Getting Naked on the Internet: What does the law say? (Telemedicine and Cyber Security)

Telemedicine and Cyber Security

The Health Information Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of your personal health information (PHI). HIPAA includes several rules and provisions that set guidelines and requirements for the administration and enforcement of HIPAA. The relevant ones for the exchange of PHI in the digital cyberspace are the Privacy Rule¹, the Security Rule², and the aptly named Health Information Technology for Economic and Clinical Health (HITECH) Act³.

Telemedicine is a burgeoning field of medicine that incorporates digital technology such as electronic health records (EHR), information sharing, and videoconferencing to enhance the interaction between physicians and their patients, and ultimately, improve the delivery of healthcare. Having been a plastic surgeon for several years now, I’m all too familiar with meeting people at social events, and immediately getting bombarded with intrusive and unusual questions and requests as soon as my chosen profession is ousted. Sure, it’s unlikely that a woman will disrobe and expose herself in front of me and my wife at a friend’s dinner party, but get us into an online “private” videoconference call, and who knows what body parts will make an abrupt entrance into the conversation. Physicians must approach with caution, says American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) President Stephen S. Park, M.D. in a recent article⁴. But, for me and most physicians I know, I feel like the cat is already out of the bag. Considering the amount of texts, emails, online chats, phone conversations over internet and satellite lines, and selfies of both pre- and post-op patients I’ve been privy to, I’m sure I’ve already broken too many laws, and completely disregarded the good doctor’s advice. The truth is, though, that we’ve only begun to scratch the surface.

Telemedicine may involve the electronic exchange of PHI which is protected under HIPAA law. Security considerations with telemedicine involve making sure unauthorized third parties cannot eavesdrop on or record a videoconferencing session where sensitive PHI is transmitted seamlessly, and unfortunately, innocently. Recently, a monumental data breach at one of the nation’s largest insurance providers has spurred a bipartisan political effort to reexamine HIPAA as it relates to telemedicine, possibly adding costly and cumbersome requirements to encrypt EHR data⁵. Additionally, a recent report done by BitSight Technologies, a cyber security risk analysis and management firm, found that healthcare and pharmaceutical companies ranked the lowest among the four industry categories studied6. Suffice it to say, people are taking heed of this emerging new threat.

The aforementioned laws, rules, and regulations guide the generation, maintenance, and implementation of telemedicine HIPAA compliance. We must be cautioned, though, that HIPAA compliance does not necessarily equate to actual cyber security, and that simply meeting standards set forth in these regulations may not be enough. As more public attention and scrutiny rise to the forefront of media exposure, look for the healthcare industry to take the cyber security threat much more seriously.

Daniel Kaufman, MD
DISCREET PLASTIC SURGERY

Bibliography
1. http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/
2. http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/
3. http://www.healthit.gov/policy-researchers-implementers/health-it-legislation-and-regulations
4. http://cosmeticsurgerytimes.modernmedicine.com/cosmetic-surgery-times/news/cosmetic-virtual-consult
5. http://medicaleconomics.modernmedicine.com/medical-economics/news/senate-review-hipaa-security-medical-records-light-anthem-breach
6. http://info.bitsighttech.com/bitsight-insights-industry-security-ratings-vol-4-rc

My breasts are cold!!

“My breasts are cold!!” said a patient of mine in her last postop visit. We did a breast augmentation with saline implants just a few weeks ago, and her postop recovery has been smooth and uneventful. It’s been an unusually cold winter this year, with Arctic blasts and heavy snowstorms, so this kind of complaint shouldn’t be surprising. I guess my southern colleagues and readers have already tuned out, I don’t remember my plastic surgeon buddies in Miami complaining about any snow, but they don’t only do breast implants in Miami you know…
Cosmetic plastic surgery, being elective in nature, is always risky business. We surgeons take the utmost effort to warn our patients about all reasonable risks and alternatives to our various procedures. But, “your breasts might feel cold when it’s cold outside” is usually not part of my consultation. In the grand scheme of things, unless you find yourself in the perfect storm of running a saline implant breast augmentation private practice in Alaska, cold breasts are probably down at the bottom of your risk list. But it is an interesting phenomenon that happens due to the specific heat of water – greatest of all substances known to man. Water, which is for all intents and purposes the major component of saline, can absorb lots of energy, and thus, is hard to heat and hard to cool. Consequently, when it’s cold outside, your saline breast implants are going to get cold. And the bigger the implants, the colder you’ll be. Now once they get cold, it’ll take just as much time in warm weather, indoors or outdoors, for them to warm up.
I find it hard enough to go thru the list of relevant risks as it is, but I suppose as long as we have cold weather and saline breast implants, cold implants are a relevant risk. Now, when I mention it in my consultations, I get more chuckles from my patients than anything else. So, I suppose that little bit of comic relief is a good effect in what is, in the least, an arduous process of informed consent. Now back to all this cold winter weather, I suppose it’s just global warming….

Dr. Daniel Kaufman
Discreet Plastic Surgery

Everybody Needs a Marijana – Marketing of Medical Practices in the Information Age

A young doctor asked me the other day how new patients, excluding patients who were referred by other doctors or previous patients, find their way to my practice. We were hanging out in a crowded party in a loud room so I couldn’t elaborate too much, but I managed to belt out one word that would sum it up: Marijana. That is actually the name of the Director of Marketing, Advertising, and Web Presence in my plastic surgery practice – Discreet Plastic Surgery. If you ask her, she’d probably tell you that she NEVER expected to be working for a plastic surgeon. But if you ask me, she’s an integral part of our practice, and should be so for all doctors, especially those in private practice.

As I finished up my training in plastic surgery and went into private practice, I soon realized that free market forces are constantly working to edge me out of the market. Competition is fierce, and people in large markets have many choices in obtaining plastic surgery, as they do in other professional services. A few print ads and radio talk shows later, I further realized that in today’s world, the majority of marketing dollars in a doctor’s practice must be geared towards their internet presence. Even your print ads eventually all end up as PDF files in the “media” section of your website – funny that people still put so much weight on how many times their doctor shows up in “People” magazine. I guess a comment about whether or not Kim Kardashian had a Brazilian butt lift really makes you an expert…

So where do I get started? …you ask. Easy. Just like most questions asked in life these days, the simple answer is: “Google it!” I have no financial disclaimer here so “Bing it” or “Yahoo it” works just as well, and is in fact, recommended as well. Seeing what internet content is out there associated with your name, an old article that you published, a hospital website listing you as a physician, a yellow pages or rate-a-doc style website, or any other peculiar locations, is of paramount paramount. In our office, we started doing our search engine optimization (SEO) by calling each of these websites and online listings and getting all the details right, including linking to our own website. From there, you will soon see how rapidly you’ll be approached from different directions regarding potential help. There’s a huge market for this work, and it rarely goes unnoticed.

As in any rapidly progressing internet-based enterprise, getting someone on your side who knows the tricks of the trade is the key to success. Sure, you can outsource all of these services away, and many do. But, when you add in all the costs of internal office marketing, advertising in a wide gamut of different media, and other costs of brand development, you have a full-time job on your hands. Please beware doctors, stick to doing what you do best. Get an expert on your side. Get yourself a Marijana!

Dr. Daniel Kaufman
Discreet Plastic Surgery

Thank GOD for the Sabbath

It’s Monday morning, and I can feel the coming pressures of the impending week ahead. Don’t get me wrong, I love what I do. But, boy, this job can get to you. My week has already started yesterday with a few office-based procedures at a dermatologist buddy’s of mine, some of my own follow-ups, a little down-time in the office the catch up with paperwork, but it’s Sunday….so we’re all relaxed. Today, I gotta see more patients in the office, do surgery in the hospital, and plan out the rest of the week’s schedule in my ambulatory surgery center, all while trying to handle dozens of emails and phonecalls. Tuesday, Wednesday, and Thursday continue with much of the same fanfare, with interwoven moments of joyous redemption in the OR doing actual surgery and perfecting my craft. Friday, just around the corner, is still a grueling operative marathon of a day, but I know that Saturday, The Sabbath, is almost here. A day of rest. A long-awaited, well-deserved day for no work at all. Well, technically, having discussed this with several Jewish religious authorities, you can do work, just not the kind of work that makes you money.

Recently, I read an article in Plastic Surgery News about the occupational hazards of surgery. Sure, I too suffer from neuropathic pain due to a few bulging discs, and have been stuck in the OR more times than I care to admit, but it is the mental and emotional toll the job exerts on you that struck a cord with me. Being an entrepreneur physician, which most private practice plastic surgeons are, is a physically and mentally taxing occupation. Practicing in an extremely competitive NYC market only adds to the daily pressures of doing so much. In the article, featured successful surgeons all seem to agree that taking at least one day a week off from work, in one way or another, has been extremely helpful to their professional and personal growth and stability. How does it happen that we all “need” this day off? Could there be a common thread to this seemingly universal benefit?

It goes back many thousands of years. When that famous dude Moses climbed up on Mount Sinai in the ancient land of Canaan. As the story goes, 40 days and 40 nights later he came down with 2 stone tablets that GOD gave him, and on them were written the 10 most commonsense and most useful laws that humanity has probably ever subscribed to. You guessed it, the 10 Commandments. Yea, it’s right there. Number 4: Respect the Sabbath, to keep it holy. Even GOD told us to take a day off. And that was way before emails, telephones, and office-based ambulatory surgery.

Speaking as a son of immigrant workaholics, I have been known to just work 24/7. And after years of residency, research, fellowships, and more, the years have taken their toll. It was noticeable to my loved ones, but so was the change that occured fairly recently in my life. These past few years, I’m glad to say, have been a breath of fresh air, as I’ve dictated the schedule and designated 1 day a week, the Sabbath, to do nothing at all. Since I can’t just sit still, I always find some activity to do on my Saturdays. Time with family, working out, a movie here, a walk in the park there, whatever! I just don’t do work…. Thank GOD for the Sabbath.

Dr. Daniel Kaufman,
Discreet Plastic Surgery

Dealing With Pain As A Physician

I admit it! I was channel surfing between CSPAN and the Lehrer News Hour…

…and not so accidentally, stumbled upon one of the Kardashian sisters getting some sort of “minimally-invasive” facial rejuvenation procedure in a posh Miami medical office. The procedure was fairly routine, but what really caught my eye was the incredible amount of pain this young lady was willing to endure. I reflected back to my training in Plastic Surgery and General Surgery, and realized how little attention we paid, as a community, to pain.

I often find myself bringing up to my patients a “Postop Pain Plan”, only to find them caught in a moment of bewilderment. “I thought I’m not gonna feel anything”, I hear sometimes. In recent years, the increasing dumbing down of medicine and plastic surgery in pop culture media, has some people denying the existence of pain after surgery. Furthermore, of the ones that do expect some postop pain, few expect to define a specific plan for managing that pain. Albeit, they come to me with much greater concerns about their appearances, but nonetheless, the change in appearance comes at a price.

As plastic surgeons, we need to address the issue of pain in a more sincere and serious manner. We need to stop painting rosy pictures and admit to our patients that surgery is painful, that what they are asking us to do is, unfortunately and necessarily, inflict pain. We need to implement a Pain Plan. A simple, lay-term, and effective protocol addressing individual patients’ postop pain control needs. We also need to document the plan and incorporate it into our informed consent plan.

As patients, we need to inquire within. Ask our surgeons about the nature of the pain, the duration, the severity. We need to request a specific plan, and decide preoperatively how to manage the pain. But most importantly, we need to stop believing everything we see and read in the lay media. We need to realize that elective surgery is surgery nonetheless. It hurts, and we ask for it. So let’s treat it like the serious business it is.

Dr. Daniel Kaufman
Discreet Plastic Surgery

Pain Control after Cosmetic Surgery

I admit it! I was channel surfing between CSPAN and the Lehrer News Hour, and not so accidentally, stumbled upon one of the Kardashian sisters getting some sort of “minimally-invasive” facial rejuvenation procedure in a posh Miami medical office. The procedure was fairly routine, but what really caught my eye was the incredible amount of pain this young lady was willing to endure. I reflected back to my training in Plastic Surgery and General Surgery, and realized how little attention we paid, as a community, to pain.

I often find myself bringing up to my patients a “Postop Pain Plan”, only to find them caught in a moment of bewilderment. “I thought I’m not gonna feel anything”, I hear sometimes. In recent years, the increasing dumbing down of medicine and plastic surgery in pop culture media, has some people denying the existence of pain after surgery. Furthermore, of the ones that do expect some postop pain, few expect to define a specific plan for managing that pain. Albeit, they come to me with much greater concerns about their appearances, but nonetheless, the change in appearance comes at a price.

As plastic surgeons, we need to address the issue of pain in a more sincere and serious manner. We need to stop painting rosy pictures and admit to our patients that surgery is painful, that what they are asking us to do is, unfortunately and necessarily, inflict pain. We need to implement a Pain Plan. A simple, lay-term, and effective protocol addressing individual patients’ postop pain control needs. We also need to document the plan and incorporate it into our informed consent plan.

As patients, we need to inquire within. Ask our surgeons about the nature of the pain, the duration, the severity. We need to request a specific plan, and decide preoperatively how to manage the pain. But most importantly, we need to stop believing everything we see and read in the lay media. We need to realize that elective surgery is surgery nonetheless. It hurts, and we ask for it. So let’s treat it like the serious business it is.

Daniel Kaufman, MD
Discreet Plastic Surgery

The Desirable Duopoly Of Doctor & Patient

Ask any corporate tycoon what the toughest business structure to beat is, and surely they’ll tell you it’s a duopoly – two co-dominant institutions presiding over a market, essentially cutting out all other competitors or outside influences.

Are the two big players friends or foes? One can make a case for both. Republicans and Democrats, Ford and GM, and even Magic and Bird – all dominant duopolies that symbiotically blasted and outlasted their competition. That is, of course, until the third party showed up – the new kid on the block. Traditionally, the third party, or its potential to arise from obscurity into the limelight, has been a great offsetting entity to the status quo of the omnipotent duopoly. Just ask the Tea Party, Chrysler, or Michael Jordan. These entities, the consummate “start-ups”, all served to destabilize the ruling double-team, and thus helped democratize whatever industry they were involved in. As it turns out, this destabilization, a requisite force of the free market, serves to wipe up the cobwebs of industry stagnation, and create new avenues and vectors for ingenuity and prosperity. But not all third parties share in this benevolent intention. Some third parties have done the exact opposite.

It might sound like blasphemy coming from a libertarian, whose inherent belief system is governed by the ultimate aspiration for democratization and equalization of opportunity; but, we need to reinstate the desired duopoly in medicine: the Doctor and Patient. Since the dawn of humanity medicine has always been a two-person dance. An elegant, professional, distinctly intimate interaction guided by altruism and professionalism on the doctor’s part and self-preservation on the patient’s part. This exchange of privileged professional services, the provision of healthcare from doctor to patient, does involve, however, an economic exchange as well. This is where the vultures and hyenas of society smell the blood. They’ve noticed something: an opportunity for profit and control. Insidiously, the third party of medicine, be it commercial healthcare insurance companies or government-run programs, has been let into the doctor’s office, and predictably, has done nothing to improve quality or cost of healthcare. Third party payers have so entrenched themselves into the healthcare system, that they no longer serve as a typical “insurance” entities, but now serve as all-powerful administrators and “approvers” of medical care. The healthcare insurance industry is no longer used only for coverage of catastrophic events, but is now “approving” CT scans, X-rays, mammograms, and blood work, to name just a few. They’ve also been deemed authoritative enough to decide whether a procedure is “medically necessary”, all without ever meeting the patient. Now, how does this make any sense?

Patients need to realize that their healthcare insurance carrier is not in the business of caring – they are in the business for profit. Corporate medicine, that is healthcare controlled and administered by centralized, detached, omnipotent bureaucrats, ultimately leads to a frustrated and powerless workforce – the doctors themselves. Ultimately, the very people delivering healthcare are driven out of the business, both materially and spiritually. Now don’t get me wrong, one mustn’t blame the corporation for being a corporation. It is, after all, acting in its own best interest and well within its moral imperative. Profit drives it, and that is good. But the ballooning administrative control that third party payers have achieved has hardly contributed to an improvement in the quality or diminution of the cost of healthcare. In fact, this burdensome control only siphons money out of the system, away from doctors and nurses and towards middlemen and pencil-pushing bureaucrats. The federal government’s solution to the problem, the Center for Medicare and Medicaid Services (CMS), has an even worse track record than private entities. Medicaid and Medicare reimbursement fees are so abysmal (perpetually controlled by the flawed Sustainable Growth Rate (SGR) formula) that many doctors can’t afford to take care of those patients, ultimately decreasing access to quality healthcare. Insolvency is all but an inevitability, and sooner or later, the system is headed for complete collapse. Dr. Milton Friedman once reiterated: “there’s no free lunch” – to mean that nothing in this world is for free. Not any product and not any service. Sadly, medicine, as we know it in 21st century America, has become the last bastion of serfdom. A virtual expectation that, at times, the doctor work for free. It is, after all, a profession born of altruism and compassion….

So, how do we fix the problem? Let us reestablish basic principles. Let us return medicine back to its free market roots. But let’s not ask narcissistic, corrupt, temporary politicians to do this by legislative fiat or decree. Let’s just do it on our own. Let us not accept the status quo of the insurance healthcare fraud. Let us unshackle ourselves from their administrative hegemony and price point controls. Let us be sovereign, willing agents of the free market. Let us rise and fall by the merits of our professional actions and demeanor. Let us educate and empower our patients to act as their own advocates and take the fight to their insurance carriers. Let us get all the pretenders and imposters out of the doctor’s office. Let’s restore the fiduciary relationship between doctor and patient, and get back to the desirable duopoly.

Dr. Daniel Kaufman
Board-Certified Plastic Surgeon

Buyer’s Remorse In Plastic Surgery

“OMG!! what did I do?! …

I must be crazy to do this!” said my patient only hours after her tummy tuck. She was in some pain and distress, as the anesthesia was wearing off, and began a tirade of self-disparaging statements reflecting all her worst fears and anxieties about the surgery.

I stopped what I was doing, and sat down with her on the recovery room bed to calm her down. It’s amazing how comfortable those recovery room beds are…and the patients seem to really like it when I take my time to explain and review things with them. She did fine after some pain meds and a little small talk, and on her 1 week postop visit, was happy as a clam with her new flat tummy. And that’s when I realized just how common “buyer’s remorse” is in plastic surgery.

Plastic surgery, especially cosmetic surgery, is elective. That means that it isn’t surgery that you need, but surgery that you want. Oftentimes, people overlook the pain and discomfort that is inherent to any surgery. Although, most people who have had plastic surgery, and, gladly, the vast majority of my patients, will say that they are happy with the decisions that they made, a certain segment of the patient population will always have difficulties in adjusting to the postoperative demands, no matter how carefully they were selected by the surgeon or how well surgery was performed.

Every plastic surgeon hones his/her patient selection skills over years of education, training, and practice. The goal of every plastic surgery practice is to only have happy patients. As this is an ideal that will probably never be reached, we surgeons must realize that some of our patients will be unhappy, at various stages of the postoperative period. Those patients need special attention, understanding, and a compassionate review of clinical details. They must be empowered, and be actively involved in the procedures of postoperative recovery. It’s also important to give your patients options as to colleagues who may serve as second opinions.

As a patient, if you find yourself unhappy with the results of a cosmetic procedure, take a deep breath and fret not, as it depends on the timing. Most early remorse cases are due to the unexpected, and probably poorly managed, pain and discomfort. Moreover, remorse is clearly correlated with incidence of complications of surgery. In the case of the former, simple and more precise pain control and behavior modification is all that is needed. In the latter, both preoperative and postoperative miscommunication between patient and surgeon is the usual contributing factor. As difficult as it is to do, as a patient you must communicate with your surgeon, even if you believe that he/she is responsible for a poor outcome.

We must realize that we can all end up being the patient who regrets having plastic surgery. It can happen if you’re the best patient, or if you have the best doctor. What’s important for both of you is to keep the lines of communication open so that proper, just, and adequate resolution is reached. No patient should abandon his/her doctor, and the opposite is just as true.

Dr. Daniel Kaufman
Board-Certified Plastic Surgeon

Surgery for Free???

“I want my surgery for free” my friend tells me… Just how many times have we (plastic surgeons) heard that before?

Plastic Surgery Costs

Obvious to me, that meant that my surgical fee will be waived. Oddly enough, for my friend, an intelligent person in her own right, this meant something completely different. She thought the entire surgery was actually for free. After a slightly awkward moment, I asked her if she knew anything about surgical fees and healthcare costs. To my astonishment, she had absolutely no idea. Being the consummate educator that I am, I decided to use this conversation as a teachable moment to instruct my friend about the economics of plastic surgery. Delving further into the topic, I found that one of the most popular Google searches regarding plastic surgery is plastic surgery costs. Frankly speaking, plastic surgery cost is so paramount, that if you listen to some of my friends and colleagues at our trade meetings, it seems that cost is so often the only determinant factor indicating performance of the surgery or not. In light of these glaring facts, here’s a brief primer on the topic.

In performing cosmetic and plastic surgery there are three basic fees that must be considered:

1) the surgical fee,

2) anesthesia fee, and

3) facility fee and materials costs.

The surgical fee is the simplest to understand, and frankly the easiest to negotiate. Basically, it is what the surgeon takes home. From this fee the surgeon pays for all the costs incurred in becoming and being a surgeon. This may included school loans, malpractice insurance fees, office rent or mortgage, staff salaries, and other costs, to name just a few. The surgical fee is determined by the judgement of one person alone, the surgeon. Depending on his/her practice expenses, he/she determines the fee, and is ultimately the one able to negotiate it. More often than not, when plastic surgery fees are negotiated and consequently lowered, the change in price comes from this portion of the overall cost of the surgery.

The anesthesia fee, one often overlooked by many, is the hardest one to negotiate. Basically, it is what the anesthesiologist takes home. This fee may depend on several factors, including the nature of the surgery, the nature of the anesthesia administered (local, regional, or general), the time of surgery, and other technical issues as well. The anesthesia fee is usually determined ahead of time between the surgeon, anesthesiologist, and/or the surgical facility, and thus, it is usually not subject to much negotiation.

The facility fee, also one that is difficult to understand, generate, and consequently, negotiate, is composed of many elements that may not be readily seen. These include the costs of nursing care, medical materials and drugs used during surgery, and other costs of running an ambulatory surgery facility. Again, this is usually a fixed price that most commonly is not subject to negotiation, especially with the operating surgeon. Additional material costs may be added, for example, when using breast or facial implants or other materials related to specific cosmetic surgery.

During your plastic surgery consultation, when the time comes to talking about the costs of surgery, it is always worthwhile to ask about each one of these fees, as some may be negotiable. The fact that cosmetic surgery is not covered by medical insurance, and is thus a luxury item paid for by discretionary income, has actually contributed to it becoming so affordable and within reach to larger segments of the population. Plastic surgery is one of the last vestiges of the healthcare industry where free market forces act to shape the economic transactions between producer (doctor) and consumer (patient). The more knowledgeable and informed you are, the better the chances you’ll get a better product and bigger bang for your buck. A cautionary note, however, is that in plastic surgery, as in most industries, you get what you pay for. Your quality assurance is the doctor’s credentials and bedside manner, their specialty-specific board certification, and surgical center accreditation. If all of those factors are satisfactory, then feel free to shop around. And remember, an educated consumer gets the best deal.

By Daniel Kaufman, MD – Board-Certified Plastic Surgeron NYC and Brooklyn