M. Alexander Otto

LOS ANGELES – A few key questions must be answered before starting children on ADHD stimulants to protect them from the small but real risk the drugs pose of sudden cardiac death, according to Dr. James J. McGough.

Has the child ever fainted while exercising? Is there a family history of early sudden death? Does the child have any known cardiac abnormalities? Is there a click or murmur on physical exam?

"If you get a ‘yes’ to any of [those questions], that is the time to refer," Dr. McGough of the division of child and adolescent psychiatry at the University of California, Los Angeles, said at a psychopharmacology update sponsored by the American Academy of Child & Adolescent Psychiatry.

An "EKG is reasonable, if you want it," he added; a recent study showed a small benefit prior to stimulant treatment (Circulation 2010;121:1329-37).

In general, the sudden death risk with ADHD stimulants is low, on par with the "risk of sudden death [at] Saturday morning soccer," Dr. McGough said. Still, "this is something where you really do need to be thoughtful," he said.

An audience member asked whether he thought the arrhythmia risk increased when alpha2-adrenergic agonists (clonidine or guanfacine, for example) are used with stimulants to increase ADHD control, or for other reasons.

"We will be able to answer that," Dr. McGough said, because he and his colleagues are completing a 200-child ADHD study of that and other questions. But in the meantime, "I would not have those concerns," he said.

In fact, Dr. McGough and his colleagues use the combination "commonly. I think it is a really good treatment," he said.

Dr. McGough noted that he has treated children with cardiac abnormalities, with the help of a pediatric cardiologist. "I had one boy who could not function without stimulants. He has an aortic outflow obstruction. The parents and the boy knew the risk, [and] we were very careful. So you can do it, but you should get the further work-up," he said.

Once cardiac issues are dealt with, ADHD treatment starts with methylphenidate or amphetamines. "There’s nothing to direct you one way or the other. If [patients] fail one, it suggests you try the other class. I can think of no good reason to prescribe an amphetamine and a methylphenidate in the same kid," Dr. McGough said.

To maintain effect, "you need to keep the [drug] blood level rising" throughout the day, he said.

That’s possible with immediate-release formulations if they are given every few hours, but extended-release medications save the hassle. Because of that, "I would never start with immediate-release stimulants," Dr. McGough said.

The conference moderator, Dr. Gabrielle Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook, objected to the comment.

She noted that sometimes children do not respond to extended-release medications but do respond to immediate-release formulations. In addition, sometimes children are unable to tolerate ascending blood levels and become toxic; with immediate-release stimulants, you can often tell in the office whether the drug will work.

Dr. McGough acknowledged the concerns but said he still prefers to initiate treatment with extended-release products.

"What I typically do is send people out with usually around 30 small-dose, extended-release tablets [and instructions to] take one a day for 5 days; two a day for 5 days; and three a day for 5 days," then return for re-evaluation, he said. "That’s how I do it, and it’s effective for me."

Dr. McGough had a tip about one long-acting medication in particular: Adderall XR. "You only get 10-12 hours of benefit from it, but the actual half-life is much longer," he said. As a result – and especially if doses are increased to maintain effect – the drug can build up in children’s systems.

Eventually, a wall might be hit where the drug no longer seems to work. The problem is that children "have this swamp of amphetamine doing nothing for [them]. You’ve got to ramp up out of that before you get effect," Dr. McGough said.

Once the dosage is above 30 mg/day and the child is still nonresponsive, consider that "maybe they’re getting too much medicine. Let their bodies clear out, and start again on a lower dose," he suggested.

Should stimulants fail even with proper dosing, nonstimulants are the next step for ADHD management. "Research suggests atomoxetine, but I think we could now move the alpha2-agonists up [to be] equal with that, because there’s evidence those medicines work," Dr. McGough said.

Those drugs can also be used with stimulants to reduce stimulant doses when appetite loss, insomnia, cognitive freezing, or other stimulant side effects are a problem.

Dr. McGough disclosed that he is an adviser or consultant to Eli Lilly and Shire Pharmaceuticals, and also receives research funding from Lilly.

LOS ANGELES – A few key questions must be answered before starting children on ADHD stimulants to protect them from the small but real risk the drugs pose of sudden cardiac death, according to Dr. James J. McGough.

Has the child ever fainted while exercising? Is there a family history of early sudden death? Does the child have any known cardiac abnormalities? Is there a click or murmur on physical exam?

"If you get a ‘yes’ to any of [those questions], that is the time to refer," Dr. McGough of the division of child and adolescent psychiatry at the University of California, Los Angeles, said at a psychopharmacology update sponsored by the American Academy of Child & Adolescent Psychiatry.

An "EKG is reasonable, if you want it," he added; a recent study showed a small benefit prior to stimulant treatment (Circulation 2010;121:1329-37).

In general, the sudden death risk with ADHD stimulants is low, on par with the "risk of sudden death [at] Saturday morning soccer," Dr. McGough said. Still, "this is something where you really do need to be thoughtful," he said.

An audience member asked whether he thought the arrhythmia risk increased when alpha2-adrenergic agonists (clonidine or guanfacine, for example) are used with stimulants to increase ADHD control, or for other reasons.

"We will be able to answer that," Dr. McGough said, because he and his colleagues are completing a 200-child ADHD study of that and other questions. But in the meantime, "I would not have those concerns," he said.

In fact, Dr. McGough and his colleagues use the combination "commonly. I think it is a really good treatment," he said.

Dr. McGough noted that he has treated children with cardiac abnormalities, with the help of a pediatric cardiologist. "I had one boy who could not function without stimulants. He has an aortic outflow obstruction. The parents and the boy knew the risk, [and] we were very careful. So you can do it, but you should get the further work-up," he said.

Once cardiac issues are dealt with, ADHD treatment starts with methylphenidate or amphetamines. "There’s nothing to direct you one way or the other. If [patients] fail one, it suggests you try the other class. I can think of no good reason to prescribe an amphetamine and a methylphenidate in the same kid," Dr. McGough said.

To maintain effect, "you need to keep the [drug] blood level rising" throughout the day, he said.

That’s possible with immediate-release formulations if they are given every few hours, but extended-release medications save the hassle. Because of that, "I would never start with immediate-release stimulants," Dr. McGough said.

The conference moderator, Dr. Gabrielle Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook, objected to the comment.

She noted that sometimes children do not respond to extended-release medications but do respond to immediate-release formulations. In addition, sometimes children are unable to tolerate ascending blood levels and become toxic; with immediate-release stimulants, you can often tell in the office whether the drug will work.

Dr. McGough acknowledged the concerns but said he still prefers to initiate treatment with extended-release products.

"What I typically do is send people out with usually around 30 small-dose, extended-release tablets [and instructions to] take one a day for 5 days; two a day for 5 days; and three a day for 5 days," then return for re-evaluation, he said. "That’s how I do it, and it’s effective for me."

Dr. McGough had a tip about one long-acting medication in particular: Adderall XR. "You only get 10-12 hours of benefit from it, but the actual half-life is much longer," he said. As a result – and especially if doses are increased to maintain effect – the drug can build up in children’s systems.

Eventually, a wall might be hit where the drug no longer seems to work. The problem is that children "have this swamp of amphetamine doing nothing for [them]. You’ve got to ramp up out of that before you get effect," Dr. McGough said.

Once the dosage is above 30 mg/day and the child is still nonresponsive, consider that "maybe they’re getting too much medicine. Let their bodies clear out, and start again on a lower dose," he suggested.

Should stimulants fail even with proper dosing, nonstimulants are the next step for ADHD management. "Research suggests atomoxetine, but I think we could now move the alpha2-agonists up [to be] equal with that, because there’s evidence those medicines work," Dr. McGough said.

Those drugs can also be used with stimulants to reduce stimulant doses when appetite loss, insomnia, cognitive freezing, or other stimulant side effects are a problem.

Dr. McGough disclosed that he is an adviser or consultant to Eli Lilly and Shire Pharmaceuticals, and also receives research funding from Lilly.

LOS ANGELES – A few key questions must be answered before starting children on ADHD stimulants to protect them from the small but real risk the drugs pose of sudden cardiac death, according to Dr. James J. McGough.

Has the child ever fainted while exercising? Is there a family history of early sudden death? Does the child have any known cardiac abnormalities? Is there a click or murmur on physical exam?

"If you get a ‘yes’ to any of [those questions], that is the time to refer," Dr. McGough of the division of child and adolescent psychiatry at the University of California, Los Angeles, said at a psychopharmacology update sponsored by the American Academy of Child & Adolescent Psychiatry.

An "EKG is reasonable, if you want it," he added; a recent study showed a small benefit prior to stimulant treatment (Circulation 2010;121:1329-37).

In general, the sudden death risk with ADHD stimulants is low, on par with the "risk of sudden death [at] Saturday morning soccer," Dr. McGough said. Still, "this is something where you really do need to be thoughtful," he said.

An audience member asked whether he thought the arrhythmia risk increased when alpha2-adrenergic agonists (clonidine or guanfacine, for example) are used with stimulants to increase ADHD control, or for other reasons.

"We will be able to answer that," Dr. McGough said, because he and his colleagues are completing a 200-child ADHD study of that and other questions. But in the meantime, "I would not have those concerns," he said.

In fact, Dr. McGough and his colleagues use the combination "commonly. I think it is a really good treatment," he said.

Dr. McGough noted that he has treated children with cardiac abnormalities, with the help of a pediatric cardiologist. "I had one boy who could not function without stimulants. He has an aortic outflow obstruction. The parents and the boy knew the risk, [and] we were very careful. So you can do it, but you should get the further work-up," he said.

Once cardiac issues are dealt with, ADHD treatment starts with methylphenidate or amphetamines. "There’s nothing to direct you one way or the other. If [patients] fail one, it suggests you try the other class. I can think of no good reason to prescribe an amphetamine and a methylphenidate in the same kid," Dr. McGough said.

To maintain effect, "you need to keep the [drug] blood level rising" throughout the day, he said.

That’s possible with immediate-release formulations if they are given every few hours, but extended-release medications save the hassle. Because of that, "I would never start with immediate-release stimulants," Dr. McGough said.

The conference moderator, Dr. Gabrielle Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook, objected to the comment.

She noted that sometimes children do not respond to extended-release medications but do respond to immediate-release formulations. In addition, sometimes children are unable to tolerate ascending blood levels and become toxic; with immediate-release stimulants, you can often tell in the office whether the drug will work.

Dr. McGough acknowledged the concerns but said he still prefers to initiate treatment with extended-release products.

"What I typically do is send people out with usually around 30 small-dose, extended-release tablets [and instructions to] take one a day for 5 days; two a day for 5 days; and three a day for 5 days," then return for re-evaluation, he said. "That’s how I do it, and it’s effective for me."

Dr. McGough had a tip about one long-acting medication in particular: Adderall XR. "You only get 10-12 hours of benefit from it, but the actual half-life is much longer," he said. As a result – and especially if doses are increased to maintain effect – the drug can build up in children’s systems.

Eventually, a wall might be hit where the drug no longer seems to work. The problem is that children "have this swamp of amphetamine doing nothing for [them]. You’ve got to ramp up out of that before you get effect," Dr. McGough said.

Once the dosage is above 30 mg/day and the child is still nonresponsive, consider that "maybe they’re getting too much medicine. Let their bodies clear out, and start again on a lower dose," he suggested.

Should stimulants fail even with proper dosing, nonstimulants are the next step for ADHD management. "Research suggests atomoxetine, but I think we could now move the alpha2-agonists up [to be] equal with that, because there’s evidence those medicines work," Dr. McGough said.

Those drugs can also be used with stimulants to reduce stimulant doses when appetite loss, insomnia, cognitive freezing, or other stimulant side effects are a problem.

Dr. McGough disclosed that he is an adviser or consultant to Eli Lilly and Shire Pharmaceuticals, and also receives research funding from Lilly.

SAN ANTONIO – When pharmacists enter the exam room to educate patients about diabetes, physicians save time and diabetes control improves.

At least that’s what happened at the Cabarrus Family Medicine clinic in Concord, N.C. In fact, pharmacist counseling there was so successful that Cabarrus recently hired two more pharmacists to work with patients, according to Sandy Robertson, a Cabarrus PharmD.

At a time when clinics across the country are adding pharmacists to patient-centered medical home teams, the Concord experience indicates what works, and what does not.

The story there began in July 2009, when Dr. Robertson volunteered to counsel patients on 2 half-days per week, taking time off from her usual teaching duties in Cabarrus’s residency program. She and managers at the 11-clinic family medicine chain wanted to see if pharmacist counseling would improve care. Dr. Robertson worked primarily with diabetes patients, she said in an interview.

To prepare for the visits, she scanned the clinic’s electronic health records to identify diabetic patients who needed extra help – those with hemoglobin A1c values above 9%. At first, Dr. Robertson called those patients to schedule an appointment about diabetes management; that approach was a mistake.

They thought pharmacists only filled prescriptions, she said. One patient, confused by a call from a druggist, even got angry, thinking she was being accused of abusing drugs.

Dr. Robertson quickly abandoned cold calls and instead asked doctors to schedule her with struggling patients during upcoming visits. Patients, she found, were happy to talk so long as she was first introduced by a doctor. The initial visits almost always took a half hour or longer. Meanwhile, doctors would see other patients, popping back into the exam room in about 30 minutes.

"I did a lot of listening. My job was to find out why they were having problems. I certainly didn’t have a canned diabetes talk," Dr. Robertson said. "Some patients didn’t even understand how to take their insulin, and asked me the most elementary questions. Some were well educated about their diabetes, but were choosing not to follow [recommendations] because they’re too hard," she said.

In the latter cases, Dr. Robertson would say something like, " ‘Okay, let’s make a deal. Instead of eating a whole bowl of ice cream every night, will you shake my hand and promise me that you’ll only eat half a bowl? I am going to try to negotiate with you.’ They would respond to that," she said.

Much of the time, Dr. Robertson was a cheerleader, telling patients, for instance, " ‘You’re going to have to come back in 3 months and your numbers are going to be great, and your doctor is going to be so pleased with you,’ " she said.

Dr. Robertson also called patients between visits to remind them of upcoming appointments, and to encourage them to take better care of themselves; physicians in Concord simply didn’t have time for such hand holding, she explained.

Her methods worked.

At a conference on practice improvement sponsored by the Society of Teachers of Family Medicine, Dr. Robertson presented data from her 9 toughest patients out of the 130-plus she counseled. Each dropped their hemoglobin A1c levels within the first 3 months. One patient’s HbA1c fell from 14% to 5.8%, another’s from 11% to 7%. After working with Dr. Robertson for 6 months, a third patient’s HbA1c fell from 10.8% to 6.8%.

"We don’t have enough data yet to do any kind of statistical analysis, [but] I feel really good about" the outcomes, she said. Physicians did, too. After a while, they were simply pulling Dr. Robertson into exam rooms to talk with newly diagnosed patients. "Their biggest complaint was I wasn’t there enough."

Dr. Robertson’s pilot project ended May 2010; Cabarrus immediately hired another pharmacist to do similar work full time, part of the week at Concord, the balance at the Cabarrus Family Medicine clinic in nearby Mt. Pleasant.

Polled last fall about the new pharmacist, 9 of the 12 doctors at the two clinics strongly agreed that patients appreciated her attention and that she improved patients’ medication knowledge, overall chronic disease management, and physicians’ satisfaction in managing challenging patients.

In December, Cabarrus hired another pharmacist to work at a third clinic.

During her pilot project, Dr. Robertson was paid out of the residency program. The two new pharmacists are also on salary. Only about half of third-party payers are reimbursing their efforts – billed mostly as medication management – at about $35-$75 per half hour. "We are billing what we can," Dr. Robertson said.

The conference was also sponsored by the American Academy of Family Physicians.

SAN ANTONIO – When pharmacists enter the exam room to educate patients about diabetes, physicians save time and diabetes control improves.

At least that’s what happened at the Cabarrus Family Medicine clinic in Concord, N.C. In fact, pharmacist counseling there was so successful that Cabarrus recently hired two more pharmacists to work with patients, according to Sandy Robertson, a Cabarrus PharmD.

At a time when clinics across the country are adding pharmacists to patient-centered medical home teams, the Concord experience indicates what works, and what does not.

The story there began in July 2009, when Dr. Robertson volunteered to counsel patients on 2 half-days per week, taking time off from her usual teaching duties in Cabarrus’s residency program. She and managers at the 11-clinic family medicine chain wanted to see if pharmacist counseling would improve care. Dr. Robertson worked primarily with diabetes patients, she said in an interview.

To prepare for the visits, she scanned the clinic’s electronic health records to identify diabetic patients who needed extra help – those with hemoglobin A1c values above 9%. At first, Dr. Robertson called those patients to schedule an appointment about diabetes management; that approach was a mistake.

They thought pharmacists only filled prescriptions, she said. One patient, confused by a call from a druggist, even got angry, thinking she was being accused of abusing drugs.

Dr. Robertson quickly abandoned cold calls and instead asked doctors to schedule her with struggling patients during upcoming visits. Patients, she found, were happy to talk so long as she was first introduced by a doctor. The initial visits almost always took a half hour or longer. Meanwhile, doctors would see other patients, popping back into the exam room in about 30 minutes.

"I did a lot of listening. My job was to find out why they were having problems. I certainly didn’t have a canned diabetes talk," Dr. Robertson said. "Some patients didn’t even understand how to take their insulin, and asked me the most elementary questions. Some were well educated about their diabetes, but were choosing not to follow [recommendations] because they’re too hard," she said.

In the latter cases, Dr. Robertson would say something like, " ‘Okay, let’s make a deal. Instead of eating a whole bowl of ice cream every night, will you shake my hand and promise me that you’ll only eat half a bowl? I am going to try to negotiate with you.’ They would respond to that," she said.

Much of the time, Dr. Robertson was a cheerleader, telling patients, for instance, " ‘You’re going to have to come back in 3 months and your numbers are going to be great, and your doctor is going to be so pleased with you,’ " she said.

Dr. Robertson also called patients between visits to remind them of upcoming appointments, and to encourage them to take better care of themselves; physicians in Concord simply didn’t have time for such hand holding, she explained.

Her methods worked.

At a conference on practice improvement sponsored by the Society of Teachers of Family Medicine, Dr. Robertson presented data from her 9 toughest patients out of the 130-plus she counseled. Each dropped their hemoglobin A1c levels within the first 3 months. One patient’s HbA1c fell from 14% to 5.8%, another’s from 11% to 7%. After working with Dr. Robertson for 6 months, a third patient’s HbA1c fell from 10.8% to 6.8%.

"We don’t have enough data yet to do any kind of statistical analysis, [but] I feel really good about" the outcomes, she said. Physicians did, too. After a while, they were simply pulling Dr. Robertson into exam rooms to talk with newly diagnosed patients. "Their biggest complaint was I wasn’t there enough."

Dr. Robertson’s pilot project ended May 2010; Cabarrus immediately hired another pharmacist to do similar work full time, part of the week at Concord, the balance at the Cabarrus Family Medicine clinic in nearby Mt. Pleasant.

Polled last fall about the new pharmacist, 9 of the 12 doctors at the two clinics strongly agreed that patients appreciated her attention and that she improved patients’ medication knowledge, overall chronic disease management, and physicians’ satisfaction in managing challenging patients.

In December, Cabarrus hired another pharmacist to work at a third clinic.

During her pilot project, Dr. Robertson was paid out of the residency program. The two new pharmacists are also on salary. Only about half of third-party payers are reimbursing their efforts – billed mostly as medication management – at about $35-$75 per half hour. "We are billing what we can," Dr. Robertson said.

The conference was also sponsored by the American Academy of Family Physicians.

SAN ANTONIO – When pharmacists enter the exam room to educate patients about diabetes, physicians save time and diabetes control improves.

At least that’s what happened at the Cabarrus Family Medicine clinic in Concord, N.C. In fact, pharmacist counseling there was so successful that Cabarrus recently hired two more pharmacists to work with patients, according to Sandy Robertson, a Cabarrus PharmD.

At a time when clinics across the country are adding pharmacists to patient-centered medical home teams, the Concord experience indicates what works, and what does not.

The story there began in July 2009, when Dr. Robertson volunteered to counsel patients on 2 half-days per week, taking time off from her usual teaching duties in Cabarrus’s residency program. She and managers at the 11-clinic family medicine chain wanted to see if pharmacist counseling would improve care. Dr. Robertson worked primarily with diabetes patients, she said in an interview.

To prepare for the visits, she scanned the clinic’s electronic health records to identify diabetic patients who needed extra help – those with hemoglobin A1c values above 9%. At first, Dr. Robertson called those patients to schedule an appointment about diabetes management; that approach was a mistake.

They thought pharmacists only filled prescriptions, she said. One patient, confused by a call from a druggist, even got angry, thinking she was being accused of abusing drugs.

Dr. Robertson quickly abandoned cold calls and instead asked doctors to schedule her with struggling patients during upcoming visits. Patients, she found, were happy to talk so long as she was first introduced by a doctor. The initial visits almost always took a half hour or longer. Meanwhile, doctors would see other patients, popping back into the exam room in about 30 minutes.

"I did a lot of listening. My job was to find out why they were having problems. I certainly didn’t have a canned diabetes talk," Dr. Robertson said. "Some patients didn’t even understand how to take their insulin, and asked me the most elementary questions. Some were well educated about their diabetes, but were choosing not to follow [recommendations] because they’re too hard," she said.

In the latter cases, Dr. Robertson would say something like, " ‘Okay, let’s make a deal. Instead of eating a whole bowl of ice cream every night, will you shake my hand and promise me that you’ll only eat half a bowl? I am going to try to negotiate with you.’ They would respond to that," she said.

Much of the time, Dr. Robertson was a cheerleader, telling patients, for instance, " ‘You’re going to have to come back in 3 months and your numbers are going to be great, and your doctor is going to be so pleased with you,’ " she said.

Dr. Robertson also called patients between visits to remind them of upcoming appointments, and to encourage them to take better care of themselves; physicians in Concord simply didn’t have time for such hand holding, she explained.

Her methods worked.

At a conference on practice improvement sponsored by the Society of Teachers of Family Medicine, Dr. Robertson presented data from her 9 toughest patients out of the 130-plus she counseled. Each dropped their hemoglobin A1c levels within the first 3 months. One patient’s HbA1c fell from 14% to 5.8%, another’s from 11% to 7%. After working with Dr. Robertson for 6 months, a third patient’s HbA1c fell from 10.8% to 6.8%.

"We don’t have enough data yet to do any kind of statistical analysis, [but] I feel really good about" the outcomes, she said. Physicians did, too. After a while, they were simply pulling Dr. Robertson into exam rooms to talk with newly diagnosed patients. "Their biggest complaint was I wasn’t there enough."

Dr. Robertson’s pilot project ended May 2010; Cabarrus immediately hired another pharmacist to do similar work full time, part of the week at Concord, the balance at the Cabarrus Family Medicine clinic in nearby Mt. Pleasant.

Polled last fall about the new pharmacist, 9 of the 12 doctors at the two clinics strongly agreed that patients appreciated her attention and that she improved patients’ medication knowledge, overall chronic disease management, and physicians’ satisfaction in managing challenging patients.

In December, Cabarrus hired another pharmacist to work at a third clinic.

During her pilot project, Dr. Robertson was paid out of the residency program. The two new pharmacists are also on salary. Only about half of third-party payers are reimbursing their efforts – billed mostly as medication management – at about $35-$75 per half hour. "We are billing what we can," Dr. Robertson said.

The conference was also sponsored by the American Academy of Family Physicians.

SAN ANTONIO – Group visits aren’t just for diabetics.

At the Maine Medical Center in Portland, they also help – along with other measures – to keep recently discharged patients from being readmitted, according to Dr. Ann Skelton, chief of the center’s department of family medicine, who presented her findings at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine.

Upon discharge from the Family Medicine Inpatient Service (FMIS) to the outpatient Family Medicine Center (FMC), patients are given the option of having their first follow-up visit with their primary care doctor, or in a group with other patients led by a team that includes an attending physician, a nurse, a social worker, pharmacist, and care manager, among others.

The slightly-more-than half who opt for the group find all of their hospital-to-home issues addressed at one time, in one place, and without delay.

If a patient has trouble getting through to a specialist, for instance, the social worker is there to help. If a patient needs home care, the care manager can set up an appointment, maybe for the same day. And there’s no need to go elsewhere for the physical exam – a physician does them during the meeting.

Patients also bring in their medications for the pharmacist to review. Sometimes the dosages are wrong; other times patients are taking the brand and generic versions of the same drug, or taking drugs that carry the risk of potential drug interactions – omeprazole and hydroxyzine, for example. COPD inhalers, warfarin, and allopurinol, among other drugs, often have had to be added to some patients’ regimens.

Overall, group visits are "a very effective way to do posthospital care. Bringing that team together makes it flow smoothly," Dr. Skelton said in an interview.

In a pilot project from June 2009 – shortly after the groups started – to November 2009, Dr. Skelton and her colleagues tracked outcomes for 175 patients admitted from the outpatient FMC to the inpatient FMIS, and then discharged back to the outpatient center.

The 30-day readmission rate among those who opted for the group was 2.4%; for those who opted for office follow-up, 9.4%. Overall, the 30-day readmission rate dropped from 14.2% to 12.6%, saving an estimated $158,884 on an annualized basis.

More recent data supports the trend. From June 2009 to September 2010, the 30-day readmission rate for those who opted for the group was 6.7%; Among all FMC patients, those who attended the group following discharge and those who did not, the 30-day readmissions rate was 8.9%.

It is not known whether the patients who opted for the group had lower readmission rates because they were less sick to begin with, or if other confounding variables contributed to the results; that analysis has not been done, Dr. Skelton said.

However, patients polled said that they understood their medications and care plans better after the group visit; virtually all said they’d recommend the group to recently discharged patients.

The 2-hour group visits are offered at the FMC every Wednesday morning, so patients who opt for them can attend within 7 days of discharge. Usually about 4, but sometimes up to 7, patients attend. The team knows who is coming and can prepare for the visits because the FMIS and FMC have improved how they track recently discharged patients. They share a common electronic registry of hospitalized patients; the system alerts staff on the outpatient side when a patient is admitted and discharged. Discharge summaries are almost always available within 24 hours. Nurses also call patients within 48 hours of discharge, making a note of any issues in the system.

The group visits and tracking upgrades are "catching things that used to fall through the cracks," one physician said in a poll.

The annual cost of the efforts, due mostly to the care team’s group visit time, is $30, 212. That’s offset by an annual gross revenue from the group visits of $30,368, billed under CPT code 99214, Dr. Skelton said at the conference, which was also sponsored by the American Academy of Family Physicians.

"As long as you have more than a couple patients in any week" so discharge group visits are cost-effective, they "make sense," she said.

There was no outside funding for the efforts, "just creative reallocation of human resources," said Dr. Skelton, who reported having no relevant conflicts of interests.

SAN ANTONIO – Group visits aren’t just for diabetics.

At the Maine Medical Center in Portland, they also help – along with other measures – to keep recently discharged patients from being readmitted, according to Dr. Ann Skelton, chief of the center’s department of family medicine, who presented her findings at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine.

Upon discharge from the Family Medicine Inpatient Service (FMIS) to the outpatient Family Medicine Center (FMC), patients are given the option of having their first follow-up visit with their primary care doctor, or in a group with other patients led by a team that includes an attending physician, a nurse, a social worker, pharmacist, and care manager, among others.

The slightly-more-than half who opt for the group find all of their hospital-to-home issues addressed at one time, in one place, and without delay.

If a patient has trouble getting through to a specialist, for instance, the social worker is there to help. If a patient needs home care, the care manager can set up an appointment, maybe for the same day. And there’s no need to go elsewhere for the physical exam – a physician does them during the meeting.

Patients also bring in their medications for the pharmacist to review. Sometimes the dosages are wrong; other times patients are taking the brand and generic versions of the same drug, or taking drugs that carry the risk of potential drug interactions – omeprazole and hydroxyzine, for example. COPD inhalers, warfarin, and allopurinol, among other drugs, often have had to be added to some patients’ regimens.

Overall, group visits are "a very effective way to do posthospital care. Bringing that team together makes it flow smoothly," Dr. Skelton said in an interview.

In a pilot project from June 2009 – shortly after the groups started – to November 2009, Dr. Skelton and her colleagues tracked outcomes for 175 patients admitted from the outpatient FMC to the inpatient FMIS, and then discharged back to the outpatient center.

The 30-day readmission rate among those who opted for the group was 2.4%; for those who opted for office follow-up, 9.4%. Overall, the 30-day readmission rate dropped from 14.2% to 12.6%, saving an estimated $158,884 on an annualized basis.

More recent data supports the trend. From June 2009 to September 2010, the 30-day readmission rate for those who opted for the group was 6.7%; Among all FMC patients, those who attended the group following discharge and those who did not, the 30-day readmissions rate was 8.9%.

It is not known whether the patients who opted for the group had lower readmission rates because they were less sick to begin with, or if other confounding variables contributed to the results; that analysis has not been done, Dr. Skelton said.

However, patients polled said that they understood their medications and care plans better after the group visit; virtually all said they’d recommend the group to recently discharged patients.

The 2-hour group visits are offered at the FMC every Wednesday morning, so patients who opt for them can attend within 7 days of discharge. Usually about 4, but sometimes up to 7, patients attend. The team knows who is coming and can prepare for the visits because the FMIS and FMC have improved how they track recently discharged patients. They share a common electronic registry of hospitalized patients; the system alerts staff on the outpatient side when a patient is admitted and discharged. Discharge summaries are almost always available within 24 hours. Nurses also call patients within 48 hours of discharge, making a note of any issues in the system.

The group visits and tracking upgrades are "catching things that used to fall through the cracks," one physician said in a poll.

The annual cost of the efforts, due mostly to the care team’s group visit time, is $30, 212. That’s offset by an annual gross revenue from the group visits of $30,368, billed under CPT code 99214, Dr. Skelton said at the conference, which was also sponsored by the American Academy of Family Physicians.

"As long as you have more than a couple patients in any week" so discharge group visits are cost-effective, they "make sense," she said.

There was no outside funding for the efforts, "just creative reallocation of human resources," said Dr. Skelton, who reported having no relevant conflicts of interests.

SAN ANTONIO – Group visits aren’t just for diabetics.

At the Maine Medical Center in Portland, they also help – along with other measures – to keep recently discharged patients from being readmitted, according to Dr. Ann Skelton, chief of the center’s department of family medicine, who presented her findings at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine.

Upon discharge from the Family Medicine Inpatient Service (FMIS) to the outpatient Family Medicine Center (FMC), patients are given the option of having their first follow-up visit with their primary care doctor, or in a group with other patients led by a team that includes an attending physician, a nurse, a social worker, pharmacist, and care manager, among others.

The slightly-more-than half who opt for the group find all of their hospital-to-home issues addressed at one time, in one place, and without delay.

If a patient has trouble getting through to a specialist, for instance, the social worker is there to help. If a patient needs home care, the care manager can set up an appointment, maybe for the same day. And there’s no need to go elsewhere for the physical exam – a physician does them during the meeting.

Patients also bring in their medications for the pharmacist to review. Sometimes the dosages are wrong; other times patients are taking the brand and generic versions of the same drug, or taking drugs that carry the risk of potential drug interactions – omeprazole and hydroxyzine, for example. COPD inhalers, warfarin, and allopurinol, among other drugs, often have had to be added to some patients’ regimens.

Overall, group visits are "a very effective way to do posthospital care. Bringing that team together makes it flow smoothly," Dr. Skelton said in an interview.

In a pilot project from June 2009 – shortly after the groups started – to November 2009, Dr. Skelton and her colleagues tracked outcomes for 175 patients admitted from the outpatient FMC to the inpatient FMIS, and then discharged back to the outpatient center.

The 30-day readmission rate among those who opted for the group was 2.4%; for those who opted for office follow-up, 9.4%. Overall, the 30-day readmission rate dropped from 14.2% to 12.6%, saving an estimated $158,884 on an annualized basis.

More recent data supports the trend. From June 2009 to September 2010, the 30-day readmission rate for those who opted for the group was 6.7%; Among all FMC patients, those who attended the group following discharge and those who did not, the 30-day readmissions rate was 8.9%.

It is not known whether the patients who opted for the group had lower readmission rates because they were less sick to begin with, or if other confounding variables contributed to the results; that analysis has not been done, Dr. Skelton said.

However, patients polled said that they understood their medications and care plans better after the group visit; virtually all said they’d recommend the group to recently discharged patients.

The 2-hour group visits are offered at the FMC every Wednesday morning, so patients who opt for them can attend within 7 days of discharge. Usually about 4, but sometimes up to 7, patients attend. The team knows who is coming and can prepare for the visits because the FMIS and FMC have improved how they track recently discharged patients. They share a common electronic registry of hospitalized patients; the system alerts staff on the outpatient side when a patient is admitted and discharged. Discharge summaries are almost always available within 24 hours. Nurses also call patients within 48 hours of discharge, making a note of any issues in the system.

The group visits and tracking upgrades are "catching things that used to fall through the cracks," one physician said in a poll.

The annual cost of the efforts, due mostly to the care team’s group visit time, is $30, 212. That’s offset by an annual gross revenue from the group visits of $30,368, billed under CPT code 99214, Dr. Skelton said at the conference, which was also sponsored by the American Academy of Family Physicians.

"As long as you have more than a couple patients in any week" so discharge group visits are cost-effective, they "make sense," she said.

There was no outside funding for the efforts, "just creative reallocation of human resources," said Dr. Skelton, who reported having no relevant conflicts of interests.

SAN ANTONIO – Group visits aren’t just for diabetics.

At the Maine Medical Center in Portland, they also help – along with other measures – to keep recently discharged patients from being readmitted, according to Dr. Ann Skelton, chief of the center’s department of family medicine, who presented her findings at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine.

Upon discharge from the Family Medicine Inpatient Service (FMIS) to the outpatient Family Medicine Center (FMC), patients are given the option of having their first follow-up visit with their primary care doctor, or in a group with other patients led by a team that includes an attending physician, a nurse, a social worker, pharmacist, and care manager, among others.

The slightly-more-than half who opt for the group find all of their hospital-to-home issues addressed at one time, in one place, and without delay.

If a patient has trouble getting through to a specialist, for instance, the social worker is there to help. If a patient needs home care, the care manager can set up an appointment, maybe for the same day. And there’s no need to go elsewhere for the physical exam – a physician does them during the meeting.

Patients also bring in their medications for the pharmacist to review. Sometimes the dosages are wrong; other times patients are taking the brand and generic versions of the same drug, or taking drugs that carry the risk of potential drug interactions – omeprazole and hydroxyzine, for example. COPD inhalers, warfarin, and allopurinol, among other drugs, often have had to be added to some patients’ regimens.

Overall, group visits are "a very effective way to do posthospital care. Bringing that team together makes it flow smoothly," Dr. Skelton said in an interview.

In a pilot project from June 2009 – shortly after the groups started – to November 2009, Dr. Skelton and her colleagues tracked outcomes for 175 patients admitted from the outpatient FMC to the inpatient FMIS, and then discharged back to the outpatient center.

The 30-day readmission rate among those who opted for the group was 2.4%; for those who opted for office follow-up, 9.4%. Overall, the 30-day readmission rate dropped from 14.2% to 12.6%, saving an estimated $158,884 on an annualized basis.

More recent data supports the trend. From June 2009 to September 2010, the 30-day readmission rate for those who opted for the group was 6.7%; Among all FMC patients, those who attended the group following discharge and those who did not, the 30-day readmissions rate was 8.9%.

It is not known whether the patients who opted for the group had lower readmission rates because they were less sick to begin with, or if other confounding variables contributed to the results; that analysis has not been done, Dr. Skelton said.

However, patients polled said that they understood their medications and care plans better after the group visit; virtually all said they’d recommend the group to recently discharged patients.

The 2-hour group visits are offered at the FMC every Wednesday morning, so patients who opt for them can attend within 7 days of discharge. Usually about 4, but sometimes up to 7, patients attend. The team knows who is coming and can prepare for the visits because the FMIS and FMC have improved how they track recently discharged patients. They share a common electronic registry of hospitalized patients; the system alerts staff on the outpatient side when a patient is admitted and discharged. Discharge summaries are almost always available within 24 hours. Nurses also call patients within 48 hours of discharge, making a note of any issues in the system.

The group visits and tracking upgrades are "catching things that used to fall through the cracks," one physician said in a poll.

The annual cost of the efforts, due mostly to the care team’s group visit time, is $30, 212. That’s offset by an annual gross revenue from the group visits of $30,368, billed under CPT code 99214, Dr. Skelton said at the conference, which was also sponsored by the American Academy of Family Physicians.

"As long as you have more than a couple patients in any week" so discharge group visits are cost-effective, they "make sense," she said.

There was no outside funding for the efforts, "just creative reallocation of human resources," said Dr. Skelton, who reported having no relevant conflicts of interests.

SAN ANTONIO – Group visits aren’t just for diabetics.

At the Maine Medical Center in Portland, they also help – along with other measures – to keep recently discharged patients from being readmitted, according to Dr. Ann Skelton, chief of the center’s department of family medicine, who presented her findings at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine.

Upon discharge from the Family Medicine Inpatient Service (FMIS) to the outpatient Family Medicine Center (FMC), patients are given the option of having their first follow-up visit with their primary care doctor, or in a group with other patients led by a team that includes an attending physician, a nurse, a social worker, pharmacist, and care manager, among others.

The slightly-more-than half who opt for the group find all of their hospital-to-home issues addressed at one time, in one place, and without delay.

If a patient has trouble getting through to a specialist, for instance, the social worker is there to help. If a patient needs home care, the care manager can set up an appointment, maybe for the same day. And there’s no need to go elsewhere for the physical exam – a physician does them during the meeting.

Patients also bring in their medications for the pharmacist to review. Sometimes the dosages are wrong; other times patients are taking the brand and generic versions of the same drug, or taking drugs that carry the risk of potential drug interactions – omeprazole and hydroxyzine, for example. COPD inhalers, warfarin, and allopurinol, among other drugs, often have had to be added to some patients’ regimens.

Overall, group visits are "a very effective way to do posthospital care. Bringing that team together makes it flow smoothly," Dr. Skelton said in an interview.

In a pilot project from June 2009 – shortly after the groups started – to November 2009, Dr. Skelton and her colleagues tracked outcomes for 175 patients admitted from the outpatient FMC to the inpatient FMIS, and then discharged back to the outpatient center.

The 30-day readmission rate among those who opted for the group was 2.4%; for those who opted for office follow-up, 9.4%. Overall, the 30-day readmission rate dropped from 14.2% to 12.6%, saving an estimated $158,884 on an annualized basis.

More recent data supports the trend. From June 2009 to September 2010, the 30-day readmission rate for those who opted for the group was 6.7%; Among all FMC patients, those who attended the group following discharge and those who did not, the 30-day readmissions rate was 8.9%.

It is not known whether the patients who opted for the group had lower readmission rates because they were less sick to begin with, or if other confounding variables contributed to the results; that analysis has not been done, Dr. Skelton said.

However, patients polled said that they understood their medications and care plans better after the group visit; virtually all said they’d recommend the group to recently discharged patients.

The 2-hour group visits are offered at the FMC every Wednesday morning, so patients who opt for them can attend within 7 days of discharge. Usually about 4, but sometimes up to 7, patients attend. The team knows who is coming and can prepare for the visits because the FMIS and FMC have improved how they track recently discharged patients. They share a common electronic registry of hospitalized patients; the system alerts staff on the outpatient side when a patient is admitted and discharged. Discharge summaries are almost always available within 24 hours. Nurses also call patients within 48 hours of discharge, making a note of any issues in the system.

The group visits and tracking upgrades are "catching things that used to fall through the cracks," one physician said in a poll.

The annual cost of the efforts, due mostly to the care team’s group visit time, is $30, 212. That’s offset by an annual gross revenue from the group visits of $30,368, billed under CPT code 99214, Dr. Skelton said at the conference, which was also sponsored by the American Academy of Family Physicians.

"As long as you have more than a couple patients in any week" so discharge group visits are cost-effective, they "make sense," she said.

There was no outside funding for the efforts, "just creative reallocation of human resources," said Dr. Skelton, who reported having no relevant conflicts of interests.

SAN ANTONIO – Group visits aren’t just for diabetics.

At the Maine Medical Center in Portland, they also help – along with other measures – to keep recently discharged patients from being readmitted, according to Dr. Ann Skelton, chief of the center’s department of family medicine, who presented her findings at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine.

Upon discharge from the Family Medicine Inpatient Service (FMIS) to the outpatient Family Medicine Center (FMC), patients are given the option of having their first follow-up visit with their primary care doctor, or in a group with other patients led by a team that includes an attending physician, a nurse, a social worker, pharmacist, and care manager, among others.

The slightly-more-than half who opt for the group find all of their hospital-to-home issues addressed at one time, in one place, and without delay.

If a patient has trouble getting through to a specialist, for instance, the social worker is there to help. If a patient needs home care, the care manager can set up an appointment, maybe for the same day. And there’s no need to go elsewhere for the physical exam – a physician does them during the meeting.

Patients also bring in their medications for the pharmacist to review. Sometimes the dosages are wrong; other times patients are taking the brand and generic versions of the same drug, or taking drugs that carry the risk of potential drug interactions – omeprazole and hydroxyzine, for example. COPD inhalers, warfarin, and allopurinol, among other drugs, often have had to be added to some patients’ regimens.

Overall, group visits are "a very effective way to do posthospital care. Bringing that team together makes it flow smoothly," Dr. Skelton said in an interview.

In a pilot project from June 2009 – shortly after the groups started – to November 2009, Dr. Skelton and her colleagues tracked outcomes for 175 patients admitted from the outpatient FMC to the inpatient FMIS, and then discharged back to the outpatient center.

The 30-day readmission rate among those who opted for the group was 2.4%; for those who opted for office follow-up, 9.4%. Overall, the 30-day readmission rate dropped from 14.2% to 12.6%, saving an estimated $158,884 on an annualized basis.

More recent data supports the trend. From June 2009 to September 2010, the 30-day readmission rate for those who opted for the group was 6.7%; Among all FMC patients, those who attended the group following discharge and those who did not, the 30-day readmissions rate was 8.9%.

It is not known whether the patients who opted for the group had lower readmission rates because they were less sick to begin with, or if other confounding variables contributed to the results; that analysis has not been done, Dr. Skelton said.

However, patients polled said that they understood their medications and care plans better after the group visit; virtually all said they’d recommend the group to recently discharged patients.

The 2-hour group visits are offered at the FMC every Wednesday morning, so patients who opt for them can attend within 7 days of discharge. Usually about 4, but sometimes up to 7, patients attend. The team knows who is coming and can prepare for the visits because the FMIS and FMC have improved how they track recently discharged patients. They share a common electronic registry of hospitalized patients; the system alerts staff on the outpatient side when a patient is admitted and discharged. Discharge summaries are almost always available within 24 hours. Nurses also call patients within 48 hours of discharge, making a note of any issues in the system.

The group visits and tracking upgrades are "catching things that used to fall through the cracks," one physician said in a poll.

The annual cost of the efforts, due mostly to the care team’s group visit time, is $30, 212. That’s offset by an annual gross revenue from the group visits of $30,368, billed under CPT code 99214, Dr. Skelton said at the conference, which was also sponsored by the American Academy of Family Physicians.

"As long as you have more than a couple patients in any week" so discharge group visits are cost-effective, they "make sense," she said.

There was no outside funding for the efforts, "just creative reallocation of human resources," said Dr. Skelton, who reported having no relevant conflicts of interests.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children’s Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer’s teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog’s topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she’s a regular person, making her more approachable. Also, her teen patients don’t like e-mail, preferring Facebook’s messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital’s policy, Dr. Dyer can’t initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she’s not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn’t been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what’s best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children’s Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer’s teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog’s topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she’s a regular person, making her more approachable. Also, her teen patients don’t like e-mail, preferring Facebook’s messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital’s policy, Dr. Dyer can’t initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she’s not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn’t been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what’s best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children’s Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer’s teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog’s topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she’s a regular person, making her more approachable. Also, her teen patients don’t like e-mail, preferring Facebook’s messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital’s policy, Dr. Dyer can’t initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she’s not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn’t been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what’s best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children's Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer's teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog's topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she's a regular person, making her more approachable. Also, her teen patients don't like e-mail, preferring Facebook's messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital's policy, Dr. Dyer can't initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she's not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn't been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what's best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children's Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer's teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog's topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she's a regular person, making her more approachable. Also, her teen patients don't like e-mail, preferring Facebook's messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital's policy, Dr. Dyer can't initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she's not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn't been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what's best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children's Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer's teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog's topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she's a regular person, making her more approachable. Also, her teen patients don't like e-mail, preferring Facebook's messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital's policy, Dr. Dyer can't initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she's not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn't been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what's best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children’s Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer’s teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog’s topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she’s a regular person, making her more approachable. Also, her teen patients don’t like e-mail, preferring Facebook’s messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital’s policy, Dr. Dyer can’t initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she’s not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn’t been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what’s best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children’s Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer’s teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog’s topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she’s a regular person, making her more approachable. Also, her teen patients don’t like e-mail, preferring Facebook’s messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital’s policy, Dr. Dyer can’t initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she’s not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn’t been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what’s best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SEATTLE – Social media are making inroads into medicine; doctors are blogging, engaging patients on Facebook, and using Twitter to keep up to date, panelists said during a discussion of the phenomenon at the 2010 Swedish Medical Center health care symposium.

A few panelists, like Dr. Jennifer Dyer, a pediatric endocrinologist at Nationwide Children’s Hospital in Columbus, Ohio, are texting patients, too.

In a preliminary study, Dr. Dyer texted three of her teenage diabetes patients weekly reminders about glucose testing and mealtime boluses, and asked them about the frequency of their blood sugar highs and lows.

The approach had previously been shown to help Scottish teens with diabetes (Diabet. Med. 2006;23:1332-8).

At the end of 3 months, Dr. Dyer’s teenage patients were missing only about three boluses a week, instead of nine or more, and their hemoglobin A1c levels averaged 9%, instead of 11%, according to a hospital press release and a post by Dr. Dyer on the Diabetes Mine blog.

She plans to expand the study to include 50 patients. "The use of social media to help outcomes is powerful," Dr. Dyer said during the panel discussion.

Social media help in other ways, too, panelists said.

"For me, [Twitter has] extended my colleagues and created an ability for me to keep up to date," said Dr. Kent Bottles, a health care consultant based in Philadelphia and recent past president of the Institute for Clinical Systems Improvement.

Dr. Bottles, who blogs at Kent Bottles Private Views, said he tweeted recently about attending a health care meeting in Colorado. A nurse he had never met before but who followed his Twitter stream offered to pick him up at the airport and took him to a vineyard, because she also knew from his tweets that he’s a wine aficionado.

In response to another tweet, a physician sent him a paper that helped at the meeting. Neither "would have happened without Twitter," Dr. Bottles said.

Another panelist, Dr. Bryan Vartabedian, an assistant pediatrics professor at Baylor College of Medicine, Houston, said his blog, 33Charts, has given him "a powerful voice" regarding the convergence of social media and medicine, the blog’s topic, as well as other matters.

More than influence is at stake. Eventually, "being in the [social media] space will confer market advantage," he said.

Dr. Dyer and the fourth panelist, Dr. Mike Sevilla, a family physician in Salem, Ohio, who blogs at Doctor Anonymous, both said they share some personal information on their Facebook pages, but are careful not to post anything they could later regret.

Dr. Dyer has friended four patients on Facebook; she said it helps them see she’s a regular person, making her more approachable. Also, her teen patients don’t like e-mail, preferring Facebook’s messaging service, another reason she engages some of them on Facebook.

E-mail is also an increasingly important tool, panelists said.

Because of her hospital’s policy, Dr. Dyer can’t initiate patient e-mails, so she tells patients to e-mail her first for test results and other matters. She cuts-and-pastes exchanges into the electronic health record so colleagues know what transpired.

Although e-mail takes less time than trying to reach patients by phone, Dr. Dyer has office staff help with the messages so she’s not overwhelmed.

That was a concern among all the panelists – dealing with the extra work social media bring.

Dr. Vartabedian said he knows colleagues who are "spending their evenings opening e-mails" from patients, and not getting paid for it. Social media also raise concerns about patient privacy and legal liability.

A robust digital presence has its benefits, Dr. Vartabedian said, including countering negative online reviews. But it also opens the possibility that offhand remarks could show up later in legal proceedings. "A lot of this stuff hasn’t been tested in courts," he said.

An audience member even noted that lawyers at her hospital banned physicians from engaging in social media.

Dr. Bottles acknowledged the concerns, but said that "you can never [completely] protect yourself against malpractice suits."

"You have to do what’s best for your patients, give it your best shot, and get over it. We have patients to take care of, lives to live, and pinot noir to drink," he said.

SAN ANTONIO – When the Family Medical Center of Johnstown, Pa., encouraged patients to use its services for nonemergency care – instead of the nearby Memorial Medical Center emergency department – the number of center patients using the ED declined .

The results of the intervention were presented in a poster by Dr. Jeanne Spencer and Dr. Rashmin Adesara at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine. The conference was also sponsored by the American Academy of Family Physicians.

The reminders came in the form of posters mounted in the Family Medical Center (FMC), a residency program with about 1,000 patient visits per month, plus follow-up letters to FMC patients who had used the ED for routine care during FMC operating hours.

Like most EDs, "[Memorial Medical Center] is overcrowded, and at times the wait times are longer than we want. We all recognized some of the people going to the [ED] would have been better served coming to our office. We were trying to encourage them to come to the FMC," said the center’s director, Dr. Spencer, in an interview.

Some FMC patients were visiting the ED two to three times per month, either out of habit, because they were not aware that the center had same-day appointments, or because they assumed they would get better care in the ED, according to Dr. Adesara, who was a third-year FMC resident when he tackled the problem with Dr. Spencer’s help.

Money probably wasn’t the issue. Medicaid patients – the focus of the intervention – had no copay in the ED, but only a $2-$3 copay at the FMC, Dr. Adesara said, also in an interview.

The posters – a large one in the waiting room, smaller versions in the exam rooms – were hung in July 2009.

"We are here for you" was the message stated prominently on the posters.

The posters asked patients to call FMC for nonemergencies before going to the ED, and displayed the FMC’s telephone number. Patients were also reminded they’d be treated more quickly at the center, and by doctors who knew their medical histories.

Those who went to the ED anyway for nonurgent care got Dr. Spencer’s letter, after they were identified by Dr. Adesara’s record reviews.

"As your primary care physician, we came to know that you recently visited the emergency room. We hope that you are feeling better now," the form letter began.

It reemphasized the poster message, and mentioned the same-day appointments.

"Next time you have a problem like back pain, ear ache, nausea, diarrhea, sinus infection, [or] sore throat, call us before going to the emergency room. In most cases, we will be able to schedule you an appointment that meets your needs," the letter concluded.

Dr. Adesara sent 316 letters from July to the end of September; only two people complained, insisting their ED visits had been emergencies.

To assess the impact of the interventions, he compared the percentage of Memorial Medical Center ED visits by FMC patients from April to June 2009 – the period before the posters went up and the letters went out – to their percentage from October to December 2009, the postintervention period.

FMC patients accounted for about 7% of 17,865 total emergency room visits from April to June. The percentage began to decline during the intervention period, and then stabilized at about 6% of 17,363 ED visits from October to December.

Meanwhile, the percentage of patients from an internal medicine clinic in FMC’s building – which served as a control in the study – increased slightly from about 1.3% to 1.4% of ED visits over the same period.

"Our intervention appears to have resulted in a decrease in total ED utilization by our patients," Dr. Spencer and Dr. Adesara concluded in a poster displaying the study results.

"Putting up the posters is very quick and inexpensive. We bought our large poster for $25," she said. They are still up in the FMC.

Likewise, "if you see somebody going to the [ED] all the time, it might be pretty easy to have a staff person send them a quick letter to encourage them to come to the office rather than the [ED]," she said.

The study had no external funding and the investigators reported no conflicts of interest.

SAN ANTONIO – When the Family Medical Center of Johnstown, Pa., encouraged patients to use its services for nonemergency care – instead of the nearby Memorial Medical Center emergency department – the number of center patients using the ED declined .

The results of the intervention were presented in a poster by Dr. Jeanne Spencer and Dr. Rashmin Adesara at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine. The conference was also sponsored by the American Academy of Family Physicians.

The reminders came in the form of posters mounted in the Family Medical Center (FMC), a residency program with about 1,000 patient visits per month, plus follow-up letters to FMC patients who had used the ED for routine care during FMC operating hours.

Like most EDs, "[Memorial Medical Center] is overcrowded, and at times the wait times are longer than we want. We all recognized some of the people going to the [ED] would have been better served coming to our office. We were trying to encourage them to come to the FMC," said the center’s director, Dr. Spencer, in an interview.

Some FMC patients were visiting the ED two to three times per month, either out of habit, because they were not aware that the center had same-day appointments, or because they assumed they would get better care in the ED, according to Dr. Adesara, who was a third-year FMC resident when he tackled the problem with Dr. Spencer’s help.

Money probably wasn’t the issue. Medicaid patients – the focus of the intervention – had no copay in the ED, but only a $2-$3 copay at the FMC, Dr. Adesara said, also in an interview.

The posters – a large one in the waiting room, smaller versions in the exam rooms – were hung in July 2009.

"We are here for you" was the message stated prominently on the posters.

The posters asked patients to call FMC for nonemergencies before going to the ED, and displayed the FMC’s telephone number. Patients were also reminded they’d be treated more quickly at the center, and by doctors who knew their medical histories.

Those who went to the ED anyway for nonurgent care got Dr. Spencer’s letter, after they were identified by Dr. Adesara’s record reviews.

"As your primary care physician, we came to know that you recently visited the emergency room. We hope that you are feeling better now," the form letter began.

It reemphasized the poster message, and mentioned the same-day appointments.

"Next time you have a problem like back pain, ear ache, nausea, diarrhea, sinus infection, [or] sore throat, call us before going to the emergency room. In most cases, we will be able to schedule you an appointment that meets your needs," the letter concluded.

Dr. Adesara sent 316 letters from July to the end of September; only two people complained, insisting their ED visits had been emergencies.

To assess the impact of the interventions, he compared the percentage of Memorial Medical Center ED visits by FMC patients from April to June 2009 – the period before the posters went up and the letters went out – to their percentage from October to December 2009, the postintervention period.

FMC patients accounted for about 7% of 17,865 total emergency room visits from April to June. The percentage began to decline during the intervention period, and then stabilized at about 6% of 17,363 ED visits from October to December.

Meanwhile, the percentage of patients from an internal medicine clinic in FMC’s building – which served as a control in the study – increased slightly from about 1.3% to 1.4% of ED visits over the same period.

"Our intervention appears to have resulted in a decrease in total ED utilization by our patients," Dr. Spencer and Dr. Adesara concluded in a poster displaying the study results.

"Putting up the posters is very quick and inexpensive. We bought our large poster for $25," she said. They are still up in the FMC.

Likewise, "if you see somebody going to the [ED] all the time, it might be pretty easy to have a staff person send them a quick letter to encourage them to come to the office rather than the [ED]," she said.

The study had no external funding and the investigators reported no conflicts of interest.

SAN ANTONIO – When the Family Medical Center of Johnstown, Pa., encouraged patients to use its services for nonemergency care – instead of the nearby Memorial Medical Center emergency department – the number of center patients using the ED declined .

The results of the intervention were presented in a poster by Dr. Jeanne Spencer and Dr. Rashmin Adesara at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine. The conference was also sponsored by the American Academy of Family Physicians.

The reminders came in the form of posters mounted in the Family Medical Center (FMC), a residency program with about 1,000 patient visits per month, plus follow-up letters to FMC patients who had used the ED for routine care during FMC operating hours.

Like most EDs, "[Memorial Medical Center] is overcrowded, and at times the wait times are longer than we want. We all recognized some of the people going to the [ED] would have been better served coming to our office. We were trying to encourage them to come to the FMC," said the center’s director, Dr. Spencer, in an interview.

Some FMC patients were visiting the ED two to three times per month, either out of habit, because they were not aware that the center had same-day appointments, or because they assumed they would get better care in the ED, according to Dr. Adesara, who was a third-year FMC resident when he tackled the problem with Dr. Spencer’s help.

Money probably wasn’t the issue. Medicaid patients – the focus of the intervention – had no copay in the ED, but only a $2-$3 copay at the FMC, Dr. Adesara said, also in an interview.

The posters – a large one in the waiting room, smaller versions in the exam rooms – were hung in July 2009.

"We are here for you" was the message stated prominently on the posters.

The posters asked patients to call FMC for nonemergencies before going to the ED, and displayed the FMC’s telephone number. Patients were also reminded they’d be treated more quickly at the center, and by doctors who knew their medical histories.

Those who went to the ED anyway for nonurgent care got Dr. Spencer’s letter, after they were identified by Dr. Adesara’s record reviews.

"As your primary care physician, we came to know that you recently visited the emergency room. We hope that you are feeling better now," the form letter began.

It reemphasized the poster message, and mentioned the same-day appointments.

"Next time you have a problem like back pain, ear ache, nausea, diarrhea, sinus infection, [or] sore throat, call us before going to the emergency room. In most cases, we will be able to schedule you an appointment that meets your needs," the letter concluded.

Dr. Adesara sent 316 letters from July to the end of September; only two people complained, insisting their ED visits had been emergencies.

To assess the impact of the interventions, he compared the percentage of Memorial Medical Center ED visits by FMC patients from April to June 2009 – the period before the posters went up and the letters went out – to their percentage from October to December 2009, the postintervention period.

FMC patients accounted for about 7% of 17,865 total emergency room visits from April to June. The percentage began to decline during the intervention period, and then stabilized at about 6% of 17,363 ED visits from October to December.

Meanwhile, the percentage of patients from an internal medicine clinic in FMC’s building – which served as a control in the study – increased slightly from about 1.3% to 1.4% of ED visits over the same period.

"Our intervention appears to have resulted in a decrease in total ED utilization by our patients," Dr. Spencer and Dr. Adesara concluded in a poster displaying the study results.

"Putting up the posters is very quick and inexpensive. We bought our large poster for $25," she said. They are still up in the FMC.

Likewise, "if you see somebody going to the [ED] all the time, it might be pretty easy to have a staff person send them a quick letter to encourage them to come to the office rather than the [ED]," she said.

The study had no external funding and the investigators reported no conflicts of interest.

SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.

As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.

Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.

"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.

There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.

In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.

Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.

"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."

The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.

The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.

A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.

Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.

The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.

Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.

At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.

"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."

By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.

Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.

Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.

If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.

SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.

As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.

Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.

"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.

There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.

In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.

Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.

"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."

The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.

The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.

A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.

Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.

The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.

Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.

At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.

"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."

By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.

Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.

Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.

If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.

SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.

As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.

Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.

"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.

There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.

In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.

Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.

"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."

The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.

The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.

A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.

Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.

The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.

Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.

At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.

"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."

By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.

Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.

Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.

If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.

SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.

As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.

Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.

"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.

There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.

In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.

Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.

"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."

The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.

The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.

A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.

Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.

The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.

Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.

At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.

"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."

By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.

Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.

Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.

If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.

SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.

As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.

Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.

"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.

There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.

In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.

Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.

"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."

The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.

The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.

A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.

Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.

The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.

Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.

At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.

"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."

By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.

Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.

Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.

If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.

SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.

As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.

Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.

"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.

There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.

In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.

Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.

"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."

The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.

The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.

A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.

Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.

The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.

Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.

At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.

"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."

By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.

Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.

Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.

If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.