Are Doctors Lobbying Themselves Out into the Cold?

When I wrote this blog, I had suspicions that this was the case, but not enough information to include it then. And did it happen – three days after my post. Nurse Practitioners (NPs) are being targeted very heavily as medical boards lobby state legislators to limit what NPs can do and not do. If they continue to lobby for restrictions on NPs, you can almost understand what patients are going to say when they have to wait to see a doctor when NPs are available. It isn't going to be pretty when they learn why the NP cannot see them and they must wait many months to resolve a health problem. If you think emergency rooms will pick up the slack, this may or may not happen

This is some startling facts you need to be aware of and understand about the positions of our medical professionals. Currently there are 18 states and the District of Columbia that allow nurse practitioners to diagnose and treat patients and prescribe medications without a doctor's involvement. On the other side, 32 states require a physician's involvement to diagnosis and treat or prescribe medications, or both. The National Conference of State Legislatures reports that as of February 2012, 245 bills had been introduced in various state legislatures related to changing scopes of practice. About 50 of these bills would affect nurses, including advanced-practice nurses. It looks like our physicians are out to hamstring their own profession, by shutting out the people that could come to their assistance.

What are the issues? Nurse practitioners are a type of advanced-practice registered nurse. They are registered nurses who have also obtained a postgraduate nursing degree, usually a master's degree. Doctor groups are claiming that NPs will create safety concerns and must be restricted in their scope of practice. At the state level, the battles are being waged by the medical boards and the legislatures to determine the scope of practice for non-physicians, including nurse practitioners. At the federal level, the problems are on the NP's ability to be reimbursed for the care they provide.

Because of the predicted shortage of primary care as the population grows and as millions of people become newly insured starting in 2014, one of the proposed solutions is to expand the role of nurse practitioners in many more areas of the country, and to allow them to provide a wider range of preventive and acute health care services. Many areas of the country will be without medical care if the physician shortage becomes as severe as some are predicting. Rural areas will be particularly hard hit and residents will face long commutes to see a doctor. Even some small cities will have limited numbers of physicians.
 

The above map presently shows where nurse practitioners are appreciated and valued and the states where physicians in general don't want them. I am pleased that my state still values them.

Some of the problems inherent in the physician shortage will be the compromise of a broad range of medical services. This will include initial valuation of new symptoms, ongoing care for chronic diseases, and many of the preventive services. If continued restrictions are placed on nurse practitioners, the absence of availability of primary care will mean increased mortality, increased emergency department visits (if these remain available), and increased hospitalizations at hospitals distant from the patient's residence.

I wish there were maps available to depict the areas that the Health Resources and Services Administration (HRSA) says that people are uninsured, isolated, or medically vulnerable. The HRSA says it has identified roughly 5700 geographic areas containing 55 million residents as being in primary care health professional shortage areas. To satisfy the target ratio of one primary care practitioner for every 2000 residents, more than 15,000 additional practitioners would be required. Primary care shortages will increase if the current trend continues.

For the last decade at least, there has been less medical graduates entering the primary care arena. The pay for specialists is the biggest reason for the decline in primary care. Some policy makers are urging that there be pay equality to bring more physicians into primary care. They are suggesting loan forgiveness programs for physicians who practice in under served areas.

What many physicians are unhappy about is the increasing research that clearly demonstrates that patients want primary care and this is more important that who is providing these services. A careful review of 26 studies published since 2000 found that health status, treatment practices, and prescribing were consistent between nurse practitioners and physicians. Two other factors that are important are – patients say they have higher levels of satisfaction with their care from NPs, and NPs have a better reputation than physicians when evaluating patient follow up, time spent in consultations, and other measures. I don't agree with this, but it may be part of the equation to fill in the gaps in primary care. “Nurse-led clinics may provide care in under served areas or meet the demand for more convenient care by providing a limited number of low-intensity, commonly needed services, in locations such as retail stores.”

Many advocates say that changes in federal and state laws need to be made to remove barriers to the advancement of nurse practitioners. However, many physician groups, chief among them, the American Medical Association, assert that encouraging patients to see nurse practitioners rather than primary care physicians may put patients' health at risk. This assertion is not supported by evidence and even the Institute of Medicine (IOM) is speaking out in favor of allowing nurse practitioners to fill the gap being created by the primary care physician shortage.

“The IOM recommended specifically that state legislatures reform scope-of-practice laws and regulations to conform to the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, which outline scopes of practice for advanced-practice registered nurses. It further recommended that state legislatures require fee-for-service plans within the state to similarly cover nurse practitioner services. At the federal level, the IOM recommended that the Federal Trade Commission identify state regulations related to advanced-practice nursing that have an anticompetitive effect without contributing to the health and safety of the public, and that states be urged to change such policies.”

“The IOM recommended that Congress change the Medicare law to make coverage of nurse practitioner services consistent with coverage of physician services. It further recommended that the Centers for Medicare and Medicaid Services clarify that hospitals participating in the Medicare program must allow nurse practitioners to have clinical and admitting privileges and to be eligible to be on the medical staff. The IOM also endorsed the notion that the federal government should require plans participating in the Federal Employee Health Benefits Program to cover services provided by nurse practitioners operating within state laws.”

Whether the Institute of Medicine's recommendations will be enough to tip the scales for nurse practitioners, at lease members of state legislatures around the country have something to support changes and no longer have to listen entirely to self-serving physicians.

Helping a Spouse That Has Diabetes

If you have been reading David Mendosa's blog, “Suppose Your Husband Has Diabetes” and found your way to my blog, thank you. David has much more experience with this than I have by about 17 years. He has been writing about diabetes that much longer. I still enjoy learning from him, but I was surprised in our discussion that he has not some successes. He may have had some success and not realize this because the wives asking for help did not continue the discussion.

I don't think either of us has a corner on this discussion and I do think I have been extremely fortunately to have had some success. Naturally, we can view situations differently and this is to be expected. He views most things in a positive light, whereas I can go off on a tangent and totally make a mess of things. This has taught me to read emails seeking help with a very jaundiced eye and I admit I often try to read between the lines. Most are looking for help, but what kind of help needs to be determined. Most of mine have been wives looking for help, but not exclusively.

As a result, my first reply is seeking information on which to base future replies. Some spouses do know the stage their spouse is at, but most often, they do not. Until Gretchen Becker wrote her blog on July 20, 2012 and I wrote mine on July 4, 2012, I would summarize the stages from Gretchen's book The First Year - Type 2 Diabetes, New York, Marlow & Company, 312 pages. I have both the first and second edition, and I highly recommend reading it.

It is the first stage – shock, anger? Is it the second stage – most often denial? Is it depression? I seldom ask about whether the spouse has accepted the diagnosis because if this were the case – most often the call for help would not have been needed. I also ask the age – the younger, the more likely a possible mis-diagnosis and I want them to be sure. Sometimes this leads to what tests were done and further discussion. One time this did pay off and the spouse did have LADA, not type 2 diabetes.

How I proceed from here depends on what I can read between the lines. Then I wait for a response. In most cases, I do receive a reply that they are even more confused and I know that the task is even more difficult.

Some do reply denial and I have had a few say depression – from minor to serious. I immediately reply to anyone thinking serious and advise them to call the doctor and get the doctor to see them as soon as possible and see if it is indeed depression. One was and after treatment – the spouse was back to normal self and took responsibility for his diabetes. Others were in a combination denial and minor depression and were able to recover after I explained that diabetes was “not their fault.” I do explain a little about genetics playing a part and whether they may have triggered it early by their eating habits, they would have likely developed diabetes later.

The spouses that are looking for true help will do what is necessary. I do make the suggestion that the wife encourage and challenge her husband to be the husband she knows he is and take charge of his diabetes. I try to get them to be positive and tell their husband that they can live a long and happy life in spite of diabetes and encourage him to come out if his shell and join her. Those spouses who know how to apply this are the most successful and resulted in two of the husbands actually replying to me and asking questions. One other wife did tell me that this worked and her husband was taking charge of his diabetes. She said he was reading about it, but she felt it could be some time before he would talk to others about his diabetes. All of them put the ownership clearly on the husband and encourage him by saying she knew he was capable, and that she was there for support and as a resource if needed.

I have used this on occasion, but don't like to. One husband was asking for help and could not get his wife to take ownership of her diabetes and I think he really tried from what he was telling me. I suggested that he tell her he was making sure that her life insurance was paid. He went further and added that because they could afford additional insurance, he was meeting with the agent to get additional insurance under the guaranteed clause in the policy. In this case, it worked because she was finally convinced he was not going to manage her diabetes. This can backfire badly, and is the reason I don't recommend using this.

In all situations, it is important to have the spouse take ownership of their diabetes and the other spouse to give them positive encouragement and do this patiently. Like David said, “nagging is not productive.” David covered the other points and I won't duplicate his work. If either of us has given you ideas – great – make use of them.

Vote

Tuesday is an important day!  It does not matter which political party you are member of or if you are what is determined as an Independent.  Please make sure you exercise you right to vote and get it done.

                                  V O T E           V O T E


Early voting is over in those states that allowed it, so find out where your voting place is and go VOTE!

Why Some Medical Practices Are Successful

Defining and discerning why medical practices are successful or even wildly successful is more difficult than often why they fail. While it does not require a masters in business administration, it does require understanding some business principals. Here is a list of reasons some medical practices are doing so well and being very successful:

It is treated as a business – meaning that the decisions made about staffing and duties of staff are well defined and often some staff members are cross trained to cover more than just one facet of the duties. Office managers know how to motivate office staff and make them want to be more efficient and productive.

The rules of HIPAA are laid out and everyone understands them and knows the consequences of violating them. This also means they know the rules and don't try to hide behind them and hide essential patient information from that patient. I even had one nurse say no to me about discussing a medication with my wife, even after I directed her to because my wife is a certified medications aid and I wanted to know what she thought. The nurse said no a second time and I said “lawsuit”. She panicked and went to get a second opinion and came back very apologetic and explained the medication to both of us. My wife had her PDA with the drug information on it. She said no that the medication had sulfa in it and I was allergic to sulfa. The nurse was going to give me the prescription anyway and I said I would be in the hospital and maybe not even make it when I could not breath. With that she brought the doctor back and when he heard that I was severely allergic to sulfa drugs, he said that would not work and issued another prescription after talking with my wife.

There is no substitute for an entrepreneurial spirit. This means not focusing on the problems of our current healthcare system, but looking for opportunities to work with what we have and making it work for you. It is not waiting for organic growth, but being positive and seeking out new opportunities to grow and raise revenue.

Have a strategy and a plan that is understood and followed by everyone. It does not matter the simplicity or how complex the strategy and plan is, it is presented and explained to everyone until it is understood. This means that the strategy and plan are open to discussion and if someone sees something that could be improved, it will be discussed and a change made if it is beneficial. This often converts people to the system and creates a willingness for people to work harder.  Visibility is imperative to growing the practice. This means visible in the community, doing some advertising, and even volunteering for community events when possible. Every community activity is not necessary, but if members of your practice have community interests, encourage them to participate in that interest. Let people know about the practice and do not hide from this.

A world of potential in reliable data is often available, but unless it is used, it will not help generate a profit. Do not guess what something costs, when payers will make a payment, or which payers are problem payers and use the information available to correct the problem. Practice management programs can produce volumes of raw data, but unless it is properly programed, the data means nothing and is wasted information. The same can be said for electronic patient data. If something can be added to present the data in a more usable form – make it happen.

A patient-centered culture makes a difference and this should be nurtured and practiced to the utmost. While some physician-owners believe this will take care of itself, those that are successful do not make this assumption and strive every day to cultivate this unified patient-centered culture. The physician-owners exemplify this when they hire to find new doctors and staff that share their goals and work ethic. It is their desire that every time a patient has contact with the practice, they feel that the practice has their best interests front and center.

Strong leaders and an outstanding staff is part of a successful practice, but only if they work well together and as a unit. Great physicians do not micromanage. Instead they hire capable staff and see to it that they stay current in their training, surround them with updated technological tools to assist them in being efficient in their work and handling everyday tasks of making the practice profitable. Strong leaders can step back knowing that they are spending 95% of their time seeing the patients. The other 5% is spent monitoring and checking the state of the business, in other words focusing on the big picture and what will be advantageous for the practice. Successful practices will use physician assistants and nurse practitioners to expand their services and provide excellent care thus earning a high return.

Willingness to create helpful partners when needed is a hallmark of a successful practice. These practices know when to seek expert advice and make efficient use of it. Often this means using outside practice management and communications services. These services often can create more efficient and improved customer care.

Great doctors are continually working to be more efficient, productive, and disciplined with their time usage. They rely on effective practice management tools to boost efficiency and productivity. When physicians and staff are more efficient with their time, the improved work flow creates a more professional, calm environment, which benefits staff and patients in many ways.

As a patient, I admit that I enjoy keeping some of my appointments because I know that I can see the efficiency and work flow progressing smoothly. If the doctor had an unforeseen situation arise, no excuses are being made, and the facts are presented – like a patient needed to be admitted to the hospital or the doctor needed to spend more time with a patient. This is presented and they keep working and when the doctor arrives, you are not treated differently or made to feel they will be curtailing the time spent with you.

Those that I don't enjoy (aside from not feeling good to begin with) always have an excuse for everything and leave you wondering if they know what to do and why. The doctor tries to be calm, but if he is operating behind schedule, you get the feeling that he is trying to short cut the appointment to get to the next patient.

This is bound to happen in every practice – a patient fails to keep an appointment and the doctor has time available. This is one reason I generally try to be early to all my appointments and more than once was able to get in early. One doctor took time to thank me and say that I and the next patient were early and thus they would be able to schedule a patient from the call list that was local and could get in timely.

So if you are the patient and are able to discern what is happening, cherish those where you are the center of their world for the time allotted and realize that even then they can have interruptions.

Interesting Ploys to Make Spam Comments

I have to write this. I disabled captcha so that people would be able to post that were having trouble with this. It has spawned many computer-generated comments, which fortunately the spam or delete key takes care of. First, if the comment is from “anonymous”, that is the first strike against letting the comment to be posted. Second, if they are foolish enough to think I am allowing advertising of other products or even diabetes products, I will state, at present I am not even allowing Google to place ads on my blog. If you think I will allow you – no way.

I do allow myself to write about products when I feel there is a need to make people aware of them, but that is as far as I will take it. I have a couple of anonymous posters that do not use English and I will not allow this especially after putting a few through a translator. For the few that think they are going to get their pron sites listed – forget it. I will continue to leave moderation in operation, which will prevent these comments from being posted, and I do check them. I almost let one through, but after checking a link in their blog that looked innocent enough, my anti-virus program stopped access for the link – you guessed it – I clicked on the spam key and deleted the email notification. I will not knowingly allow links to viruses,

Several of my email followers have thanked me for removing the captcha, but as of yet they have not posted to my blogs. One did ask if I would even allow him to post as “anonymous” because he will not create an account on Google. I told him yes as long as he does not try to promote his product and asks questions or makes comments like those that he does in his emails.

There are a few that have programs that post comments to blogs that don't have the captcha activated and I understand their need to flood the blogosphere with their drivel. However, with moderation activated, the delete key is very handy.

Will Congress Revisit Compounding Pharmacies Issue?

How many more deaths is it going to take to convince our congressional leaders to do what should have been done about a decade ago. Compounding pharmacies have lobbied so long and hard on Capitol Hill that they have been able to remain unregulated. This is a little-known fact about the pharmaceutical industry and how they have been able to operate without supervision for so many years and out of sight of the public. The pharmaceutical industry through their compounders has been able to lobby against regulation oversight and impress the politicians and their staffers for the need of compounding.

If congress does not act, some groups may be able to if they follow actions by Sandra Fusco, director of patient advocacy at Allergy & Asthma Network Mothers of Asthmatics. She took on the Compounding Industry and succeeded in forcing them out of the nebulizer drug business. When the nebulizers were found out to have contamination and poor potency, she and her supporters succeeded in getting insurers not to reimburse for compounded nebulizer drugs. This may be one way to force compounders to correct their errors. Don't take this to the bank as the compounders are well established on Capital Hill and know how to bring in people to plead their case for drugs not otherwise available in regular channels.

Even some of our well-known hospitals are not ordering medications from certified pharmacies. John Hopkins University had scientists investigate bacterial infections in six intensive care unit patients. They traced the infection to contaminated fentanyl from a compounding pharmacy. The trouble is they assumed any drug bought in large quantities by a healthcare facility comes from an FDA-approved and licensed manufacturer. When this information was shared with the hospital pharmacists, they said they could not stop ordering from compounders: they were the only source of the fentanyl doses the ICU needed.

Even with deaths from medications received from compounding pharmacies, only 162 of several thousand compounding pharmacies have become accredited. In order to obtain accreditation, an on-site inspection is made to assess workers' competence, equipment, record keeping, air quality and clean-room qualities meet certain standards. Even this has not made the market demanding accreditation. Who pays the price for this lack of oversight – the patients of course!

“Now, as the deaths and illnesses mount from fungal meningitis linked to a contaminated steroid injection, the question of why early concerns about pharmacy compounding did not change U.S. law is a top focus for patients, regulators and lawmakers.”

The FDA has traced the steroid injections to New England Compounding Center, or NECC, a Framingham, Massachusetts compounding pharmacy founded in 1998. Unfortunately, this is just the tip of the problem with much wider implications. It is highly doubtful that this will bring about actions necessary to bring these compounding pharmacies under FDA control or even oversight. We don't know how much is being funneled into campaigns to insure no legislation will result.

You can be sure that once the elections are over, lobbying will begin in earnest and these compounding pharmacies will go to their people that rely on their compounds to lobby on their behalf. This problem with the compounding pharmacies is one that I hope Congress will finally do something to bring them under supervision and closer regulation. I nothing more stiff penalties need to be imposed and I am not suggesting a few thousands, but a minimum of half a million since these compounding pharmacies a killing people because keeping equipment sterile seems to take second place to profits.

Other information can be read here about a congressional representative calling on the Department of Justice to conduct an investigation into whether NECC violated federal laws designed to stem illegal activity in controlled drugs. Then this article discusses some of the other compounds involved in the meningitis outbreak by NECC.

And now there is new information about the sister compounding pharmacy in Westborough, Massachusetts.  This compounding pharmacy, Ameridose, has issued a recall of all its products in cooperation with the FDA investigation because of sterility issues. 

FDA Warns Most Online Pharmacies Fake

Two topics have come to the fore in the last month. The first is online pharmacies and the National Association of Boards of Pharmacy and the Food and Drug Administration are both warning consumers about the dangers. The second and equally serious problem is the Compounding Pharmacies that are at present unregulated. This will be my topic for the next blog and I am focusing on online pharmacies in this blog.

“Of the 10,065 online pharmacies in the NABP study, 9,734 -- 97% -- violated state or federal laws and/or NABP safety and practice standards.” This means that 331 online pharmacies may be legitimate or only 3 percent may be trustworthy. The FDA is right in issuing warnings that online pharmacies are an emerging health threat. Personally, I will never use an online pharmacy just because of the above. In addition, the many spammers employed by these people continue to fill my one email inbox and attempt to get their garbage through comment moderation on this blog. Thank goodness for the delete or spam key that is easy to use.

What is not surprising is that when they are found out, they just shut down the site and open another often before the other is shut down. They never miss an opportunity to pedal their snake oil. Many of these fake pharmacies are so good at what they do that it takes experts to discern the fake from the real drugs. The patients often do find out when they take the fake drugs and their medical condition worsens, or when they have to go to the emergency department for unknown causes. Unfortunately, some never make it to the emergency department, but to the morgue.

“A group of interested companies has formed the Center for Safe Internet Pharmacies. The founding members of the CSIP include American Express, Discover, eNom, Go Daddy, Google, MasterCard, Microsoft, Neustar, PayPal, Visa, and Yahoo. CSIP has an online pharmacy checker at safemedsonline.org, where consumers can check out and report rogue pharmacy web sites.”

The company in the list above I really must wonder about is Yahoo. It seems like Yahoo sells their email lists to these fake pharmacies as these make up the bulk of my spam emails along with another group of sites. This is unproven, but may be what happens.

Fake online pharmacy warning signs include many of the following - The FDA warns consumers to beware online pharmacies that:

1. Online pharmacies may offer low, low prices.

2. Allow you to buy drugs without a prescription from your doctor.

3. Offer deep discounts or cheap prices that seem too good to be true.

4. Send spam or unsolicited email offering cheap drugs.

5. Are located outside of the United States.

6. Are not licensed in the United States.

The following list may indicate a safe online pharmacy:

1. Always requires a doctor's prescription for prescription drugs.

2. Provides a physical address and telephone number in the U.S.

3. Has a pharmacist available to answer your questions.

4. Is licensed with your state's board of pharmacy.

Why Some Medical Practices Fail

On the surface, this seems like a no-brainer, but the outcome is in the details. It is often easy to see why some practices fail and many patients are often the cause of a medical practice on the margin not staying in existence. Word of mouth is very strong among patients that are not happy with the care they receive and can be the cause of a practice not succeeding.

Many years ago, I was a patient in a practice that was not doing well and I had to evaluate if I was going to stay or try to find another doctor. More than once, I was told that a test result was in the mail and never would receive it. Then one day I happened to be in the waiting room and heard the office manager tell a patient that something was in the mail. As soon as she hung up the phone, she and the receptionist were joking about it and went back to exchanging the latest gossip about a patient. I don't know whether they knew I could hear or even cared that other patients in the waiting room could hear, among them the patient they were talking about.

I could see the patient getting very red faced and it was not long before she got up and walked out the door. Then another patient got up and left and only two of us were left to listen to the two of them continuing to run different patients down. As the two of us got up to leave, the nurse was at the door calling my name. The other fellow continued to walk out the door. The nurse wisely waited until she had me in the room and asked why patients were walking out. I told her none too politely that it was the office manager and the receptionist causing patients to leave. She stated that the office manager was the doctor's niece and nothing could be done about this. Then she stated that this was her last day at the practice, as she could not get along with the office manager.

Shortly, the doctor walked in and I admit I was not it the best of moods. When the doctor asked what was wrong with me today, I opened up with both barrels and probably said more that I should have, but I wanted him to know that I was leaving and why I was not coming back. This was long before HIPAA (Health Insurance Portability and Accountability Act of 1996), so there were no regulations in place to protect patient rights or privacy, only what the doctor determined was right and wrong. As I was walking out the door, the doctor said he would not fire his niece. I quipped that because of her he had lost four patients in less than an hour and he should reconsider.

Two months later the office closed and I heard the doctor was in a large city in another state. He did need to return for the trial against him, his niece, and the receptionist for defamation of character, which they lost. Shortly after all were gone out of town and I have heard nothing more about them. Before becoming a patient of my current doctor, I left two other practices as a patient because of overly chatty office personnel. My current primary care doctor is a hospitalist and seems to have new staff twice a year. On one visit that was my first question. He answered that seems to be the only way they could prevent overly chatty receptionists and others for violating HIPAA. The office manager is very strict about HIPAA and terminates any employee caught violating patient privacy rules with no second chances.

I did get an opportunity to visit with her and I can appreciate why the doctors like her so well. She requires every new employee to read the pertinent rules and sign that they understand them and what will happen if they are caught violating them. Her only comment that I agree and support is how often people think they can get away with looking at a patients record and then chat about it with other people. I could only say that three employees were people that I have seen for more than one year. That does not mean that there couldn't have been more tending to patients or on a day off. I do know that a few are rotated to other departments on a regular basis. I know of one that I see in different departments and she did say she likes the rotation for the variety of duties she can do.

The above is just one reason that physician practices fail. There are others – financial mismanagement, not making the patients feel welcome, doctor indifference, and communication failures. Yes, some practices hang around because the patients are totally passive and as long as they get the pill they need to resolve a health problem, the patients are none the wiser and care less about how they or the office is handling their records and problems within the office.

As patients learn more about HIPAA and become more empowered, this is slowly changing for the best. Patients are demanding better health care, respect as patients, patient privacy, and access to their health records. In many cases, patients are active in opposition of some budget cuts by Medicare that is damaging good doctors financially. One doctor that is in a clinic knows me and that I can advocate, asked if I would support him and others by writing our federal elected officials. He looked rather hurt when I said no. He did have the courage to ask why. I pointed out several personnel deficiencies I could see just standing in the hallway. We had an unobstructed view to the receptionist and billing department. Three employees could see us, but they continued chatting and one pulled out a patient file and they started talking about that patient.

The doctor was getting the idea and we moved to the other side of the hallway and closer to the talk. No, they were not talking about a coding problem in billing and it was rather clear they were talking about a patient and what the medical problems were. The doctor admitted he had heard enough and asked me to go to the waiting room and return with the two patients closest to where the employees were talking. I was surprised that no questions were raised when the three of us headed down the hall to the doctor's office. When we got to his office, he directed them into his office and got them seated. He then carefully asked them if they had overheard what the employees were talking about. One of the patients said she knew who they were talking about and was clearly upset about this. The other patient said she knew that they were talking about a patient, but did not know the person. At that point the nurse who had been with the doctor's next patient knocked and entered the office. When she saw the three of us, she apologized and started to leave, but the doctor asked her to stay.

He asked if these were his last two patients for the day and the nurse checked the schedule and said there was one more already waiting to see him. He asked if they could wait an hour while he corrected a problem and the two said they could come back another day, and they understood and appreciated his need to correct the problem. The doctor asked the nurse to take their names and phone numbers to call them later or the next day and reschedule them. He thanked the three of us for our information, said it would be taken care of immediately, and asked the nurse to escort the two patients back to the waiting room to leave. I started to leave and he asked me to stay and got the nurse to check if the patient was the one that was going to be leaving for vacation and he would see her if that was the case. She was not and agreed that she could come back another day.

The doctor accompanied the last patient out and asked the three employees to come to his office while the nurse and I answered the phone and took care of anyone coming in. The nurse was still in the dark and once the door to his office was closed, she asked if there was anything I could say. I said “HIPAA violation.” She said “good” and that was the end of the conversation. The nurse went to a filing cabinet, pulled out a stack of papers, sat down, and started looking through them. She stopped and asked what my position was and I stated just a friend of the doctors. I asked if she knew where the HIPAA file was. She said in the doctor's office, and I asked if any of the computers were hooked to the Internet and she stated only in the doctors office. Then someone came in and the nurse sent her directly to the doctor’s office and then said to me, “the payroll clerk.”

The doctor called the nurse and asked her to find three boxes for personal belongings and to stand by to enter his office when he brought each employee out. The doctor brought one employee at a time to remove her personal belongings and then escorted them to the door. When he was finished, he asked the nurse to get him the applications file. She handed him the file and she said the three positions for each were clipped together in the order she thought would help him. She said your friend has something to discuss about HIPAA. The doctor instead said he wanted to apologize to his nurse for not taking her serious and having a friend make him realize that things were not right.

Then he asked what was on my mind. I asked him if he had the HIPAA rules and he said he did. I told him it would be a good idea to have a copy together with a paper stating that the employee had read and understood them and a place for them to sign to that effect. Then a second page stating that if they chose to violate the HIPAA rules that they could be dismissed immediately and a place for their signature stating that they understood this. This would become part of their employee file. In addition another copy would be placed where they would see it each day.

He thanked me for the advice and asked if in the next three days I would come in and get this accomplished. I agreed and he asked if I would also be the receptionist for the next two days and that I would be compensated. Then he asked the nurse to clear and reschedule the next day's patients and if I could stay while he looked over the applications and assist with some calls. We changed desks and he started looking at the applications. We were fortunate to find seven applicants still looking for work and scheduled four for interviews the next morning and three in the afternoon. We reviewed what had been done and only one patient had not been actually contacted, but a message had been left. Other partners in the clinic were stopping by and they were sent to the doctor's office. Sheryl, the nurse, and I finished up and she asked if I could be there by 7:30 the next morning and when I said yes, she told the doctor we were leaving. He asked if I needed a key and Sheryl said she would be in by then. The doctor stated he would have a laptop hooked up in case I needed the Internet and have it also connected to a printer

The office returned to normal the following week and the doctor and I do not talk about it. Sheryl says things are better than before and they have lost a position when one employee decided she did not like the work, but that the other two are doing what three were before. She said that one of the billing employees from another office does help occasionally.