ces in Cincinnati, Fort Lauderdale, Austin, Phoenix, and New York City. They welcome questions at (877)656-4362. 

This article contains general information that is not suitable for everyone. The information contained herein should not be construed as personalized tax advice.  There is no guarantee that the views and opinions expressed in this article will come to pass or that they will be appropriate for your particular circumstances. US tax law changes= frequently, accordingly information presented herein is subject to change without notice. You should seek professional tax, ï¬nancial planning, and legal advice before implementing any strategy discussed herein. For additional information about the OJM

Group, including fees and services, send for our disclosure statement as set forth on Form ADV using the contact information herein. Please read the disclosure statement carefully before you invest or send money.

What Comes after a Trillion?  Big Numbers and High Anxiety in a Time of Economic Uncertainty 

Type the link codes in the search bar above to access these third-pary resources.

The online home of Kiplinger, the business forecast and personal ï¬nance advice publisher, includes a comprehensive section dedicated to taxes. Here, site visitors can access the “Taxopedia,” an “Is it Deductible?” quiz that tests whether you can “separate the legitimate deductions from the ones you only wish you could claim,” and other tools. There’s also a slideshow that reviews the most overlooked tax deductions, and videos that provide advice on getting your tax refund quicker, preparing for an audit, and tax planning. Scroll to the bottom of the page to link to professional answers to common tax- related questions, a collection of tax calculators, and sections dedicated to tax planning and do-it-yourself tax savings. Visitors can also sign up for the electronic version of the Kiplinger Tax Letter.

This highly active blog (averaging probably two posts per day) from Michael Rozbruch, certiï¬ed tax resolution specialist, member of the American Society of IRS Problem Solvers, and Maryland CPA, provides “tax relief and IRS resolution tips and resources from the nation’s leading tax negotiation & mediation ï¬rm.” Including a tax problem FAQ section and a tax help glossary, the blog covers dozens of key topics, with the majority of posts addressing back taxes, IRS tax cases, tax help, and tax news and tips.

Part of the Wall Street Journal digital network, MarketWatch offers this tax-speciï¬c site that collects the latest tax news and headlines. Articles focus on a variety of topics, including ï¬ling tips, tax-reduction strategies, education, deductions, and penalties. Visitors can also watch video interviews and news features.

The mission of the Tax Foundation is “to educate taxpayers about sound tax policy and the size of the tax burden borne by Americans at all levels of government. From its founding in 1937, the Tax Foundation has been grounded in the belief that the dissemination of basic information about government ï¬nance is the foundation of sound policy in a free society.” With this in mind, the foundation offers this weekly podcast series, featuring experts who address such issues as the expiring Bush tax cuts, value-added taxes, and retroactivity and retained refunds.

Part of the LexisNexis community of sites, this series includes podcasts posted on roughly a weekly basis. Recent podcasts tackle higher-level topics, including codiï¬ cation of the economic substance doctrine, partnership and limited liability company agreement drafting, and the recent IRS announcement 2010-9 about uncertain tax position reporting. The 20 podcasts available at writing date back to August 2009.

Whether you ï¬‚y solo or are part of a larger medical practice, this resource from the IRS will either answer all of your questions relating to taxes, or point you in the right direction for more information. Go to this site to obtain general tax information, or get facts speciï¬c to the size of your business on dozens of topics ranging from estate and gift taxes to disaster assistance and emergency relief. Visitors can also ï¬nd out what qualiï¬es as a deductible business expense; download or print a tax calendar; and obtain information about the provisions of the Hiring Individuals to Restore Employment Act that provide a payroll exemption and a retention credit for qualiï¬ed employers who hire certain qualifying employees.

TurboTax—the company that has become public enemy #1 to accountants everywhere&mdash;offers this collection of calculators and “money-saving tax guides.” Featured on the site are a number of videos, including: “Child Care Tax Credits,” “IRS Rules for Charitable Giving,” “How to Reduce Errors on Your Tax Return,” and “Who Can You Claim as a Dependent on Your Tax Return;” a listing of helpful tax guides, including one focused on how healthcare reform will affect your taxes; and the Tax Stimulus Center. Also of note are TaxCaster, a calculator that can help determine how big your refund will be, and the Life Events Advisor application, both of which are available on the iPhone.

It’s never too early to start gearing up for tax season—or so claim the good people at H&R Block, who are “here for you” year-round with this collection of resources. Perhaps the top draw on the site is the tax estimator; simply select your ï¬ling status, enter your age, and enter your total wages to ï¬nd out whether you owe money or are due a refund. Visitors can also learn how to claim all of the credits and deductions to which they are entitled; learn how to deduct Haiti relief donations or deduct unreimbursed business expenses as miscellaneous itemized deductions; utilize the withholding calculator or self-employment tax estimator; and access information on tax law changes.

As the debate on how to handle the expiration of Bush-era tax cuts rages on, more taxpayers will start to wonder what this will mean for them come April. The Tax Foundation seeks to provide some answers with this tool, which allows you to “estimate your 2011 income tax under three scenarios: 1) Congress allows all of the Bush tax cuts to expire; 2) Congress acts to extend into 2011 all of the Bush tax cuts; and 3) Congress passes the tax laws suggested in President Obama’s budget, letting some tax cuts expire, extending some, and enacting some new tax laws.” Be aware, however, that the process is somewhat complex, and requires “19 inputs from income to the number of dependents and dividend income,” according to a 

Because “doctors have little time to learn about the latest tax law,” and as a result, “tax planning is often neglected in the crush of other obligations,” the consultancy of Case/Foster-Potter/Kunitzer, based in Battle Creek, MI, has made available this listing of 20 tax tips for physicians. After visiting this simply designed yet informative site, you’ll be better prepared to tackle tax season. Among the many topics covered include keeping adequate records of travel, meal, and entertainment expenses; tracking continuing education expenses; leasing rather than buying medical equipment; using caution when making purchasing for tax reasons; considering taxes in building a college fund; and more.

The Net Guide: Tax Resources

Is your practice losing thousands of dollars each month by being too cautious with coding and billing? Web-based billing analytics tools and other resources can help you establish a benchmark for what you should be earning and ensure that your billing is audit-proof

Caution is a learned reaction to negative experiences and is often a wise course of action in the practice of medicine. In your clinic’s billing department, however, caution may be costing you much-needed revenue.

Many practices err on the side of caution when assigning procedure codes. In a majority of cases, the fear of a chart audit is undoubtedly near top of mind. It’s an understandable concern. But such reticence can also cause practices to undercode for a procedure. The trouble is, unless you have some way of uncovering such decision-making, you’ll never know if you’re receiving all of the income you’ve rightfully earned.

One of the best ways to identify undercoding is through the use of billing analytics and benchmarking tools. Such tools, often made available by revenue cycle management solution providers, offer benchmarks that allow you to compare your billing policies and performance against clinics in similar specialties. The benchmarks factor out geographic, practice size, and other differences to give you and potential auditors a reliable comparison. Benchmark statistics delivered via a Web-based service are also constantly updated in order to reï¬‚ect the latest aggregated information.

When judging the appropriateness of billing decisions, benchmarks can be invaluable. Not only will they help you quickly identify potential points of departure from industry norms, but also, as long as your assignment of procedure codes is at the benchmark, any changes you make will be clearly defensible.

Let’s look at how benchmarks can uncover the high cost of undercoding. In one recent real-world example, a surgical practice specializing in spine injuries and disorders was shown to be billing 94% of its ofï¬ce/outpatient visits under Evaluation and Management (E/M) code 99213—which is the code for a 15-minute face-to-face visit. Just over 5% of the practice’s visits were assigned to code 99214, denoting a 25-minute face-to-face visit.

Based on appointment records, all of this was appropriate. The trouble is that minutes are not the only criteria that determine accurate visit coding. For patients with high acuity or complexity levels, code 99214 can be assigned even for visits of less than 15 minutes. The difference for this provider, when compared to substantiated benchmarks and using a blended Medicaid/Medicare/commercial payment rate to estimate the underbilling, was remarkable: nearly $8,000 in lost revenue due to underpayment per month.

By undercoding, this clinic was leaving nearly $100,000 on the table each year. Moreover, this was only one of several instances of undercoding at this practice that was identiï¬ ed by the benchmark comparisons.

Only by measuring coding practices against benchmarks can such revenue losses be fairly and justiï¬ably recovered. Remember, this is just by meeting the benchmark, not exceeding it. When compared to the loss in income that a clinic may experience—a virtual certainty&mdash;isn’t the chance of an audit that only establishes benchmark performance worth the low risk?

If your practice uses electronic medical record (EMR) technology, you have an added coding asset. Typically, billers require documentation in three key areas (history, physical exam, and medical decision-making) to assign codes properly. EMR systems automatically capture rendered services, including review of systems, exam elements, and other information in bulleted form; these data not only help accurately determine proper billing codes, but also provide a later audit trail if needed.

Like most physicians, you no doubt labor long hours in the exam room each day, tending to your patients. What you don’t want is for income to slip away just down the hall at your billing desk. By using today’s automated record-keeping and revenue analytics tools, such losses will occur far less often.

James S. Lacy is chief ï¬ nancial ofï¬cer, general counsel, and corporate secretary of ZirMed Inc (

), a Louisville-based technology company providing revenue cycle management solutions to healthcare providers. Lacy is licensed to practice law in the Commonwealth of Kentucky.

Is your practice losing thousands of dollars each month by being too cautious with coding and billing? 

The High Cost of Undercoding 

Ah, coffee… I’m not into it, but figured you might be, so I opened with that sentence to get your brain’s nostalgia quarter all worked up. Speaking of getting your brain worked up, how about that caffeine? Lifehacker goes in-depth on “everybody’s favorite mind-altering substance.” Why, exactly, does it work so well? Caffeine binds to adenosine “receptors in efï¬cient fashion, but doesn’t activate them—they’re plugged up by caffeine’s unique shape and chemical makeup. With those receptors blocked, the brain’s own stimulants, dopamine and glutamate, can do their work more freely…like taking the chaperones out of a high school dance.” As you probably anticipated, this can be really fun&mdash;but also harmful&mdash;as “there are adenosine receptors all over the body.”

The Mosquitoes Are Lovely Today, eh Farnsworth?

) we mentioned a few months back? Pack it away and let the buzzing beasts feast upon your delicious blood...in 10 years, that is. Well, I guess there’s really no need to let mosquitos give you itchy welts, but at least you won’t have to worry about getting malaria if scientists are able to replicate laboratory ï¬ndings in the wild. By “engineer[ing] a special version of the Akt gene into the eggs of Anopheles stephensi mosquitoes,” researchers were able to eliminate all traces of the malaria parasites. “What they’ve done is take a key point in the insulin signaling pathway, and expressed an active form of it in the gut,” said Mark Brown, PhD, adoctor at the University of Georgia who is familiar with the new research. Now all they need is an “effective way to drive the inserted genes through the entire population” and a world health crisis has met its match.

Moving into my ï¬rst home has taught me a few things: 1) don’t buy a ï¬xer-upper; 2) “helpful” friends sometimes make more work for you; 3) technology has fried my brain. Over the past few years, I feel that my memory has gotten noticeably worse, that my mental reï¬‚exes have gotten slower, and that I have a much harder time maintaining focus on one thing at a time (what’s your diagnosis?). This past week, however, has been a bit different. After all of the trips to Home Depot subsided, and the painting and furniture rearranging were ï¬nished, I found myself with nothing much to do after dinner. We have no cable (other than public access and Spanish language channels) or Internet, so I’ve just been writing and helping my wife put together a 1000-piece puzzle; in the morning, I read. More importantly, I feel more alert, more awake, like my head isn’t adrift in a foggy swamp all the time. This may or may not have something to do with the Internet or cable (

), but I’m starting to think that after staring at a screen all day at work, taking a break at home is probably a good thing; so does Eyal Ophir, a Research Assistant in the Symbolic Systems Program at Stanford  University’s CHIMe Lab (Communication Between Humans & Interactive Media). Ophir and his colleagues, using a test in which subjects had to identify moving red and blue rectangles (

), found that multitaskers “did a signiï¬ cantly worse job than the non-multitaskers at recognizing whether red rectangles had changed position…The multitaskers [also] took longer than non-multitaskers to switch among tasks, like differentiating vowels from consonants and then odd from even numbers.” Still, debate rages. Numerous studies have highlighted the rehabilitative and educational power of video games, while imaging studies suggest that Internet use spurs growth in neural circuitry. Steven Yantis, a brain science researcher at Johns Hopkins University, says that “the brain is wired to adapt” and “rewiring goes on all the time,” though he cautions that it’s “too early to say whether the changes caused by technology were materially different from others in the past.” I don’t know about you, but I’m going to have to wait until True Blood comes out on DVD (though I’ll probably break down and get Internet access).

Our pals over at Medgadget have taken inspiration from Chatroulette and created a healthcare version that seeks to connect patients to other people “with the same condition as yours”…and hopefully eliminate the proliferation of random male anatomy shots that has basically destroyed Chatroullete’s reputation (

). It is very simple to use: 1) indicate your sex; 2) identify the sex of users you’d like to chat with; 2) choose a topic (back & neck, diabetes, heart disease, cancer, pregnancy & childbirth) and subtopic; 3) click the “Find/Next” button and start chatting. The site is still in beta, so check it out and give them feedback at 

Want to know every single time you are mentioned in a blog posting, Facebook status update, tweet, or anywhere else in the Web? Are you interested to know how all of your social media proï¬les are doing? Want to keep an eye on your referral trafï¬c and see what social media sites are serving you better than others? Perhaps you’d like to create a landing page to capture the information of your website visitors by offering a white paper or podcast; Hubspot provides all of this information at your ï¬ngertips, and it’s just the tip of the iceberg.

The Power, Limits, and Dangers of Social Media

We love social media around here, and as you know, we think you should be using it (responsibly) whenever possible to improve practice efï¬ciency and patient relationships. However, as world events have shown us, social media has the power to literally change lives for good (Text Haiti 90999 raised more than $40 million for the Red Cross) and ill (Iran restricted access to Facebook, YouTube, Twitter, and other sites during 2009-2010 election protests to hinder efforts at coordination). Think of this piece as a macro look at social media that you can learn from: “How are political leaders using these tools for diplomacy, and how can I leverage them in the same manner?”

Medical Mashup For Better Practice Health

Nearly 1/3 of Docs Wouldn’t Report Impaired or Incompetent Colleague

One in three physicians who know a colleague is impaired or incompetent would not report that person to the proper authorities, a new survey reports. Doctors, has this ever happened to you?

Make Better Decisions, You Know, Like Now

Larry Prusak, Brook Manville, and Tom Davenport are working on a book about “How Great Organizations Make Great Decisions” on “judgment days” that “were shaped and succeeded by activities to improve organizational judgment.” It’s not out yet, but they provide a free sample through this mini proï¬le of Pixar. What lessons can you learn from them to improve the way in which your practice runs? Here’s a quick run down: 1) “managers give directors a lot of autonomy;” 2) “even though directors have autonomy, they get feedback from others;” 3) after its movies are completed, Pixar holds “postmortem” meetings; 4) Pixar has an extensive education program at Pixar University; 5) Pixar admits mistakes.

This Newsweek feature has more to do with medicine than one would think at ï¬rst glance. The publication asked three well-known architecture ï¬rms to examine what three American cities will look like in 2030, and each faces issues currently confronting medicine today: resource shortages, crisis of identity, a need to retool aging infrastructure, moving beyond outdated business models, catering to ever-changing demographics, and expanding responsibly and efï¬ciently.

Something tells us this guy would have been arrested in addition to having his medical license stripped if he were practicing today. “In 1929, while working in Eberswalde…[Werner Forssman] ignored his department chief and when a nurse tried to stop him, he tied her to an operating table. Then, he anesthetized his own lower arm and inserted a cannula into his antecubital vein, threading it 65 cm all the way to his heart.” And thus, human cardiac catheterization was born.

Medical marijuana advocates seem to have history on their side: A 2,700-year-old tomb discovered in the Gobi desert contained the remains of a “blue-eyed Caucasian man…[who] researchers believe…was a shaman from the Gushi people, who spoke a now-extinct language called Tocharian that was similar to Celtic.” What separated this ï¬nd from the countless others that archaeologists uncover each day was the “leather basket found next to the buried man’s skull.” In it was a wooden bowl containing a lot of cannabis, out of which “someone had carefully picked all of the male plant parts, which are less psychoactive, so researchers believe there is little doubt as to why the cannabis was grown.”

As we speak, 3 billion bugs (increasing to as many as 6 billion as you inch toward the equator), from butterï¬‚ies and gypsy moths, to beetles and aphids, are ï¬‚oating on air currents in search of “food, sex, and space.” This summer-time ritual is well-known within science circles (“Famed aviator Charles Lindbergh contributing to the data-collection effort by carrying sticky glass slides on his 1933 ï¬‚ ight crossing the Atlantic at 2,460 to 5,410 feet and over Greenland at 7,870 to 12,135 feet”), but the average citizen is probably oblivious to all of the insect trafï¬ c unless it happens to be attacking them during a picnic. The all-time record is a termite caught at 19,000 feet, but we think the spiders, who hang on to “silk threads that carry them up like balloons,” are more impressive (and are haunting our dreams).

Internet Kills the Video Star, YouTube Resuscitates Them

Music videos haven’t been relevant for some time, so much so that pained whines about MTV not playing them anymore are seen as quaint complaints from a simpler time. Well those naïve grumblers are about to get blown back to 1981 in a big way, because Google has found a way to monetize the medium: “Every time YouTube broadcasts a video through Vevo online, it is accompanied by a brief ad, and for every 1,000 such “impressions,” Vevo earns at least $25. Let’s hope this means a revival of all (

Who knows how this thing works? All we can tell from the diagram is that the camera lens is integrated with the stamp body, and it somehow creates temporary stamps from pictures. A nifty novelty, if you ask us. The nifty level will rise signiï¬ cantly once they incorporate multi-color ink, rather than just red.

First, the Gloggomobil costs $899. Second, the accompanying video sounds like someone banging silverware on glasses with a cat moaning in the background. But don’t run! The price is justiï¬ed because the instrument is handcrafted in Switzerland and the video is from some weird art installation. Now that we’ve gotten beyond those hurdles, think of what an excellent instructional tool this could be for children and adults alike. “Instead of just listening to music, a child will enjoy being able to compose music as well,” and you’ll get a nice conversation piece for parties.

Shocking: People Don’t Remember Anything

Remember that whole dust up over the replacement of the commanding general in Afghanistan and this pesky oil spill in the Gulf of Mexico that won’t go away? Half of respondents to a recent survey couldn’t name Gen. Stanley McChrystal’s replacement (Gen. David Petraeus) or say how deep BP was drilling when the well blew (5,000 feet). A full 37% couldn’t say where the 2010 World Cup was being held (South Africa), even though the survey was taken while the tournament was in full swing. Not many had a problem, however, identifying what Twitter is. No wonder the healthcare reform debate was so contentious.

After more than “20 years of painstaking work by Markus Kobert, a Swiss fruit grower,” the Redlove, an apple with red ï¬‚esh through to the core, will be arriving on store shelves in Britain over the next few years. Can’t say when it will make its way to American shores, but when it does, recommend it to your patients. “It has a ‘berry nuance’ and is even healthier than your average apple as its red ï¬‚esh is richer in antioxidants.”

Editors' picks for this month's best websites, news, resources, and online information for physicians. 

The Check Up

Stocks, Options, Alerts and Ratings with Push Notiï¬ cation

Average App Store Rating: 4 stars (11 ratings)

The reviews say it all for this stock monitoring app: “Wow, covers almost all stock exchanges across the world” and “This is an excellent app. Very nice user interface. Alerts come in right in time for me to take action…Worth every penny.”

Average App Store Rating: 4 stars (44,662 ratings)

Sticking with this month's money theme, we scoured the Apple App Store for the best ï¬nance-focused apps for physicians. Here's what we found.

July 2010