The largest US financial institutions are on government life support. Smaller banks are collapsing under the weight of plunging real estate values and worthless loans. Other than 

 debt, with near-zero interest rates, there aren’t many safe places left to park your savings. In this toxic financial climate, does it make sense to look to the traditional banking havens in Switzerlandribbean? It depends ou are looking for; there are several advantages to the specialized private banking available in some off shore locations, but there are risks to consider as well.  

The strongest argument for off shore banking is the availability of asset protection benefits. In most cases, accounts can be held in the name of a trust or a formed in a jurisdiction with favorable finance laws. For example, sometimes our firm advises clients to use a Delaware LLC for tax reasons but eslish the bank account in an overseas location. Or we might create the LLC or trust outside the US because of favorable rules that protect these structures from creditors. However, although these arrangements can confer substantial asset protection benefits, some of their purported advantages should be viewed with a critical eye. 

Foreign banks have government deposit guarantees that vary by country. Deposits in US banks are insured by the FDIC up to $250,000 and can be combined within a family to increase those limits. Switzerland has increased its guarantee to the equivalent of about $85,000 and also allows combination accounts. You should avoid financial institutions with significant and unknown exposure to loans or other risky asset classes. The overseas private wealth management banks, unlike the commercial banks, generally make few, if any, loans and earn their fees solely from advisory and custodial services. These institutions are generally the safest bets for off shore accounts. 

Accounts in countries with strict bank secrecy laws provide enhanced privacy. In the US, your records and the details of your financial life are widely available because there are very few legal restrictions on banks’ ability to sell your personal account information to third parties. The banks in countries with strict secrecy laws are prohibited from these practices; revealing any customer information is a crime in most circumstances. That said, violations can still occur: an employee of the largest bank in Lichtenstein recently sold thousands of customer records to the German government, which was investigating tax evasion by some of its wealthy citizens. In another case, the giant Swiss bank UBS allegedly promoted a variety of tax schemes to some of its wealthy US clients involving the use of “secret” Swiss accounts. The US is now prosecuting the bank, and it’s likely that the names and accounts of these clients will be turned over to the authorities. Although, the privacy of overseas accounts can be a valuable tool in limiting access to your bank records, this protection has definite limits, and all reporting and disclosure requirements should always be strictly followed. 

Can you make more money overseas due to higher interest rates or investments that earn more than current opportunities in the US? Just like in the US, the rate will vary based on the level of risk. Interest rates on dollar-denominated investments will be similar to US money market rates. In fact, if you’re offered a return greater than you can get in the US, chances are it’s a phony deal. Many off shore banks, along with their US counterparts, funneled investor money into the  scheme with promises of unusually high and consistent returns. As I write this, Stanford Financial Group, a multi-billion dollar institution, is accused by the SEC of a massive fraud, offering bogus high-yielding CDs through its off shore bank. It’s likely that investor losses will be substantial. In these times, since the amount of risk in any investment can’t be accurately calculated and therefore can’t be accurately priced, the highest degree of skepticism should be applied to any investment opportunity. 

For those seeking asset protection and privacy advantages, overseas banking may be worth investigating as a part of a strong financial plan. However, with a global financial crisis at hand, exercise extreme caution before opening an account with any bank, and certainly avoid investments with promised returns that exceed rates that are generally available in the market. 

Robert J. Mintz, JD, is an attorney and the author of the book 

Asset Protection for Physicians and High-Risk Business Owners

. To receive a complimentary copy of the book, call 800-223-4291 or visit 

Articles

Columns

The largest US financial institutions are on government life support.

Gimme Shelter: Are Financial Safe Havens Truly Safe Anymore?

President Obama has signed a stimulus bill that calls for eventually punishing physicians who do not “meaningfully” use a “certified” EHR system by imposing up to a 5% Medicare payment penalty—non-compliance penalties start at 1% in 2015, increasing to 5% in 2019, at the discretion of the Secretary of HHS, if the nationwide EHR adoption rate remains below 75% (

www.fmaonline.org/pages/practice/files/Stimulus_101.pdf

). CMS will use these penalties as a cost-cutting measure, which may force many physicians to consider withdrawing from Medicare.  

To understand why this may happen, consider a physician who in 2019 bills $100,000 to Medicare and gets punished the full 5% for failing to meaningfully use a c-EHR, and compare her situation over five years to a physician who successfully uses a c-EHR, and also to a physician whose use of a c-EHR fails to qualify as “meaningful”: 

The non-complying physician will lose $5,000 per year for five years, for a total loss of $25,000. 

The physician who fails to comply due to a poor c-EHR installation or who ends up de-installing the system will have a slightly higher total loss: 

 for the estimated up-front cost of a c-EHR (plus $1,500 each month for maintenance fees; see 

 (penalty for non-compliance based on above math)

____________________________________________________ 

The physician who complies during the five years beginning in 2019 could end up incurring the highest losses: 

 (cost of purchasing an EHR system, plus $1,500 per month for maintenance, multiplied by 60 months)

   (one-third of a full-time employee for reporting and documentation at an estimated $10,000/year for five years).

 in estimated workflow losses (say it takes an extra five minutes per encounter to capture required data. An office grossing $100,000/year in Medicare funds, at $100 per encounter, comes out to 1,000 encounters x 5 min/encounter = 5,000 minutes. That adds up to 250 “lost” 20-minute encounters, or another $25,000/year for five years.)

 Medicare reimbursement (if physician “meaningfully uses” c-EHR successfully)

The actual profit/loss calculation depends on the c-EHR that you end up buying. Some systems cost significantly less than the “average” cost stated above. Most vendors will promise a positive return on investment (ROI) due to perceived “efficiencies” gained by using their c-EHR systems. A minority of physicians on several discussion threads at Sermo, emrupdate, and other sites concur and state that they love their c-EHR software systems.

Only 17% of 2,758 physicians recently surveyed use the kind of EHR systems that Obama envisions for the whole nation, and just 4% use their EHR in a “meaningful way” (

). The reasons that the majority of physicians continue to dislike c-EHR systems include: 

 Poor ROI; c-EHR systems are expensive, increase overall costs, and disrupt work flow.

c-EHR systems have not been shown to decrease errors. On the contrary, they have been shown to increase them, introducing 22 new errors in one study (

). According to the US Pharmacopeia’s 5th annual study of medication errors, in 2003, computer entry errors were the 4th leading cause of errors, accounting for 13% of total medication errors; handwriting errors were the 15th leading cause, accounting for only 2.9% of reported medication errors (

 Purchasing a CCHIT-certified EHR is associated with a 50% installation failure rate (

) and an 8% deinstallation rate thereafter (

 c-EHR systems increase quality only slightly, if at all, and secondarily lead to increased spending (

 Doctors generally dislike e-prescribing and CPOE (

These are turbulent times indeed for US physicians. Their ability to practice medicine is being encroached upon by government mandates based on unproven technology. I hope that physicians can make the right choices that have the least impact on their practices’ ability to survive financially. 

Alberto Borges, MD, is in private practice and is an assistant clinical professor of medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Check out his website at 

The opinions expressed in this column do not necessarily reflect those of 

President Obama has signed a stimulus bill that calls for eventually punishing physicians who do not "meaningfully" use a "certified" EHR system.

The Costs of Medicare HIT Mandate Noncompliance

It started with an e-mail to thousands of health bloggers from Dr. Geoff Rutledge, Chief Medical Information Officer at the health website 

: “I was on a search for the best medical blogs, when I found you… I think your blog is great. I’d like to invite you to participate in the network of medical expert bloggers at Wellsphere… I offer you the opportunity to be a featured medical expert blogger for a new Wellsphere community. Members and visitors will see your postings highlighted, featured, and clearly marked as authored by a true medical expert.” 

A large number of health bloggers—at least 1,500, according to Wellsphere&mdash;accepted Rutledge’s invitation. Most linked up with Wellsphere because they hoped the company would help them reach new readers. 

, who writes at the blog “Every Patient’s Advocate” wrote “[W]hen Wellsphere came along, I saw it as an opportunity to maximize exposure… In fact, my blog numbers (about 4,000 people per month), doubled when my blog began to appear on Wellsphere.” 

For many months, Wellsphere recruited bloggers with little controversy. However, on January 28, 2009, Wellsphere announced that the HealthCentral Network had purchased the company for an undisclosed sum. Soon after the press release hit the Web, health bloggers were up in arms. Many felt that Wellsphere took advantage of them by aggregating their content and selling it to HealthCentral Network. Others objected to Wellsphere’s terms of service agreement, which gave the company permission to redistribute and monetize bloggers’ content. 

Although many health bloggers were angry at Wellsphere for selling their content to the HealthCentral Network, others were more accepting. In addition, some had little sympathy for those who had not taken time to read Wellsphere’s terms of service agreement before consenting to let the company repost blog content on its site. 

Wellsphere is not the only social media company that has run into controversy regarding content ownership. The popular social network Facebook recently changed its terms of service agreement to note that after a user leaves the site, Facebook will retain some rights over content and information that the user uploaded. After much outcry, Facebook deleted the new language from its agreement and engaged its users in a discussion about the issue. 

The Wellsphere and Facebook controversies illustrate how difficult it is to reconcile two opposing needs: 

• The public’s growing need to quickly and easily find and share information online using social media technologies 

• Technology providers’ need to run profitable businesses while protecting themselves from potential user lawsuits

• Site developers should recognize and clearly acknowledge that users of social media services retain rights and ownership over their content. 

• Social media companies should understand that most people are not lawyers. Developing “plain English” terms of service agreements for the masses is critical.

Users of social media should recognize that, in order to continue providing valuable services, many sites need to focus on becoming (and remaining) profitable; this means that they may repurpose or redistribute site content to attract sponsorship dollars. However, these activities should be clearly spelled out to users. 

There are no easy answers to the content ownership and distribution question. Despite this, it is important to foster and participate in robust debate about this issue. Only then will people come to a broad understanding and agreement about how to foster collaboration and conversation while ensuring that sites that provide useful information and technologies continue to function.

The path toward resolving the thorny issue of content ownership may lie in both sides understanding and accommodating the needs of the other. Specifically:

Do you read the terms of service agreement for blogs and other social media sites before posting content? As the user-generated content business model gains popularity, will members demand to be compensated in some way when sites capitalize on the traffic generated by members of the community?

Fard Johnmar is the founder of Envision Solutions, LLC, a full-service healthcare marketing communications consulting firm. Visit 

 to learn more about the company and the services it offers. 

It started with an e-mail to thousands of health bloggers from Dr. Geoff Rutledge,
Chief Medical Information Officer at the health website Wellsphere.

Wellsphere Blogger Flap Raises Questions about Content Ownership

What exactly is a medical wiki, and for that matter, a wiki in general? Are these resources useful to you and your patients?   

Our story begins, as do many great things, with jellybeans. 

Suppose the existence of a large jar of jellybeans in a room. Into the room we bring a mechanical engineer and a jellybean executive. We also bring in 1,000 other people (the room is quite large). We ask all in attendance to estimate the number of jellybeans, and offer you a choice: will you bet on the engineer’s estimate, the jellybean expert’s estimate, or the mean of the guesses of the remaining 1,000? 

, James Surowiecki finds that the combined individual efforts of a group outperform any single individual effort over a series of trials. He describes a related experiment, in which a group of volunteers travel through a maze. According to Surowiecki, investigators “figured out what a majority of the group did at each node of the maze, and then plotted a path through the maze based on the majority’s decisions.” This “collective solution” resulted in a path through the maze shorter than the path taken by any individual participant, including those who had already completed the maze once (ie, “maze experts”). 

Surowiecki goes on to argue that properly interpreting and harnessing the wisdom of crowds can produce desirable outcomes in fields ranging from economics to sociology. But what about medicine? Can reliance on the collective knowledge of a large group produce value in a discipline in which precision is paramount? Medical Wikis—practical collections of this kind of knowledge&mdash;exist and confer advantages that cannot be duplicated by any other media. But there are pitfalls, as well. Remember, Surowiecki’s optimistic title is a play on a much earlier work by Scottish journalist Charles MacKay: 

Extraordinary Popular Delusions, and the Madness of Crowds

, the largest and most famous collective effort at online information distribution. Wikipedia has become so iconic that it would be easy to assume that the terms Wikipedia and wiki are functionally equivalent, but this is not so. Which brings us to: 

Wikipedia is but one example of a wiki, and by no means the definitive one.

Broadly speaking, a wiki (from the Hawaiian word for “quick/fast”) is a group of Web pages on a particular subject that allows open modification of the content, using a simplified interface that requires only a standard Web browser. Most wikis use extensive hyperlinking (again, easily accomplished by all contributors) within each article to connect subjects and enable quick and intuitive research. The concept and the name were both products of Ward Cunningham, whose 

 (“fast fast Web”) went live in 1994. 

Ideally, a wiki article on, say, jellybeans, would be written by a contributor with extensive specific knowledge on the delectable treats, with fact-checking by additional experts. A contributor with a n in-depth understanding of the jellybean manufacturing process might add detail on that subject, while another provides a well-researched history of the Jelly Belly Company. An expert on traditional holidays might add a section on Easter, and link to a larger article on the same subject. Contributors with language expertise would polish the grammar. The result: a clean, detailed, referenced article, freely accessible to all, which can be instantly updated with breaking jellybean news. However: 

Allowing open contribution to a Web page introduces the inevitability that some contributors will make undesirable changes, additions, or deletions. 

These may range from simple vandalism (inserting profanity), spreading of misinformation (Wikipedia carried false news of the death of Ted Kennedy for some time), or even well-intentioned additions of incorrect information. The wiki approach is to make no particular effort to prevent misinformation or other damage; rather, it relies upon a community of users to quickly catch and correct damage as it occurs. In this way, says the Encyclopedia Britannica, the wiki is a rare example of “an Internet counterculture that has a basic assumption of the goodness of people.” 

Wikipedia is the most prominent wiki, with more than 12 million articles covering every subject imaginable. At this point, encounters with Wikipedia are essentially inevitable; if one of your patients decides to Google a condition or medication, a page from Wikipedia will almost surely be one of the top five hits. 

Wikipedia, like many wikis, is a truly open reference source. 

Contributors need have no particular credentials. As a result, the reliability of the material may be questionable. Malicious users can introduce misinformation; operatives can add political spin or delete disadvantageous material. There is no accountability, because editing can be anonymous. 

Thus, Wikipedia has caused a fair amount of hand-wringing. In a 2007 Encyclopedia Britannica blog post, former American Library Association president Michael Gorman wrote: “Here is a present danger that we are ‘educating’ a generation of intellectual sluggards incapable of moving beyond the Internet and of interacting with—and learning from&mdash;the myriad texts created by human minds over the millennia.” The irony of sentiments like these appearing on a blog aside, does Gorman have a point? Does the use of Wikipedia erode research standards? 

In a 2007 paper, “Creating, Destroying, and Restoring Value in Wikipedia,” a group of University of Minnesota students attempted to quantify some of the problems with Wikipedia. Among 

• The top 0.1% of Wikipedia contributors by volume of edits provides nearly half of the lasting value on Wikipedia. 

• Only two of the top 50 editors by value added were bots (automated editing programs), suggesting that human contribution is ongoing and critical. 

• About 5% of all revisions “damage” the entry in some way; the overall probability of encountering a “damaged” entry is 0.0037 per page view. 

• 42% of damage incidents are repaired within one page view (median persistence of damage is <3 minutes) 

• The most common types of damage are “mass delete” (entire entry deleted), “nonsense” (gibberish inserted), or “offensive” (profanity, etc). These are easily recognized by the casual reader, and thus, not likely to spread misinformation. 

• About 20% of damage incidents are classified as “misinformation.” Such changes are obviously the most problematic. 

Overall, then, introduction of significant misinformation is not common and generally fixed quickly. Wikipedia allows editors to click on version histories of any article (to quickly see any changes made, ever, to the document), revert to previous versions, and maintain a “Watch List,” notifying them of any changes to an article of interest.  

Nonetheless, misinformation does exist. A number of potential solutions are available. Some proposals suggest that instant changes be permitted only by individuals who have attained “trusted editor” status through consistently good contributions. Other wikis require all contributors to register, or even to be a credentialed expert in the subject matter. However, such plans have met with objection from those who fear they will reduce participation, closing down a system that derives its value from openness. 

The issue of reliability becomes even more critical in the case of wikis dealing with health and medicine. Medical misinformation can be fatal misinformation. Wikis containing medical information come in two basic flavors: wikis for patients, and wikis for doctors. 

From a patient perspective, the wiki is already commonplace. Your Web-savvy patients will almost certainly encounter wikis when they research their own conditions and treatments. 

While unbridled acceptance of any wiki-fact as reliable is not to be recommended, neither is alarmism. Patients should be cautioned that wikis, like any reference work, should be used as a first stop and not a final answer. Patients should be advised to check version histories of articles they read to see the edits that may have been made, and to confirm any information with primary sources—and with a physician&mdash;before acting on it. 

More controversial is the subject of the true medical wiki—a wiki that provides high-level information for doctors and other health professionals. Many have appeared in recent years; among the most significant is 

, founded in 2007 by Kenny Civello, MD, and colleagues from the Cleveland Clinic. The site is intended to allow users to share reviews, journal articles, and clinical experiences in a truly peer-reviewed environment. 

Bertalan Mesko, a medical student and Wikipedia administrator, notes on his own blog that “[Wikipedia] mustn’t include too deep medical trains of thought, even if [they are] important… AskDrWiki could fill this gap.” For example, says Mesko, Wikipedia wouldn’t include angiography videos, as they would be of little value to the typical Wikipedia visitor; a site like AskDrWiki, on the other hand, can provide them for a more specialized clientele. Other emergent wikis cover 

There are, of course, concerns about the quality of the information provided by medical wikis. David Rothman, an information services specialist at the Community General Hospital Medical Library in Syracuse, NY, is a frequent writer on the subject of medical wikis. He argues that the mere fact that a wiki is a wiki tells the reader precisely nothing about its content. He recommends wikis with clear and detailed editorial processes, which describe what types of material will be accepted and clearly list responsible administrators. “A medical wiki with good editorial policies and vetted contributors may soon contain information of quality similar to an established medical journal or textbook,” he notes on his site. Moreover, a wiki has the advantage of portability, ease of use, and rapid correction of errors. 

Of the qualities above, the phrase “vetted contributors” generates perhaps the most controversy. This leads to: 

A restricted access wiki is still a wiki, but it’s a very different kind of wiki.

When AskDrWiki was founded, it had an open contribution model similar to that employed by Wikipedia. As it began to grow, its founders sought advice from wiki observers like Rothman; responding to their recommendations, AskDrWiki instituted a credentialing system under which only healthcare professionals may contribute to or edit the site. 

As a result, the contributor list contains only those with recognized expertise in the subject area. It also, however, disqualifies both individuals without proper credentials who might nonetheless be able to add value, and genuine experts who are unwilling to take the time to become a formal editorial board member but would be willing to make periodic edits on an ad hoc basis. 

Mesko, who is a member of the 70+-member AskDrWiki editorial team, suggests that wikis benefit from expanding the contributor base. He notes on his blog that in the wiki world, “it’s not a question of credentials, but of references.” Wikis, including Wikipedia, tend to frown upon un-sourced material; opinion, speculation, or facts without reference are not allowed to stand regardless of their provenance. Proponents of a more open wiki community argue that if information is properly referenced to reliable primary sources, it doesn’t much matter who places it on the wiki. On the other hand, subject matter experts might be better equipped to determine whether and how a fact properly fits in an article. 

Rothman maintains a list of medical wikis at 

http://davidrothman.net/list-of-medicalwikis

. There, he indicates the degree of credentialing required by each, along with other information intended to allow the physician to make informed choices. He also recommends seeking out wikis with active revision histories, writing that frequent changes may “indicate that the information is being kept up-to-date or that there is an active community keeping an eye on the content to ensure accuracy… an unchanging wiki is not a healthy wiki.” 

The value of a medical wiki is entirely dependent upon the efforts of individual contributors. 

Perhaps the most interesting thing about the medical wiki phenomenon, compared to the many technological trends we chart in 

, is that it is one of the few areas in which the individual reader can make an immediate and substantive impact at little expense. If any of this sounds interesting, you could be contributing to a medical wiki on a topic of particular interest within minutes (perhaps one in the near future focusing on HIT or EMRs on 

), or editing a Wikipedia entry with useful information on patients. If an appropriate wiki doesn’t exist, you can even create one with minimal effort, using so-called “Wiki Farms” like 

. The wisdom of crowds exists only in the context of a willingness to share the wisdom of individuals. 

Have you contributed knowledge to a medical wiki or similar online information resource?

Frank Ferrara is a freelance medical writer and former 

Feature Articles

What exactly is a medical wiki, and for that matter, a wiki in general? Are these resources useful to you and your patients?

Argumentum Ad Populum: Medical Wikis 101

The hottest trend right now in mobile communications is location-based services (LBS) on smartphones. Packed with numerous features such as touch-screen interfaces or full QWERTY keyboards, along with speedier Web browsing, smartphones represented 23% of all handset purchases in the fourth quarter of 2008, compared to just 12% for the same period in 2007, according to NPD Market Research (http://tinyurl.com/bee3mz).  

More and more of these mobile devices are being sold with built-in global positioning system (GPS) modules, so chances are that the next mobile phone you buy will already have GPS. Network operators like Sprint and Verizon require a small monthly fee for GPS service, or it is bundled into your regular monthly fees, depending on the package you choose. 

Although GPS use is most closely identified within-car or pedestrian navigation, a growing number of people are using LBS applications for information and entertainment. Here’s how it works: the GPS receiver knows where you are based on signals from satellites circling the earth. The accuracy of a position determined with GPS depends on the type of receiver. Most handheld GPS units have an accuracy of about 10-20 meters. With knowledge of your physical vicinity, the application can locate other things nearby. In GPS-speak, these are generally known as points of interest (POI) and include everything from hotels, museums, and hospitals to restaurants, banks, and retailers. A GPS system linked to a social network like Twitter will tell you the location of the friends and colleagues who are part of the network. 

Suppose you’re driving or walking in an unfamiliar neighborhood and you want to know where the nearest ATM is located. Simply pull out your cell phone and look up the closest bank. I was in midtown Manhattan not too long ago when I had a sudden craving for sushi. I used my Blackberry to pull up the Zagat restaurant guide online. Based on my location, the service was able to show me all the Japanese restaurants within a few blocks of where I was standing. I could even adjust the search parameters to look for restaurants inside a quarter-mile radius. How cool is that? My service provider, Sprint, charges $4 per month for this Zagat mobile service. 

Another great service when you’re driving is the ability to find cheap gas. Of course, you can use a free website to do this, but the main advantage of lBS is that mobile users don’t have to manually specify ZIP codes or other location identifiers—the system already knows where you are. Other location-based content services that make sense for drivers provide real-time information about traffic jams, locations of cameras designed to catch speeders, parking reservations, and concierge services. 

Mobile commerce is another growing application, taking the form of coupons or advertising directed at customers based on their current location. Say you’re driving or walking past a Starbucks, your phone rings and you see a coupon for $1 off a latte. Consider this an invasion of privacy? I might, too, which is why this particular service hasn’t caught fire with consumers yet. But I can imagine that many people will be happy to get discounts for products and services they already want, so look for this kind of “push” marketing to proliferate in the near future. 

How can doctors use LBS in their practice? Just like for most busy professionals with not enough hours in the day, location-based services can be a real time saver, whether you’re avoiding traffic as you drive to the hospital to round, or using the service to find the closest ice cream parlor as you’re walking around town with the family on the weekend. Depending on the kind of practice you run, it might make sense to have your medical office listed as a point of interest in the directories published by GPS device companies like Garmin, Tom-Tom, and others. You never know, your next patient may be driving or walking by your office right now. 

Do you use location-based services on your cell phone or PDA? Do you foresee this technology being applied in meaningful ways in healthcare? Do you have concerns over security and privacy issues associated with LBS technology?

Editor-in-Chief of MDNG: Primary Care/ Cardiology Editio

n. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of 

, a leading developer of EHR software. He is also the founder and president of 

, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI. 

The hottest trend right now in mobile communications is location-based services on smartphones.

The ABCs of Location-based Services

Who will lead the way in promoting greater adoption of e-prescribing, and how can physicians get the most out of using this technology in their practice?  

Private payers often set their reimbursement rates based on Medicare payment schedules and take their lead on policy changes from the government as well. But with e-prescribing, the relationship might be more of a codependency, with each sector taking cues from the other. Thanks to the Medicare Improvements for Patients and Providers Act (MIPPA) that became law last July, the 

Centers for Medicare and Medicaid Services

 this year and next is providing physicians who “successfully” e-prescribe—according to CMS’s definition&mdash;with 2% bonus payments on top of regular Medicare Part B fees. That rate falls to 1% in 2011 and to 0.5% in 2013. And starting in 2012, CMS will dock 1% from anyone not writing electronic prescriptions for a majority of Medicare-eligible patients, a penalty that climbs to 1.5% in 2013 and 2% in 2014. Any bonuses are in addition to the extra money doctors can earn for participating in the 

 program (this year, the PQRI bonus is 2%). Under the 

, a qualified e-prescribing system must be able to: 

• Generate a “complete active medication list” based on data sent by pharmacies and pharmacy benefit managers; 

• Select medications, produce safety alerts, and both print and electronically transmit prescriptions to pharmacies, though CMS backed off from an earlier ruling that electronic faxes would not qualify as e-prescriptions; 

• Receive details on tiered formularies or otherwise provide information on lower-cost options; 

• Provide formularies, and if available, patient eligibility and authorization requirements. 

This incentive program replaces PQRI measure 125, which listed three G-codes to indicate whether the participating practice attempted to write electronic prescriptions. Reporting continues to go through the PQRI framework. 

 that federally qualified health centers that do not bill under Medicare Part B and others that apply the e-prescribing measure to less than 10% of total Part B charges are ineligible for the bonus payments. The agency also may exclude providers that do not submit an adequate volume of prescriptions under Medicare Part D. 

LEADERSHIP AT THE FEDERAL, REGIONAL, AND STATE LEVEL 

The Medicare bonus is the first truly national incentive program to encourage physicians to ditch their prescription pad in favor of an electronic link to pharmacies, though 

 has included e-prescribing in its “virtual house call” reimbursement plan that went nationwide in January 2008. Other payers have been supporting e-prescribing at the state level for several years. 

, has a program similar to Cigna’s in its home state. Notably, the 

 has been promoting and subsidizing e-prescribing hardware and software in Massachusetts since 2003. The group, which includes 

, report that participating clinicians wrote 2.1 million electronic scripts during the first half of 2008. Automatic checking for drug—drug and drug–allergy interactions at the point of care led to 104,000 prescriptions being changed in 2007, potentially preventing thousands of medication errors, according to the eRx Collaborative. Nationally, the 

 estimates that medication errors cause 7,000 deaths and 1.5 million injuries annually. “It’s the old thing that I don’t know what I don’t know,” says Rick Spurr, chief executive of Dallas-based ZixCorp, producer of PocketScript e-prescribing software for personal digital assistants and other mobile devices. What doctors don’t always know is the complete list of all medications a patient is on, patient-specific allergies, and—without actively taking the time to consult a reference guide&mdash;all potential interactions. E-prescribing software checks the relevant databases automatically and provides immediate warnings. The proper technology also can connect to payer formularies so the prescriber knows exactly what the patient’s health plan covers, and at what cost to the patient. Elsewhere, Zix alone has announced regional partnerships with 

 in Los Angeles County, and Blues plans in Louisiana, Illinois, Alabama, and Pennsylvania. 

Blue Cross and Blue Shield of North Carolina

 (BCBSNC) started an e-prescribing incentive program in early 2006 by covering the cost of PDAs, e-prescribing software, and wireless Internet interfaces for about 1,000 physicians in the state. But utilization initially was very low; less than 1% of all prescriptions that BCBSNC processed statewide in 2006 were electronic, according to Ron Smith, PharmD, vice president of employer health and corporate pharmacy for the health insurer. “The No. 1 complaint from physicians was that pharmacies weren’t participating,” Smith says. So North Carolina Blues added incentives for pharmacies to connect to the Pharmacy Health Information Exchange, an e-prescribing connectivity service operated by 

National Association of Chain Drug Stores

National Community Pharmacists Association

. Smith says 87% of North Carolina pharmacies are capable of receiving e-scripts, higher than the national average of 70—75%. SureScripts says that 98% of chain pharmacies are connected, though only about one in five independent pharmacies is part of the network. The health plan also teamed with 

, a state-run network of small, rural healthcare providers that serve Medicaid patients to help train physicians to use e-prescribing technology. After bumping utilization up to about 2% in 2007, North Carolina Blues offered some more financial motivation last year, a one-time bonus of $1,000 to physicians who registered with a certified e-prescribing vendor and then accessed medication history online for at least 20 patients during the fourth quarter of 2008. Payments will go out in the first quarter of 2009 for about 2,000 doctors who qualified, Smith says. At the same time, the Blues entered into partnerships with several technology companies to offer discounted e-prescribing hardware, software, and wireless services, including a free e-prescribing service through a portal on the BCBSNC website. The latter comes from the 

National ePrescribing Patient Safety Initiative

, an initiative spearheaded by Chicago-based health IT vendor 

Allscripts, in part, sees the free service not only as a means of boosting e-prescribing, but also as a way to drive interest in EMRs. “It leads to questions about what’s the pathway from e-prescribing to a full EMR,” says President and Chief Operating Officer Lee Shapiro. “Doctors know that they’re going to have to do more,” agrees David Rosenblum, president of 

, a healthcare revenue cycle management and practice management firm in Somerset, NJ. MTBC added e-prescribing services to its portfolio last July. “Right now, we’re at the point where people are asking questions,” Rosenblum says, though physicians are not exactly jumping on the e-prescribing bandwagon just yet. One major reason is that the 

 currently prohibits electronic prescribing of controlled substances, forcing doctors who prescribe Schedule II drugs to choose between either running dual systems or simply sticking with paper. The choice usually is an easy one. Though the DEA has proposed easing the restriction, former acting CMS Administrator Kerry Weems said that as long as the bar remains in place, Medicare will not penalize providers in the bonus program for writing paper prescriptions for controlled substances. Physicians are still eligible for the bonus if the patient specifically requests a paper script. Since the MIPAA incentive is new, CMS does not have hard numbers on participation, but the agency is pushing e-prescribing as a way to save taxpayers money. The agency estimates that Medicare could save $156 million over the five-year life of the program through error prevention and efficiency improvements, but that figure is based on the 6% of US physicians said to have e-prescribing systems at the end of 2007. That number now is closer to 9% and rising. “E-prescribing needs to be routine in every doctor’s office and every clinic in America,” Weems said at an October conference meant to drum up interest in the Medicare incentive. Weems had a lot of help from other e-prescribing advocates, including former national health IT coordinator David Brailer, MD, PhD, who called e-prescribing “bite-sized in terms of what physicians need to change and do,” something that will help doctors make the first step toward full EMRs. “You won’t go wrong investing your time and money,” said Brailer, whose San Francisco-based investment firm 

 for one of its first investments. “What’s the thin end of the spear? What’s the thing that really drives this [technology] into physician offices?” Brailer asked. He said e-prescribing is the answer, and that bonus payments are the enticement. “Doctors are never sure what to focus their time on, so they do follow the money,” he said. Whether an extra 2% of total Medicare billing is enough to shift doctors to e-prescribing remains to be seen. But in this economy, every little bit helps. “I don’t have any question that e-prescribing is going to happen,” Spurr says, “and the health plans are going to play an important role.” 

Unlike so many other forms of information technology, electronic prescribing seems to be winning over physicians. Though the vast majority of prescriptions still are written by hand, those who have tried e-prescribing are pretty much thrilled with it—at least according to one survey. More than 70% of e-prescribing users in the four-year old Southeast Michigan E-Prescribing Initiative (SEMI) were “highly satisfied” with the technology. “When we saw that number, we nearly fell out of our chairs,” says SEMI project manager Anthony J. Schueth. Only 6% of the 500 respondents expressed a high level of dissatisfaction. SEMI started in January 2005 as a way for the Big Three US automakers to reduce healthcare expenditures on their Detroit-area employees and retirees&mdash; the very same benefits blamed for adding $1,500 to the price of every vehicle 

, as well as pharmacy benefit managers and technology vendors. The program has since expanded to include 12 Detroit-area physician organizations. Through November, 3,375 physicians had enrolled in SEMI. About 500 took the survey. A whopping 90% of participants said that their current e-prescribing systems either met or exceeded their expectations. Nearly three-quarters indicated a belief that e-prescribing improves patient safety, and close to 70% said the technology raises the quality of care. Though there was no consensus on whether e-prescribing saves money for patients and practices, a majority of those surveyed said that e-prescribing saves them time and makes clinicians more efficient. Payers like it, too. “There’s a real return on investment. It’s not just conceptual anymore,” Schueth said during a January 14 Webcast on payer-sponsored e-prescribing efforts, convened by a national project called the 

Will private payers follow Medicare’s lead and reimburse for e-prescribing? Are the workflow disruptions associated with this technology a bigger barrier than proponents claim? Is a 2% Medicare bonus payment enough incentive?

Neil Versel is a freelance writer and proprietor of Neil Versel’s 

Who will lead the way in promoting greater adoption of e-prescribing, and how can physicians get the most out of using this technology in their practice? 

As Medicare Goes, so Goes Managed Care (Or so the Saying Goes)

Much has been made of the American public's general lack of health literacy and the effect it has on patients’ abilities to make informed health decisions. A key component of health literacy is the ability to understand statistics and concepts like “probability” and “risk.” Thus, it is important that physicians be able to explain these concepts in a way that enables patients to incorporate the information into their decision-making process.

 Life is uncertain, and, as stated by Kathryn Montgomery in her treatise 

, “few experiences feel as uncertain as illness.” Furthermore, what is true for patients is equally true for their physicians. Uncertainty has been rightly 

 as “a fundamental feature of medicine… the physician’s constant companion.” Much of medicine is, in fact, about making effective decisions in the face of uncertainty. 

Sound medical decisions depend on an informed physician and an informed patient. Physicians must know or be able to find relevant data to support assessments of the risks and benefits of studies and treatments. They must understand the limitations of such data along with basic statistical concepts of uncertainty. Furthermore, physicians must be able to communicate this information in such a way that a patient can comprehend it within his or her unique cultural and educational background and values. Clearly, guiding patients to sound, informed medical decisions in the face of inherent uncertainty is no small feat. 

Much of the medical decision-making process involves evaluating risk. Risk is 

 as uncertainty about the state of the world that can be quantified as a probability. Assessment of risk therefore depends on the availability of reliable empirical data. Unfortunately, in spite of the advances made by evidence-based medicine, such data often remains illusory or incomplete, introducing uncertainty even into the things we “know.” 

Risk is classically expressed using several methods. The absolute risk reduction (ARR) (or, in the case of harm, absolute risk increase) is the most straightforward measure of risk. The ARR is defined as the absolute difference in the proportion of treated and untreated patients who experience an outcome. Another commonly used measure is the relative risk ratio (RRR). RRR is the difference in the proportions of untreated and treated patients who experience a particular outcome relative to the proportion of untreated patients who would experience the outcome. The major problem with RRR is that relative risk measures tend to exaggerate small differences in effect (it is for this reason that relative risk measures might be preferentially reported when the purpose is to support sales of a product or to create sensationalism). 

Another risk descriptor preferred by many is number needed to treat. The number needed to treat is the reciprocal of the absolute risk reduction and represents the total number of patients who must be treated to produce the target outcome in one patient. Number needed to treat has the advantage of facilitating comparisons of risks and benefits between several options. The smaller the number needed to treat, the better the treatment. Conversely, the larger the number needed to harm, the less the risk. 

The relative merits and disadvantages of using each of these measures to communicate risk can be illustrated by the following example. Suppose 100,000 subjects are given a drug thought to prevent death from heart disease and 100,000 subjects are given placebo. If two subjects in the control group die while only one in the drug group dies, the absolute risk reduction is 1/100,000 (2 out of 100,000 minus 1 out of 100,000). If a similarly designed study of 100,000 subjects using another drug found that 20,000 control subjects and 10,000 drug subjects died, the absolute risk reduction would be 10,000/100,000 (20,000/100,000 minus 10,000/100,000). The number needed to treat in the first study would be 100,000, whereas it would be just 10 for the second. In essence, the second drug is 1000 times more effective. This benefit is completely obscured, however, if expressed as relative risk reduction (a 50% reduction in each study). Clearly, RRR is not the best way to convey risk information. 

Do doctors and patients understand risk? 

It turns out that a large proportion of people, including otherwise well-educated adults, simply do not know how to think and understand using numbers. This problem has been termed innumeracy by the mathematician 

. Kurz-Milcke and colleagues describe one 

 that reported findings in terms of a relative risk: 

“In the mid-1990s, the British press reported the results of a study that women who took [a particular] contraceptive pill increased their risk of thromboembolism by 100%... Hearing the bad news, thousands of British women panicked and stopped taking the pill, which led to a wave of unwanted pregnancies. But what did the study in fact show? Out of every 14,000 who took it, this number increased from one to two. That is, the absolute risk increase is 1 in 14,000, but the relative increase is 100%. Most of these women, like the majority of people, had never learned the difference between absolute and relative risks and thus could easily be frightened by the 100% figure.” 

 that found that 88% of subjects indicated they would take a hypothetical lipid-lowering drug that would result in a 34% reduction in heart attacks (relative risk reduction), but only 42% would take the drug when told it would result in 1.4% fewer patients having heart attacks (the equivalent absolute rate reduction). When informed that 71 subjects would have to be treated for five years to prevent one heart attack (the equivalent NNT), only 31% would do so. Yet, 

 that death rates expressed as “1,286 out of 10,000” were rated by subjects as more risky than rates of “24.14 out of 100.” 

Unfortunately, statistical innumeracy is not limited to the lay public. Hoffrage and Gigerenzer 

 48 physicians with an average of 14 years of professional experience. Each physician was asked to estimate the chances of breast cancer in a woman age 40-50 years given a positive routine screening. Physicians who were given the relevant information in probabilities (eg, 0.8%) estimated the likelihood to be between 1% and 90% with surprisingly little consensus (the correct answer was 9%). Physicians did better when they were given the same information in natural frequencies (for example, “8 out of every 1,000”) instead of probabilities. Presented this way, the majority were able to respond with the correct answer or close to it. Other researchers 

 similar results. Since patients also find percentages difficult to comprehend, it is suggested that risks always be considered and described in terms of natural frequencies. 

Some patients prefer to avoid any reference to numerical descriptions. For example, Woloshin and colleagues 

 that nearly 30% of subjects preferred that risk information be conveyed using words only. However, avoiding numerical risk information did not remove the potential for misunderstanding. Only 80.3% of their subjects agreed that “certain” meant 100 of 100 people, and only 67.8% agreed that “never” meant zero of 100 people. As would be expected, words describing less polarized alternatives were even more ambiguously interpreted. 

Newer approaches to communicating risk involve visual representations designed to convey information more intuitively. One simple approach uses a diagram containing 100 icons designed to represent patients and possible outcomes. For example, an absolute risk reduction of 7% might be visually represented by shading seven of the 100 icons differently to indicate that this number of patients would be expected to benefit from a therapy relative to the total population of 100. Such a diagram incorporates the advantages of absolute risk reductions represented as a natural frequency. Rifkin and Bouwer 

,” a simple graphic illustration of a typical theater seating chart with 1000 seats. In this easily understandable example of a population sample, seats are colored differently to indicate the number of individuals in a hypothetical theater audience who would be expected to experience a given outcome. 

Dr. Chris Cates has further extended visual risk representation in an innovative and entertaining method that represents numbers needed to treat and/or numbers needed to harm in a single diagram (Figure 1). In my opinion, this clever plot provides a significant and practical advance in risk communication. Furthermore, Dr. Cates has created the program 

, which allows anyone to generate such a plot by entering data available from the medical literature for the condition and treatment of interest. 

Given the difficulty that both patients and physicians have in innately understanding numerical concepts of risk and the lack of consensus about the meaning of even commonly used words to describe uncertainty, how can we communicate risk to patients? Are there available guidelines? 

First, clinicians must be sure that they understand the merits and drawbacks of the commonly used measures of risk, as reviewed above. Risks should be communicated using absolute measures, such as number needed to treat (or harm) and absolute risk reduction (or increase). Given their inherent potential for misinterpretation, relative risk measures should generally be avoided in discussions with patients. Probabilities should be described as natural frequencies instead of percentages, and commonplace words such as “likely” and “uncommon,” if used, should be defined as explicitly as possible. Visual aids, such as the Risk Characterization Theater and Cates Plots, may be particularly helpful in conveying quantitative concepts more intuitively. 

Apart from the content, attention should also be given to the context in which risk information is given. For example, patients 

 to be sensitive to the ways in which risk information might be framed. Framing the benefit of a screening test in terms of what the patient might lose by not having it has been shown to be more persuasive than framing involving potential gains. Likewise, framing risk information in positive terms (for example, chance of survival) is more likely to persuade patients to accept risky options than information presented in negative terms (chance of death). 

Risk communication is multidimensional and must be primarily patient-centered. To remind physicians of this, 

, suggest approaching risk communication using the mnemonic RISK: R — Relate relevant evidence; I – Individualize the message, using a flexible approach; S – Seek the patient’s perspectives and share the decision-making; and K-checK the patient’s understanding, monitor, and review decisions. In regard to the last point, I have found that asking a patient to teach back to me what I have just explained is one of the simplest ways to find out whether or not they truly comprehend the message. 

We cannot attain certainty in life (with the exception of death and taxes, according to Benjamin Franklin). At best, we can try to offer clear information to our patients by attempting to quantify and communicate anticipated risks. Ultimately, the success of that communication will not be gauged by how we convey risk information, but by whether or not it is understood by patients who make important decisions based on the information we provide. Certainly, we owe this to them. 

 editorial board member, and assistant professor of clinical medicine and associate program director in the Department of Medicine at the University of Illinois College of Medicine, Peoria, IL.

The Cates Plot shown above is an example of the output from a Cochrane Review of the use of antibiotics in Acute Otitis Media (middle ear infection) in children. The data is taken from the Cochrane Library 1999 issue 4.

A key component of health literacy is the ability to understand statistics and concepts like "probability" and "risk."

March 2009

Gimme Shelter: Are Financial Safe Havens Truly Safe Anymore?

The Costs of Medicare HIT Mandate Noncompliance

Wellsphere Blogger Flap Raises Questions about Content Ownership

Argumentum Ad Populum: Medical Wikis 101

The ABCs of Location-based Services

As Medicare Goes, so Goes Managed Care (Or so the Saying Goes)

The Risk of Risk: Explaining Difficult Concepts to Patients

Automating the Documentation and Coding Process

Interoperability Is the Key to a Patient-centric Transformation of the Healthcare System

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