Joseph S. Eastern

A recent claim against a New Jersey physician attracted considerable attention in the medical community, not because it resulted in a substantial jury award, but because the award was not covered by the doctor's malpractice insurance.

It is a good reminder for the rest of us: Your malpractice policy covers allegations of malpractice only, which is generally defined as negligence or deviation from the standard of care. This case involved a charge of discrimination against a hearing-impaired patient—which meant the physician not only had to fund his own defense, but he was personally responsible for the $400,000 award against him. (The case is now on appeal.)

The Americans With Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations—including, specifically, “the professional office of a health care professional.”

When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to ensure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally, it does not, particularly when complex medical concepts are involved, and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.

The claim involved a hearing-impaired patient with lupus erythematosus who was being treated by a rheumatologist. For almost 2 years, the patient's partner and her daughter provided translation, but that arrangement was inadequate, the patient testified, because her partner and daughter were unfamiliar with medical terminology, and the patient was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”

So she repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and, therefore, exempt from ADA requirements.

But the “undue burden” exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist's annual income of $425,000 rendered the cost of an interpreter quite affordable.

The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved, and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.

In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be perfectly acceptable to one patient and unsuitable for another.

If the patient agrees to written notes and lip reading, as most do, you need to remember to speak slowly, and to write down critical information to avoid any miscommunication. And as always, it is crucial to document all communication and the methods used for that communication—specifically the fact that the patient agreed to those forms of communication.

As I so often say, documentation is like garlic: There is no such thing as too much.

Should a patient not agree that written notes are sufficient, other alternatives can be offered: computer transcription, assisted listening devices, videotext displays (often available in hospitals), and telecommunication devices such as TTY and TDD. But if the patient rejects all of those options and continues to insist on a professional interpreter, the precedent set by the New Jersey case (if upheld on appeal) suggests that you need to acquiesce, even if the interpreter's fee exceeds the visit reimbursement; the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.

If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted with or related to the patient (for confidentiality reasons). Your state may have an online registry of available interpreters, as, for example, New Jersey does at www.njrid.org

The good news is several states have responded to this issue by introducing legislation that would require health insurance carriers to pay for the cost of interpreters.

To respond to this column, e-mail Dr. Eastern at [email protected]

A recent claim against a New Jersey physician attracted considerable attention in the medical community, not because it resulted in a substantial jury award, but because the award was not covered by the doctor's malpractice insurance.

It is a good reminder for the rest of us: Your malpractice policy covers allegations of malpractice only, which is generally defined as negligence or deviation from the standard of care. This case involved a charge of discrimination against a hearing-impaired patient—which meant the physician not only had to fund his own defense, but he was personally responsible for the $400,000 award against him. (The case is now on appeal.)

The Americans With Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations—including, specifically, “the professional office of a health care professional.”

When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to ensure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally, it does not, particularly when complex medical concepts are involved, and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.

The claim involved a hearing-impaired patient with lupus erythematosus who was being treated by a rheumatologist. For almost 2 years, the patient's partner and her daughter provided translation, but that arrangement was inadequate, the patient testified, because her partner and daughter were unfamiliar with medical terminology, and the patient was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”

So she repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and, therefore, exempt from ADA requirements.

But the “undue burden” exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist's annual income of $425,000 rendered the cost of an interpreter quite affordable.

The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved, and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.

In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be perfectly acceptable to one patient and unsuitable for another.

If the patient agrees to written notes and lip reading, as most do, you need to remember to speak slowly, and to write down critical information to avoid any miscommunication. And as always, it is crucial to document all communication and the methods used for that communication—specifically the fact that the patient agreed to those forms of communication.

As I so often say, documentation is like garlic: There is no such thing as too much.

Should a patient not agree that written notes are sufficient, other alternatives can be offered: computer transcription, assisted listening devices, videotext displays (often available in hospitals), and telecommunication devices such as TTY and TDD. But if the patient rejects all of those options and continues to insist on a professional interpreter, the precedent set by the New Jersey case (if upheld on appeal) suggests that you need to acquiesce, even if the interpreter's fee exceeds the visit reimbursement; the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.

If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted with or related to the patient (for confidentiality reasons). Your state may have an online registry of available interpreters, as, for example, New Jersey does at www.njrid.org

The good news is several states have responded to this issue by introducing legislation that would require health insurance carriers to pay for the cost of interpreters.

To respond to this column, e-mail Dr. Eastern at [email protected]

A recent claim against a New Jersey physician attracted considerable attention in the medical community, not because it resulted in a substantial jury award, but because the award was not covered by the doctor's malpractice insurance.

It is a good reminder for the rest of us: Your malpractice policy covers allegations of malpractice only, which is generally defined as negligence or deviation from the standard of care. This case involved a charge of discrimination against a hearing-impaired patient—which meant the physician not only had to fund his own defense, but he was personally responsible for the $400,000 award against him. (The case is now on appeal.)

The Americans With Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations—including, specifically, “the professional office of a health care professional.”

When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to ensure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally, it does not, particularly when complex medical concepts are involved, and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.

The claim involved a hearing-impaired patient with lupus erythematosus who was being treated by a rheumatologist. For almost 2 years, the patient's partner and her daughter provided translation, but that arrangement was inadequate, the patient testified, because her partner and daughter were unfamiliar with medical terminology, and the patient was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”

So she repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and, therefore, exempt from ADA requirements.

But the “undue burden” exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist's annual income of $425,000 rendered the cost of an interpreter quite affordable.

The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved, and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.

In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be perfectly acceptable to one patient and unsuitable for another.

If the patient agrees to written notes and lip reading, as most do, you need to remember to speak slowly, and to write down critical information to avoid any miscommunication. And as always, it is crucial to document all communication and the methods used for that communication—specifically the fact that the patient agreed to those forms of communication.

As I so often say, documentation is like garlic: There is no such thing as too much.

Should a patient not agree that written notes are sufficient, other alternatives can be offered: computer transcription, assisted listening devices, videotext displays (often available in hospitals), and telecommunication devices such as TTY and TDD. But if the patient rejects all of those options and continues to insist on a professional interpreter, the precedent set by the New Jersey case (if upheld on appeal) suggests that you need to acquiesce, even if the interpreter's fee exceeds the visit reimbursement; the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.

If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted with or related to the patient (for confidentiality reasons). Your state may have an online registry of available interpreters, as, for example, New Jersey does at www.njrid.org

The good news is several states have responded to this issue by introducing legislation that would require health insurance carriers to pay for the cost of interpreters.

To respond to this column, e-mail Dr. Eastern at [email protected]

A recent claim against a physician in New Jersey attracted considerable attention, not because it resulted in a substantial jury award, but because the award was not covered by the doctor's malpractice insurance.

It is a good reminder for the rest of us: Your malpractice policy covers allegations of malpractice only, which is generally defined as negligence or deviation from the standard of care. This case involved a charge of discrimination against a hearing-impaired patient—which meant the physician not only had to fund his own defense, but he was personally responsible for the $400,000 award against him. (The case is now on appeal.)

The Americans With Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations—including, specifically, “the professional office of a health care professional.”

When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to ensure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally, it does not, particularly when complex medical concepts are involved, and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.

The claim involved a hearing-impaired patient with lupus erythematosus who was being treated by a rheumatologist. For almost 2 years, the patient's partner and her daughter provided translation, but that arrangement was inadequate, the patient testified, because her partner and daughter were unfamiliar with medical terminology, and the patient was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”

So she repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and, therefore, exempt from ADA requirements.

But the “undue burden” exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist's annual income of $425,000 rendered the cost of an interpreter affordable.

The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved, and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.

In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be acceptable to one patient and unsuitable for another.

If the patient agrees to written notes and lip reading, you need to remember to speak slowly, and to write down critical information to avoid any miscommunication. And it is crucial to document all communication and the methods.

Should a patient insist on a professional interpreter, the precedent set by the New Jersey case (if upheld on appeal) suggests that you need to acquiesce, even if the interpreter's fee exceeds the visit reimbursement; the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.

If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted with or related to the patient (for confidentiality reasons). Your state may have an online registry of available interpreters.

A recent claim against a physician in New Jersey attracted considerable attention, not because it resulted in a substantial jury award, but because the award was not covered by the doctor's malpractice insurance.

It is a good reminder for the rest of us: Your malpractice policy covers allegations of malpractice only, which is generally defined as negligence or deviation from the standard of care. This case involved a charge of discrimination against a hearing-impaired patient—which meant the physician not only had to fund his own defense, but he was personally responsible for the $400,000 award against him. (The case is now on appeal.)

The Americans With Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations—including, specifically, “the professional office of a health care professional.”

When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to ensure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally, it does not, particularly when complex medical concepts are involved, and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.

The claim involved a hearing-impaired patient with lupus erythematosus who was being treated by a rheumatologist. For almost 2 years, the patient's partner and her daughter provided translation, but that arrangement was inadequate, the patient testified, because her partner and daughter were unfamiliar with medical terminology, and the patient was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”

So she repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and, therefore, exempt from ADA requirements.

But the “undue burden” exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist's annual income of $425,000 rendered the cost of an interpreter affordable.

The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved, and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.

In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be acceptable to one patient and unsuitable for another.

If the patient agrees to written notes and lip reading, you need to remember to speak slowly, and to write down critical information to avoid any miscommunication. And it is crucial to document all communication and the methods.

Should a patient insist on a professional interpreter, the precedent set by the New Jersey case (if upheld on appeal) suggests that you need to acquiesce, even if the interpreter's fee exceeds the visit reimbursement; the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.

If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted with or related to the patient (for confidentiality reasons). Your state may have an online registry of available interpreters.

A recent claim against a physician in New Jersey attracted considerable attention, not because it resulted in a substantial jury award, but because the award was not covered by the doctor's malpractice insurance.

It is a good reminder for the rest of us: Your malpractice policy covers allegations of malpractice only, which is generally defined as negligence or deviation from the standard of care. This case involved a charge of discrimination against a hearing-impaired patient—which meant the physician not only had to fund his own defense, but he was personally responsible for the $400,000 award against him. (The case is now on appeal.)

The Americans With Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations—including, specifically, “the professional office of a health care professional.”

When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to ensure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally, it does not, particularly when complex medical concepts are involved, and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.

The claim involved a hearing-impaired patient with lupus erythematosus who was being treated by a rheumatologist. For almost 2 years, the patient's partner and her daughter provided translation, but that arrangement was inadequate, the patient testified, because her partner and daughter were unfamiliar with medical terminology, and the patient was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”

So she repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and, therefore, exempt from ADA requirements.

But the “undue burden” exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist's annual income of $425,000 rendered the cost of an interpreter affordable.

The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved, and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.

In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be acceptable to one patient and unsuitable for another.

If the patient agrees to written notes and lip reading, you need to remember to speak slowly, and to write down critical information to avoid any miscommunication. And it is crucial to document all communication and the methods.

Should a patient insist on a professional interpreter, the precedent set by the New Jersey case (if upheld on appeal) suggests that you need to acquiesce, even if the interpreter's fee exceeds the visit reimbursement; the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.

If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted with or related to the patient (for confidentiality reasons). Your state may have an online registry of available interpreters.

By now, you are probably aware of the Fair and Accurate Credit Transactions (FACT) Act of 2003 and its “Identity Theft Red Flags Rule,” which require creditors to establish a program to prevent identity theft. The law will be enforced beginning this month, so if you haven't taken any action yet you'd better get cracking.

The law was originally aimed only at financial institutions, but the Federal Trade Commission, which is charged with enforcing it, subsequently decided it could apply to any group that would be considered a creditor, which the law defines as “any entity that regularly extends, renews, continues credit or arranges for the extension of credit.”

The FTC has specifically said that it will include medical providers in this definition “if [the provider] does not regularly demand payment in full for services or supplies at the time of service.”

In other words, if you routinely bill patients for any portion of your fees, including the portions not paid by insurance carriers, you are considered a creditor under this law.

To comply with the law, the FTC says that you must develop a program that allows you to do four things: identify relevant red flags (more on that below), detect red flags, prevent and mitigate identity theft, and update your program periodically.

So what is a red flag? Basically, it is a warning sign that should alert your practice to suspicious activity that may indicate identity theft. The FTC guidelines list five categories of warning signs that should be identified and addressed:

▸ Alerts, notifications, or warnings from a consumer reporting agency or any entity that performs services on your “covered accounts.”

▸ Suspicious documents.

▸ Suspicious identification documents.

▸ Suspicious activity relating to a “covered account.”

▸ Notices from customers, victims of identity theft, law enforcement authorities, or other entities about possible identity theft in connection with “covered accounts.”

Okay, so what is a “covered account?” It is any financial account used mostly for personal purposes that involves multiple payments or transactions, for which there is a foreseeable risk of identity theft.

The FTC says it is particularly worried about medical billing accounts because the theft of a patient's information to fraudulently obtain medical care can cause a variety of serious problems over and above those usually associated with identity theft, including exhaustion of the victim's health benefits and a potentially life-threatening corruption of medical records.

The law requires you to develop a written program appropriate to the size and complexity of your practice that spells out your responses to red flags and the preventive actions you plan to take if there is a breach or attempted breach of your database. The program should include appropriate staff training, as well as a plan for monitoring staff to ensure that they are all following the program.

You must update your program “periodically” (the law is no more specific than that) to reflect changes in risks to patients, ensuring that the program remains current and relevant as methods of identity theft change.

In other words, designing a program and putting it on a shelf to collect dust will not satisfy the law's requirements, nor adequately protect your patients.

If you employ a billing service and/or collection agency, or any other outside entity that has access to your covered accounts, you also must take steps to ensure that their activities are conducted using a reasonable identity theft program. This could be done through a written contract with the service provider, or by amending your existing HIPAA Business Associate Agreements.

Some states have their own additional rules that may need to be incorporated into your identity theft prevention program. Check with relevant agencies in your state regarding that possibility.

Violations of the Red Flags Rule can subject your practice to significant penalties—particularly if a patient suffers an identity theft that could have been prevented by your program, had it been properly implemented.

The exercise is not as onerous or time consuming as many assume. The American Academy of Dermatology points out that the law permits great flexibility, so if you determine that your practice has a low risk of identity theft, developing a program should be simple and straightforward, with only a few red flags to identify and deal with.

Medical practices and other businesses can find help online for developing their own programs. One good example, with a template that should be modifiable to fit most dermatology offices, is online at the California Society of Municipal Finance Officers' Web site www.csmfo.org/index.cfm?fuseaction=DetailGroup&CID=2478&NavID=181

The AAD also has more information at its site www.aad.org/pm/_doc/FTCRedFlagsRulesFactSheet.pdf

To respond to this column, e-mail Dr. Eastern at [email protected]

By now, you are probably aware of the Fair and Accurate Credit Transactions (FACT) Act of 2003 and its “Identity Theft Red Flags Rule,” which require creditors to establish a program to prevent identity theft. The law will be enforced beginning this month, so if you haven't taken any action yet you'd better get cracking.

The law was originally aimed only at financial institutions, but the Federal Trade Commission, which is charged with enforcing it, subsequently decided it could apply to any group that would be considered a creditor, which the law defines as “any entity that regularly extends, renews, continues credit or arranges for the extension of credit.”

The FTC has specifically said that it will include medical providers in this definition “if [the provider] does not regularly demand payment in full for services or supplies at the time of service.”

In other words, if you routinely bill patients for any portion of your fees, including the portions not paid by insurance carriers, you are considered a creditor under this law.

To comply with the law, the FTC says that you must develop a program that allows you to do four things: identify relevant red flags (more on that below), detect red flags, prevent and mitigate identity theft, and update your program periodically.

So what is a red flag? Basically, it is a warning sign that should alert your practice to suspicious activity that may indicate identity theft. The FTC guidelines list five categories of warning signs that should be identified and addressed:

▸ Alerts, notifications, or warnings from a consumer reporting agency or any entity that performs services on your “covered accounts.”

▸ Suspicious documents.

▸ Suspicious identification documents.

▸ Suspicious activity relating to a “covered account.”

▸ Notices from customers, victims of identity theft, law enforcement authorities, or other entities about possible identity theft in connection with “covered accounts.”

Okay, so what is a “covered account?” It is any financial account used mostly for personal purposes that involves multiple payments or transactions, for which there is a foreseeable risk of identity theft.

The FTC says it is particularly worried about medical billing accounts because the theft of a patient's information to fraudulently obtain medical care can cause a variety of serious problems over and above those usually associated with identity theft, including exhaustion of the victim's health benefits and a potentially life-threatening corruption of medical records.

The law requires you to develop a written program appropriate to the size and complexity of your practice that spells out your responses to red flags and the preventive actions you plan to take if there is a breach or attempted breach of your database. The program should include appropriate staff training, as well as a plan for monitoring staff to ensure that they are all following the program.

You must update your program “periodically” (the law is no more specific than that) to reflect changes in risks to patients, ensuring that the program remains current and relevant as methods of identity theft change.

In other words, designing a program and putting it on a shelf to collect dust will not satisfy the law's requirements, nor adequately protect your patients.

If you employ a billing service and/or collection agency, or any other outside entity that has access to your covered accounts, you also must take steps to ensure that their activities are conducted using a reasonable identity theft program. This could be done through a written contract with the service provider, or by amending your existing HIPAA Business Associate Agreements.

Some states have their own additional rules that may need to be incorporated into your identity theft prevention program. Check with relevant agencies in your state regarding that possibility.

Violations of the Red Flags Rule can subject your practice to significant penalties—particularly if a patient suffers an identity theft that could have been prevented by your program, had it been properly implemented.

The exercise is not as onerous or time consuming as many assume. The American Academy of Dermatology points out that the law permits great flexibility, so if you determine that your practice has a low risk of identity theft, developing a program should be simple and straightforward, with only a few red flags to identify and deal with.

Medical practices and other businesses can find help online for developing their own programs. One good example, with a template that should be modifiable to fit most dermatology offices, is online at the California Society of Municipal Finance Officers' Web site www.csmfo.org/index.cfm?fuseaction=DetailGroup&CID=2478&NavID=181

The AAD also has more information at its site www.aad.org/pm/_doc/FTCRedFlagsRulesFactSheet.pdf

To respond to this column, e-mail Dr. Eastern at [email protected]

By now, you are probably aware of the Fair and Accurate Credit Transactions (FACT) Act of 2003 and its “Identity Theft Red Flags Rule,” which require creditors to establish a program to prevent identity theft. The law will be enforced beginning this month, so if you haven't taken any action yet you'd better get cracking.

The law was originally aimed only at financial institutions, but the Federal Trade Commission, which is charged with enforcing it, subsequently decided it could apply to any group that would be considered a creditor, which the law defines as “any entity that regularly extends, renews, continues credit or arranges for the extension of credit.”

The FTC has specifically said that it will include medical providers in this definition “if [the provider] does not regularly demand payment in full for services or supplies at the time of service.”

In other words, if you routinely bill patients for any portion of your fees, including the portions not paid by insurance carriers, you are considered a creditor under this law.

To comply with the law, the FTC says that you must develop a program that allows you to do four things: identify relevant red flags (more on that below), detect red flags, prevent and mitigate identity theft, and update your program periodically.

So what is a red flag? Basically, it is a warning sign that should alert your practice to suspicious activity that may indicate identity theft. The FTC guidelines list five categories of warning signs that should be identified and addressed:

▸ Alerts, notifications, or warnings from a consumer reporting agency or any entity that performs services on your “covered accounts.”

▸ Suspicious documents.

▸ Suspicious identification documents.

▸ Suspicious activity relating to a “covered account.”

▸ Notices from customers, victims of identity theft, law enforcement authorities, or other entities about possible identity theft in connection with “covered accounts.”

Okay, so what is a “covered account?” It is any financial account used mostly for personal purposes that involves multiple payments or transactions, for which there is a foreseeable risk of identity theft.

The FTC says it is particularly worried about medical billing accounts because the theft of a patient's information to fraudulently obtain medical care can cause a variety of serious problems over and above those usually associated with identity theft, including exhaustion of the victim's health benefits and a potentially life-threatening corruption of medical records.

The law requires you to develop a written program appropriate to the size and complexity of your practice that spells out your responses to red flags and the preventive actions you plan to take if there is a breach or attempted breach of your database. The program should include appropriate staff training, as well as a plan for monitoring staff to ensure that they are all following the program.

You must update your program “periodically” (the law is no more specific than that) to reflect changes in risks to patients, ensuring that the program remains current and relevant as methods of identity theft change.

In other words, designing a program and putting it on a shelf to collect dust will not satisfy the law's requirements, nor adequately protect your patients.

If you employ a billing service and/or collection agency, or any other outside entity that has access to your covered accounts, you also must take steps to ensure that their activities are conducted using a reasonable identity theft program. This could be done through a written contract with the service provider, or by amending your existing HIPAA Business Associate Agreements.

Some states have their own additional rules that may need to be incorporated into your identity theft prevention program. Check with relevant agencies in your state regarding that possibility.

Violations of the Red Flags Rule can subject your practice to significant penalties—particularly if a patient suffers an identity theft that could have been prevented by your program, had it been properly implemented.

The exercise is not as onerous or time consuming as many assume. The American Academy of Dermatology points out that the law permits great flexibility, so if you determine that your practice has a low risk of identity theft, developing a program should be simple and straightforward, with only a few red flags to identify and deal with.

Medical practices and other businesses can find help online for developing their own programs. One good example, with a template that should be modifiable to fit most dermatology offices, is online at the California Society of Municipal Finance Officers' Web site www.csmfo.org/index.cfm?fuseaction=DetailGroup&CID=2478&NavID=181

The AAD also has more information at its site www.aad.org/pm/_doc/FTCRedFlagsRulesFactSheet.pdf

To respond to this column, e-mail Dr. Eastern at [email protected]

As the economy continues to founder, fraud and economic crime are on the rise, according to many law enforcement officials around the country.

Tight money increases embezzlement temptations, so this is an excellent time to review your bookkeeping procedures and remove any obvious opportunities for theft by your employees.

People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected, sometimes for years, because no one is looking.

The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.

Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:

Hire honest employees. It is amazing how few doctors check applicants' references. Find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites to see if they have criminal records or if they have been sued or are suing others.

Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, but there ways to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that.

Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated, and that someone other than the person accepting cash reconciles the receipts and the cash daily.

Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. One employee should enter invoices into the system, another should issue the check, and a third should match invoices to goods and services received.

Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.

Safeguard your computer. Computers have made embezzlement easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system.

Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility?

Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.

To respond to this column, e-mail Dr. Eastern at [email protected]

As the economy continues to founder, fraud and economic crime are on the rise, according to many law enforcement officials around the country.

Tight money increases embezzlement temptations, so this is an excellent time to review your bookkeeping procedures and remove any obvious opportunities for theft by your employees.

People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected, sometimes for years, because no one is looking.

The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.

Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:

Hire honest employees. It is amazing how few doctors check applicants' references. Find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites to see if they have criminal records or if they have been sued or are suing others.

Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, but there ways to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that.

Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated, and that someone other than the person accepting cash reconciles the receipts and the cash daily.

Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. One employee should enter invoices into the system, another should issue the check, and a third should match invoices to goods and services received.

Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.

Safeguard your computer. Computers have made embezzlement easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system.

Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility?

Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.

To respond to this column, e-mail Dr. Eastern at [email protected]

As the economy continues to founder, fraud and economic crime are on the rise, according to many law enforcement officials around the country.

Tight money increases embezzlement temptations, so this is an excellent time to review your bookkeeping procedures and remove any obvious opportunities for theft by your employees.

People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected, sometimes for years, because no one is looking.

The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.

Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:

Hire honest employees. It is amazing how few doctors check applicants' references. Find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites to see if they have criminal records or if they have been sued or are suing others.

Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, but there ways to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that.

Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated, and that someone other than the person accepting cash reconciles the receipts and the cash daily.

Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. One employee should enter invoices into the system, another should issue the check, and a third should match invoices to goods and services received.

Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.

Safeguard your computer. Computers have made embezzlement easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system.

Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility?

Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.

To respond to this column, e-mail Dr. Eastern at [email protected]

Each of us knows colleagues for whom medicine no longer holds the aura of excitement and fascination that we assume will last forever. Having faced their challenges and attained their goals, they are unwilling or unable to find new challenges and design new goals. In the modern vernacular, they are “burned out.”

These people are prisoners of the Comfort Zone.

The Comfort Zone is a product of a dangerous state of mind, complacency—the perception of doing okay, of having arrived, of believing it is okay to take it easy.

Complacency triggers the construction of a protective envelope of actions and situations that are familiar and comfortable and do not require any major risks or significant uncertainties. Unfortunately, the human psyche cannot function within the Comfort Zone for any length of time before it starts looking for distractions.

A patient of mine once owned one of the largest and most popular restaurants in northern New Jersey. He had all the wealth, power, and prestige he ever dreamed of. Now it's all gone. He gambled it all away.

I felt I knew him well enough to ask what had gone wrong. Why risk losing it all? Why did he allow such a catastrophe to happen? “Doc,” he replied, “if the game no longer challenges you, you will screw it up—just to have something to do!”

I found this lesson profound and enlightening, and it is a shame that this man had to learn it the hard way, as so many heretofore successful people do.

But if we cannot be happy within the Comfort Zone and have to constantly look for distractions, must the distractions necessarily be destructive? Why not look for constructive distractions? Why not push the other side of the envelope?

That is the solution to the Comfort Zone problem: Constantly expand the zone itself. You must continually incorporate new activities and situations into your envelope, so that you remain interested, focused, and enthused.

What do you look for? Anything that would make you uncomfortable. Such a situation, by definition, is outside your Comfort Zone. Of course, you must screen out detrimental things, considering only those additions to your zone that will improve you personally or professionally.

In your office, this can be as minor as trying a new appointment scheduling method or as major as adding a satellite office or purchasing a new, cutting edge piece of equipment and mastering its use. Rather than perpetuating the old, comfortable, risk-free, mind-numbing routine, conquer the fear and take some new risks. Once your Comfort Zone grows to encompass the new routine, you will be one step further away from burnout.

The concept of enlarging your Comfort Zone applies equally well to life outside the office. Find and seize opportunities to do things your zone tries to discourage but that you wish to learn to do comfortably. It doesn't have to be a life-changing project: Start small. If you tend to avoid talking on the phone, for example, make a conscious effort to initiate a phone call every day. When it becomes part of your zone, those important phone calls will be far easier and more comfortable to make.

“Do something every day that you don't want to do,” Mark Twain once wrote. “This is the golden rule for acquiring the habit of doing your duty without pain.”

So the solution to burnout is to recognize that your Comfort Zone exists and must be managed, rather than allowing it to manage you and restrict you. By molding your zone to activities and situations that will keep you enthused, you can keep complacency at bay. Rather than permitting distractions to take a destructive course, look for distractions that are constructive, educational, and pleasurable.

Next month, my wife and I will be leading a group of doctors on a trip to Uzbekistan in Central Asia on the old Silk Road. It will be a new experience in an unfamiliar part of the world, and the decision to take it on was not made lightly. It would have been easy to stay home or to plan a “safer” trip to a more familiar destination, but in settling for a comfortable option we would have missed a golden opportunity to push our envelope in an educational and exciting way.

So if you're burned out, find something uncomfortably new and constructive, and go for it. When you conquer the fear, you'll conquer complacency.

Each of us knows colleagues for whom medicine no longer holds the aura of excitement and fascination that we assume will last forever. Having faced their challenges and attained their goals, they are unwilling or unable to find new challenges and design new goals. In the modern vernacular, they are “burned out.”

These people are prisoners of the Comfort Zone.

The Comfort Zone is a product of a dangerous state of mind, complacency—the perception of doing okay, of having arrived, of believing it is okay to take it easy.

Complacency triggers the construction of a protective envelope of actions and situations that are familiar and comfortable and do not require any major risks or significant uncertainties. Unfortunately, the human psyche cannot function within the Comfort Zone for any length of time before it starts looking for distractions.

A patient of mine once owned one of the largest and most popular restaurants in northern New Jersey. He had all the wealth, power, and prestige he ever dreamed of. Now it's all gone. He gambled it all away.

I felt I knew him well enough to ask what had gone wrong. Why risk losing it all? Why did he allow such a catastrophe to happen? “Doc,” he replied, “if the game no longer challenges you, you will screw it up—just to have something to do!”

I found this lesson profound and enlightening, and it is a shame that this man had to learn it the hard way, as so many heretofore successful people do.

But if we cannot be happy within the Comfort Zone and have to constantly look for distractions, must the distractions necessarily be destructive? Why not look for constructive distractions? Why not push the other side of the envelope?

That is the solution to the Comfort Zone problem: Constantly expand the zone itself. You must continually incorporate new activities and situations into your envelope, so that you remain interested, focused, and enthused.

What do you look for? Anything that would make you uncomfortable. Such a situation, by definition, is outside your Comfort Zone. Of course, you must screen out detrimental things, considering only those additions to your zone that will improve you personally or professionally.

In your office, this can be as minor as trying a new appointment scheduling method or as major as adding a satellite office or purchasing a new, cutting edge piece of equipment and mastering its use. Rather than perpetuating the old, comfortable, risk-free, mind-numbing routine, conquer the fear and take some new risks. Once your Comfort Zone grows to encompass the new routine, you will be one step further away from burnout.

The concept of enlarging your Comfort Zone applies equally well to life outside the office. Find and seize opportunities to do things your zone tries to discourage but that you wish to learn to do comfortably. It doesn't have to be a life-changing project: Start small. If you tend to avoid talking on the phone, for example, make a conscious effort to initiate a phone call every day. When it becomes part of your zone, those important phone calls will be far easier and more comfortable to make.

“Do something every day that you don't want to do,” Mark Twain once wrote. “This is the golden rule for acquiring the habit of doing your duty without pain.”

So the solution to burnout is to recognize that your Comfort Zone exists and must be managed, rather than allowing it to manage you and restrict you. By molding your zone to activities and situations that will keep you enthused, you can keep complacency at bay. Rather than permitting distractions to take a destructive course, look for distractions that are constructive, educational, and pleasurable.

Next month, my wife and I will be leading a group of doctors on a trip to Uzbekistan in Central Asia on the old Silk Road. It will be a new experience in an unfamiliar part of the world, and the decision to take it on was not made lightly. It would have been easy to stay home or to plan a “safer” trip to a more familiar destination, but in settling for a comfortable option we would have missed a golden opportunity to push our envelope in an educational and exciting way.

So if you're burned out, find something uncomfortably new and constructive, and go for it. When you conquer the fear, you'll conquer complacency.

Each of us knows colleagues for whom medicine no longer holds the aura of excitement and fascination that we assume will last forever. Having faced their challenges and attained their goals, they are unwilling or unable to find new challenges and design new goals. In the modern vernacular, they are “burned out.”

These people are prisoners of the Comfort Zone.

The Comfort Zone is a product of a dangerous state of mind, complacency—the perception of doing okay, of having arrived, of believing it is okay to take it easy.

Complacency triggers the construction of a protective envelope of actions and situations that are familiar and comfortable and do not require any major risks or significant uncertainties. Unfortunately, the human psyche cannot function within the Comfort Zone for any length of time before it starts looking for distractions.

A patient of mine once owned one of the largest and most popular restaurants in northern New Jersey. He had all the wealth, power, and prestige he ever dreamed of. Now it's all gone. He gambled it all away.

I felt I knew him well enough to ask what had gone wrong. Why risk losing it all? Why did he allow such a catastrophe to happen? “Doc,” he replied, “if the game no longer challenges you, you will screw it up—just to have something to do!”

I found this lesson profound and enlightening, and it is a shame that this man had to learn it the hard way, as so many heretofore successful people do.

But if we cannot be happy within the Comfort Zone and have to constantly look for distractions, must the distractions necessarily be destructive? Why not look for constructive distractions? Why not push the other side of the envelope?

That is the solution to the Comfort Zone problem: Constantly expand the zone itself. You must continually incorporate new activities and situations into your envelope, so that you remain interested, focused, and enthused.

What do you look for? Anything that would make you uncomfortable. Such a situation, by definition, is outside your Comfort Zone. Of course, you must screen out detrimental things, considering only those additions to your zone that will improve you personally or professionally.

In your office, this can be as minor as trying a new appointment scheduling method or as major as adding a satellite office or purchasing a new, cutting edge piece of equipment and mastering its use. Rather than perpetuating the old, comfortable, risk-free, mind-numbing routine, conquer the fear and take some new risks. Once your Comfort Zone grows to encompass the new routine, you will be one step further away from burnout.

The concept of enlarging your Comfort Zone applies equally well to life outside the office. Find and seize opportunities to do things your zone tries to discourage but that you wish to learn to do comfortably. It doesn't have to be a life-changing project: Start small. If you tend to avoid talking on the phone, for example, make a conscious effort to initiate a phone call every day. When it becomes part of your zone, those important phone calls will be far easier and more comfortable to make.

“Do something every day that you don't want to do,” Mark Twain once wrote. “This is the golden rule for acquiring the habit of doing your duty without pain.”

So the solution to burnout is to recognize that your Comfort Zone exists and must be managed, rather than allowing it to manage you and restrict you. By molding your zone to activities and situations that will keep you enthused, you can keep complacency at bay. Rather than permitting distractions to take a destructive course, look for distractions that are constructive, educational, and pleasurable.

Next month, my wife and I will be leading a group of doctors on a trip to Uzbekistan in Central Asia on the old Silk Road. It will be a new experience in an unfamiliar part of the world, and the decision to take it on was not made lightly. It would have been easy to stay home or to plan a “safer” trip to a more familiar destination, but in settling for a comfortable option we would have missed a golden opportunity to push our envelope in an educational and exciting way.

So if you're burned out, find something uncomfortably new and constructive, and go for it. When you conquer the fear, you'll conquer complacency.

All too often, our office computers are disasters waiting to happen. We store huge amounts of important information on them and risk losing it all by neglecting to back up the data. No amount of casualty insurance will recoup the loss of the data on stolen or destroyed computers.

Industry statistics show that fully 10% of hard drives fail in any given year and that 43% of computer users lose one or more files every year in the form of clinical data, financial records, photos, e-mail, documents, and other important information. Recovery of lost data, when it's possible at all, can be very expensive.

Yet a Harris Interactive study last year found that 35% of Americans admitted they never back up their computers. And amazingly, many people who have lost important data in a crash still refuse to do regular backups. Why do so many of us neglect such a basic precaution? Because it's inconvenient and time-consuming. Clearly, the only way to get many people to back up their data regularly is to make the process automatic.

Some computer companies have taken steps in that direction. Apple, for example, has a feature called Time Machine that backs up Macs to an external drive automatically. But that does you no good if, for example, a fire destroys the computers and also incinerates the backup drives.

So, the first rule is to store your backup drives in a different location from your computers. Unfortunately, that's a pain, too, and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup.

Several companies offer this service: two of the most popular are Mozy (www.mozy.comwww.carbonite.com

The cost is very reasonable for individual computers. In fact, Mozy lets you store up to two gigabytes of data for free. Its basic package, which includes unlimited storage, costs $4.95 a month per computer. Carbonite is a bit cheaper ($49.95 per year, also for unlimited capacity), but Mozy is a little more customizable, and you can specify the files you want regularly backed up and when it will be done. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it's still very reasonable and includes other services such as operating system and network share support.

The procedure is simple: You create an account and tell the service which files to copy. Your first backup can take a long time, often days, depending on how much data you are sending and the speed of your Internet connection. After that, the program runs in the background, copying only files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service's data center, making them HIPAA compliant and, theoretically, accessible only to you.

To restore files, you open a sort of virtual representation of your backed-up files and click on what you want restored. You also can log into the Web site from any other computer and pick any file or folder to retrieve. If your computer is stolen or the hard drive is destroyed, you can go to a site to initiate a full restore to a new computer. Remote backups might even help you recover a lost or stolen machine: If the finder or thief opens new files, they will be backed up to your new machine, which could allow you (or the police) to trace the original computer's whereabouts.

If you ever decide to terminate the service or simply want a hard copy of your data, Mozy will send you a DVD of all your files, for a fee. (Carbonite does not mention this service on its site.)

Soon, though, you might be able to use these services for a lot more than simply storing and retrieving files. Mozy's parent company, EMC, has announced a new subsidiary called Decho (www.decho.com

All too often, our office computers are disasters waiting to happen. We store huge amounts of important information on them and risk losing it all by neglecting to back up the data. No amount of casualty insurance will recoup the loss of the data on stolen or destroyed computers.

Industry statistics show that fully 10% of hard drives fail in any given year and that 43% of computer users lose one or more files every year in the form of clinical data, financial records, photos, e-mail, documents, and other important information. Recovery of lost data, when it's possible at all, can be very expensive.

Yet a Harris Interactive study last year found that 35% of Americans admitted they never back up their computers. And amazingly, many people who have lost important data in a crash still refuse to do regular backups. Why do so many of us neglect such a basic precaution? Because it's inconvenient and time-consuming. Clearly, the only way to get many people to back up their data regularly is to make the process automatic.

Some computer companies have taken steps in that direction. Apple, for example, has a feature called Time Machine that backs up Macs to an external drive automatically. But that does you no good if, for example, a fire destroys the computers and also incinerates the backup drives.

So, the first rule is to store your backup drives in a different location from your computers. Unfortunately, that's a pain, too, and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup.

Several companies offer this service: two of the most popular are Mozy (www.mozy.comwww.carbonite.com

The cost is very reasonable for individual computers. In fact, Mozy lets you store up to two gigabytes of data for free. Its basic package, which includes unlimited storage, costs $4.95 a month per computer. Carbonite is a bit cheaper ($49.95 per year, also for unlimited capacity), but Mozy is a little more customizable, and you can specify the files you want regularly backed up and when it will be done. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it's still very reasonable and includes other services such as operating system and network share support.

The procedure is simple: You create an account and tell the service which files to copy. Your first backup can take a long time, often days, depending on how much data you are sending and the speed of your Internet connection. After that, the program runs in the background, copying only files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service's data center, making them HIPAA compliant and, theoretically, accessible only to you.

To restore files, you open a sort of virtual representation of your backed-up files and click on what you want restored. You also can log into the Web site from any other computer and pick any file or folder to retrieve. If your computer is stolen or the hard drive is destroyed, you can go to a site to initiate a full restore to a new computer. Remote backups might even help you recover a lost or stolen machine: If the finder or thief opens new files, they will be backed up to your new machine, which could allow you (or the police) to trace the original computer's whereabouts.

If you ever decide to terminate the service or simply want a hard copy of your data, Mozy will send you a DVD of all your files, for a fee. (Carbonite does not mention this service on its site.)

Soon, though, you might be able to use these services for a lot more than simply storing and retrieving files. Mozy's parent company, EMC, has announced a new subsidiary called Decho (www.decho.com

All too often, our office computers are disasters waiting to happen. We store huge amounts of important information on them and risk losing it all by neglecting to back up the data. No amount of casualty insurance will recoup the loss of the data on stolen or destroyed computers.

Industry statistics show that fully 10% of hard drives fail in any given year and that 43% of computer users lose one or more files every year in the form of clinical data, financial records, photos, e-mail, documents, and other important information. Recovery of lost data, when it's possible at all, can be very expensive.

Yet a Harris Interactive study last year found that 35% of Americans admitted they never back up their computers. And amazingly, many people who have lost important data in a crash still refuse to do regular backups. Why do so many of us neglect such a basic precaution? Because it's inconvenient and time-consuming. Clearly, the only way to get many people to back up their data regularly is to make the process automatic.

Some computer companies have taken steps in that direction. Apple, for example, has a feature called Time Machine that backs up Macs to an external drive automatically. But that does you no good if, for example, a fire destroys the computers and also incinerates the backup drives.

So, the first rule is to store your backup drives in a different location from your computers. Unfortunately, that's a pain, too, and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup.

Several companies offer this service: two of the most popular are Mozy (www.mozy.comwww.carbonite.com

The cost is very reasonable for individual computers. In fact, Mozy lets you store up to two gigabytes of data for free. Its basic package, which includes unlimited storage, costs $4.95 a month per computer. Carbonite is a bit cheaper ($49.95 per year, also for unlimited capacity), but Mozy is a little more customizable, and you can specify the files you want regularly backed up and when it will be done. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it's still very reasonable and includes other services such as operating system and network share support.

The procedure is simple: You create an account and tell the service which files to copy. Your first backup can take a long time, often days, depending on how much data you are sending and the speed of your Internet connection. After that, the program runs in the background, copying only files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service's data center, making them HIPAA compliant and, theoretically, accessible only to you.

To restore files, you open a sort of virtual representation of your backed-up files and click on what you want restored. You also can log into the Web site from any other computer and pick any file or folder to retrieve. If your computer is stolen or the hard drive is destroyed, you can go to a site to initiate a full restore to a new computer. Remote backups might even help you recover a lost or stolen machine: If the finder or thief opens new files, they will be backed up to your new machine, which could allow you (or the police) to trace the original computer's whereabouts.

If you ever decide to terminate the service or simply want a hard copy of your data, Mozy will send you a DVD of all your files, for a fee. (Carbonite does not mention this service on its site.)

Soon, though, you might be able to use these services for a lot more than simply storing and retrieving files. Mozy's parent company, EMC, has announced a new subsidiary called Decho (www.decho.com

Last month I wrote about a dermatologist from the Midwest whose office was ransacked and then set on fire. I covered the steps necessary to file a timely and accurate insurance claim.

No amount of insurance, however, will recoup one of his worst losses: the data on his destroyed computers.

Industry statistics show that fully 10% of hard drives fail in any given year and that 43% of computer users lose one or more files every year. Recovery of lost data, when it's possible at all, can be very expensive.

Despite that, a Harris Interactive study found that 35% of Americans admitted they never back up their computers. My guess is that the actual percentage is substantially higher. And amazingly, many people who have lost important, irretrievable data in a crash still refuse to do regular backups.

Why do so many of us neglect such a basic precaution? Because it's an annoyance and an inconvenience and takes too much time. Clearly, the only way to get many people to back up their data regularly is to make the process automatic.

Some computer companies have taken steps in that direction. Apple, for example, has a feature called Time Machine that backs up Macs to an external drive automatically. But that does you no good if, as happened to the Midwestern dermatologist, the fire that destroys the computers also incinerates the backup drives.

So, the first rule is to store your backup drives in a different location from your computers. Unfortunately, that's a pain, too, and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup.

There are several companies that offer this service: two of the most popular are Mozy (www.mozy.comwww.carbonite.com

(As always, I have no financial interest in any product or service discussed in this column.)

The cost is very reasonable. In fact, Mozy lets you store up to two gigabytes of data for free. Its basic package, which includes unlimited storage, costs $4.95 a month per computer. Carbonite is a bit cheaper ($49.95 per year, also for unlimited capacity), but Mozy is a little more customizable, and you can specify the files you want regularly backed up and when it will be done. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it's still very reasonable and includes other services such as operating system and network share support.

The procedure is simple: You create an account and tell the service which files you want copied. Your first backup can take a long time, often days, depending on how much data you are sending and the speed of your Internet connection. After that, the program runs in the background, copying only those files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service's data center, making them HIPAA compliant and, theoretically, accessible only to you.

To restore files, you open a sort of virtual representation of your backed-up files and click on what you want restored. You also can log into the Web site from any other computer and pick any file or folder to retrieve. If your computer is stolen or the hard drive is destroyed, you can go to a site to initiate a full restore to a new computer.

If you ever decide to terminate the service or simply want a hard copy of your data, Mozy will send you a DVD of all your files, for a fee.

Mozy's parent company, EMC, has announced a new subsidiary called Decho www.decho.com

To respond to this column, e-mail Dr. Eastern at [email protected]

Last month I wrote about a dermatologist from the Midwest whose office was ransacked and then set on fire. I covered the steps necessary to file a timely and accurate insurance claim.

No amount of insurance, however, will recoup one of his worst losses: the data on his destroyed computers.

Industry statistics show that fully 10% of hard drives fail in any given year and that 43% of computer users lose one or more files every year. Recovery of lost data, when it's possible at all, can be very expensive.

Despite that, a Harris Interactive study found that 35% of Americans admitted they never back up their computers. My guess is that the actual percentage is substantially higher. And amazingly, many people who have lost important, irretrievable data in a crash still refuse to do regular backups.

Why do so many of us neglect such a basic precaution? Because it's an annoyance and an inconvenience and takes too much time. Clearly, the only way to get many people to back up their data regularly is to make the process automatic.

Some computer companies have taken steps in that direction. Apple, for example, has a feature called Time Machine that backs up Macs to an external drive automatically. But that does you no good if, as happened to the Midwestern dermatologist, the fire that destroys the computers also incinerates the backup drives.

So, the first rule is to store your backup drives in a different location from your computers. Unfortunately, that's a pain, too, and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup.

There are several companies that offer this service: two of the most popular are Mozy (www.mozy.comwww.carbonite.com

(As always, I have no financial interest in any product or service discussed in this column.)

The cost is very reasonable. In fact, Mozy lets you store up to two gigabytes of data for free. Its basic package, which includes unlimited storage, costs $4.95 a month per computer. Carbonite is a bit cheaper ($49.95 per year, also for unlimited capacity), but Mozy is a little more customizable, and you can specify the files you want regularly backed up and when it will be done. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it's still very reasonable and includes other services such as operating system and network share support.

The procedure is simple: You create an account and tell the service which files you want copied. Your first backup can take a long time, often days, depending on how much data you are sending and the speed of your Internet connection. After that, the program runs in the background, copying only those files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service's data center, making them HIPAA compliant and, theoretically, accessible only to you.

To restore files, you open a sort of virtual representation of your backed-up files and click on what you want restored. You also can log into the Web site from any other computer and pick any file or folder to retrieve. If your computer is stolen or the hard drive is destroyed, you can go to a site to initiate a full restore to a new computer.

If you ever decide to terminate the service or simply want a hard copy of your data, Mozy will send you a DVD of all your files, for a fee.

Mozy's parent company, EMC, has announced a new subsidiary called Decho www.decho.com

To respond to this column, e-mail Dr. Eastern at [email protected]

Last month I wrote about a dermatologist from the Midwest whose office was ransacked and then set on fire. I covered the steps necessary to file a timely and accurate insurance claim.

No amount of insurance, however, will recoup one of his worst losses: the data on his destroyed computers.

Industry statistics show that fully 10% of hard drives fail in any given year and that 43% of computer users lose one or more files every year. Recovery of lost data, when it's possible at all, can be very expensive.

Despite that, a Harris Interactive study found that 35% of Americans admitted they never back up their computers. My guess is that the actual percentage is substantially higher. And amazingly, many people who have lost important, irretrievable data in a crash still refuse to do regular backups.

Why do so many of us neglect such a basic precaution? Because it's an annoyance and an inconvenience and takes too much time. Clearly, the only way to get many people to back up their data regularly is to make the process automatic.

Some computer companies have taken steps in that direction. Apple, for example, has a feature called Time Machine that backs up Macs to an external drive automatically. But that does you no good if, as happened to the Midwestern dermatologist, the fire that destroys the computers also incinerates the backup drives.

So, the first rule is to store your backup drives in a different location from your computers. Unfortunately, that's a pain, too, and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup.

There are several companies that offer this service: two of the most popular are Mozy (www.mozy.comwww.carbonite.com

(As always, I have no financial interest in any product or service discussed in this column.)

The cost is very reasonable. In fact, Mozy lets you store up to two gigabytes of data for free. Its basic package, which includes unlimited storage, costs $4.95 a month per computer. Carbonite is a bit cheaper ($49.95 per year, also for unlimited capacity), but Mozy is a little more customizable, and you can specify the files you want regularly backed up and when it will be done. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it's still very reasonable and includes other services such as operating system and network share support.

The procedure is simple: You create an account and tell the service which files you want copied. Your first backup can take a long time, often days, depending on how much data you are sending and the speed of your Internet connection. After that, the program runs in the background, copying only those files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service's data center, making them HIPAA compliant and, theoretically, accessible only to you.

To restore files, you open a sort of virtual representation of your backed-up files and click on what you want restored. You also can log into the Web site from any other computer and pick any file or folder to retrieve. If your computer is stolen or the hard drive is destroyed, you can go to a site to initiate a full restore to a new computer.

If you ever decide to terminate the service or simply want a hard copy of your data, Mozy will send you a DVD of all your files, for a fee.

Mozy's parent company, EMC, has announced a new subsidiary called Decho www.decho.com

To respond to this column, e-mail Dr. Eastern at [email protected]

A dermatologist in the Midwest wrote to me for advice on dealing with everyone's worst nightmare, the burglary and arson of his office.

Filing an insurance claim was his first priority, of course. We all buy insurance hoping we will never need it, but when we do, it's important to get it right.

Prompt claim filing is key. All policies have a filing deadline, which varies for different policies and states, but just because you file promptly does not mean you have to settle on a payment just as fast.

Most insurers want a quick resolution as much as you do, but if you allow yourself to be rushed, you could end up with a smaller settlement than you deserve.

If you're a regular reader, you're quite familiar with my first rule of dealing with health insurers: Everything is negotiable. It's no different with casualty insurers. Regardless of what adjusters tell you, the initial amount offered is never engraved in stone. Adjusters are evaluated on the basis of how much money they “save” on claims, so their initial number will usually be low.

As with health insurance claims, casualty policies have gray areas. Those areas include reasonable expenses for repairing or replacing damaged medical equipment or the rental of alternative office space.

Other negotiable costs include moving expenses, storage of damaged and undamaged equipment, and depreciation on specific items. And as we all know from our health insurance experience, injuries are fertile areas for negotiation.

Another adjuster's trick, which you may have already encountered with a damaged car, is to steer people to certain repair shops and contractors that give the insurer better prices for their work but may offer inferior parts and service. Most policies do not require that you accept the insurer's choice of contractors. Insist on having work done by people you know and trust.

Do your own research on the value of lost and damaged items—the more documentation you have, the less likely an adjuster is to question your claim.

Document your losses very specifically. Adjusters often attempt to group material losses nonselectively, just as health insurers sometimes attempt to bundle your services. If a certain cabinet contained medical supplies, be very specific about the supplies it contained so you can assign value to the individual items.

Also remember that, after the trauma of a burglary or fire, you may overlook some losses. Your insurer may not tell you that you can file another claim for additional losses, even after you settle.

Don't be intimidated by the limits of your policy coverage. Depending on the policy, you may be able to recover more than the cited policy limit if you have “replacement cost” coverage. And don't assume you won't make your deductible in spite of initial estimates. Damage that is not immediately apparent can add up to a significant sum later.

It is usually not wise to rely solely on your insurance agent in such situations because an agent's loyalty resides primarily with the insurance company, not the insured. Retaining a lawyer is often a good idea, if only to review paperwork and help you value your losses. It will cost comparatively little and is usually money well spent.

A lawyer also can help negotiate any disputes with the insurer, but a public insurance adjuster may be a less expensive alternative. Public adjusters are professionals, employed by policyholders rather than insurers, who handle all aspects of a claim. You can find more information at the Web site of the National Association of Public Insurance Adjusters www.napia.com

To respond to this column, e-mail Dr. Eastern at [email protected]

A dermatologist in the Midwest wrote to me for advice on dealing with everyone's worst nightmare, the burglary and arson of his office.

Filing an insurance claim was his first priority, of course. We all buy insurance hoping we will never need it, but when we do, it's important to get it right.

Prompt claim filing is key. All policies have a filing deadline, which varies for different policies and states, but just because you file promptly does not mean you have to settle on a payment just as fast.

Most insurers want a quick resolution as much as you do, but if you allow yourself to be rushed, you could end up with a smaller settlement than you deserve.

If you're a regular reader, you're quite familiar with my first rule of dealing with health insurers: Everything is negotiable. It's no different with casualty insurers. Regardless of what adjusters tell you, the initial amount offered is never engraved in stone. Adjusters are evaluated on the basis of how much money they “save” on claims, so their initial number will usually be low.

As with health insurance claims, casualty policies have gray areas. Those areas include reasonable expenses for repairing or replacing damaged medical equipment or the rental of alternative office space.

Other negotiable costs include moving expenses, storage of damaged and undamaged equipment, and depreciation on specific items. And as we all know from our health insurance experience, injuries are fertile areas for negotiation.

Another adjuster's trick, which you may have already encountered with a damaged car, is to steer people to certain repair shops and contractors that give the insurer better prices for their work but may offer inferior parts and service. Most policies do not require that you accept the insurer's choice of contractors. Insist on having work done by people you know and trust.

Do your own research on the value of lost and damaged items—the more documentation you have, the less likely an adjuster is to question your claim.

Document your losses very specifically. Adjusters often attempt to group material losses nonselectively, just as health insurers sometimes attempt to bundle your services. If a certain cabinet contained medical supplies, be very specific about the supplies it contained so you can assign value to the individual items.

Also remember that, after the trauma of a burglary or fire, you may overlook some losses. Your insurer may not tell you that you can file another claim for additional losses, even after you settle.

Don't be intimidated by the limits of your policy coverage. Depending on the policy, you may be able to recover more than the cited policy limit if you have “replacement cost” coverage. And don't assume you won't make your deductible in spite of initial estimates. Damage that is not immediately apparent can add up to a significant sum later.

It is usually not wise to rely solely on your insurance agent in such situations because an agent's loyalty resides primarily with the insurance company, not the insured. Retaining a lawyer is often a good idea, if only to review paperwork and help you value your losses. It will cost comparatively little and is usually money well spent.

A lawyer also can help negotiate any disputes with the insurer, but a public insurance adjuster may be a less expensive alternative. Public adjusters are professionals, employed by policyholders rather than insurers, who handle all aspects of a claim. You can find more information at the Web site of the National Association of Public Insurance Adjusters www.napia.com

To respond to this column, e-mail Dr. Eastern at [email protected]

A dermatologist in the Midwest wrote to me for advice on dealing with everyone's worst nightmare, the burglary and arson of his office.

Filing an insurance claim was his first priority, of course. We all buy insurance hoping we will never need it, but when we do, it's important to get it right.

Prompt claim filing is key. All policies have a filing deadline, which varies for different policies and states, but just because you file promptly does not mean you have to settle on a payment just as fast.

Most insurers want a quick resolution as much as you do, but if you allow yourself to be rushed, you could end up with a smaller settlement than you deserve.

If you're a regular reader, you're quite familiar with my first rule of dealing with health insurers: Everything is negotiable. It's no different with casualty insurers. Regardless of what adjusters tell you, the initial amount offered is never engraved in stone. Adjusters are evaluated on the basis of how much money they “save” on claims, so their initial number will usually be low.

As with health insurance claims, casualty policies have gray areas. Those areas include reasonable expenses for repairing or replacing damaged medical equipment or the rental of alternative office space.

Other negotiable costs include moving expenses, storage of damaged and undamaged equipment, and depreciation on specific items. And as we all know from our health insurance experience, injuries are fertile areas for negotiation.

Another adjuster's trick, which you may have already encountered with a damaged car, is to steer people to certain repair shops and contractors that give the insurer better prices for their work but may offer inferior parts and service. Most policies do not require that you accept the insurer's choice of contractors. Insist on having work done by people you know and trust.

Do your own research on the value of lost and damaged items—the more documentation you have, the less likely an adjuster is to question your claim.

Document your losses very specifically. Adjusters often attempt to group material losses nonselectively, just as health insurers sometimes attempt to bundle your services. If a certain cabinet contained medical supplies, be very specific about the supplies it contained so you can assign value to the individual items.

Also remember that, after the trauma of a burglary or fire, you may overlook some losses. Your insurer may not tell you that you can file another claim for additional losses, even after you settle.

Don't be intimidated by the limits of your policy coverage. Depending on the policy, you may be able to recover more than the cited policy limit if you have “replacement cost” coverage. And don't assume you won't make your deductible in spite of initial estimates. Damage that is not immediately apparent can add up to a significant sum later.

It is usually not wise to rely solely on your insurance agent in such situations because an agent's loyalty resides primarily with the insurance company, not the insured. Retaining a lawyer is often a good idea, if only to review paperwork and help you value your losses. It will cost comparatively little and is usually money well spent.

A lawyer also can help negotiate any disputes with the insurer, but a public insurance adjuster may be a less expensive alternative. Public adjusters are professionals, employed by policyholders rather than insurers, who handle all aspects of a claim. You can find more information at the Web site of the National Association of Public Insurance Adjusters www.napia.com

To respond to this column, e-mail Dr. Eastern at [email protected]

Consumer Reports surveyed its readers last year regarding their satisfaction with their medical care and found that the “overwhelming majority … were highly satisfied with their doctors.” Of course, they did have some complaints.

As you might expect, their top complaint was the time spent waiting to see their doctors—24% said they frequently waited 30 minutes or longer. Here are some suggestions to help keep you on track:

▸ Start on time. That seems obvious, but I'm always amazed at the number of doctors who admit to running late who also admit that they start late. If you're in the hole before you start, you can seldom dig yourself out. Sometimes an on-time start is the solution to the entire problem. Try it.

▸ Book realistically. Everyone works at a different pace. Determine the number of patients you can comfortably see in an hour, and book only that number. If you want to see more patients, the solution is working longer hours or hiring physicians or physician extenders (or both), not overloading your schedule.

▸ Time-stamp each chart. Every office should have a time clock, not only for employees, but for patients as well. As each patient arrives, have your receptionist time-stamp the “encounter form” that goes to the back with the chart. As you take each chart off the door and enter the room, a quick glance at the time stamp will tell you how long the patient has been waiting.

▸ Schedule all procedures. If you haven't scheduled the time necessary for a procedure, don't do it. It may be tempting to squeeze it in because you feel guilty that the patient has had to wait for you, but every unscheduled procedure puts you that much further behind. And hurrying increases the risk of mistakes. Tell the patient the procedure requires extra time and can't be rushed, so you will have to schedule.

▸ Work-ins come last, not first. Patients with urgent problems should be seen after scheduled patients. Receptionists often assume it's better to squeeze them in early, while you're still running on time, but doing that guarantees you will run late, and it isn't fair to patients who have appointments and expect to be seen promptly. Work-ins expect a wait because they have no appointment. We tell them our schedule is full, but if they come at the end of hours, they'll see a doctor though they may have a wait. Far from complaining, they invariably thank us for seeing them.

▸ Seize the list. You know which list I mean: “No. 16: My right big toe itches. No. 17: I think I feel something on my back…” When a list is produced, the best option is to read it yourself. Identify the most important two or three problems and address them. For the rest, I will say, “This group of problems deserves a visit of its own, and we will schedule that visit.” Ask if you can place the list (or a photocopy) in the patient's chart. It is, after all, important clinical information. All of these problems are important to the patient and should be addressed—but on your schedule, not the patient's.

▸ Avoid interruptions. Especially phone calls. Unless it's an emergency or an immediate family member, my receptionists say, “I'm sorry, the doctor is with patients. May I take a message?” Everyone—even other physicians—understands. Just be sure to return those calls promptly.

Pharmaceutical reps should not be allowed to interrupt you, either. Have them make an appointment. Don't stop to open the mail, do paperwork, or perform any other task that can be delegated.

There will be times, of course, when you run late, but they should be the exception rather than the rule.

Incidentally, the other leading patient complaints in the Consumer Reports survey were: couldn't schedule an appointment within a week (19%), spent too little time with me (9%), didn't provide test results promptly (7%), and didn't respond to my phone calls promptly (6%).

Now would be an excellent opportunity to identify and address any of those problems as well.

Consumer Reports surveyed its readers last year regarding their satisfaction with their medical care and found that the “overwhelming majority … were highly satisfied with their doctors.” Of course, they did have some complaints.

As you might expect, their top complaint was the time spent waiting to see their doctors—24% said they frequently waited 30 minutes or longer. Here are some suggestions to help keep you on track:

▸ Start on time. That seems obvious, but I'm always amazed at the number of doctors who admit to running late who also admit that they start late. If you're in the hole before you start, you can seldom dig yourself out. Sometimes an on-time start is the solution to the entire problem. Try it.

▸ Book realistically. Everyone works at a different pace. Determine the number of patients you can comfortably see in an hour, and book only that number. If you want to see more patients, the solution is working longer hours or hiring physicians or physician extenders (or both), not overloading your schedule.

▸ Time-stamp each chart. Every office should have a time clock, not only for employees, but for patients as well. As each patient arrives, have your receptionist time-stamp the “encounter form” that goes to the back with the chart. As you take each chart off the door and enter the room, a quick glance at the time stamp will tell you how long the patient has been waiting.

▸ Schedule all procedures. If you haven't scheduled the time necessary for a procedure, don't do it. It may be tempting to squeeze it in because you feel guilty that the patient has had to wait for you, but every unscheduled procedure puts you that much further behind. And hurrying increases the risk of mistakes. Tell the patient the procedure requires extra time and can't be rushed, so you will have to schedule.

▸ Work-ins come last, not first. Patients with urgent problems should be seen after scheduled patients. Receptionists often assume it's better to squeeze them in early, while you're still running on time, but doing that guarantees you will run late, and it isn't fair to patients who have appointments and expect to be seen promptly. Work-ins expect a wait because they have no appointment. We tell them our schedule is full, but if they come at the end of hours, they'll see a doctor though they may have a wait. Far from complaining, they invariably thank us for seeing them.

▸ Seize the list. You know which list I mean: “No. 16: My right big toe itches. No. 17: I think I feel something on my back…” When a list is produced, the best option is to read it yourself. Identify the most important two or three problems and address them. For the rest, I will say, “This group of problems deserves a visit of its own, and we will schedule that visit.” Ask if you can place the list (or a photocopy) in the patient's chart. It is, after all, important clinical information. All of these problems are important to the patient and should be addressed—but on your schedule, not the patient's.

▸ Avoid interruptions. Especially phone calls. Unless it's an emergency or an immediate family member, my receptionists say, “I'm sorry, the doctor is with patients. May I take a message?” Everyone—even other physicians—understands. Just be sure to return those calls promptly.

Pharmaceutical reps should not be allowed to interrupt you, either. Have them make an appointment. Don't stop to open the mail, do paperwork, or perform any other task that can be delegated.

There will be times, of course, when you run late, but they should be the exception rather than the rule.

Incidentally, the other leading patient complaints in the Consumer Reports survey were: couldn't schedule an appointment within a week (19%), spent too little time with me (9%), didn't provide test results promptly (7%), and didn't respond to my phone calls promptly (6%).

Now would be an excellent opportunity to identify and address any of those problems as well.

Consumer Reports surveyed its readers last year regarding their satisfaction with their medical care and found that the “overwhelming majority … were highly satisfied with their doctors.” Of course, they did have some complaints.

As you might expect, their top complaint was the time spent waiting to see their doctors—24% said they frequently waited 30 minutes or longer. Here are some suggestions to help keep you on track:

▸ Start on time. That seems obvious, but I'm always amazed at the number of doctors who admit to running late who also admit that they start late. If you're in the hole before you start, you can seldom dig yourself out. Sometimes an on-time start is the solution to the entire problem. Try it.

▸ Book realistically. Everyone works at a different pace. Determine the number of patients you can comfortably see in an hour, and book only that number. If you want to see more patients, the solution is working longer hours or hiring physicians or physician extenders (or both), not overloading your schedule.

▸ Time-stamp each chart. Every office should have a time clock, not only for employees, but for patients as well. As each patient arrives, have your receptionist time-stamp the “encounter form” that goes to the back with the chart. As you take each chart off the door and enter the room, a quick glance at the time stamp will tell you how long the patient has been waiting.

▸ Schedule all procedures. If you haven't scheduled the time necessary for a procedure, don't do it. It may be tempting to squeeze it in because you feel guilty that the patient has had to wait for you, but every unscheduled procedure puts you that much further behind. And hurrying increases the risk of mistakes. Tell the patient the procedure requires extra time and can't be rushed, so you will have to schedule.

▸ Work-ins come last, not first. Patients with urgent problems should be seen after scheduled patients. Receptionists often assume it's better to squeeze them in early, while you're still running on time, but doing that guarantees you will run late, and it isn't fair to patients who have appointments and expect to be seen promptly. Work-ins expect a wait because they have no appointment. We tell them our schedule is full, but if they come at the end of hours, they'll see a doctor though they may have a wait. Far from complaining, they invariably thank us for seeing them.

▸ Seize the list. You know which list I mean: “No. 16: My right big toe itches. No. 17: I think I feel something on my back…” When a list is produced, the best option is to read it yourself. Identify the most important two or three problems and address them. For the rest, I will say, “This group of problems deserves a visit of its own, and we will schedule that visit.” Ask if you can place the list (or a photocopy) in the patient's chart. It is, after all, important clinical information. All of these problems are important to the patient and should be addressed—but on your schedule, not the patient's.

▸ Avoid interruptions. Especially phone calls. Unless it's an emergency or an immediate family member, my receptionists say, “I'm sorry, the doctor is with patients. May I take a message?” Everyone—even other physicians—understands. Just be sure to return those calls promptly.

Pharmaceutical reps should not be allowed to interrupt you, either. Have them make an appointment. Don't stop to open the mail, do paperwork, or perform any other task that can be delegated.

There will be times, of course, when you run late, but they should be the exception rather than the rule.

Incidentally, the other leading patient complaints in the Consumer Reports survey were: couldn't schedule an appointment within a week (19%), spent too little time with me (9%), didn't provide test results promptly (7%), and didn't respond to my phone calls promptly (6%).

Now would be an excellent opportunity to identify and address any of those problems as well.

My last two columns discussed the complaint patients make most often: waiting too long in the office.

However, another prevalent complaint—and one that shows no sign of improving in many areas of the country—is the inability to get an appointment with a dermatologist within a reasonable period of time.

In general, patients consider any delay longer than a few days—a week at most—unreasonable. And many dermatologists are booked several weeks in advance.

A patient who finds a suspicious-looking mole and wants to see a dermatologist can expect an average wait of 38 days in the United States, and up to 73 days in Boston, according to a study from the University of California, San Francisco.

Such backlogs, besides arousing patients' ire, cost you money: The longer the wait time, the higher the likelihood of cancellations and no-shows. These leave gaps in your supposedly “full” schedule while adding to administrative work, hurting your bottom line, and driving up costs. A 2001 study showed missed appointments result in a loss of 3%–14% of annual revenues.

Backlogs also are a major reason why dermatologists are losing an increasing amount of business to less-qualified practitioners who will see patients sooner.

In the business world, this would be called a supply and demand issue, one that most successful businesses learned long ago to solve. For example, no McDonald's customer ever hears, “We don't have any Big Macs today; come back tomorrow.” Each McDonald's outlet makes certain it can match its supply with its customers' demand at any given time; if it can't, it loses big chunks of business to competitors.

And if dermatologists don't wish to continue losing ever-larger chunks of business to general practitioners and spas, we too will have to learn to balance supply (the number of available physician hours) with demand (the number of patients).

Options for increasing supply are fairly straightforward. You can increase personnel by bringing in a new associate, or hiring a physician assistant or nurse practitioner. Or you can expand appointment slots by adding hours during early mornings, evenings, or weekends.

Alternatively, you can decrease demand by eliminating third-party contracts that pay too poorly or too slowly, or restricting the type or number of new patients your practice accepts. Or you can narrow the scope of your practice: Eliminate surgery, for example, or eliminate everything except surgery, or focus on one type of surgery, such as Mohs or cosmetic procedures. Or concentrate on something in which you have special interest or expertise, such as psoriasis or pediatric dermatology.

You may find it necessary to combine several of these options to work down your backlog of appointments to a manageable level.

Once supply and demand are well balanced, you may wish to consider adopting an increasingly popular system called open-access scheduling. With open access, most patients are seen on the day they call for an appointment regardless of the reason for their visit. And surprisingly enough, when implemented correctly, it works.

Studies have shown open access to be an effective way of cutting wait times in both managed-care and fee-for-service settings. The advantages are obvious: It greatly increases patient satisfaction while making practices more profitable by virtually eliminating the financial drain of cancellations and missed appointments.

While not for everyone, open access is a viable option in many situations. It can be adopted gradually, starting with reserving some slots each day for last-minute appointments, and then gradually increasing the number of same-day slots until everyone is comfortable with them. At that point you can begin offering all patients an appointment on the day they call your office.

Of course, those patients who do not want to be seen on the day they call can be scheduled for an appointment at a time of their choice. (They should not be told to call back on the day they want to be seen.) And, while seeing patients, you will probably want to schedule some surgeries and other procedures as necessary. (Such advance appointments are known in the open access parlance as “good backlog.”)

When properly managed, open access gets high marks from both patients, who are thrilled to be able to get appointments when they want them, and office personnel, who report that the frenetic routine of answering calls, scheduling visits, and providing clinical care takes place at a much calmer pace. The phones are quieter, and schedulers, nurses, physicians, and staff spend much less time dealing with backlog issues, which leaves more time to care for patients.

Of course, eliminating all wait time, cancellations, missed appointments, and loss of patients to other physicians will take more than just creative scheduling. It will take a basic change in the way we think about the business aspects of health care, such as supply and demand, which most physicians think do not apply to them.

To respond to this column, e-mail Dr. Eastern at [email protected]

My last two columns discussed the complaint patients make most often: waiting too long in the office.

However, another prevalent complaint—and one that shows no sign of improving in many areas of the country—is the inability to get an appointment with a dermatologist within a reasonable period of time.

In general, patients consider any delay longer than a few days—a week at most—unreasonable. And many dermatologists are booked several weeks in advance.

A patient who finds a suspicious-looking mole and wants to see a dermatologist can expect an average wait of 38 days in the United States, and up to 73 days in Boston, according to a study from the University of California, San Francisco.

Such backlogs, besides arousing patients' ire, cost you money: The longer the wait time, the higher the likelihood of cancellations and no-shows. These leave gaps in your supposedly “full” schedule while adding to administrative work, hurting your bottom line, and driving up costs. A 2001 study showed missed appointments result in a loss of 3%–14% of annual revenues.

Backlogs also are a major reason why dermatologists are losing an increasing amount of business to less-qualified practitioners who will see patients sooner.

In the business world, this would be called a supply and demand issue, one that most successful businesses learned long ago to solve. For example, no McDonald's customer ever hears, “We don't have any Big Macs today; come back tomorrow.” Each McDonald's outlet makes certain it can match its supply with its customers' demand at any given time; if it can't, it loses big chunks of business to competitors.

And if dermatologists don't wish to continue losing ever-larger chunks of business to general practitioners and spas, we too will have to learn to balance supply (the number of available physician hours) with demand (the number of patients).

Options for increasing supply are fairly straightforward. You can increase personnel by bringing in a new associate, or hiring a physician assistant or nurse practitioner. Or you can expand appointment slots by adding hours during early mornings, evenings, or weekends.

Alternatively, you can decrease demand by eliminating third-party contracts that pay too poorly or too slowly, or restricting the type or number of new patients your practice accepts. Or you can narrow the scope of your practice: Eliminate surgery, for example, or eliminate everything except surgery, or focus on one type of surgery, such as Mohs or cosmetic procedures. Or concentrate on something in which you have special interest or expertise, such as psoriasis or pediatric dermatology.

You may find it necessary to combine several of these options to work down your backlog of appointments to a manageable level.

Once supply and demand are well balanced, you may wish to consider adopting an increasingly popular system called open-access scheduling. With open access, most patients are seen on the day they call for an appointment regardless of the reason for their visit. And surprisingly enough, when implemented correctly, it works.

Studies have shown open access to be an effective way of cutting wait times in both managed-care and fee-for-service settings. The advantages are obvious: It greatly increases patient satisfaction while making practices more profitable by virtually eliminating the financial drain of cancellations and missed appointments.

While not for everyone, open access is a viable option in many situations. It can be adopted gradually, starting with reserving some slots each day for last-minute appointments, and then gradually increasing the number of same-day slots until everyone is comfortable with them. At that point you can begin offering all patients an appointment on the day they call your office.

Of course, those patients who do not want to be seen on the day they call can be scheduled for an appointment at a time of their choice. (They should not be told to call back on the day they want to be seen.) And, while seeing patients, you will probably want to schedule some surgeries and other procedures as necessary. (Such advance appointments are known in the open access parlance as “good backlog.”)

When properly managed, open access gets high marks from both patients, who are thrilled to be able to get appointments when they want them, and office personnel, who report that the frenetic routine of answering calls, scheduling visits, and providing clinical care takes place at a much calmer pace. The phones are quieter, and schedulers, nurses, physicians, and staff spend much less time dealing with backlog issues, which leaves more time to care for patients.

Of course, eliminating all wait time, cancellations, missed appointments, and loss of patients to other physicians will take more than just creative scheduling. It will take a basic change in the way we think about the business aspects of health care, such as supply and demand, which most physicians think do not apply to them.

To respond to this column, e-mail Dr. Eastern at [email protected]

My last two columns discussed the complaint patients make most often: waiting too long in the office.

However, another prevalent complaint—and one that shows no sign of improving in many areas of the country—is the inability to get an appointment with a dermatologist within a reasonable period of time.

In general, patients consider any delay longer than a few days—a week at most—unreasonable. And many dermatologists are booked several weeks in advance.

A patient who finds a suspicious-looking mole and wants to see a dermatologist can expect an average wait of 38 days in the United States, and up to 73 days in Boston, according to a study from the University of California, San Francisco.

Such backlogs, besides arousing patients' ire, cost you money: The longer the wait time, the higher the likelihood of cancellations and no-shows. These leave gaps in your supposedly “full” schedule while adding to administrative work, hurting your bottom line, and driving up costs. A 2001 study showed missed appointments result in a loss of 3%–14% of annual revenues.

Backlogs also are a major reason why dermatologists are losing an increasing amount of business to less-qualified practitioners who will see patients sooner.

In the business world, this would be called a supply and demand issue, one that most successful businesses learned long ago to solve. For example, no McDonald's customer ever hears, “We don't have any Big Macs today; come back tomorrow.” Each McDonald's outlet makes certain it can match its supply with its customers' demand at any given time; if it can't, it loses big chunks of business to competitors.

And if dermatologists don't wish to continue losing ever-larger chunks of business to general practitioners and spas, we too will have to learn to balance supply (the number of available physician hours) with demand (the number of patients).

Options for increasing supply are fairly straightforward. You can increase personnel by bringing in a new associate, or hiring a physician assistant or nurse practitioner. Or you can expand appointment slots by adding hours during early mornings, evenings, or weekends.

Alternatively, you can decrease demand by eliminating third-party contracts that pay too poorly or too slowly, or restricting the type or number of new patients your practice accepts. Or you can narrow the scope of your practice: Eliminate surgery, for example, or eliminate everything except surgery, or focus on one type of surgery, such as Mohs or cosmetic procedures. Or concentrate on something in which you have special interest or expertise, such as psoriasis or pediatric dermatology.

You may find it necessary to combine several of these options to work down your backlog of appointments to a manageable level.

Once supply and demand are well balanced, you may wish to consider adopting an increasingly popular system called open-access scheduling. With open access, most patients are seen on the day they call for an appointment regardless of the reason for their visit. And surprisingly enough, when implemented correctly, it works.

Studies have shown open access to be an effective way of cutting wait times in both managed-care and fee-for-service settings. The advantages are obvious: It greatly increases patient satisfaction while making practices more profitable by virtually eliminating the financial drain of cancellations and missed appointments.

While not for everyone, open access is a viable option in many situations. It can be adopted gradually, starting with reserving some slots each day for last-minute appointments, and then gradually increasing the number of same-day slots until everyone is comfortable with them. At that point you can begin offering all patients an appointment on the day they call your office.

Of course, those patients who do not want to be seen on the day they call can be scheduled for an appointment at a time of their choice. (They should not be told to call back on the day they want to be seen.) And, while seeing patients, you will probably want to schedule some surgeries and other procedures as necessary. (Such advance appointments are known in the open access parlance as “good backlog.”)

When properly managed, open access gets high marks from both patients, who are thrilled to be able to get appointments when they want them, and office personnel, who report that the frenetic routine of answering calls, scheduling visits, and providing clinical care takes place at a much calmer pace. The phones are quieter, and schedulers, nurses, physicians, and staff spend much less time dealing with backlog issues, which leaves more time to care for patients.

Of course, eliminating all wait time, cancellations, missed appointments, and loss of patients to other physicians will take more than just creative scheduling. It will take a basic change in the way we think about the business aspects of health care, such as supply and demand, which most physicians think do not apply to them.

To respond to this column, e-mail Dr. Eastern at [email protected]