Commentary

Summer months can be dreadful for patients with atopic dermatitis. The chlorine, heat, and humidity can lead to flares. Furthermore, noncompliance with skin care regimens because of changing summer routines, travel, and the use of hotel products can exacerbate even the calmest skin disease.

Share these tips with your patients to help them keep their atopic skin under control in the summer heat, and stop flares before they start.

• Rinse the skin well after swimming. Chlorine and saltwater can dry out the skin. Showers after swimming in chlorinated pools can help retain the skin’s natural oils.

• Avoid hot tubs. Cracks and fissures in atopic skin can become infected in hot tubs with Staphylococcus and Pseudomonas. Advise your atopic patients to avoid hot tubs, even if they claim the tubs have been cleaned.

• Bring your own products. Many soaps and shower gels available in hotels and resorts are extremely drying, and may contain ingredients that could irritate atopic skin.

• Don’t switch from thick creams to thin lotions just because it is summer. Remind your patients that a thin lotion does not provide the same occlusive and humectant properties as thicker creams, although they are not as easy to apply, and can feel thick and sticky on the skin with humidity.

• In case of an active eczema flare, topical steroids should be used and sun exposure should be avoided. Topical steroids are the most effective treatment when used correctly. However, any occurrence of hypopigmentation as a result of their use becomes more evident if the skin tans around the area of treatment.

• Wear physical sunscreen. This seems obvious, but most chemical blockers – even the formulations made for babies – can burn on cracked, inflamed skin. Instead, stress to your patients that they use a physical blocker made of pure titanium dioxide or zinc oxide on inflamed skin.

• Oral steroids and sun do not mix. Oral steroids can be potent photosensitizers. If they are needed, UV exposure should be avoided.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Summer months can be dreadful for patients with atopic dermatitis. The chlorine, heat, and humidity can lead to flares. Furthermore, noncompliance with skin care regimens because of changing summer routines, travel, and the use of hotel products can exacerbate even the calmest skin disease.

Share these tips with your patients to help them keep their atopic skin under control in the summer heat, and stop flares before they start.

• Rinse the skin well after swimming. Chlorine and saltwater can dry out the skin. Showers after swimming in chlorinated pools can help retain the skin’s natural oils.

• Avoid hot tubs. Cracks and fissures in atopic skin can become infected in hot tubs with Staphylococcus and Pseudomonas. Advise your atopic patients to avoid hot tubs, even if they claim the tubs have been cleaned.

• Bring your own products. Many soaps and shower gels available in hotels and resorts are extremely drying, and may contain ingredients that could irritate atopic skin.

• Don’t switch from thick creams to thin lotions just because it is summer. Remind your patients that a thin lotion does not provide the same occlusive and humectant properties as thicker creams, although they are not as easy to apply, and can feel thick and sticky on the skin with humidity.

• In case of an active eczema flare, topical steroids should be used and sun exposure should be avoided. Topical steroids are the most effective treatment when used correctly. However, any occurrence of hypopigmentation as a result of their use becomes more evident if the skin tans around the area of treatment.

• Wear physical sunscreen. This seems obvious, but most chemical blockers – even the formulations made for babies – can burn on cracked, inflamed skin. Instead, stress to your patients that they use a physical blocker made of pure titanium dioxide or zinc oxide on inflamed skin.

• Oral steroids and sun do not mix. Oral steroids can be potent photosensitizers. If they are needed, UV exposure should be avoided.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Summer months can be dreadful for patients with atopic dermatitis. The chlorine, heat, and humidity can lead to flares. Furthermore, noncompliance with skin care regimens because of changing summer routines, travel, and the use of hotel products can exacerbate even the calmest skin disease.

Share these tips with your patients to help them keep their atopic skin under control in the summer heat, and stop flares before they start.

• Rinse the skin well after swimming. Chlorine and saltwater can dry out the skin. Showers after swimming in chlorinated pools can help retain the skin’s natural oils.

• Avoid hot tubs. Cracks and fissures in atopic skin can become infected in hot tubs with Staphylococcus and Pseudomonas. Advise your atopic patients to avoid hot tubs, even if they claim the tubs have been cleaned.

• Bring your own products. Many soaps and shower gels available in hotels and resorts are extremely drying, and may contain ingredients that could irritate atopic skin.

• Don’t switch from thick creams to thin lotions just because it is summer. Remind your patients that a thin lotion does not provide the same occlusive and humectant properties as thicker creams, although they are not as easy to apply, and can feel thick and sticky on the skin with humidity.

• In case of an active eczema flare, topical steroids should be used and sun exposure should be avoided. Topical steroids are the most effective treatment when used correctly. However, any occurrence of hypopigmentation as a result of their use becomes more evident if the skin tans around the area of treatment.

• Wear physical sunscreen. This seems obvious, but most chemical blockers – even the formulations made for babies – can burn on cracked, inflamed skin. Instead, stress to your patients that they use a physical blocker made of pure titanium dioxide or zinc oxide on inflamed skin.

• Oral steroids and sun do not mix. Oral steroids can be potent photosensitizers. If they are needed, UV exposure should be avoided.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

I have been writing Cosmeceutical Critique for more than a decade, and over the years I have received many calls and e-mails about the column. The most frequent question is, "I read your column every month and understand the ingredient science, but I still do not know what products to sell in my practice. Can you help?" For this reason, I will begin to add columns that discuss the process of skin care retail, and how to choose which products to sell. I admit that finding effective products and designing the right regimen for each patient are daunting tasks, but I have simplified the process out of necessity in my own Miami practice.

The goal is to achieve good patient outcomes with minimal side effects, which strengthens the physician-patient relationship. In order to achieve this goal, you need to find the most efficacious products and properly match them to your patient’s skin type. In addition, patients must be compliant with the prescribed regimen. If only it were that simple. The difficulty in separating fact (science) from fiction (marketing claims), time constraints with each patient, and the need for staff training can complicate this process.

In my practice, we use the Skin Type Solutions system that I developed to match skin care products for each skin type (

<cf number="\"2\"">’</cf>

Fitzpatricks Dermatology in General Medicine, 8th Ed., 2012, Ch. 250, p. 1343).This system accurately determines a patient’s Baumann Skin Type (there are 16) and provides a preset regimen designed to address that particular skin type’s needs. The system has been tested in more than 100,000 people worldwide, of all ethnicities and ages, as well as both genders, and has demonstrated accuracy in assessing skin care needs (Dermatol. Clin. 2008;26:359-73; J. Cosmet. Dermatol. Sci. Appl. 2014;4:78-84).

The Baumann Skin Typing System saves my staff time by streamlining the process of designing skin care regimens. It works like this:

• The patient takes the skin type questionnaire and is assigned to one of the 16 Baumann Skin types.

• A staff member matches the skin type to the preset regimen.

• The doctor (or designee) reviews the regimen and makes any necessary changes or additions (including prescription medications).

• The patient is given a step-by-step skin care regimen.

• The patient purchases the correct products.

• The patient is given instruction sheets to increase compliance.

• The patient returns in 4 weeks for follow-up with the staff designee to ensure that the regimen is being properly followed.

Sounds easy, right? The hard part is choosing which products to use for each skin type. In order to ethically sell skin care products to patients, you must ensure that they are getting efficacious products to address their skin concerns (Clin. Dermatol. 2012;30:522-7).

Keep these steps in mind when selecting skin care products:

• Know your ingredient science.

There is so much interesting research on cosmetic ingredients, but there is also plenty of hype and misinformation. One key point is that no one ingredient is right for all skin types. It’s essential to know which ingredients work well together and which do not. The order in which ingredients are placed on the skin is crucial as well, because they can inactivate each other and affect absorption. All of my ingredient columns are available at edermatologynews.com and will be published in my new book, Cosmeceuticals and Cosmetic Ingredients (McGraw-Hill).

It is important to understand which ingredients are worthless (like stem cells and peptides) and which ones are crucial (such as retinoids and antioxidants) so that you can arm your patients with products that work. When products do not work, your patients will have poor outcomes, your physician-patient relationships will be damaged, and patients’ trust in you will decrease.

• Choose ingredients appropriate for the patient’s skin type.

It is important to understand the characteristics of various ingredients and match those to your patient’s skin type. The process of assessing the patient’s skin type can be long because you need to ask numerous historical questions (invariably including, "Do you get irritated from skin care products?" and "What happens if you do not use a moisturizer?"). Looking at a patient’s skin at one point in time is not as accurate as asking a series of questions about how their skin has behaved in the past under varying conditions. I use a validated questionnaire to streamline this process in my practice. The questionnaire takes 3 to 5 minutes, does not require a staff member, and is done on a tablet device in the waiting room or exam room.

• Properly identify the Baumann Skin Type using a validated questionnaire.

To determine a patient’s true skin type, a scientifically validated questionnaire is used to assess skin oiliness, dryness, sensitivity, uneven skin tone, and risk factors for wrinkles. When these parameters are combined, there are 16 possible Baumann Skin Types, which yield an accurate history of the patient’s skin characteristics.

• Choose products for each skin type.

There are many factors to consider in choosing what brands and SKUs (stock keeping units, in industry parlance, but particular products for our purposes) to use for each skin type. I use a brand-agnostic approach to choose the best technologies from various brands from around the world. I believe that brands often have a core competency, such as sunscreen technology, but that not all of the products in a particular line are superior. I select the best products (SKUs) from each brand, and combine and test them on various skin types to see which products and what combinations of products work best.

The following are the factors that I take into account when choosing SKUs for each Baumann Skin Type:

A. Importance of the ingredient recipe

Although the product label lists ingredients, it does not list the formulation’s recipe, which is proprietary and often patented. The "recipe" includes the order that ingredients are added in the process, the pH, the amount of each ingredient, the temperature at which the ingredient is added, and many other important factors that determine the final chemistry. Ingredients like vitamin C, green tea, and argan oil are expensive when formulated properly. Many copycat brands, such as the Walgreens and CVS knockoffs, use the same ingredients. However, they cannot use the patented recipe, and therefore their end product is different.

B. Manufacturing and packaging process

How a product is made and packaged is crucial. For example, retinol breaks down when exposed to light and air. I once visited a manufacturing plant that was stirring its "antiaging" retinol preparation in open vats. The retinol was losing its activity, which is why the product was "less irritating." The process of packaging the completed product is also important. In some cases the product is formulated in one place and shipped to another location for final packaging – and several ingredients can lose their potency during transit. Finally, the container that the product is packaged in is important. Air and light can get into tubes, affecting the efficacy of a product.

C. Ingredient interactions

The order of application and the combination of ingredients affect stability, efficacy, safety, and the chemical structure. Master formulators understand that every ingredient in the formulation matters, and there is really no such thing as an inactive ingredient. Ingredients can affect penetration and render other ingredients more or less effective depending on the order in which the ingredients are used on the skin. For example, olive oil actually increases penetration of other ingredients because it has a high content of oleic acid, while safflower oil can decrease penetration by strengthening the skin barrier.

• Design the regimen and order of application of products.

Once you have determined your patient’s skin type and matched the proper products to their skin type, you must tell them exactly how to apply them. The order in which products are applied makes a difference. Consider ingredient interactions, ingredient penetration times, and cross-reactions, plus skin type factors such as the condition of the skin barrier, sebum production, thickness of the stratum corneum, sun exposure, and bathing habits. I recommend providing a printed regimen with step-by-step instructions for morning and night.

• Educate patients.

Take the time to educate your patients on their skin issues. If you explain why you chose each product and why the particular ingredients are important, they are more likely to be compliant and get better results (and return to you for product recommendations and repurchases). Because we do not have the time to sit and explain all of these issues to each patient, we use educational newsletters that we send to patients based on their Baumann Skin Type. This helps keep them engaged and educates them about new technologies and products that are appropriate for their skin type.

• Encourage compliance.

Schedule a follow-up visit after 1 month to check on their progress and ensure compliance, and emphasize the importance of this visit. If you prescribed a retinoid, patients may experience irritation and stop using it. If you have an imaging system, baseline and follow-up photos help illustrate patients’ progress and keep them vigilant. Four weeks is a good time frame because patients tend to lose interest at that point.

• Sell skin care products in your practice.

I was against selling skin care products for ethical reasons for several years. However, in 2005, I surveyed my patients, and 100% of them wanted me to sell products so that they could feel sure that they were purchasing the right products for their needs. In fact, my patients appreciate expert medical advice on skin care. As a practitioner, you can make more educated choices about skin care products and help them avoid products that don’t work or cause harm.

• Contact me for more information.

In order to improve patient outcomes, you must ensure that you stay current on skin care science so your patients can benefit from your expertise. I recognize that not everyone has the time and inclination to stay current on the various skin care ingredients, products, and brands. Several of my dermatology friends have adopted my skin typing system in their practices and, in the process, observed better patient outcomes and increased profitability, while reducing the burden on their staff. These successes led to the development of an in-office store system utilizing my concept, which I am offering only to dermatologists. Feel free to email me at [email protected], or visit STSFranchise.com, if you want to learn more.

• Look for this column each month.

I will be sharing more advice on in-office skin care retail and will continue my review of new cosmeceutical ingredients. Let’s work together to put skin care back in the hands of dermatologists.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.

I have been writing Cosmeceutical Critique for more than a decade, and over the years I have received many calls and e-mails about the column. The most frequent question is, "I read your column every month and understand the ingredient science, but I still do not know what products to sell in my practice. Can you help?" For this reason, I will begin to add columns that discuss the process of skin care retail, and how to choose which products to sell. I admit that finding effective products and designing the right regimen for each patient are daunting tasks, but I have simplified the process out of necessity in my own Miami practice.

The goal is to achieve good patient outcomes with minimal side effects, which strengthens the physician-patient relationship. In order to achieve this goal, you need to find the most efficacious products and properly match them to your patient’s skin type. In addition, patients must be compliant with the prescribed regimen. If only it were that simple. The difficulty in separating fact (science) from fiction (marketing claims), time constraints with each patient, and the need for staff training can complicate this process.

In my practice, we use the Skin Type Solutions system that I developed to match skin care products for each skin type (

<cf number="\"2\"">’</cf>

Fitzpatricks Dermatology in General Medicine, 8th Ed., 2012, Ch. 250, p. 1343).This system accurately determines a patient’s Baumann Skin Type (there are 16) and provides a preset regimen designed to address that particular skin type’s needs. The system has been tested in more than 100,000 people worldwide, of all ethnicities and ages, as well as both genders, and has demonstrated accuracy in assessing skin care needs (Dermatol. Clin. 2008;26:359-73; J. Cosmet. Dermatol. Sci. Appl. 2014;4:78-84).

The Baumann Skin Typing System saves my staff time by streamlining the process of designing skin care regimens. It works like this:

• The patient takes the skin type questionnaire and is assigned to one of the 16 Baumann Skin types.

• A staff member matches the skin type to the preset regimen.

• The doctor (or designee) reviews the regimen and makes any necessary changes or additions (including prescription medications).

• The patient is given a step-by-step skin care regimen.

• The patient purchases the correct products.

• The patient is given instruction sheets to increase compliance.

• The patient returns in 4 weeks for follow-up with the staff designee to ensure that the regimen is being properly followed.

Sounds easy, right? The hard part is choosing which products to use for each skin type. In order to ethically sell skin care products to patients, you must ensure that they are getting efficacious products to address their skin concerns (Clin. Dermatol. 2012;30:522-7).

Keep these steps in mind when selecting skin care products:

• Know your ingredient science.

There is so much interesting research on cosmetic ingredients, but there is also plenty of hype and misinformation. One key point is that no one ingredient is right for all skin types. It’s essential to know which ingredients work well together and which do not. The order in which ingredients are placed on the skin is crucial as well, because they can inactivate each other and affect absorption. All of my ingredient columns are available at edermatologynews.com and will be published in my new book, Cosmeceuticals and Cosmetic Ingredients (McGraw-Hill).

It is important to understand which ingredients are worthless (like stem cells and peptides) and which ones are crucial (such as retinoids and antioxidants) so that you can arm your patients with products that work. When products do not work, your patients will have poor outcomes, your physician-patient relationships will be damaged, and patients’ trust in you will decrease.

• Choose ingredients appropriate for the patient’s skin type.

It is important to understand the characteristics of various ingredients and match those to your patient’s skin type. The process of assessing the patient’s skin type can be long because you need to ask numerous historical questions (invariably including, "Do you get irritated from skin care products?" and "What happens if you do not use a moisturizer?"). Looking at a patient’s skin at one point in time is not as accurate as asking a series of questions about how their skin has behaved in the past under varying conditions. I use a validated questionnaire to streamline this process in my practice. The questionnaire takes 3 to 5 minutes, does not require a staff member, and is done on a tablet device in the waiting room or exam room.

• Properly identify the Baumann Skin Type using a validated questionnaire.

To determine a patient’s true skin type, a scientifically validated questionnaire is used to assess skin oiliness, dryness, sensitivity, uneven skin tone, and risk factors for wrinkles. When these parameters are combined, there are 16 possible Baumann Skin Types, which yield an accurate history of the patient’s skin characteristics.

• Choose products for each skin type.

There are many factors to consider in choosing what brands and SKUs (stock keeping units, in industry parlance, but particular products for our purposes) to use for each skin type. I use a brand-agnostic approach to choose the best technologies from various brands from around the world. I believe that brands often have a core competency, such as sunscreen technology, but that not all of the products in a particular line are superior. I select the best products (SKUs) from each brand, and combine and test them on various skin types to see which products and what combinations of products work best.

The following are the factors that I take into account when choosing SKUs for each Baumann Skin Type:

A. Importance of the ingredient recipe

Although the product label lists ingredients, it does not list the formulation’s recipe, which is proprietary and often patented. The "recipe" includes the order that ingredients are added in the process, the pH, the amount of each ingredient, the temperature at which the ingredient is added, and many other important factors that determine the final chemistry. Ingredients like vitamin C, green tea, and argan oil are expensive when formulated properly. Many copycat brands, such as the Walgreens and CVS knockoffs, use the same ingredients. However, they cannot use the patented recipe, and therefore their end product is different.

B. Manufacturing and packaging process

How a product is made and packaged is crucial. For example, retinol breaks down when exposed to light and air. I once visited a manufacturing plant that was stirring its "antiaging" retinol preparation in open vats. The retinol was losing its activity, which is why the product was "less irritating." The process of packaging the completed product is also important. In some cases the product is formulated in one place and shipped to another location for final packaging – and several ingredients can lose their potency during transit. Finally, the container that the product is packaged in is important. Air and light can get into tubes, affecting the efficacy of a product.

C. Ingredient interactions

The order of application and the combination of ingredients affect stability, efficacy, safety, and the chemical structure. Master formulators understand that every ingredient in the formulation matters, and there is really no such thing as an inactive ingredient. Ingredients can affect penetration and render other ingredients more or less effective depending on the order in which the ingredients are used on the skin. For example, olive oil actually increases penetration of other ingredients because it has a high content of oleic acid, while safflower oil can decrease penetration by strengthening the skin barrier.

• Design the regimen and order of application of products.

Once you have determined your patient’s skin type and matched the proper products to their skin type, you must tell them exactly how to apply them. The order in which products are applied makes a difference. Consider ingredient interactions, ingredient penetration times, and cross-reactions, plus skin type factors such as the condition of the skin barrier, sebum production, thickness of the stratum corneum, sun exposure, and bathing habits. I recommend providing a printed regimen with step-by-step instructions for morning and night.

• Educate patients.

Take the time to educate your patients on their skin issues. If you explain why you chose each product and why the particular ingredients are important, they are more likely to be compliant and get better results (and return to you for product recommendations and repurchases). Because we do not have the time to sit and explain all of these issues to each patient, we use educational newsletters that we send to patients based on their Baumann Skin Type. This helps keep them engaged and educates them about new technologies and products that are appropriate for their skin type.

• Encourage compliance.

Schedule a follow-up visit after 1 month to check on their progress and ensure compliance, and emphasize the importance of this visit. If you prescribed a retinoid, patients may experience irritation and stop using it. If you have an imaging system, baseline and follow-up photos help illustrate patients’ progress and keep them vigilant. Four weeks is a good time frame because patients tend to lose interest at that point.

• Sell skin care products in your practice.

I was against selling skin care products for ethical reasons for several years. However, in 2005, I surveyed my patients, and 100% of them wanted me to sell products so that they could feel sure that they were purchasing the right products for their needs. In fact, my patients appreciate expert medical advice on skin care. As a practitioner, you can make more educated choices about skin care products and help them avoid products that don’t work or cause harm.

• Contact me for more information.

In order to improve patient outcomes, you must ensure that you stay current on skin care science so your patients can benefit from your expertise. I recognize that not everyone has the time and inclination to stay current on the various skin care ingredients, products, and brands. Several of my dermatology friends have adopted my skin typing system in their practices and, in the process, observed better patient outcomes and increased profitability, while reducing the burden on their staff. These successes led to the development of an in-office store system utilizing my concept, which I am offering only to dermatologists. Feel free to email me at [email protected], or visit STSFranchise.com, if you want to learn more.

• Look for this column each month.

I will be sharing more advice on in-office skin care retail and will continue my review of new cosmeceutical ingredients. Let’s work together to put skin care back in the hands of dermatologists.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.

I have been writing Cosmeceutical Critique for more than a decade, and over the years I have received many calls and e-mails about the column. The most frequent question is, "I read your column every month and understand the ingredient science, but I still do not know what products to sell in my practice. Can you help?" For this reason, I will begin to add columns that discuss the process of skin care retail, and how to choose which products to sell. I admit that finding effective products and designing the right regimen for each patient are daunting tasks, but I have simplified the process out of necessity in my own Miami practice.

The goal is to achieve good patient outcomes with minimal side effects, which strengthens the physician-patient relationship. In order to achieve this goal, you need to find the most efficacious products and properly match them to your patient’s skin type. In addition, patients must be compliant with the prescribed regimen. If only it were that simple. The difficulty in separating fact (science) from fiction (marketing claims), time constraints with each patient, and the need for staff training can complicate this process.

In my practice, we use the Skin Type Solutions system that I developed to match skin care products for each skin type (

<cf number="\"2\"">’</cf>

Fitzpatricks Dermatology in General Medicine, 8th Ed., 2012, Ch. 250, p. 1343).This system accurately determines a patient’s Baumann Skin Type (there are 16) and provides a preset regimen designed to address that particular skin type’s needs. The system has been tested in more than 100,000 people worldwide, of all ethnicities and ages, as well as both genders, and has demonstrated accuracy in assessing skin care needs (Dermatol. Clin. 2008;26:359-73; J. Cosmet. Dermatol. Sci. Appl. 2014;4:78-84).

The Baumann Skin Typing System saves my staff time by streamlining the process of designing skin care regimens. It works like this:

• The patient takes the skin type questionnaire and is assigned to one of the 16 Baumann Skin types.

• A staff member matches the skin type to the preset regimen.

• The doctor (or designee) reviews the regimen and makes any necessary changes or additions (including prescription medications).

• The patient is given a step-by-step skin care regimen.

• The patient purchases the correct products.

• The patient is given instruction sheets to increase compliance.

• The patient returns in 4 weeks for follow-up with the staff designee to ensure that the regimen is being properly followed.

Sounds easy, right? The hard part is choosing which products to use for each skin type. In order to ethically sell skin care products to patients, you must ensure that they are getting efficacious products to address their skin concerns (Clin. Dermatol. 2012;30:522-7).

Keep these steps in mind when selecting skin care products:

• Know your ingredient science.

There is so much interesting research on cosmetic ingredients, but there is also plenty of hype and misinformation. One key point is that no one ingredient is right for all skin types. It’s essential to know which ingredients work well together and which do not. The order in which ingredients are placed on the skin is crucial as well, because they can inactivate each other and affect absorption. All of my ingredient columns are available at edermatologynews.com and will be published in my new book, Cosmeceuticals and Cosmetic Ingredients (McGraw-Hill).

It is important to understand which ingredients are worthless (like stem cells and peptides) and which ones are crucial (such as retinoids and antioxidants) so that you can arm your patients with products that work. When products do not work, your patients will have poor outcomes, your physician-patient relationships will be damaged, and patients’ trust in you will decrease.

• Choose ingredients appropriate for the patient’s skin type.

It is important to understand the characteristics of various ingredients and match those to your patient’s skin type. The process of assessing the patient’s skin type can be long because you need to ask numerous historical questions (invariably including, "Do you get irritated from skin care products?" and "What happens if you do not use a moisturizer?"). Looking at a patient’s skin at one point in time is not as accurate as asking a series of questions about how their skin has behaved in the past under varying conditions. I use a validated questionnaire to streamline this process in my practice. The questionnaire takes 3 to 5 minutes, does not require a staff member, and is done on a tablet device in the waiting room or exam room.

• Properly identify the Baumann Skin Type using a validated questionnaire.

To determine a patient’s true skin type, a scientifically validated questionnaire is used to assess skin oiliness, dryness, sensitivity, uneven skin tone, and risk factors for wrinkles. When these parameters are combined, there are 16 possible Baumann Skin Types, which yield an accurate history of the patient’s skin characteristics.

• Choose products for each skin type.

There are many factors to consider in choosing what brands and SKUs (stock keeping units, in industry parlance, but particular products for our purposes) to use for each skin type. I use a brand-agnostic approach to choose the best technologies from various brands from around the world. I believe that brands often have a core competency, such as sunscreen technology, but that not all of the products in a particular line are superior. I select the best products (SKUs) from each brand, and combine and test them on various skin types to see which products and what combinations of products work best.

The following are the factors that I take into account when choosing SKUs for each Baumann Skin Type:

A. Importance of the ingredient recipe

Although the product label lists ingredients, it does not list the formulation’s recipe, which is proprietary and often patented. The "recipe" includes the order that ingredients are added in the process, the pH, the amount of each ingredient, the temperature at which the ingredient is added, and many other important factors that determine the final chemistry. Ingredients like vitamin C, green tea, and argan oil are expensive when formulated properly. Many copycat brands, such as the Walgreens and CVS knockoffs, use the same ingredients. However, they cannot use the patented recipe, and therefore their end product is different.

B. Manufacturing and packaging process

How a product is made and packaged is crucial. For example, retinol breaks down when exposed to light and air. I once visited a manufacturing plant that was stirring its "antiaging" retinol preparation in open vats. The retinol was losing its activity, which is why the product was "less irritating." The process of packaging the completed product is also important. In some cases the product is formulated in one place and shipped to another location for final packaging – and several ingredients can lose their potency during transit. Finally, the container that the product is packaged in is important. Air and light can get into tubes, affecting the efficacy of a product.

C. Ingredient interactions

The order of application and the combination of ingredients affect stability, efficacy, safety, and the chemical structure. Master formulators understand that every ingredient in the formulation matters, and there is really no such thing as an inactive ingredient. Ingredients can affect penetration and render other ingredients more or less effective depending on the order in which the ingredients are used on the skin. For example, olive oil actually increases penetration of other ingredients because it has a high content of oleic acid, while safflower oil can decrease penetration by strengthening the skin barrier.

• Design the regimen and order of application of products.

Once you have determined your patient’s skin type and matched the proper products to their skin type, you must tell them exactly how to apply them. The order in which products are applied makes a difference. Consider ingredient interactions, ingredient penetration times, and cross-reactions, plus skin type factors such as the condition of the skin barrier, sebum production, thickness of the stratum corneum, sun exposure, and bathing habits. I recommend providing a printed regimen with step-by-step instructions for morning and night.

• Educate patients.

Take the time to educate your patients on their skin issues. If you explain why you chose each product and why the particular ingredients are important, they are more likely to be compliant and get better results (and return to you for product recommendations and repurchases). Because we do not have the time to sit and explain all of these issues to each patient, we use educational newsletters that we send to patients based on their Baumann Skin Type. This helps keep them engaged and educates them about new technologies and products that are appropriate for their skin type.

• Encourage compliance.

Schedule a follow-up visit after 1 month to check on their progress and ensure compliance, and emphasize the importance of this visit. If you prescribed a retinoid, patients may experience irritation and stop using it. If you have an imaging system, baseline and follow-up photos help illustrate patients’ progress and keep them vigilant. Four weeks is a good time frame because patients tend to lose interest at that point.

• Sell skin care products in your practice.

I was against selling skin care products for ethical reasons for several years. However, in 2005, I surveyed my patients, and 100% of them wanted me to sell products so that they could feel sure that they were purchasing the right products for their needs. In fact, my patients appreciate expert medical advice on skin care. As a practitioner, you can make more educated choices about skin care products and help them avoid products that don’t work or cause harm.

• Contact me for more information.

In order to improve patient outcomes, you must ensure that you stay current on skin care science so your patients can benefit from your expertise. I recognize that not everyone has the time and inclination to stay current on the various skin care ingredients, products, and brands. Several of my dermatology friends have adopted my skin typing system in their practices and, in the process, observed better patient outcomes and increased profitability, while reducing the burden on their staff. These successes led to the development of an in-office store system utilizing my concept, which I am offering only to dermatologists. Feel free to email me at [email protected], or visit STSFranchise.com, if you want to learn more.

• Look for this column each month.

I will be sharing more advice on in-office skin care retail and will continue my review of new cosmeceutical ingredients. Let’s work together to put skin care back in the hands of dermatologists.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Last July, I summarized the significant changes in the Health Insurance Portability and Accountability Act (HIPAA). With the last of the deadlines mandated by those changes fast approaching, and a significant enforcement action levied against a dermatology group in the interim, an update is warranted.

The deadline is Sept. 23; by then, all of your business associate (BA) agreements must be modified to reflect the new privacy rules. A recent enforcement action involved a Massachusetts dermatology group that was hit with a substantial fine for violating one of those rules, sending a clear signal from the Centers for Medicare & Medicaid Services (CMS) and its enforcer, the Office for Civil Rights, that these tighter regulations cannot be taken lightly.

The criteria for identifying BAs remain the same: Nonemployees, performing "functions or activities" on behalf of the "covered entity" (your practice), that involve "creating, receiving, maintaining, or transmitting" personal health information (PHI).

Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services are BAs if they must have direct access to PHI in order to do their jobs.

Mail carriers, package delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs, even though they might conceivably come in contact with PHI on occasion. You are required to use "reasonable diligence" in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.

Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement; just train them, as you do your employees. (More on HIPAA and OSHA training soon.)

What is new is the additional onus placed on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract; you are expected to use "reasonable diligence" in monitoring the work of your BAs. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is yours. Furthermore, you must now assume the worst-case scenario. Previously, when PHI was compromised, you would only have to notify affected patients (and the government) if there was a "significant risk of financial or reputational harm," but now, any incident involving patient records is assumed to be a breach, and must be reported.

Failure to report could subject your practice, as well as the contractor, to significant fines. That is where the Massachusetts group had trouble: It lost a thumb drive containing unencrypted PHI, and was forced to pay a $150,000 fine early this year as a result. There is no excuse for not encrypting HIPAA-protected information; encryption software is cheap, readily available, and easy to use. Had the drive lost in Massachusetts been encrypted, according to the CMS, the incident would not have been considered a breach, because its contents would not have been viewable by the finder. Stay tuned for a list of popular encryption programs. (As always, I have no financial interest in any company or product that I mention in this column.)

Patients have new rights under the new rules as well; they may now restrict any PHI shared with third-party insurers and health plans, if they pay for the services themselves. They also have the right to request copies of their electronic health records. You can bill the costs of responding to such requests. If you have EHRs, work out a system for doing this, because the response time has been decreased from 90 days to 30 – and is even shorter in some states.

If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. You need to explain the breach notification process, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there; but you need not mail a copy to every patient.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.

Last July, I summarized the significant changes in the Health Insurance Portability and Accountability Act (HIPAA). With the last of the deadlines mandated by those changes fast approaching, and a significant enforcement action levied against a dermatology group in the interim, an update is warranted.

The deadline is Sept. 23; by then, all of your business associate (BA) agreements must be modified to reflect the new privacy rules. A recent enforcement action involved a Massachusetts dermatology group that was hit with a substantial fine for violating one of those rules, sending a clear signal from the Centers for Medicare & Medicaid Services (CMS) and its enforcer, the Office for Civil Rights, that these tighter regulations cannot be taken lightly.

The criteria for identifying BAs remain the same: Nonemployees, performing "functions or activities" on behalf of the "covered entity" (your practice), that involve "creating, receiving, maintaining, or transmitting" personal health information (PHI).

Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services are BAs if they must have direct access to PHI in order to do their jobs.

Mail carriers, package delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs, even though they might conceivably come in contact with PHI on occasion. You are required to use "reasonable diligence" in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.

Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement; just train them, as you do your employees. (More on HIPAA and OSHA training soon.)

What is new is the additional onus placed on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract; you are expected to use "reasonable diligence" in monitoring the work of your BAs. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is yours. Furthermore, you must now assume the worst-case scenario. Previously, when PHI was compromised, you would only have to notify affected patients (and the government) if there was a "significant risk of financial or reputational harm," but now, any incident involving patient records is assumed to be a breach, and must be reported.

Failure to report could subject your practice, as well as the contractor, to significant fines. That is where the Massachusetts group had trouble: It lost a thumb drive containing unencrypted PHI, and was forced to pay a $150,000 fine early this year as a result. There is no excuse for not encrypting HIPAA-protected information; encryption software is cheap, readily available, and easy to use. Had the drive lost in Massachusetts been encrypted, according to the CMS, the incident would not have been considered a breach, because its contents would not have been viewable by the finder. Stay tuned for a list of popular encryption programs. (As always, I have no financial interest in any company or product that I mention in this column.)

Patients have new rights under the new rules as well; they may now restrict any PHI shared with third-party insurers and health plans, if they pay for the services themselves. They also have the right to request copies of their electronic health records. You can bill the costs of responding to such requests. If you have EHRs, work out a system for doing this, because the response time has been decreased from 90 days to 30 – and is even shorter in some states.

If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. You need to explain the breach notification process, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there; but you need not mail a copy to every patient.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.

Last July, I summarized the significant changes in the Health Insurance Portability and Accountability Act (HIPAA). With the last of the deadlines mandated by those changes fast approaching, and a significant enforcement action levied against a dermatology group in the interim, an update is warranted.

The deadline is Sept. 23; by then, all of your business associate (BA) agreements must be modified to reflect the new privacy rules. A recent enforcement action involved a Massachusetts dermatology group that was hit with a substantial fine for violating one of those rules, sending a clear signal from the Centers for Medicare & Medicaid Services (CMS) and its enforcer, the Office for Civil Rights, that these tighter regulations cannot be taken lightly.

The criteria for identifying BAs remain the same: Nonemployees, performing "functions or activities" on behalf of the "covered entity" (your practice), that involve "creating, receiving, maintaining, or transmitting" personal health information (PHI).

Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services are BAs if they must have direct access to PHI in order to do their jobs.

Mail carriers, package delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs, even though they might conceivably come in contact with PHI on occasion. You are required to use "reasonable diligence" in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.

Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement; just train them, as you do your employees. (More on HIPAA and OSHA training soon.)

What is new is the additional onus placed on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract; you are expected to use "reasonable diligence" in monitoring the work of your BAs. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is yours. Furthermore, you must now assume the worst-case scenario. Previously, when PHI was compromised, you would only have to notify affected patients (and the government) if there was a "significant risk of financial or reputational harm," but now, any incident involving patient records is assumed to be a breach, and must be reported.

Failure to report could subject your practice, as well as the contractor, to significant fines. That is where the Massachusetts group had trouble: It lost a thumb drive containing unencrypted PHI, and was forced to pay a $150,000 fine early this year as a result. There is no excuse for not encrypting HIPAA-protected information; encryption software is cheap, readily available, and easy to use. Had the drive lost in Massachusetts been encrypted, according to the CMS, the incident would not have been considered a breach, because its contents would not have been viewable by the finder. Stay tuned for a list of popular encryption programs. (As always, I have no financial interest in any company or product that I mention in this column.)

Patients have new rights under the new rules as well; they may now restrict any PHI shared with third-party insurers and health plans, if they pay for the services themselves. They also have the right to request copies of their electronic health records. You can bill the costs of responding to such requests. If you have EHRs, work out a system for doing this, because the response time has been decreased from 90 days to 30 – and is even shorter in some states.

If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. You need to explain the breach notification process, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there; but you need not mail a copy to every patient.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.

While being discharged from the hospital even after a minor procedure is not simple, the process for a patient with comorbidities after a prolonged stay is daunting.

Physicians from multiple specialties, various nonphysician providers, the social worker, and the case manager all address different discharge-related issues. It is frustrating for both a provider and patient to experience the "I really can’t answer that question" moment. Lack of interdisciplinary communication may lead to medical errors and either premature or delayed discharges.

The date of discharge is estimated soon after admission. Some hospitals have a focus on the clock when planning discharges. If planning occurs too early, it does not account for changes in patient needs and wrong instructions might be given. Transportation and home-aide needs are time sensitive.

In contrast, some planning does need to be considered early in the admission when discharge to a non-acute care facility is obvious due to the diagnosis and/or social situation of the patient.

One study from the Brigham and Women’s Hospital identified seven clinical factors predicting hospital readmission: a hemoglobin less than 12 g/dL on discharge, discharge from an oncology service, low serum sodium level on discharge, a procedure (via ICD-9 standards) during admission, nonelective admission, length of stay greater than 4 days, and number of admissions during the previous year (JAMA Intern. Med. 2013;173:632-8).

Another study examined many predictive models found in the literature.

The researchers found that "of 7,843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large U.S. populations and had poor discriminative ability. ... Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization, ... and 5 could be used at hospital discharge" (JAMA 2011;306:1688-98).

The authors concluded that most prediction models perform poorly or require improvement. Perhaps one reason for this result lies in the fact that these models traditionally are either clinical or administrative. I believe a better approach is to combine administrative and clinical predictive models. Better analytics programs applied real-time in the electronic health record (EHR) will facilitate integration of these perspectives.

The topic of transitional care has received attention because a poor discharge process results in higher readmission rates, a new benchmark focus of Medicare (Am. J. Nurs. 2008;108:58-63). Hospitals might be very good at meeting regulatory requirements, but the patient’s understanding of diagnoses and instructions is often unclear. Though required by regulations, the caregiver may not even be included in the process. Technology can help in this situation. Some of possibilities mentioned below might not be available in the context described.

• Durable equipment needs. The care coordinator is generally the point person regarding the patient’s durable equipment needs upon discharge. Ordering the equipment (specifications as well as date, time, and place of delivery) might be the job of someone else, such as a therapist or physician. Digital tools can expedite equipment procurement. Analytics from the EHR (mining diagnoses, equipment in use at the end of the hospitalization, expected place of transition, etc.) might determine the individual’s ambulation, oxygen, bed, or other equipment requirements. This can act as a preliminary checklist for the coordinator, doing away with the need to personally go through the EHR or surveying providers. A digital ordering program can directly interact with the distributor to check product availability and verify delivery. Another useful tool would aggregate equipment distributors, which are stratified according to certification (Medicare bidding approval status), lowest price, and best-rated service.

• Visiting nurses. Often the home-needs assessment for visiting nurses is done once the patient is discharged. This can be expedited with the help of a caregiver, with the assessment completed in the hospital. Consider a tool into which the physician’s orders or recommendations for home nursing are placed and shared with the visiting nurse entity, the patient, and the caregiver. It would include the nursing assessment as well as a video of the home environment (a factor in the assessment itself). This would obviate the need for a dedicated assessment visit. Visiting nurses themselves should be equipped with mobile technology to document their time schedule for billing, to record interventions, and to record and transmit vital signs (measured via digital remote monitors) and orders; the technology also should contain a digital messaging program.

• Scheduling of outpatient provider appointments. Evidence suggests that in a general medical population, early follow-up appointments do not affect readmission rates (Arch. Intern. Med. 2010;170:955-60). However, some patients, including those with heart failure have been shown to benefit from early follow-up (JAMA 2010;303:1716-22). The success of a growing number of commercially available mobile apps intended to streamline scheduling of physician appointments is testimony to this need in the nonacute setting. Patient portal use is a requirement of Meaningful Use Stage 2. One way of encouraging patient participation in portal use would be activating it by utilizing a discharge planning scheduling application of the portal at the time of discharge. This also fits into an overall strategy of point of engagement implementation of technology.

These are only a few highlights of the complexity of the discharge process. All physicians have dealt with the many questions, complications, and frustration experienced by patients after discharge. A failed process creates unnecessary work, expense, and bad outcomes.

To many physicians, digital health technology is represented by the EHR in its present form, which is not what the doctor ordered. It is not intuitive, it is cumbersome, and it encourages impersonal encounters with patients. I will explore in future posts how digital technologies other than the EHR will change medicine in ways that physicians will appreciate.

Dr. Scher, a practicing cardiac electrophysiologist in Lancaster, Pa., is director at DLS Healthcare Consulting, advising technology companies and health care enterprises on development and adoption of mobile health technologies.

While being discharged from the hospital even after a minor procedure is not simple, the process for a patient with comorbidities after a prolonged stay is daunting.

Physicians from multiple specialties, various nonphysician providers, the social worker, and the case manager all address different discharge-related issues. It is frustrating for both a provider and patient to experience the "I really can’t answer that question" moment. Lack of interdisciplinary communication may lead to medical errors and either premature or delayed discharges.

The date of discharge is estimated soon after admission. Some hospitals have a focus on the clock when planning discharges. If planning occurs too early, it does not account for changes in patient needs and wrong instructions might be given. Transportation and home-aide needs are time sensitive.

In contrast, some planning does need to be considered early in the admission when discharge to a non-acute care facility is obvious due to the diagnosis and/or social situation of the patient.

One study from the Brigham and Women’s Hospital identified seven clinical factors predicting hospital readmission: a hemoglobin less than 12 g/dL on discharge, discharge from an oncology service, low serum sodium level on discharge, a procedure (via ICD-9 standards) during admission, nonelective admission, length of stay greater than 4 days, and number of admissions during the previous year (JAMA Intern. Med. 2013;173:632-8).

Another study examined many predictive models found in the literature.

The researchers found that "of 7,843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large U.S. populations and had poor discriminative ability. ... Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization, ... and 5 could be used at hospital discharge" (JAMA 2011;306:1688-98).

The authors concluded that most prediction models perform poorly or require improvement. Perhaps one reason for this result lies in the fact that these models traditionally are either clinical or administrative. I believe a better approach is to combine administrative and clinical predictive models. Better analytics programs applied real-time in the electronic health record (EHR) will facilitate integration of these perspectives.

The topic of transitional care has received attention because a poor discharge process results in higher readmission rates, a new benchmark focus of Medicare (Am. J. Nurs. 2008;108:58-63). Hospitals might be very good at meeting regulatory requirements, but the patient’s understanding of diagnoses and instructions is often unclear. Though required by regulations, the caregiver may not even be included in the process. Technology can help in this situation. Some of possibilities mentioned below might not be available in the context described.

• Durable equipment needs. The care coordinator is generally the point person regarding the patient’s durable equipment needs upon discharge. Ordering the equipment (specifications as well as date, time, and place of delivery) might be the job of someone else, such as a therapist or physician. Digital tools can expedite equipment procurement. Analytics from the EHR (mining diagnoses, equipment in use at the end of the hospitalization, expected place of transition, etc.) might determine the individual’s ambulation, oxygen, bed, or other equipment requirements. This can act as a preliminary checklist for the coordinator, doing away with the need to personally go through the EHR or surveying providers. A digital ordering program can directly interact with the distributor to check product availability and verify delivery. Another useful tool would aggregate equipment distributors, which are stratified according to certification (Medicare bidding approval status), lowest price, and best-rated service.

• Visiting nurses. Often the home-needs assessment for visiting nurses is done once the patient is discharged. This can be expedited with the help of a caregiver, with the assessment completed in the hospital. Consider a tool into which the physician’s orders or recommendations for home nursing are placed and shared with the visiting nurse entity, the patient, and the caregiver. It would include the nursing assessment as well as a video of the home environment (a factor in the assessment itself). This would obviate the need for a dedicated assessment visit. Visiting nurses themselves should be equipped with mobile technology to document their time schedule for billing, to record interventions, and to record and transmit vital signs (measured via digital remote monitors) and orders; the technology also should contain a digital messaging program.

• Scheduling of outpatient provider appointments. Evidence suggests that in a general medical population, early follow-up appointments do not affect readmission rates (Arch. Intern. Med. 2010;170:955-60). However, some patients, including those with heart failure have been shown to benefit from early follow-up (JAMA 2010;303:1716-22). The success of a growing number of commercially available mobile apps intended to streamline scheduling of physician appointments is testimony to this need in the nonacute setting. Patient portal use is a requirement of Meaningful Use Stage 2. One way of encouraging patient participation in portal use would be activating it by utilizing a discharge planning scheduling application of the portal at the time of discharge. This also fits into an overall strategy of point of engagement implementation of technology.

These are only a few highlights of the complexity of the discharge process. All physicians have dealt with the many questions, complications, and frustration experienced by patients after discharge. A failed process creates unnecessary work, expense, and bad outcomes.

To many physicians, digital health technology is represented by the EHR in its present form, which is not what the doctor ordered. It is not intuitive, it is cumbersome, and it encourages impersonal encounters with patients. I will explore in future posts how digital technologies other than the EHR will change medicine in ways that physicians will appreciate.

Dr. Scher, a practicing cardiac electrophysiologist in Lancaster, Pa., is director at DLS Healthcare Consulting, advising technology companies and health care enterprises on development and adoption of mobile health technologies.

While being discharged from the hospital even after a minor procedure is not simple, the process for a patient with comorbidities after a prolonged stay is daunting.

Physicians from multiple specialties, various nonphysician providers, the social worker, and the case manager all address different discharge-related issues. It is frustrating for both a provider and patient to experience the "I really can’t answer that question" moment. Lack of interdisciplinary communication may lead to medical errors and either premature or delayed discharges.

The date of discharge is estimated soon after admission. Some hospitals have a focus on the clock when planning discharges. If planning occurs too early, it does not account for changes in patient needs and wrong instructions might be given. Transportation and home-aide needs are time sensitive.

In contrast, some planning does need to be considered early in the admission when discharge to a non-acute care facility is obvious due to the diagnosis and/or social situation of the patient.

One study from the Brigham and Women’s Hospital identified seven clinical factors predicting hospital readmission: a hemoglobin less than 12 g/dL on discharge, discharge from an oncology service, low serum sodium level on discharge, a procedure (via ICD-9 standards) during admission, nonelective admission, length of stay greater than 4 days, and number of admissions during the previous year (JAMA Intern. Med. 2013;173:632-8).

Another study examined many predictive models found in the literature.

The researchers found that "of 7,843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large U.S. populations and had poor discriminative ability. ... Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization, ... and 5 could be used at hospital discharge" (JAMA 2011;306:1688-98).

The authors concluded that most prediction models perform poorly or require improvement. Perhaps one reason for this result lies in the fact that these models traditionally are either clinical or administrative. I believe a better approach is to combine administrative and clinical predictive models. Better analytics programs applied real-time in the electronic health record (EHR) will facilitate integration of these perspectives.

The topic of transitional care has received attention because a poor discharge process results in higher readmission rates, a new benchmark focus of Medicare (Am. J. Nurs. 2008;108:58-63). Hospitals might be very good at meeting regulatory requirements, but the patient’s understanding of diagnoses and instructions is often unclear. Though required by regulations, the caregiver may not even be included in the process. Technology can help in this situation. Some of possibilities mentioned below might not be available in the context described.

• Durable equipment needs. The care coordinator is generally the point person regarding the patient’s durable equipment needs upon discharge. Ordering the equipment (specifications as well as date, time, and place of delivery) might be the job of someone else, such as a therapist or physician. Digital tools can expedite equipment procurement. Analytics from the EHR (mining diagnoses, equipment in use at the end of the hospitalization, expected place of transition, etc.) might determine the individual’s ambulation, oxygen, bed, or other equipment requirements. This can act as a preliminary checklist for the coordinator, doing away with the need to personally go through the EHR or surveying providers. A digital ordering program can directly interact with the distributor to check product availability and verify delivery. Another useful tool would aggregate equipment distributors, which are stratified according to certification (Medicare bidding approval status), lowest price, and best-rated service.

• Visiting nurses. Often the home-needs assessment for visiting nurses is done once the patient is discharged. This can be expedited with the help of a caregiver, with the assessment completed in the hospital. Consider a tool into which the physician’s orders or recommendations for home nursing are placed and shared with the visiting nurse entity, the patient, and the caregiver. It would include the nursing assessment as well as a video of the home environment (a factor in the assessment itself). This would obviate the need for a dedicated assessment visit. Visiting nurses themselves should be equipped with mobile technology to document their time schedule for billing, to record interventions, and to record and transmit vital signs (measured via digital remote monitors) and orders; the technology also should contain a digital messaging program.

• Scheduling of outpatient provider appointments. Evidence suggests that in a general medical population, early follow-up appointments do not affect readmission rates (Arch. Intern. Med. 2010;170:955-60). However, some patients, including those with heart failure have been shown to benefit from early follow-up (JAMA 2010;303:1716-22). The success of a growing number of commercially available mobile apps intended to streamline scheduling of physician appointments is testimony to this need in the nonacute setting. Patient portal use is a requirement of Meaningful Use Stage 2. One way of encouraging patient participation in portal use would be activating it by utilizing a discharge planning scheduling application of the portal at the time of discharge. This also fits into an overall strategy of point of engagement implementation of technology.

These are only a few highlights of the complexity of the discharge process. All physicians have dealt with the many questions, complications, and frustration experienced by patients after discharge. A failed process creates unnecessary work, expense, and bad outcomes.

To many physicians, digital health technology is represented by the EHR in its present form, which is not what the doctor ordered. It is not intuitive, it is cumbersome, and it encourages impersonal encounters with patients. I will explore in future posts how digital technologies other than the EHR will change medicine in ways that physicians will appreciate.

Dr. Scher, a practicing cardiac electrophysiologist in Lancaster, Pa., is director at DLS Healthcare Consulting, advising technology companies and health care enterprises on development and adoption of mobile health technologies.