Re: virtual visit content

[Guest guest]

Depends on the patient and how well we know each other, but, if any hesitancy, would

set a policy that any controlled substance planning must be done in person.

And it seems you have some reservations. VV may be perfect for a lot of the

follow up except for the occasional vitals as you mention.TimOn Thu, May 29, 2008 7:21 am EDT, Lynn Ho

wrote:

Help! Virtual Visits are trying to take off

on their own, and I wonder if this is appropriate for a VV. Yesterday I did a UTI

and a premenopausal period for 9 weeks over VVs. Today I get this in depth review

via email of someone who thinks for years she has ADD, makes a good case, strong FH,

giving some giant presentations in Germany about her work, want to take stimulants

on an occasional basis for these big talks she is giving so she can focus, maybe a

few other similar situations, wants to do this via VV. I can get an adult ADD

rating scale through the VV platform, but is this appropriate? No concerns at all

for abuse/diversion, I know this person and family well. The only reason I would

see her in f/u is to get a blood pressure/ possibly weight (these have always been

low normal in the office previously), and I'd have to mail in or leave a

prescription in the office for hard copy.Anyone have any strong feelings about

this?Lynn E-mail for the greater good. Join the i’m Initiative from Microsoft.

---------------------------------------- Malia, MDMalia

Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton

Square MallFairport, NY 14450 (phone / fax)www.relayhealth.com/doc/DrMaliawww.SkinSenseLaser.com--

Confidentiality Notice --This email message, including all the attachments, is

for the sole use of the intended recipient(s) and contains confidential information.

Unauthorized use or disclosure is prohibited. If you are not the intended recipient,

you may not use, disclose, copy or disseminate this information. If you are not the

intended recipient, please contact the sender immediately by reply email and destroy

all copies of the original message, including attachments.----------------------------------------

[Guest guest]

Lynn,

Don’t do it. I would have any

controlled substance person come and see me face to face. Doing the initial

diagnosis of ADD in an adult if dicey enough, doing it through the computer

would not stand up as a standard if brought to court. The other red flag is

that when under stress, like a large presentation, I would expect those with

ADD to be able to focus much better—after all don’t we all get a

surge of adrenaline prior to our presentations, and isn’t adrenaline the

original stimulant?

Although I am not yet as advanced as you and

cannot offer VV, there are too many nuances in this case to make me feel like I

could treat it over the internet.

P.S. I wonder if there is an increase in

VV due to the economy—less cost, less money to gas. Have others who offer

this service seen the same surge??

virtual visit content

Help! Virtual Visits are trying to take off on their own, and I wonder

if this is appropriate for a VV. Yesterday I did a UTI and a premenopausal

period for 9 weeks over VVs. Today I get this in depth review via email

of someone who thinks for years she has ADD, makes a good case, strong FH,

giving some giant presentations in Germany about her work, want to take

stimulants on an occasional basis for these big talks she is giving so

she can focus, maybe a few other similar situations, wants to do this via VV.

I can get an adult ADD rating scale through the VV platform, but is this

appropriate? No concerns at all for abuse/diversion, I know this person and

family well. The only reason I would see her in f/u is to get a blood

pressure/ possibly weight (these have always been low normal in the office

previously), and I'd have to mail in or leave a prescription in the office for

hard copy.

Anyone have any strong feelings about this?

Lynn

E-mail for the greater good. Join the i’m Initiative from Microsoft.

[Guest guest]

Lynn, Can I ask how you have organized your virtual visits since I think you have AC/Onebox/etc. Are you using secure email with folks or just getting consent and how to arrange payment? Thanks,Neva Re: virtual visit contentTo: lynnhri@..., practiceimprovement1 > > > Depends on the patient and how well we know each other, but, if > any hesitancy, would> set a policy that any controlled substance planning must be done > in person. > And it seems you have some reservations. VV may be perfect for > a lot of the> follow up except for the occasional vitals as you mention.> Tim> > > > > > <style type="text/css">> .hmmessage P> {> margin:0px;> padding:0px> }> body.hmmessage> {> FONT-SIZE: 10pt;> FONT-FAMILY:Tahoma> }> </style>> > > > > > Help! Virtual Visits are trying to take off> on their own, and I wonder if this is appropriate for a VV. > Yesterday I did a UTI> and a premenopausal period for 9 weeks over VVs. Today I > get this in depth review> via email of someone who thinks for years she has ADD, makes a > good case, strong FH,> giving some giant presentations in Germany about her work, want > to take stimulants> on an occasional basis for these big talks she is giving > so she can focus, maybe a> few other similar situations, wants to do this via VV. I > can get an adult ADD> rating scale through the VV platform, but is this appropriate? > No concerns at all> for abuse/diversion, I know this person and family well. > The only reason I would> see her in f/u is to get a blood pressure/ possibly weight > (these have always been> low normal in the office previously), and I'd have to mail in or > leave a> prescription in the office for hard copy.> Anyone have any strong feelings about> this?> Lynn> > > <style type="text/css">.ExternalClass #EC_ygrp-mkp> {border:1px> solid #d8d8d8;font-family:Arial;padding:0px 14px;}> .ExternalClass #EC_ygrp-mkp> hr> {border:1px solid #d8d8d8;}> .ExternalClass #EC_ygrp-mkp #EC_hd> {color:#628c2a;font-size:85%;font-weight:bold;line-height:122%;}> .ExternalClass #EC_ygrp-mkp #EC_ads> {margin-bottom:10px;}> .ExternalClass> #EC_ygrp-mkp .EC_ad> {padding:0 0;}> .ExternalClass #EC_ygrp-mkp .EC_ad a> {color:#0000ff;text-decoration:none;}> > </style><style type="text/css">> .ExternalClass #EC_ygrp-sponsor #EC_ygrp-lc> {font-family:Arial;}> .ExternalClass #EC_ygrp-sponsor #EC_ygrp-lc #EC_hd> {font-weight:bold;font-size:78%;line-height:122%;}> .ExternalClass> #EC_ygrp-sponsor #EC_ygrp-lc .EC_ad> {margin-bottom:10px;padding:0 0;}> > </style><style type="text/css">> .ExternalClass #EC_ygrp-mlmsg> {font-size:13px;font-family:arial,helvetica,clean,sans-serif;}> .ExternalClass> #EC_ygrp-mlmsg table> {font-size:inherit;font:100%;}> .ExternalClass> #EC_ygrp-mlmsg select, .ExternalClass input, .ExternalClass textarea> {font:99%> arial,helvetica,clean,sans-serif;}> .ExternalClass #EC_ygrp-mlmsg pre,> .ExternalClass code> {font:115% monospace;}> .ExternalClass #EC_ygrp-mlmsg> EC_*> {line-height:1.22em;}> .ExternalClass #EC_ygrp-text> {font-family:Georgia;}> .ExternalClass #EC_ygrp-text p> {;}> .ExternalClass #EC_ygrp-tpmsgs> {font-family:Arial;clear:both;}> .ExternalClass #EC_ygrp-vitnav> {padding-top:10px;font-family:Verdana;font-size:77%;}> .ExternalClass> #EC_ygrp-vitnav a> {padding:0 1px;}> .ExternalClass #EC_ygrp-actbar> {clear:both;white-space:nowrap;color:#666;text-align:right;}> .ExternalClass> #EC_ygrp-actbar .EC_left> {float:left;white-space:nowrap;}> .ExternalClass> .EC_bld> {font-weight:bold;}> .ExternalClass #EC_ygrp-grft> {font-family:Verdana;font-size:77%;padding:15px 0;}> .ExternalClass> #EC_ygrp-ft> {font-family:verdana;font-size:77%;border-top:1px solid> #666;padding:5px 0;}> .ExternalClass #EC_ygrp-mlmsg #EC_logo> {padding-bottom:10px;}> .ExternalClass #EC_ygrp-reco> {margin-bottom:20px;padding:0px;}> .ExternalClass #EC_ygrp-reco> #EC_reco-head> {font-weight:bold;color:#ff7900;}> .ExternalClass> #EC_reco-grpname> {font-weight:bold;}> .ExternalClass #EC_reco-category> {font-size:77%;}> .ExternalClass #EC_reco-desc> {font-size:77%;}> .ExternalClass #EC_ygrp-vital> {background-color:#e0ecee;margin-bottom:20px;padding:2px 0 8px 8px;}> .ExternalClass #EC_ygrp-vital #EC_vithd> {font-size:77%;font-family:Verdana;font-> weight:bold;color:#333;text-transform:uppercase;}> .ExternalClass #EC_ygrp-vital ul> {padding:0;}> .ExternalClass> #EC_ygrp-vital ul li> {list-style-type:none;clear:both;border:1px solid> #e0ecee;}> .ExternalClass #EC_ygrp-vital ul li .EC_ct> {font-weight:bold;color:#ff7900;float:right;width:2em;text-> align:right;padding-right:.5em;}> .ExternalClass #EC_ygrp-vital ul li .EC_cat> {font-weight:bold;}> .ExternalClass #EC_ygrp-vital a> {text-decoration:none;}> .ExternalClass> #EC_ygrp-vital a:hover> {text-decoration:underline;}> .ExternalClass> #EC_ygrp-sponsor #EC_hd> {color:#999;font-size:77%;}> .ExternalClass> #EC_ygrp-sponsor #EC_ov> {padding:6px> 13px;background-color:#e0ecee;margin-bottom:20px;}> .ExternalClass> #EC_ygrp-sponsor #EC_ov ul> {padding:0 0 0 8px;}> .ExternalClass> #EC_ygrp-sponsor #EC_ov li> {list-style-type:square;padding:6px> 0;font-size:77%;}> .ExternalClass #EC_ygrp-sponsor #EC_ov li a> {text-decoration:none;font-size:130%;}> .ExternalClass #EC_ygrp-sponsor> #EC_nc> {background-color:#eee;margin-bottom:20px;padding:0 8px;}> .ExternalClass #EC_ygrp-sponsor .EC_ad> {padding:8px 0;}> .ExternalClass> #EC_ygrp-sponsor .EC_ad #EC_hd1> {font-family:Arial;font-weight:bold;color:#628c2a;font-> size:100%;line-height:122%;}> .ExternalClass #EC_ygrp-sponsor .EC_ad a> {text-decoration:none;}> .ExternalClass #EC_ygrp-sponsor .EC_ad a:hover> {text-decoration:underline;}> .ExternalClass #EC_ygrp-sponsor .EC_ad p> {;}> .ExternalClass EC_o> {font-size:0;}> .ExternalClass> .EC_MsoNormal> {;}> .ExternalClass #EC_ygrp-text tt> {font-size:120%;}> .ExternalClass blockquote> {;}> .ExternalClass> .EC_replbq> {;}> > </style>> > > > > > E-mail for the greater good. Join the i’m Initiative from > Microsoft.> > > > > > > ----------------------------------------> Malia, MD> > Malia> Family Medicine & Skin Sense Laser> 6720 Pittsford-Palmyra Rd.> Perinton> Square Mall> Fairport, NY 14450> > (phone / fax)> www.relayhealth.com/doc/DrMalia> www.SkinSenseLaser.com> > --> Confidentiality Notice --> This email message, including all the attachments, is> for the sole use of the intended recipient(s) and contains > confidential information.> Unauthorized use or disclosure is prohibited. If you are not the > intended recipient,> you may not use, disclose, copy or disseminate this information. > If you are not the> intended recipient, please contact the sender immediately by > reply email and destroy> all copies of the original message, including attachments.> ----------------------------------------> >

[Guest guest]

Yeah lynn I think the fact that you have reservations means do not do itVV ar e really for htings that are straightforwardadultADD s not straightforwardAt least not to me It might be that you renew the scipts at VV- I do that with previoously dx'd adhd

but this is a psych dx you should document speech tone speed flucnecy grooming etc and besides I mean that is a dicey dx I am actually leery of making itas to long stories extensive ros- nip that in the bud

vv I think are for uti's/ conjuncitivitid/ f/u dm a nd htn etc and while it is your calll ,when they start to go on and on it loses the context of a practical way to get care to becoming venting and losing boundaries perhaps?

If in doubt- they come in.

Help! Virtual Visits are trying to take off on their own, and I wonder if this is appropriate for a VV. Yesterday I did a UTI and a premenopausal period for 9 weeks over VVs. Today I get this in depth review via email of someone who thinks for years she has ADD, makes a good case, strong FH, giving some giant presentations in Germany about her work, want to take stimulants on an occasional basis for these big talks she is giving so she can focus, maybe a few other similar situations, wants to do this via VV. I can get an adult ADD rating scale through the VV platform, but is this appropriate? No concerns at all for abuse/diversion, I know this person and family well. The only reason I would see her in f/u is to get a blood pressure/ possibly weight (these have always been low normal in the office previously), and I'd have to mail in or leave a prescription in the office for hard copy.

Anyone have any strong feelings about this?Lynn E-mail for the greater good. Join the i'm Initiative from Microsoft.

-- If you are a patient please allow up to 4-8 hours for a reply by email/please note the new email address/e mail may not be entirely secure/ MD

ph fax

[Guest guest]

For what it's worth - I agree on no VV for ADHD diagnosis (maybe not for follow up).Although I treat this all the time I am always concerned about the initial diagnosis and making sure I haven't missed significant depression, anxiety, substance abuse, domestic violence and other things that may affect focus and attention. I personally couldn't feel I did that without visualizing the patient. Sounds like your gut is telling you that too.Neva Re: virtual visit contentTo: > Yeah lynn I think the fact that you have reservations > means do not do it> VV ar e really for htings that are straightforward> adultADD s not straightforwardAt least not to me> > It might be that you renew the scipts at VV- I do that > with previoously> dx'd adhd> but this is a psych dx you should document speech tone > speed flucnecy> grooming etc and besides I mean that is a dicey dx I am actually > leery of> making it> > > as to long stories extensive ros-> nip that in the bud> vv I think are for uti's/ conjuncitivitid/ f/u dm a > nd htn etc and while> it is your calll ,when they start to go on and on it loses the > context of a> practical way to get care to becoming venting and > losing boundaries> perhaps?> If in doubt- they come in.> > > > > Help! Virtual Visits are trying to take off > on their own, and I wonder> > if this is appropriate for a VV. Yesterday I did a UTI and a > premenopausal> period for 9 weeks over VVs. Today I get > this in depth review via email of> > someone who thinks for years she has ADD, makes a good case, > strong FH,> > giving some giant presentations in Germany about her work, > want to take> > stimulants on an occasional basis for these big talks > she is giving so she> > can focus, maybe a few other similar situations, wants to do > this via VV. I> > can get an adult ADD rating scale through the VV platform, but > is this> > appropriate? No concerns at all for abuse/diversion, I know > this person and> > family well. The only reason I would see her in f/u is > to get a blood> > pressure/ possibly weight (these have always been low normal > in the office> > previously), and I'd have to mail in or leave a prescription > in the office> > for hard copy.> > Anyone have any strong feelings about this?> > Lynn> >> >> > ------------------------------> >> >> > ------------------------------> > E-mail for the greater good. Join the i'm Initiative from > Microsoft.<http://im.live.com/Messenger/IM/Join/Default.aspx?source=EML_WL_+GreaterGood>> > >> > > > -- > If you are a patient please allow up to 4-8 hours for a reply by > email/please note the new email address/> e mail may not be entirely secure/> MD> > > ph fax >

[Guest guest]

Nevathe details of set up are on the wiki , it's a relatively straight forward do it yourself:http://idealhealth.wikispaces.com/Virtual+office+visitsI am not using onebox for my email, just regular email with a disclaimer "this email is not secure, blah blah,,,"sign here if you want to use it to email with me.In the words of the inimitable Lou Spikol, 'convenience trumps security' for email.Patients pay before they access the VV page through Payapl and then are redirected from paypal to the IMH history taking webpage for VV history. LynnTo: CC: lynnhri@...; practiceimprovement1@yahoFrom: edens@...Date: Thu, 29 May 2008 07:36:59 -0400Subject: Re: virtual visit content

Lynn, Can I ask how you have organized your virtual visits since I think you have AC/Onebox/etc. Are you using secure email with folks or just getting consent and how to arrange payment? Thanks,Neva.

E-mail for the greater good. Join the i’m Initiative from Microsoft.

[Guest guest]

Tim, , Neva-Thanks for the input, I think you guys are probably right.I am just wondering however, if I feel uncomfortable about doing it just because it's a new way to do it and I haven't done it that way before, or because of the flags that you guys mention. I am looking at Bachman's EMR posts and he renews/increases doses of ritalin scripts all the time via VV, and that seems reasonable to me. The extension being, I do know this patient well enough - quite well- so that I know substance abuse domestic violence depression (but perhaps not anxiety) are not playing a part, and I am not concerned about abuse of this medication. She dislikes taking medications, all and any. Her worry was that after she becomes jet lagged she is not at the top of her game for focus in terms of giving the talks, being on a panel, schmoozing during schmoozy events etc. - seems reasonable to me.I don't know though, I think I will see her in person, but I could just do the VV. Jean-documenting psych diagnosis- does that mean one could never do a VV for a psych diagnosis, missing too much human element?Interesting, I will keep thinking about it and probably have her come in today.Lynn Change the world with e-mail. Join the i’m Initiative from Microsoft.

[Guest guest]

Lynn,

One of the constant difficulties I have

with living and working in the same neighborhood is whether to do something I

otherwise wouldn’t do just because I know somebody. In fact, yesterday I

had a friend call up and ask if she could come in to get sutures removed because

she did not want to drive 5 miles to see her regular doctor. I think this is a

slippery slope. In this case, I told the friend I would have to see her and

have an “established” relationship in order to take out the

stitches—note: I likely would have done it without question if she had

come to our house and asked as a friend. My point is that what would you do if

you did not know this patient as well? Would a VV work for you then? If not,

then you should see her and follow-up just as you would if you did not know her

as well. Then again, I’m pretty mean to my friends J

RE:

virtual visit content

Tim, , Neva-

Thanks for the input, I think you guys are probably right.

I am just wondering however, if I feel uncomfortable about doing it just

because it's a new way to do it and I haven't done it that way before, or

because of the flags that you guys mention.

I am looking at Bachman's EMR posts and he renews/increases doses of

ritalin scripts all the time via VV, and that seems reasonable to me. The

extension being, I do know this patient well enough - quite well- so that I

know substance abuse domestic violence depression (but perhaps not anxiety) are

not playing a part, and I am not concerned about abuse of this

medication. She dislikes taking medications, all and any. Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me.

I don't know though, I think I will see her in person, but I could just

do the VV.

Jean-documenting psych diagnosis- does that mean one could never do a VV

for a psych diagnosis, missing too much human element?

Interesting, I will keep thinking about it and probably have her come in today.

Lynn

Change the world with e-mail. Join the i’m Initiative from Microsoft.

[Guest guest]

Lynn,

This comment concerns me: “. Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me.”

That’s not ADD, that’s looking for speed to

perform better. None of us are at the top of our game when sleep

deprived. Would you take speed? It improves everybody’s

performance which is why it’s a drug of abuse. I wouldn’t

start a Class 2 drug without having an office visit. However, what you

are describing doesn’t even sound like ADD. My adults with ADD need

to take it to do their paperwork, fill out forms, you know, the boring

tasks. This would be the history I expect, trouble getting paperwork done

because can’t stay focused. Especially with intermittent use.

Sleep deprivation, anxiety, depression all cause attention deficit but not

ADD. Don’t forget that people with ADD have a lifetime history of

it.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Lynn Ho

Sent: Thursday, May 29, 2008 8:54 AM

To: practiceimprovement1

Subject: RE: virtual visit content

Tim, , Neva-

Thanks for the input, I think you guys are probably right.

I am just wondering however, if I feel uncomfortable about doing it just

because it's a new way to do it and I haven't done it that way before, or

because of the flags that you guys mention.

I am looking at Bachman's EMR posts and he renews/increases doses of

ritalin scripts all the time via VV, and that seems reasonable to me. The

extension being, I do know this patient well enough - quite well- so that I

know substance abuse domestic violence depression (but perhaps not anxiety) are

not playing a part, and I am not concerned about abuse of this

medication. She dislikes taking medications, all and any. Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me.

I don't know though, I think I will see her in person, but I could just

do the VV.

Jean-documenting psych diagnosis- does that mean one could never do a VV

for a psych diagnosis, missing too much human element?

Interesting, I will keep thinking about it and probably have her come in today.

Lynn

Change the world with e-mail. Join the i’m Initiative from Microsoft.

[Guest guest]

But - isn't it one of the characteristics of our practices that we do know our patients exceedingly well (sometimes more than we want to) and shouldn't we able to use that knowledge in how we treat them and the methods that we employ to treat them? Somehow it doesn't seem like a bad thing to me to use what I know from past history when trying to make a treatment decision, it isn't abusive and doesn't seem to be crossing a boundary. I don't know this person socially at all so luckily that doesn't figure into the mix. I am still bemused. Money may figure into the mix for her a little - time out of work, gas, cost of VV is less, she is paying by HSA. Plays into it a little for me too - I certainly would get paid more for a traditional OV and have the space....so...does that mean for the finances I should think more about asking for the visit? In the case of the sutures below, I think it is crossing a line in that (if showing up at your house) your friend is asking you to work for free, which isn't really right. Can't she just BITE THEM OUT herself at home?LynnTo: From: drbrady@...Date: Thu, 29 May 2008 09:31:43 -0400Subject: RE: virtual visit content

Lynn,

One of the constant difficulties I have

with living and working in the same neighborhood is whether to do something I

otherwise wouldn’t do just because I know somebody. In fact, yesterday I

had a friend call up and ask if she could come in to get sutures removed because

she did not want to drive 5 miles to see her regular doctor. I think this is a

slippery slope. In this case, I told the friend I would have to see her and

have an “established” relationship in order to take out the

stitches—note: I likely would have done it without question if she had

come to our house and asked as a friend. My point is that what would you do if

you did not know this patient as well? Would a VV work for you then? If not,

then you should see her and follow-up just as you would if you did not know her

as well. Then again, I’m pretty mean to my friends J

RE:

virtual visit content

Tim, , Neva-

Thanks for the input, I think you guys are probably right.

I am just wondering however, if I feel uncomfortable about doing it just

because it's a new way to do it and I haven't done it that way before, or

because of the flags that you guys mention.

I am looking at Bachman's EMR posts and he renews/increases doses of

ritalin scripts all the time via VV, and that seems reasonable to me. The

extension being, I do know this patient well enough - quite well- so that I

know substance abuse domestic violence depression (but perhaps not anxiety) are

not playing a part, and I am not concerned about abuse of this

medication. She dislikes taking medications, all and any. Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me.

I don't know though, I think I will see her in person, but I could just

do the VV.

Jean-documenting psych diagnosis- does that mean one could never do a VV

for a psych diagnosis, missing too much human element?

Interesting, I will keep thinking about it and probably have her come in today.

Lynn

Change the world with e-mail. Join the i’m Initiative from Microsoft.

Give to a good cause with every e-mail. Join the i’m Initiative from Microsoft.

[Guest guest]

No I do not think all psych visits are in person but on the other hand the value is greater in person If you were rechcking dperession that was stabilized- v v could be fine I am using the global notion of VV for simple visits that do not need an exam

Her complaints do not fit. It isn't simpleI renew ritalin also by VV but the kid is way stable If I hear hint of not stable- in they must come.What you want to define for yourself is the general definition of care that can be given through this medium.

Lynn,

This comment concerns me: ". Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me."

That's not ADD, that's looking for speed to

perform better. None of us are at the top of our game when sleep

deprived. Would you take speed? It improves everybody's

performance which is why it's a drug of abuse. I wouldn't

start a Class 2 drug without having an office visit. However, what you

are describing doesn't even sound like ADD. My adults with ADD need

to take it to do their paperwork, fill out forms, you know, the boring

tasks. This would be the history I expect, trouble getting paperwork done

because can't stay focused. Especially with intermittent use.

Sleep deprivation, anxiety, depression all cause attention deficit but not

ADD. Don't forget that people with ADD have a lifetime history of

it.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Lynn Ho

Sent: Thursday, May 29, 2008 8:54 AM

To: practiceimprovement1

Subject: RE: virtual visit content

Tim, , Neva-

Thanks for the input, I think you guys are probably right.

I am just wondering however, if I feel uncomfortable about doing it just

because it's a new way to do it and I haven't done it that way before, or

because of the flags that you guys mention.

I am looking at Bachman's EMR posts and he renews/increases doses of

ritalin scripts all the time via VV, and that seems reasonable to me. The

extension being, I do know this patient well enough - quite well- so that I

know substance abuse domestic violence depression (but perhaps not anxiety) are

not playing a part, and I am not concerned about abuse of this

medication. She dislikes taking medications, all and any. Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me.

I don't know though, I think I will see her in person, but I could just

do the VV.

Jean-documenting psych diagnosis- does that mean one could never do a VV

for a psych diagnosis, missing too much human element?

Interesting, I will keep thinking about it and probably have her come in today.

Lynn

Change the world with e-mail. Join the i'm Initiative from Microsoft.

-- If you are a patient please allow up to 4-8 hours for a reply by email/please note the new email address/e mail may not be entirely secure/ MD

ph fax

[Guest guest]

Lynn,

In a case like this, I would insist that the patient use IMH

first for full psych assessment, then come in for a visit to go over the results.

I agree with Kathy that this does not sound like ADD. Perhaps addressing

the issues of jet lag and getting enough sleep while travelling would be more

helpful to her than adding a stimulant prior to a presentation.

dts

From:

[mailto: ] On Behalf Of Kathy

Saradarian

Sent: Thursday, May 29, 2008 6:45 AM

To:

Subject: RE: virtual visit content

Lynn,

This comment concerns me: “.

Her worry was that after she becomes jet lagged she is not at the top of her

game for focus in terms of giving the talks, being on a panel, schmoozing

during schmoozy events etc. - seems reasonable to me.”

That’s

not ADD, that’s looking for speed to perform better. None of us are

at the top of our game when sleep deprived. Would you take speed?

It improves everybody’s performance which is why it’s a drug of

abuse. I wouldn’t start a Class 2 drug without having an

office visit. However, what you are describing doesn’t even sound

like ADD. My adults with ADD need to take it to do their paperwork, fill

out forms, you know, the boring tasks. This would be the history I

expect, trouble getting paperwork done because can’t stay focused.

Especially with intermittent use. Sleep deprivation, anxiety, depression

all cause attention deficit but not ADD. Don’t forget that people

with ADD have a lifetime history of it.

Kathy

Saradarian, MD

Branchville,

NJ

www.qualityfamilypractice.com

Solo 4/03,

Practicing since 9/90

Practice

Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Lynn Ho

Sent: Thursday, May 29, 2008 8:54 AM

To: practiceimprovement1

Subject: RE: virtual visit content

Tim, , Neva-

Thanks for the input, I think you guys are probably right.

I am just wondering however, if I feel uncomfortable about doing it just because

it's a new way to do it and I haven't done it that way before, or because of

the flags that you guys mention.

I am looking at Bachman's EMR posts and he renews/increases doses of

ritalin scripts all the time via VV, and that seems reasonable to me. The

extension being, I do know this patient well enough - quite well- so that I

know substance abuse domestic violence depression (but perhaps not anxiety) are

not playing a part, and I am not concerned about abuse of this

medication. She dislikes taking medications, all and any. Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me.

I don't know though, I think I will see her in person, but I could just

do the VV.

Jean-documenting psych diagnosis- does that mean one could never do a VV

for a psych diagnosis, missing too much human element?

Interesting, I will keep thinking about it and probably have her come in today.

Lynn

Change

the world with e-mail. Join the i’m Initiative from Microsoft.

[Guest guest]

I'm always intrigued by how our society has labeled and feared the use of medicines

and stimulants,etc. But it is the law and we are responsible to monitor even the

reasonable patients who we feel would not abuse a medicine ... and, as we've seen

mentioned, there are a number of patients who will mis-use/abuse medicines while

putting up a nice face to us -- we can be fooled.Pretty clear from the

discussion that this patient may not have a " diagnosis " of ADD, so caution

is advisable.Typically, besides sleep/rest, folks use coffee/tea for

stimulation when traveling or needing a " pick-me-up " for focusing on

work. Others use alcohol for anxiety. I'd argue that in some ways,

sensible use of a medicinal stimulant, like methylphenidate, or an anxiolytic, like

alprazolam, may be better than caffeine or alcohol respectively.But, in

her case, there may be other natural stimulants that would serve the purpose.

Consider Mate de Coca (tea of the coca leaf) which I'm well acquainted with from

visits to Bolivia. It's a much more pleasant stimulant than caffeine (which

I'm addicted/dependent to) and is great for altitude sickness. ...

and when dancing at 13,000 ft elevation for Carnaval, I recommend chewing on the

coca leaves themselves like the locals -- they've been doing it for hundreds of

years for a reason, it helps a lot!TimOn Thu, May 29, 2008 11:51 am EDT, T. , MD wrote:

Lynn,

In a case like this, I would insist

that the patient use IMHfirst for full psych assessment, then come in for a

visit to go over the results. I agree with Kathy that this does not sound like

ADD. Perhaps addressingthe issues of jet lag and getting enough sleep while

travelling would be morehelpful to her than adding a stimulant prior to a

presentation.

dts

From: [mailto: ] On Behalf Of

KathySaradarianSent: Thursday, May 29, 2008

6:45 AMTo: Subject: RE: virtual visit

content

Lynn,

This comment concerns me: “. Her worry was that after she

becomes jet lagged she is not at the top of hergame for focus in terms of

giving the talks, being on a panel, schmoozingduring schmoozy events etc. -

seems reasonable to me.”

That’snot ADD, that’s looking for

speed to perform better. None of us areat the top of our game when sleep

deprived. Would you take speed? It improves everybody’s performance

which is why it’s a drug ofabuse. I wouldn’t start a Class 2

drug without having anoffice visit. However, what you are describing

doesn’t even soundlike ADD. My adults with ADD need to take it to do

their paperwork, fillout forms, you know, the boring tasks. This would be the

history Iexpect, trouble getting paperwork done because can’t stay

focused. Especially with intermittent use. Sleep deprivation, anxiety,

depressionall cause attention deficit but not ADD. Don’t forget that

peoplewith ADD have a lifetime history of it.

KathySaradarian, MD

Branchville,NJ

www.qualityfamilypractice.com

Solo 4/03,Practicing since

9/90

PracticePartner 5/03

Low staffing

From: [mailto: ] On Behalf Of Lynn

HoSent: Thursday, May 29, 2008 8:54 AMTo: practiceimprovement1 Subject: RE: virtual visit

content

Tim, , Neva-Thanks for the input, I

think you guys are probably right.I am just wondering however, if I feel

uncomfortable about doing it just becauseit's a new way to do it and I haven't

done it that way before, or because ofthe flags that you guys mention. I am looking at Bachman's EMR posts and he renews/increases doses ofritalin scripts all the time via VV, and that seems reasonable to me. Theextension being, I do know this patient well enough - quite well- so that Iknow substance abuse domestic violence depression (but perhaps not anxiety) arenot playing a part, and I am not concerned about abuse of thismedication. She dislikes taking medications, all and any. Her worrywas that after she

becomes jet lagged she is not at the top of her game forfocus in terms of

giving the talks, being on a panel, schmoozing duringschmoozy events etc. -

seems reasonable to me.I don't know though, I think I will see her in person,

but I could justdo the VV. Jean-documenting psych diagnosis- does that

mean one could never do a VVfor a psych diagnosis, missing too much human

element?Interesting, I will keep thinking about it and probably have her come

in today.Lynn

Changethe world with e-mail. Join

the i’m Initiative from Microsoft.

---------------------------------------- Malia, MDMalia

Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton

Square MallFairport, NY 14450 (phone / fax)www.relayhealth.com/doc/DrMaliawww.SkinSenseLaser.com--

Confidentiality Notice --This email message, including all the attachments, is

for the sole use of the intended recipient(s) and contains confidential information.

Unauthorized use or disclosure is prohibited. If you are not the intended recipient,

you may not use, disclose, copy or disseminate this information. If you are not the

intended recipient, please contact the sender immediately by reply email and destroy

all copies of the original message, including attachments.----------------------------------------

[Guest guest]

On Thu, May 29, 2008 9:53 am EDT, Lynn

Ho wrote:I suspect more of us

might do VV if we coud get reimbursed.. the ethics seem fine since we know our

patients so well all the best geord

But - isn't it one of the characteristics of our

practices that we do know our patients exceedingly well (sometimes more than we want

to) and shouldn't we able to use that knowledge in how we treat them and the methods

that we employ to treat them? Somehow it doesn't seem like a bad thing to me to use

what I know from past history when trying to make a treatment decision, it isn't

abusive and doesn't seem to be crossing a boundary. I don't know this person

socially at all so luckily that doesn't figure into the mix. I am still bemused. Money may figure into the mix for her a little - time out of work, gas, cost of VV

is less, she is paying by HSA. Plays into it a little for me too - I certainly

would get paid more for a traditional OV and have the space....so...does

that mean for the finances I should think more about asking for the visit? In

the case of the sutures below, I think it is crossing a line in that (if showing up

at your house) your friend is asking you to work for free, which isn't really right.

Can't she just BITE THEM OUT herself at home?Lynn

To: From: drbradythevillagedoctor (DOT) hrcoxmail.comDate: Thu,

29 May 2008 09:31:43 -0400Subject: RE:

virtual visit content

Lynn,

One of the constant

difficulties I havewith living and working in the same neighborhood is whether

to do something Iotherwise wouldn’t do just because I know somebody. In

fact, yesterday Ihad a friend call up and ask if she could come in to get

sutures removed becauseshe did not want to drive 5 miles to see her regular

doctor. I think this is aslippery slope. In this case, I told the friend I

would have to see her andhave an “established” relationship in

order to take out thestitches—note: I likely would have done it without

question if she hadcome to our house and asked as a friend. My point is that

what would you do ifyou did not know this patient as well? Would a VV work for

you then? If not,then you should see her and follow-up just as you would if

you did not know heras well. Then again, I’m pretty mean to my friends

J

RE:

virtual visit content

Tim, , Neva-Thanks for the input, I think

you guys are probably right.I am just wondering however, if I feel

uncomfortable about doing it justbecause it's a new way to do it and I haven't

done it that way before, orbecause of the flags that you guys mention. I am looking at Bachman's EMR posts and he renews/increases doses ofritalin scripts all the time via VV, and that seems reasonable to me. Theextension being, I do know this patient well enough - quite well- so that Iknow substance abuse domestic violence depression (but perhaps not anxiety) arenot playing a part, and I am not concerned about abuse of thismedication. She dislikes taking medications, all and any. Her worrywas that after she

becomes jet lagged she is not at the top of her game forfocus in terms of

giving the talks, being on a panel, schmoozing duringschmoozy events etc. -

seems reasonable to me.I don't know though, I think I will see her in person,

but I could justdo the VV. Jean-documenting psych diagnosis- does that

mean one could never do a VVfor a psych diagnosis, missing too much human

element?Interesting, I will keep thinking about it and probably have her come

in today.Lynn

Change the world with e-mail. Join

the i’m Initiative from Microsoft.

Give to a good cause with every e-mail. Join the i’m Initiative from Microsoft.

[Guest guest]

NIce timing. A month ago or so I had some long phone calls I documented and some

clinical care through emails and submitted the claims for them to see how my

insurance companies would respond. They all were denied by insurance, until

today. One of the email services (VV basically) was finally paid... I got a $1

payment from the insurance company! Patient is to pay $20. Too bad I

couldn't charge for a 99211, get paid more and patient wouldn't have a copay.

But that would mean more money out of the insurance companies' coffers, so it's not

acceptable ... I apologize for any sarcasm but the whole system is just plain stupid

and frustrating.TimOn

Thu, May 29, 2008 8:15 pm EDT, gthomson@... wrote:

On Thu, May 29, 2008 9:53

am EDT, LynnHo wrote:I suspect more of usmight

do VV if we coud get reimbursed.. the ethics seem fine since we know ourpatients so well all the best geord

But - isn't it one of the characteristics of ourpractices that we do know our patients exceedingly well (sometimes more than we

wantto) and shouldn't we able to use that knowledge in how we treat them and

the methodsthat we employ to treat them? Somehow it doesn't seem like a bad

thing to me to usewhat I know from past history when trying to make a

treatment decision, it isn'tabusive and doesn't seem to be crossing a

boundary. I don't know this personsocially at all so luckily that doesn't

figure into the mix. I am still bemused. Money may figure into the mix for

her a little - time out of work, gas, cost of VVis less, she is paying by HSA.

Plays into it a little for me too - I certainlywould get paid more for a

traditional OV and have the space....so...doesthat mean for the

finances I should think more about asking for the visit? Inthe case of

the sutures below, I think it is crossing a line in that (if showing upat your

house) your friend is asking you to work for free, which isn't really right.

Can't she just BITE THEM OUT herself at home?Lynn

To: From: drbradythevillagedoctor (DOT) hrcoxmail.comDate:

Thu,29 May 2008 09:31:43 -0400Subject: RE:

virtual visit content

Lynn,

One of the constantdifficulties I havewith living and working in the same neighborhood is

whetherto do something Iotherwise wouldn’t do just because I know

somebody. Infact, yesterday Ihad a friend call up and ask if she could

come in to getsutures removed becauseshe did not want to drive 5 miles

to see her regulardoctor. I think this is aslippery slope. In this case,

I told the friend Iwould have to see her andhave an

“established” relationship inorder to take out thestitches—note: I likely would have done it withoutquestion if she

hadcome to our house and asked as a friend. My point is thatwhat would

you do ifyou did not know this patient as well? Would a VV work foryou

then? If not,then you should see her and follow-up just as you would ifyou did not know heras well. Then again, I’m pretty mean to my

friendsJ

RE: virtual visit content

Tim, , Neva-Thanks for the input, I

thinkyou guys are probably right.I am just wondering however, if I

feeluncomfortable about doing it justbecause it's a new way to do it and

I haven'tdone it that way before, orbecause of the flags that you guys

mention. I am looking at Bachman's EMR posts and he renews/increases

doses ofritalin scripts all the time via VV, and that seems reasonable to me. Theextension being, I do know this patient well enough - quite well- so that

Iknow substance abuse domestic violence depression (but perhaps not anxiety)

arenot playing a part, and I am not concerned about abuse of thismedication. She dislikes taking medications, all and any. Her worrywas that after shebecomes jet lagged she is not at the top of her game

forfocus in terms ofgiving the talks, being on a panel, schmoozing

duringschmoozy events etc. -seems reasonable to me.I don't know

though, I think I will see her in person,but I could justdo the VV. Jean-documenting psych diagnosis- does thatmean one could never do a

VVfor a psych diagnosis, missing too much humanelement?Interesting, I will keep thinking about it and probably have her comein

today.Lynn

Change the world with e-mail. Jointhe i’m

Initiative from Microsoft.

Give to a good cause with every e-mail. Join the

i’m Initiative from Microsoft.

---------------------------------------- Malia, MDMalia

Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton

Square MallFairport, NY 14450 (phone / fax)www.relayhealth.com/doc/DrMaliawww.SkinSenseLaser.com--

Confidentiality Notice --This email message, including all the attachments, is

for the sole use of the intended recipient(s) and contains confidential information.

Unauthorized use or disclosure is prohibited. If you are not the intended recipient,

you may not use, disclose, copy or disseminate this information. If you are not the

intended recipient, please contact the sender immediately by reply email and destroy

all copies of the original message, including attachments.----------------------------------------

[Guest guest]

Could we have predicted this response?NIce timing. A month ago or so I had some long phone calls I

documented and someclinical care through emails and submitted the claims for

them to see how myinsurance companies would respond. They all were denied by

insurance, untiltoday. One of the email services (VV basically) was finally

paid... I got a $1payment from the insurance company! Patient is to pay $20. Too bad Icouldn't charge for a 99211, get paid more and patient wouldn't have

a copay. But that would mean more money out of the insurance companies'

coffers, so it's notacceptable ... I apologize for any sarcasm but the whole

system is just plain stupidand frustrating.TimOnThu, May 29, 2008 8:15 pm EDT, gthomson@... wrote:

On Thu, May 29, 2008

9:53am EDT, LynnHo wrote:I suspect more of usmightdo VV if we coud get reimbursed.. the ethics seem fine since we

know ourpatients so well all the best geord

But - isn't it one of the characteristics of ourpractices that we do know our patients exceedingly well (sometimes more than wewantto) and shouldn't we able to use that knowledge in how we treat them

andthe methodsthat we employ to treat them? Somehow it doesn't seem

like a badthing to me to usewhat I know from past history when trying to

make atreatment decision, it isn'tabusive and doesn't seem to be

crossing aboundary. I don't know this personsocially at all so luckily

that doesn'tfigure into the mix. I am still bemused. Money may figure

into the mix forher a little - time out of work, gas, cost of VVis less,

she is paying by HSA. Plays into it a little for me too - I certainlywould get paid more for atraditional OV and have the

space....so...doesthat mean for thefinances I should think

more about asking for the visit? Inthe case ofthe sutures below, I

think it is crossing a line in that (if showing upat yourhouse) your

friend is asking you to work for free, which isn't really right.Can't she just

BITE THEM OUT herself at home?Lynn

To: From: drbradythevillagedoctor (DOT) hrcoxmail.comDate:Thu,29 May 2008 09:31:43 -0400Subject: RE: virtual visit content

Lynn,

One of the constantdifficulties I havewith living and working in the same neighborhood iswhetherto do something Iotherwise wouldn’t do just because I

knowsomebody. Infact, yesterday Ihad a friend call up and ask if

she couldcome in to getsutures removed becauseshe did not want to

drive 5 milesto see her regulardoctor. I think this is aslippery

slope. In this case,I told the friend Iwould have to see her andhave an“established” relationship inorder to take out

thestitches—note: I likely would have done it withoutquestion if

shehadcome to our house and asked as a friend. My point is thatwhat wouldyou do ifyou did not know this patient as well? Would a VV

work foryouthen? If not,then you should see her and follow-up just

as you would ifyou did not know heras well. Then again, I’m pretty

mean to myfriendsJ

-----Original

Message-----From: [mailto: ]OnBehalf Of LynnHoSent:

Thursday,May29, 2008 8:54AMTo:practiceimprovement1 Subject: RE: virtual visit content

Tim, , Neva-Thanks for the input, Ithinkyou guys are probably right.I am just wondering however, if Ifeeluncomfortable about doing it justbecause it's a new way to do it

andI haven'tdone it that way before, orbecause of the flags that

you guysmention. I am looking at Bachman's EMR posts and he

renews/increasesdoses ofritalin scripts all the time via VV, and that

seems reasonable to me. Theextension being, I do know this patient well

enough - quite well- so thatIknow substance abuse domestic violence

depression (but perhaps not anxiety)arenot playing a part, and I am not

concerned about abuse of thismedication. She dislikes taking

medications, all and any. Her worrywas that after shebecomes jet lagged

she is not at the top of her gameforfocus in terms ofgiving the

talks, being on a panel, schmoozingduringschmoozy events etc. -seems reasonable to me.I don't knowthough, I think I will see her in

person,but I could justdo the VV. Jean-documenting psych

diagnosis- does thatmean one could never do aVVfor a psych

diagnosis, missing too much humanelement?Interesting, I will keep

thinking about it and probably have her comeintoday.Lynn

Change the world with e-mail. Jointhe i’mInitiative from Microsoft.

Give to a good cause with every e-mail. Join thei’m Initiative from Microsoft.

----------------------------------------

Malia, MDMaliaFamily Medicine & Skin Sense Laser6720

Pittsford-Palmyra Rd.PerintonSquare MallFairport, NY 14450 (phone / fax)www.relayhealth.com/doc/DrMaliawww.SkinSenseLaser.com--Confidentiality Notice --This

email message, including all the attachments, isfor the sole use of the

intended recipient(s) and contains confidential information.Unauthorized use

or disclosure is prohibited. If you are not the intended recipient,you may not

use, disclose, copy or disseminate this information. If you are not theintended recipient, please contact the sender immediately by reply email and

destroyall copies of the original message, including attachments.----------------------------------------

[Guest guest]

Lynn,

Sorry for the late post on this…

I agree that this situation is not

appropriate for a VV as it doesn’t fit the usual situation of ADD, involves the

potential use of a controlled substance. I also agree that any newly

prescribed controlled substance deserves an office visit. Refills of that controlled

substance are fine when the pt is stable on it, in my opinion.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

www.PinnacleFamilyMedicine.com

From: [mailto: ] On Behalf Of Lynn Ho

Sent: Thursday, May 29, 2008 6:54

AM

To:

practiceimprovement1

Subject: RE:

virtual visit content

Tim, , Neva-

Thanks for the input, I think you guys are probably right.

I am just wondering however, if I feel uncomfortable about doing it just

because it's a new way to do it and I haven't done it that way before, or

because of the flags that you guys mention.

I am looking at Bachman's EMR posts and he renews/increases doses of

ritalin scripts all the time via VV, and that seems reasonable to me. The

extension being, I do know this patient well enough - quite well- so that I

know substance abuse domestic violence depression (but perhaps not anxiety) are

not playing a part, and I am not concerned about abuse of this

medication. She dislikes taking medications, all and any. Her worry

was that after she becomes jet lagged she is not at the top of her game for

focus in terms of giving the talks, being on a panel, schmoozing during

schmoozy events etc. - seems reasonable to me.

I don't know though, I think I will see her in person, but I could just

do the VV.

Jean-documenting psych diagnosis- does that mean one could never do a VV

for a psych diagnosis, missing too much human element?

Interesting, I will keep thinking about it and probably have her come in today.

Lynn

Change the world with e-mail. Join the i’m Initiative from Microsoft.