Viewpoint Volume 2 Issue 1 Spring Equinox 2016 by VerdenGroup

CONTENTS Volume 2, Issue 1 - SPRING EQUINOX EDITION 2015

Welcome

Industry News

Art of . . .

Planting the Seeds for Innovation

Next Level Med Tech: From Sci-Fi to Reality

Spring is in the air and innovation is all around us. As we watch sprouts popping up from the earth, our thoughts turn to the constant changes and recent advances in the healhcare industry. Susanne explores the many paths to innovation.

Heidi explores exciting advances in medical technology ripped from the screens and pages of Science Fiction. From holograms to bionics and a global contest to develop a Star Trek-style tricorder, it's clear that the future is now.

Innovation How do you define innovation? It turns out that the clearest definition is simply "change". Innovation comes in all shapes and sizes and we've tried to capture that in this issue. We hope these stories inspire you to action in your own life and work.

Big Impacts

Inquiry

Point Of View

Payer Innovations

Telemedicine

Physicians Are Not All Equal

Consumers demand access to information and data and Payers are giving them what they want. Digital coaches, mobile apps, and more. The result? Patients are taking charge of their health like never before.

Telemedicine is here. and it's here to stay. Are you ready? Renee Hartleib examines the benefits and advantages, as well as best practices to stay on the right side of potential liability.

Guest columnist & Verden Group Associate Robert Goff examines the potential for Core Quality Measures to drive innovation and change in physician services.

Pro Tips

Check Up

Spotlight

Simple Tech Tools for your Practice

EMR Technology

Want to improve delivery of care while saving time, money and paper? Jose walks you through the tips and tech tools you should be using now.

EMRs are now the norm and more change is coming. Guest columnist & Verden Group Associate Chip Hart explains why embracing change is the only way to move forward.

We're shining our spotlight on three innovators: Dr. Gautum Gulati, Brandon Betancourt, and Dr. Todd Wolynn., to highlight how innovation comes in many guises.

HR Matters

Payer News

Pondering how to outsource your HR? Read about the perks and pitfalls of using a professional employer organization. Our PEO primer is packed full of tips to help you decide.

How are Value Based Payments (VBPs) working for Primary Care poviders? Susanne walks us through the specific details of Blue Cross Blue Shield's growing Blue Distinction programs.

Frontlines

Overheard

Susanne interviewed Brandon Betancourt of Pediatric Inc & Salud Pediatrics about the unusual but innovative ways they're increasing patient engagement and outreach at the small, independent practice level.

Whether we heard it at the water cooler or on the conference trail, Overheard brings you snippets from interesting conversations on the hottest topics in health care.

Connect

NCQA News

Connect with us online & in person. Here you'll find details on the key events and conferences that we'll be attending this Spring and handy links to all of our media streams.

Auto-credit: the new PCMH Pre-Validation Program. Julie Wood walks you through what it is, what it costs, and how to get the most out of it for your practice.

TEAM AND CONTRIBUTORS

Susanne Madden

Jose Lopez

RenĂŠe Hartleib

Scott Hodgson

Heidi Hallett

Chip Hart 3

Julie Wood

Robert Goff

Abou t t h e i m ages i n t h i s i ssu e: Th r ou gh ou t th e pages of ViewPoin t, you wil l fin d pictu r es of n atu r e tak en by ou r team an d ou r cl ien ts. Som e ar e fr om per son al tr ips, oth er s wer e tak en on bu sin ess tr ips an d som e wh en we wer e togeth er as a team .

Th ese im ages r em in d u s of th e ever -ch an gin g l an dscape of th e h eal th car e in du str y an d in spir e u s to adapt to an d gr ow in th e m idst of th at con stan t ch an ge. If you 'd l ik e to see m or e of th e ph otogr aph y th at in spir es u s, pl ease visit th e Gr ap h i c Vi ew p oi n t section of ou r website.

? W ELCOME ? Spring has arrived and with it fresh inspiration for changes big and small! We've made some changes this issue adding some new writers to our publication - our long-standing friend, Chip Hart, whose fresh and forthright opinions we are delighted to have on our pages, and our new professional writer, RenĂŠe Hartleib, whose ability to break down the most complex health care topics is a breath of fresh air! The new season has also inspired us to look at change; as one season gradually shifts into the next, we started to ponder the process of it and immediately realized that innovation had to be the next big topic we explored in this magazine. We found there was no shortage of areas to explore, from medical technology and EMRs to fascinating conversations with clients and colleagues about what innovation means to them (both personally and professionally). And we are observing innovation everywhere it seems, from massive industry changes, to brave clients launching new practices all across the country - it seems that the only way forward is to innovate up! In our next issue we'll be bringing you news from the World Healthcare Congress and profiling some of our most entrepreneurial start ups, but for now we hope you enjoy reading, listening and viewing the content in this issue that we've had so much fun putting together for you!

SUSANNE MADDEN | EDITOR-IN-CHIEF

VIEWPOINT MAGAZINE ONLINE Online at www.VerdenViewpoint.com you'll find expanded content, video, images, tips, interviews and more. Look out for links throughout the magazine or simply click on the link above to explore.

WHAT CAN YOU FIND ONLINE? This issue is more interactive than ever! We have added a podcast for your listening pleasure, have included video in some of our articles and online stories, and have linked up to some of the people and places that we know and love.

Look For this 'button' throughout the magazine for downloadable PDF versions of articles. Want th i s arti cl e 'to-go'? Dow nl oad a PDF v ersi on of i t f rom th e V i ew Poi nt si te h ere.

THE BEST OF . . .

GRAPHI C VI EWPOI NT Curious about the images you see in our magazine? You can read more about where these pictures were shot and who took them here.

We've selected some of the most popular articles from the Verden Group's blog, Susanne's 'Pearls' published in Physicians Practice magazine, and from past issues of ViewPoint too. Our selected articles are all packaged up as PDFs-to-go so you can report and share with your colleagues too.

www.ver denviewpoint .com 6

? INDUSTRY NEW S ?

Heidi Hallett | Communications Director

SCI ENCE FI CTI ON . . . I SN' T FI CTI ON ANYMORE

When Science Fiction Isn?t Fiction Anymore It?s not that long ago that 3D printing became a reality and Trekkies all over the world yelled, ?It?s a replicator!?and while these next generation tech devices can?t yet make you a cup of Earl Grey tea (hot!) they are a great example of how futuristic devices from yesterday?s sci-fi novels and TV shows are fast becoming today?s reality. Some of the most remarkable advances in 3D printing have been developments within the medical field. Using bio-ink, made of living cell structures, living tissue is ?printed?and then built up in layers. Scientists and researchers have already successfully printed kidney cells, sheets of cardiac tissue, and other organ tissues. In a 2013 study, researchers from Heriot-Watt University in Edinburgh created a device capable of not only printing embryonic stem cells but also keeping the cells alive so they maintain their ability to develop into different cell types. The ultimate goal of this new ?cell printer?is for surgeons to have the ability to make ?tissue on demand?for various uses, but other applications such as making 3D human tissues for testing new drugs and growing organs also hold huge potential. While science may 7

still be a ways off from the ultimate end-goal of replicating whole organs, they are clearly on the path to getting there in the not-so-distant future. Researchers at Carnegie Mellon recently hacked a 3D printer and successfully produced models of a number of human organs. There is no doubt that 3D bioprinting is making unprecedented advancements in organ recreation, but huge strides in another area of science have already been made in terms of recreating our largest organ: our skin.

doctors said he likely wouldn?t live to see 21. Beating the odds, Les is now 59 and he?s helping to test the new advanced robotic prosthetics at John Hopkins Applied Physics Laboratory. A cutting-edge procedure called Targeted Muscle Reinnervation (TMR) is now being used to reassign the nerves that were formerly used to control the hand, wrist, elbow and shoulder, to existing muscle groups still in the body. Through a process called sensory evaluation, patients like Les report where phantom limb sensations are felt and these sensation points are then used to ?map out?the nerve endings for the missing limb. The results are nothing short of remarkable.

Self-healing skin ? an ability we often associate with onscreen vampires and werewolves ? is quickly becoming a reality. Using a new type of synthetic polymer, scientists have engineered a self-healing, flexible ?e-skin?that mimics the properties of human skin. Cuts and scratches to the surface can heal quickly and repair themselves in an astonishingly short period of time, often in less than 24 hours ? in other words, considerably faster than human skin. At present, e-skin is primarily being engineered for use on prosthetics with a goal towards sensitivity to touch and changes in the environment. The advent of e-skin goes hand in hand with other technologies being applied to the engineering of a new generation of so called ?smart prosthetics?capable of sending vital information to the brain as well as anticipating the user?s intentions. And what if that prosthetic arm could also be controlled by nothing more than thought? Engineers at John Hopkins are well on their way to recreating 70?s TV hero Steve Austin, aka the Six Million Dollar Man with their work in the Revolutionizing Prosthetics program. Working together with government agencies, universities, and private firms, their aim is to develop neurally controlled upper-extremity prosthesis with near-natural motor and sensory capability.

So, we know now that there have been huge advances in terms of recreating parts of the human body, but what about advances in diagnosis? I?m sure more than a few over-worked practitioners have wished they could get their hands on a Star Trek tricorder at one time or another. Imagine a handheld device that could be waved over a patient?s body to instantly yield vital information about any conditions they are suffering from. It may sound impossible but researchers are now closer than ever to making it a reality. There are two major research projects working towards creating handheld devices that could radically change how medicine is practiced. The first is a pen-sized microscope that can identify cancer cells in patients, right from the doctors' offices and operating rooms. Engineers at the University of Washington have developed a handheld, miniature

Meet Les Baugh. At the age of 17, Les took a $5 bet from his step-brother to see who could run over a pile of gravel the quickest. Les won the race but tragically ran into a set of power lines when he turned back to look for his step-brother. In his own words, Les says the power lines ?evaporated me?and 8

this far in the competition, each of these teams has demonstrated that their technology has a feasible, concrete means to be developed into a health assessment tool. The devices are expected to accurately diagnose 10 required core conditions and a choice of 3 elective conditions, for a total of 13 conditions (or 12 conditions and the absence of 1) in addition to capturing five real-time health vital signs: blood pressure, heart rate, oxygen saturation, respiratory rate, and temperature.

ÂŠ CBS/ Paramount Pictures

On Star Trek, the medical tricorder is used by doctors to help diagnose diseases and collect bodily information about a patient

microscope which could enable surgeons to identify cancer at a cellular level in real-time. In an interview with Future Timeline, Jonathan Liu, UW assistant professor of mechanical engineering, points out that it?s difficult for surgeons to know if they?ve removed all of a tumour, "Being able to zoom and see at the cellular level during the surgery would really help them to accurately differentiate between tumor and normal tissues and improve patient outcomes." In addition to the obvious advantages during surgery, a high resolution, handheld microscope could potentially see changes at a cellular level and assess lesions and moles immediately in the dentist or dermatologist?s office, eliminating the need for out-patient procedures and lengthy wait times for biopsy results. The second research project isn?t really a project at all ? it?s a competition! In ?a highly leveraged, incentivized prize competition that pushes the limits of what?s possible to change the world for the better,? The Qualcomm Tricorder XPRIZE is a $10 million global competition to develop a device capable of capturing key health metrics and diagnosing diseases. There are currently 7 teams in the final round of this global competition, with 4 of those coming from the US, and one each from Canada, India and Taiwan. In order to make it

As expected, the guidelines for the competition are extensive and the competition is tough. It?s also important to note that one of the main motivating factors for the competition is something that many physicians may not want to hear at first ? to create a device that helps consumers make their own reliable health diagnoses. Fear not, dear doctor, this isn?t about putting you out of business: this is about putting healthcare in the hands of people in developing countries with little to no access to

ÂŠ Marvel Studios/ / Paramount Pictures

Qualcomm Tricorder XPRIZE: Team DMI

traditional healthcare due to socio-economic circumstance or geographical challenges. It?s also about finding better ways to manage inefficient systems that lead to over-spending and unnecessary care such as here in the US. The prize purse has a total value of $10 million, with prizes being awarded for first, second and third prize, but as their website says, the real prize is empowering personal healthcare. 9

What if you could interact with a completely accurate and interactive 3D visualization of your patient?s heart as easily as Princess Lea could communicate with Obi Wan Kenobi in Star Wars? Holograms have been a staple in science fiction for light years. From the ghostly blue holographic communications in Star Wars to the virtual realities of the ?holodeck?on Star Trek, and the high-tech holographic displays in Iron Man 2, we?ve been imagining real life applications of holography for decades.

With all of these advances in medical technology and delivery of care, it?s no surprise that our medical facilities will soon be following suit on this futuristic path. When all this new tech is available to the masses, what will the patient rooms in your practice look like? I?m guessing they?ll be something like this...

What conditions will the winning Qualcomm Tricorder" diagnose?

Now an Israeli start-up has created the real thing. RealView Imaging Ltd. has developed technology that projects ?dynamic 3D holographic images floating in the air?without the need for any type of eyewear or a conventional 2D screen.?The user can literally touch the image and interact with it as though it is the patient?s real anatomy for an experience the developers call ?image intimacy.?In fact, the advancements they have made in live holography are so cutting-edge that many of the Youtube viewers who have commented on this video simply can?t believe it?s true. But it is:

Required Core Health Conditions (10): -

Anemia Atrial Fibrillation (AFib) Chronic Obstructive Pulmonary Disease (COPD) Diabetes, Leukocytosis Pneumonia Otitis Media Sleep Apnea Urinary Tract Infection The Absence of condition

Elective Health Conditions (Choice of 3): 10

Allergens (airborne) Cholesterol Screen Food-borne Illness HIV Screen Hypertension Hypothyroidism/Hyperthyroidism Melanoma Mononucleosis Osteoporosis Pertussis (Whooping Cough) Shingles Strep Throat.

The Ar t of Innovat ion Susanne Madden | Founder & CEO of The Verden Group What does it mean to ?innovate?? I had to look up the definition myself because innovation seems to imply something big, some great new technology or marvelous new invention, yet I have found that the smallest change can often innovate in the most fruitful and unexpected ways. in路no路vate 'to make changes in something established, especially by introducing new methods, ideas, or products.' As it turns out, to innovate is neither a large nor a small thing, it is simply a change engineered by a new thought. And so the tone of this issue was set ? to examine what it means to innovate on a variety of levels and to explore fruitful innovations brought about in unexpected ways by some of our favorite colleagues and clients. We thought it might be fun to introduce you to these folks in a variety of ways. We encourage you to visit each of the stories under the Spotlight section where you can hear a podcast with Dr. Gautam Gulati about, well, innovating himself; see the results of Dr. Todd Wolynn?s recording studio where he's innovating communications for his practice and read an interview with Brandon Betancourt about the importance of ?relational?innovation to differentiate your services. Our take-away here is this: there are a million ways to innovate what you do, how you think, even who you are! We hope our images and content inspire you to action in some small but remarkable way.

? BIG IMPACTS ?

Susanne Madden Founder & CEO

Jose Lopez Senior Consultant

PAYER INNOVATIONS How Payers are Innovating Technology, Payments & Delivery of Care

Payer Innovations in Technology The healthcare marketplace is finally becoming more consumer driven, and consumers want apps! They want data! They want information . . . Insurance companies are meeting those demands by providing their members with innovative digital support tools such as digital coaches, online portals, mobile apps, telehealth services, and price comparison tools. And as a result, patients are becoming much more active in the choosing of their care. Let?s take a look at a few Payer innovation programs that utilize technology.

Improving Health Goals through Digital Coaching The most significant cost of healthcare in the United States are those patients that suffer from chronic care diseases (such as diabetes, heart disease and obesity). By promoting healthy goals and lifestyle choices, insurance companies hope to impact patient choices in a positive way and as a result reduce these costs in the long term. Accomplishing personal health goals can be a tough endeavor, especially when relying solely on willpower. By turning health goals 12

into, say, online games, insurance companies are making this process fun while trying to improving the health of their members and save money on the cost of their care. As with most online games and coaching tools, there is a social component that serves to motivate patients by tracking progress and showing goals and targets set and met. One example is Cigna?s Health Matters, an online rewards-based incentive program. To encourage healthy lifestyles, Health Matters participants fill out their health assessment through the online gamified application in half the time that a non-gamified health assessment would take. Once enrolled, participants receive access to tools, including reminders, inspirational messages, personalized coaching, and rewards. Rolled out in January 2014, Cigna?s Health Matters paid out close to $193 million in perks by September 2015.

iTunes store convey that users think it?s working well. In an effort to innovate their mobile platform even further, Aetna quietly launched a beta version of their new iTriage Essentials app this February, designed to be more appealing to the younger demographic of so-called digital natives who grew up using technology. Another example is Cigna?s web application, Cigna Compass. Rather than wait for the member to request information, Cigna Compass pushes out data to members by anticipating their needs and preferences and offering solutions that have been personalized, complete with customer alerts to improve health and lower healthcare costs. For example, if a member does not have a designated primary care provider, the app uses the member?s current location to provide a list of nearby in-network healthcare professionals and facilities.

Web Applications

Telehealth

Today?s consumers expect information at their fingertips and the web is the place to get it. By offering easy to use online tools and mobile apps, some insurance companies are able to increase engagement, and consumers are able to build a personal healthcare team, compare prices, and feel in control of their health and well being. One example is Aetna?s iTriage healthcare app which helps consumers find easy-to-understand information in 20 different languages, in the palm of their hand. Consumers can find a doctor quickly, locate in-and-out-of-network providers and facilities, and even check in to select Hospital Emergency Rooms and Urgent Care facilities from their phone! Not surprisingly, one of the most popular features is the enormous healthcare and medical database with information on thousands of symptoms, diseases, conditions, and medications, all reviewed by Harvard Medical School. Users also have instant access to their personal health record (PHR) and claims history, making this a truly essential healthcare tool. A quick glance at the reviews for the app in the

A rapidly growing method of care delivery area has been the use of telemedicine and virtual visits to eliminate barriers to access of care, particularly for patients who are home-bound or in rural communities. Services available through telehealth include dentistry, counseling, physical and occupational therapy, home health, disaster management and the monitoring and management of chronic diseases and much more. At the University of Mexico, Medicaid health plans partnered with Project ECHO (Extension for Community Healthcare Outcomes), a collaborative model of medical education and care management where primary care providers are trained to treat chronic and complex diseases in rural and underserved areas via video conference. A report in the New England Journal of Medicine demonstrated that Project ECHO overcame healthcare access barriers, positively impacted patient outcomes, and was associated with high rates of cure for hepatitis C. (For more on this subject, see our article in this issue ?Telemedicine: A Roadmap?) 13

Using Data to Prevent Fraud A consumer driven marketplace not only demands information, it also expects transparency and ethical behavior. In order to combat fraud and protect members, 95 percent of health insurance companies are now using anti-fraud technology, up from 88 percent in 2012, according the Coalition Against Insurance Fraud. CMS?s Fraud Prevention Systems (FPS) screens Medicare fee-for-service claims (which includes all national Medicare Part A, Part B, and DME claims) and builds profiles that are aggregated by healthcare providers and suppliers to help CMS identify aberrant or suspect behavior. The FPS generates alerts based on billing behaviors, calculates a priority score, and assigns the alert to a program integrity contractor based on jurisdiction. CMS?s system added the ability to deny or reject claims prior to payment in its second year of implementation and has continued to expand.

Innovations in Payment and Delivery of Care Models As consumers demand more information on the quality of their care and associated costs, payment models will continue to evolve to incentivize providers who are able to demonstrate this. CMS, Medicaid plans, private Payers, policymakers and provider systems are relying heavily on financial incentives (and penalties) to change provider behavior to improve quality of care and reduce costs.

Private Payer PCMH Incentives Some Insurance companies have been incentivizing practices to achieve patient-centered medical home (PCMH) recognition. The details of these plans vary greatly by state, but as more practices achieve PCMH recognition, it is rapidly becoming a standard rather than a distinction for contracted practices. A detailed listing of the available programs by private insurance companies in each state is available on the Patient-Centered Primary Care Collaborative?s website.

Federal Program Incentives Current federal programs include the Pioneer ACO program, the Bundled Payments for Care Improvement, the Agency for Healthcare Research and Quality (AHRQ), and the Medicaid Shared Savings Programs. Over the next three years, CMS will greatly expand the use of financial incentives and penalties, with quality and cost control making up half of Medicare spending by 2018, according to Obama Administration officials.

working on major payment, delivery system or program reforms, according to a survey by the National Association of Medicaid Directors. Now that the Affordable Care Act is nearly fully implemented, many Medicaid directors say they plan to turn their attention to other reform goals in 2016. Here's what the survey showed:

With the passage of the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), Medicare payments were dramatically reformed by: -

Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments. Combining existing quality reporting programs such as the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one new system. Rewarding health care providers for giving better care, not more care, through the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).

Providers who proactively participate in APMs (such as Accountable Care Organizations, Patient Centered Medical Homes, and bundled payment models) will receive an incentive payment and be excluded from adjustments based on quality scores in the MIPS program.

State Programs Incentives

Payment and delivery system reform is at the top of Medicaid agency innovations. Agencies are moving to performance-based reimbursement models within both traditional fee-for-service care delivery and managed care. High priorities for states include patient-centered medical homes, health homes, alignment of physical and behavioral health, super-utilizer programs and population health. Top issues for four-fifths of the agencies include managed long-term services and support and managed behavioral health programs.

The State Innovation Models (SIM) provide federal grants to states, under cooperative agreements, to design and test innovative, state-based multi-payer

In 2015, nearly 60 percent of Medicaid directors across the country spent half or more of their time 15

health care delivery and payment systems. A recent overview of the SIM model describes it this way, ?The purpose of the SIM initiative is to test whether new models with potential to improve care and lower costs in Medicare, Medicaid, and CHIP will produce better results when implemented in the context of a state-sponsored plan that involves multiple payers, broader state innovation, and larger health system transformation to improve population health.? While innovation is taking place at the state level, most directors cite factors such as limited staffing, data and systems infrastructures, administrative budgets and complex procurement processes as barriers to innovation.

Challenges with basing financial incentives on measured outcomes A financial incentive program works best when there is a strong relationship between effort, performance and reward. These programs face the following challenges, some of which may be addressed by the Core Quality Measures Collaborative as programs move forward: -

The effort component is hard to quantify, measure and incentivize, especially for pilot programs. It is important to select the best measures for performance. Too often, incentives for quality are tied to performance on irrelevant measures. Incentive programs must measure the quality and outcome factors that matter most. Financial incentive may be too small to facilitate and sustain long term change.

Medicare & Medicaid Issue: there is a legal requirement that CMS demonstrations either reduce federal costs or at least curb spending growth. The link between effort and reward is weakened because rewards and penalties must be budget-neutral. Thus, participants don't know until all results are in what their performance will be worth financially. As market and policy forces continue to shape tomorrow?s healthcare marketplace, insurance companies will continue to develop programs that meet the needs and demands of their members. Providers who can evolve and adapt will be best positioned to take advantage of opportunities that these programs can provide. By easily providing information to patients through the use of technology (link to JL?s article on tech tools) and providing patient-centered care by participating in alternative payment models that incentivize quality, you can utilize the investments that various Payers are making and differentiate your practice from the laggards. 16

? INQUIRY ?

RenĂŠe Hartleib | Writer & Researcher

TELEMEDI CI NE A Roadm ap t o t he Benef it s and Risks of I m plem ent at ion

If you think that telemedicine is a new phenomenon involving iPhones and iPads and laptop computers, think again. Telemedicine, or telehealth, has been around since the 1960s, and it originated with the US space program. In fact, NASA created telemedicine technology for the astronauts?spacesuits to monitor their body functions. But it was in Nebraska, in 1964, that telemedicine, using a two-way closed-circuit TV link, was first used for long-distance consultations between specialists and general practitioners. Since that time, telemedicine has spread and is now well integrated into the American healthcare system. The American Telemedicine Association (ATA) defines telemedicine as "the delivery of any healthcare service or transmission of wellness information using telecommunications technology". This means that telemedicine is both the remote monitoring of patients AND the delivery of services to them. It is one of the most rapidly growing components of healthcare in our country with approximately 200 telemedicine networks, with over half of all U.S. hospitals now using some form of telemedicine. 17

Is telemedicine the face of the future? Many in the industry feel that telemedicine is on the cusp of becoming the new standard of care. Take a look at these stats and you?ll see why: -

89% of healthcare executives said they expect telemedicine to transform the U.S. healthcare system in the next decade. (Source: iHealthBeat) The global telemedicine market is expected to grow from $11.6 billion in 2011 to $27.3 billion in 2016. (Source: BCC Research) Worldwide revenue for telehealth devices and services is expected to reach $4.5 billion in 2018, up from $440.6 million in 2013. (Source: IHS) The number of patients using telehealth services will grow to 7 million in 2018, up from 350,000 in 2013. (Source: IHS)

Patient consultations via video conferencing Electronic transmission of still images Online patient portals Health and wellness phone apps available for consumers and physicians Remote monitoring of patient vital signs, worldwide

An example of telemedicine in action in a large urban center occurred in Boston, where more than 3,000 congestive heart failure patients used at-home monitoring devices. Only 3-4 nurses were assigned to every 250 patients. They received updates of their patients?blood pressure, weight, and other metrics, and were then aided by ?clinical decision support?software to identify the patients who needed interventions. This program reduced readmissions by 44 percent and created $10 million in cost savings. Studies show that one million people per year are hospitalized with heart failure, and that the majority of those are from worsening congestion in patients already diagnosed. Stats like these reinforce the use of alternate strategies to monitor heart failure patients. With costs soaring to over $37 billion, these kind of savings, due to telemedicine innovations, are extremely timely and relevant.

If you add the fact that telemedicine is called for in the Affordable Care Act, and that members of both sides of Congress are ?pro-telemedicine,?explosive growth seems more than likely.

How is telemedicine currently used? According to ATA, telemedicine is not a separate medical specialty. It?s simply another way of providing healthcare services. The Affordable Care Act and the subsequent Medicaid expansion have meant that insurers and providers are relying even more heavily on telemedicine to address the growing number of patients who now have health insurance.

What are the benefits of telemedicine? ATA has summarized over 2,000 evaluative studies related to telemedicine that appear in PubMed, a bibliographic database of medical research that is maintained by the National Library of Medicine. Their research outcome paper details telemedicine?s impact on the quality and cost of healthcare and clearly shows that ?telemedicine saves money for patients, providers, and payers compared to

Telemedicine uses a wide variety of tools including email, cell phones, and two-way video and has been applied in situations as varied as these:

traditional healthcare practices, particularly by helping reduce the frequency and duration of hospital visits.? Here?s a quick breakdown of telemedicine?s benefits: Improved Access for Patients. Not just for those living in remote locations, where telemedicine brings valuable healthcare services to their homes and communities, many busy consumers are beginning to demand healthcare services that come to them rather than the other way around. Enhanced Reach for Doctors. Physicians and health facilities are given the ability to expand their reach and address the issue of medical provider shortages, as well as enhance their ability to meet consumer demand for ?convenient?care. Cost Savings. By adopting telemedicine technologies, efficiencies such as shared health professional staffing, reduced travel times, and more home management of symptoms are gained. This translates to fewer or shorter hospital stays, which dramatically cuts costs, and less physician time.

" Tel emedi ci ne i s not a separate medi cal speci al ty. I t?s si mpl y anoth er w ay of prov i di ng h eal th care serv i ces."

Quality Patient Care. Studies consistently show that the quality of healthcare does not suffer when delivered via telemedicine. In fact, in some specialties, telemedicine actually outperforms the traditional in-person approach and delivers more positive outcomes and higher levels of patient satisfaction. Consumer Demand. Undeniably, the greatest impact of telemedicine is on patients, their families, and their communities. Utilizing the tools of telemedicine has resulted in more convenient care, less stress and greatly reduced travel time, among other benefits. Some physicians have found that seeing patients ?virtually? enables them to cut down on office hours, work from home more, and have greater control over their own schedules. In addition, when supported by a field team there is the potential to actually see more patients in a virtual format.

Does telemedicine prompt a greater risk of malpractice? The quick answer is ?not yet.?In an ironic twist to this question ATA reports that some individuals have actually sued hospitals for not providing telemedicine as an option. We are living in interesting times! 19

According to an article in Medscape, there is still very little known about the liability risks associated with telemedicine. Why? First, although telemedicine is rapidly growing, the number of patients served is still far fewer than inpatient visits. In addition, of the liability suits that are known, most were settled, and they also included confidentiality agreements that do not allow for details to be disclosed. The experts quoted in the Medscape article did not express concern about increased liability through remote doctor-patient interactions. One of the reasons cited was that virtual visits generally don?t involve high-risk medical scenarios. It is usually the opposite, where these visits are for minor ailments such influenza, sore throat and the like. Telemedicine, when monitoring patients with chronic conditions, actually increases the likelihood that individuals experiencing problems will be spotted early. This means serious emergency situations can be avoided. That said, there is another camp that worries that new liability concerns, specifically related to technology, will surface. The expansion of technology into an outpatient or home setting will make it more difficult to ascertain who is at fault when things go wrong - equipment malfunctions? User error? Patient error? Adhering to best practices is always an effective way of avoiding malpractice lawsuits. To that end, ATA has produced a series of standards and guidelines for healthcare providers to ensure that they are using telemedicine responsibly.

Have you thought about? ? If you are considering entering into, or expanding your telemedicine practice, here are a few things to consider. Do you have reliable infrastructure in place? As a healthcare provider, you need to ensure that you have the technology to provide effective and reliable virtual services to patients. There are many third-party vendors offering medical practices this technology and several come with wrap-around services such as technicians and nurse in the field. 20

How will you be reimbursed? Few insurance companies are currently paying providers directly for telemedicine and it has been noted that Medicare has some restrictive payment guidelines. ATA is continuing to push Medicare to reconsider its payment policies and include coverage for telemedicine ?regardless of a patient?s geographic location, the services provided, or the real-time nature of the service.? Do you know your state policies? Telemedicine policies can vary from state to state, in addition to the legal definition of the ?telemedicine? itself. The onus is on you to know and comply with your state policies. These might include state-specific rules for the conduct of video visits or state-specific regulations for e-prescribing. The Center for Connected Health Policy maintains an interactive US map, that details telemedicine law and policies by state. Simply click on any state to find out about reimbursement and state-specific policies and regulations. Have you checked your malpractice policy? You?ll want to ensure it includes online patient interactions. If your malpractice policy was issued before the era of telemedicine, you may need to inform your insurance carrier that you have joined a virtual physician network or have added video conferencing functionality to your practice. Whether you see telemedicine as the next step in the evolution of healthcare or simply an add-on benefit, all parties are in agreement about one thing ? the public loves telemedicine. In a world that offers an increasing number of services in an on-demand fashion, it makes sense that consumers also want healthcare at their fingertips and within their homes. It?s convenient, less stressful, and far more accessible. With estimates of roughly 10 million Americans already using some form of virtual healthcare, one thing is certain: Telemedicine isn?t going away.

? POINT OF VIEW ?

Robert Goff | CEO University Physicians Network

ALL PHYSICIANS ARE NOT EQUAL The Potential Impact of the Core Quality Measures Collaborative

All Physicians are not equal. While this is understood on a certain level by everyone from the public to physicians and regulators, the great tragedy of our healthcare payment systems is that physicians are all treated as equal when it comes to payment methodology. Probably the greatest single frustration of physicians who provide quality and compassionate care is that they are treated as equal to those who do not. Fee-for-service reimbursement is built on equal payment for equal CPT code, yet the reality is that equal is neither fair nor equitable. Physicians are not alone in their distain for equal pay for equal processes. Payers and government have long tried to understand and develop models that would differentiate physicians by measuring ?quality?and recognize it with payment. It is estimated that the rising cost of health care ? along with Social Security costs ? could bankrupt the country by 2045 so every Payer is looking to put the brakes on that apparent upward trend. If health care spending is to be curtailed, how do you logically get the best value for those dollars? The answer is to measure quality and to reward for it or to penalize those who meet less than minimum standards. 21

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differ from Payer to Payer will be able to be compared for their impact upon quality measures that are common, regardless of the payment model. Theoretically, as payment models change, those that can produce the best ?quality?with the greatest impact in cost reduction should find wider spread support and adoption.

Here is the rub; how do you define and measure quality? Each Payer (commercial, government, or otherwise) has set up its own measures to gauge quality. It?s not enough to say, ?I know quality when I see it,?so we measure the quality of outcomes, or processes that are recognized as leading to better clinical outcomes. The result has been an overly complex and confusing list of measures and tasks that are widely (and rightly) criticized as being a burden on physicians, and too numerous and often irrelevant to be of any help to consumers in their decision-making processes. Imagine participating in multiple insurance company networks and having to report data in different ways on different measures to each one?

Access to Information A key factor in the agreed upon selection and measurement methodology between the Payers is to make the outcomes for each physician available publicly. The goal being that, in addition to Payers having comparable measurements for economic purposes, consumers would have access to relevant and understandable information to aid them in their choice of physicians. Experts have long sought ways to engage patients in their healthcare, not just for personal health improvement, but also to understand that the decisions that they make in terms of providers has significant impact on their health and economics. Outside of healthcare, the US economy is largely consumer driven; consumer choice drives businesses to improve. Customers base their decisions on public perceptions and ratings of quality, the experience and costs. Information abounds when it comes to non-medical costs and quality, from online ratings to Consumer Reports magazine. With a common scoring model, we may even see the advent of a Consumer Report on physicians!

" Th e potenti al f or Core Qual i ty M easures to dri v e i nnov ati on and ch ange i n ph ysi ci an serv i ces sh oul d not b e underesti mated." In an innovative response, government (Centers for Medicare & Medicaid, aka CMS) and commercial Payers (the major health care insurance companies) have teamed up to adopt a common core set of quality measures to replace this patchwork quilt of varied measures among the multiple Payers. In February 2016, CMS and the trade group America's Health Insurance Plans (AHIP) announced an agreement to a common core set of quality measures. Through a working group called the Core Quality Measures Collaborative, all physicians are on notice that they will be measured on their performance against the core measures and the results will be reported publicly. Historically, payment innovation has sought to address utilization, which has often resulted in the criticism that quality has been sacrificed for the cost of care. A set of common measures will allow payment innovation to occur with recognized and common measures of quality. Payment ?experiments?that

From the physician perspective, one common set of measures means compiling data once and complying with a single program, a substantially better alternative than managing multiple programs across Payer networks.

Driving Innovation The potential for Core Quality Measures to drive innovation and change in physician services should not be underestimated. With rising copayments and deductibles, patients who now bear an increasing financial responsibility for the costs of their care are choosing care based on costs and convenience. 22

commercial plans have agreed to follow Medicare?s lead and have committed to 90% of their contracts being tied to quality measures by 2020. Fee-for-service payments to physicians continue on a path to extinction and Core Quality Measures support this transition in physician compensation. Simply put, future compensation will be uncoupled from number of events (visits, procedures) and instead be tied to what services you provide, how well you provide them and the utilization of those services.

Quality hasn't been a factor for consideration because the measures have largely been inconsistent, irrelevant, or not easily understandable by the patient. With the advent of Core Quality Measures, the patient can be armed with information about physicians and the quality of care, and choose to receive care from practitioners that will help them hold the line on personal out-of-pocket costs. While physicians have long held Payer ranking programs and other quality measures in disdain (and rightly so) physicians should embrace this new opportunity for transparency. Physicians need to be prepared to take advantage of any positive economics that will come from Core Quality Measures adoption in payment methodologies.

Accountability and Patient Engagement A signifying criticism of many of the quality measurement programs that are unresolved by Core Quality Measures is that many require the active engagement of the patient in seeking out a physician to provide the care. Efforts at increasing immunization rates or breast mammography rates have often fallen short of the desired results when patients are unresponsive to pleas by their physician to come in for care. This means that physician will not only be held accountable for what they do, but also for what their patients may choose not to do. This will require significant innovation on the part of physicians to engage their patients, and to create and use tools to gain their patient?s attention and motivate them to come in for care.

Stability Unlike Payer-created measures, which change from measurement period to measurement period, the Core Quality Measures are stable. This stability allows practices to plan in advance of being measured. For example, practices should reach out to their EHR companies and find out if they plan on incorporating the Core Quality Measures into their medical record scheduling and alerts programming. Until now, a multitude of Payers with different measurement programs made it impossible for physicians to deploy technology to help as a reminder, or as patient outreach to encourage patient engagement.

Will patients actually use this information? That?s the question that quality and consumer advocates will be asking. Historically, patients have been turned off by the complexity of information available, and few seem to have relied on the commercial Payers ranking of physicians programs (such as Aetna Axxcel, United Premium, or Cigna) unless there were cost differentials in choosing ?inferior?providers. For example, some benefits are designed such that selecting a Tier 1 provider in United Healthcare?s network was rewarded by a limited cost-sharing by the patient, such as no copay required. Core Quality Measures may be just the innovation that changes how patients as consumers make decisions about their care and providers.

The Core Quality Measures announced pertain initially to performance reporting from accountable care organizations, patient-centered medical homes, primary care, cardiology, gastroenterology, providers of HIV and hepatitis C care, medical oncology, orthopedics, obstetrics and gynecology. Additional specialty measurements will promulgated. In 2018, half of Medicare spending outside of managed care will be tied to the potential for rewards or penalties for quality outcomes, making the creation of the Core Quality Measures very timely. In addition to traditional Medicare, the major 23

? PRO TIPS ?

Jose Lopez | Senior Consultant

UTI LI ZI NG SI MPLE " TECH TOOLS" I N YOUR PRACTI CE EFFECTI VELY

Utilizing Simple ?Tech Tools?in your Practice Effectively As practices continue to utilize and expand the capabilities of their Electronic Medical Records (EMRs) for Stage 2 and 3 of Meaningful Use, there are many low cost technology tools that can enhance your practice operations, saving both time and money. Many of these resources are designed to not only improve patient outcomes, but to reduce two major costs: Labor and paper.

The Hidden Costs of Labor and Paper In addition to the material costs of paper, toner, printer maintenance, etc., workflow based on paper documentation is an expensive one. Labor is the greatest cost associated with running a medical practice. To maximize the return on investment for labor, workflow should be designed to improve efficiency and to focus on higher level functions. This workflow is disrupted, often several times a day, when paper documents or patient files are not available at the point of care. According to Ricoh?s A Realistic Transition Toward the ?Paperless?Medical Practice: -

It costs $20 in labor to find a document; $120 if misfiled. The average document is copied 9-11 times at a cost of about $18. 86% of mistakes in family care offices involved document-related activities, such as misfiling patient information, prescribing the wrong medication, and ordering incorrect or duplicate tests. 24

Many of the tools and resources in this article are designed to replace paper-based processes with electronic ones. The advantages of these identified paper-to-digital resources include how to: -

benefits to the provider and the patient, including: Improving patient safety by eliminating illegible prescriptions, reducing verbal miscommunications, provides warning and alert systems when prescribing such as allergies, and provides the patient's complete medication history to eliminate redundancy.

Reduce the time and cost to file and store paper documents Better utilize existing technology your practice likely already owns such as universal fax/copy/printers Integrate within your existing processes, particularly patient-centered medical home (PCMH) models Demonstrate how once digitized, documents can flow between various technology tools, such as your EMR Ensure electronic documents sit within your server?s protected environment for HIPAA compliance and security Train staff easily, especially for younger staff and providers who are tech savvy

Saving valuable staff time by reducing phone calls to pharmacies. Improving patient compliance by making the pharmacy experience easy and convenient, and also gives feedback to the physician to address noncompliance with the patient. Reducing cost to the patient by identifying generic alternatives to formulary drugs at the point of care. 2. Electronic Fax (eFax)

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Many practices still use a paper fax machine and the labor costs involved can be heavy. Contemplate that staff have to print the fax, scan it, and then index it properly into the patient?s EMR, or route it to the appropriate provider or staff when using a manual process. By utilizing an eFax service, faxes are received into your server electronically and can be quickly indexed to the proper location, either in the EMR or emailed/routed to the proper staff/provider, cutting out the redundant need to print documents that will need to be scanned into the patient chart later.

10 Tools You Should Be Using Now 1. Electronic Prescribing (ePrescribing) The percentage of physicians e-prescribing using an EHR increased from 7 percent in 2008 to 70 percent in 2014, but it bears mentioning because there are still a large number of providers who continue to utilize paper prescriptions. ePrescribing has many 25

3. Practice Website A website that is customized to your practice is an invaluable tool to disseminate information to new and prospective patients and provides the foundation for many of the resources listed below. By providing information that is easy to access online, you can attract new patients, extend your practice beyond your ?four walls?,and reduce phone calls to your practice for basic information. A few things to keep in mind: -

Your domain name should be as simple as possible and easy to remember, preferably your practice name. Utilize a template that is customizable for your practice so it does not look ?cookie-cutter?and can show off what is unique to your practice and is easy for patients to navigate. Whatever web developer you use, make sure that they provide you with a decent ?content management system?making it easy for you to update website content. Many practices make the mistake of buying a cheap website design that is difficult or expensive to alter, requiring a complete overhaul of the website even for small changes of information. Be sure to have an attractive and engaging home page and an informative ?About Us?section that includes contact information and directions to your practice. If you have a patient portal with your EMR and / or e-messaging, display them prominently and make them easy to access Online patients forms and links to your Social Media platforms should also be prominently displayed

TECH CHECK Of the following technology tools, how many is your practice currently using? Give yourself one point for each box you check off, then proceed to the scoring key on the next page to see how you scored. -

ePrescribing eFax Patient Portal Online Patient Forms eSurveys eMessaging Practice Website Social Media Autovoice Recall Electronic Dictation and Notes Telemedicine & Virtual Visits

4. Patient Portals and Secure Electronic Messaging (E-Messaging) As patient use has lagged behind meaningful use adoption expectations, patient portals and e-messaging have gotten a bad rap ? so much so that the Center for Medicare & Medicaid Services (CMS) had to dramatically downgrade the requirements for their use. However, these tools, which are now usually included with your EMR, can be very valuable. By encouraging the use of e-messaging and the patient portal, you can save valuable staff time by reducing call volume, staff time spent looking up information, handling prescription refill requests, and sending requested forms. Some patient portals also allow for online scheduling, which in turn reduces calls and wait times for patients with more urgent requests.

To encourage the use of your patient portal and e-messaging, these services should be highlighted and easily accessible on your practice website, and posted in your waiting and exam rooms. Make sure staff and providers are promoting these services to patients as a means to quickly receive information. While CMS has temporarily reduced this portion of the Meaningful Use requirements, the reasons to fully utilize a portal have little to do with meaningful use metrics and everything to do with office productivity and patient request processing efficiency. 5. Online Patient Forms By providing patients with online forms on your website, you can save time and paper by collecting medical and insurance information prior to the visit. You can also provide patients with information about what they need to bring to their appointment, inform patients of your practice?s policies, better prepare your providers with medical information, and advise your care coordination team of any potential ancillary services and referrals. There are two ways to accomplish this: Create PDF files that are easy to download and print from your site, so that patients can fill these out ahead of time and bring them with them to the appointment,

Tech ch eck scori ng k ey: How di d you do? Scor e of 9-11 point s: You?re a tech tool pro! You recognize the value and benefits of using these tools and are improving processes and delivering better care as a result. Keep up the great work! Scor e of 6-8 point s: You realize there are real advantages to tech tools but some of them may seem too complicated or unfamiliar so you?ve resisted adopting some of them in your practice. Pat yourself on the back for getting this far and commit to adding one more tech tool from the list in the next 6 months. Scor e of 5 or lower : Whether you know it or not, your practice is falling behind the rest. By missing out on the advantages available to you through tech tools, you?re giving your competitors a leg up. When you?re ready to catch up and take the first steps towards saving time and money, drop us a note at inquiry@theverdengroup.com and one of our experts can help you on your way.

Utilize a HIPAA-compliant online electronic form platform (such as Jotform.com) which allow you to create custom online templates for your forms that can be embedded on your practice website at minimal cost and best of all, it?s easy to use! Just make sure that if you utilize an online form that you DO NOT have the details passed from the Form system to your email, as that would allow information to leave a secure environment and pass through a non-secure environment (your email service). Notification that a form has been received in your account is all that should be emailed to you. 6. Electronic Surveys Have you ever wondered what your patients want? Why not ask them? Many practices make business decisions without getting feedback from their customers, the patients. Thinking of expanding your hours, adding certain ancillary services, or want feedback on the state of your practice or performance of your providers and staff? How about getting feedback from your staff and providers on job satisfaction? Online survey collection tools such as Survey Monkey provide a free platform for creating and analyzing survey data that can be collected anonymously, and one again, it?s free and easy to use! Note: having a feedback form available (such as on a tablet or ipad) to complete at the check in desk is the best way to ask your patients for feedback. Emailing them after the visit can often result in a low response rate. 27

into the EMR and dictates the notes for the visit. Many providers really like this technology and the cost to benefit ratio typically more than pays for itself.

7. Social Media Every practice should have a social media presence across at least one social media platform (facebook, Twitter, Pinterest, Instagram, etc.). These platforms are best used to encourage relationships, whereby patients feel connected to your practice on a regular basis. Social media can be used simply to share operational information such as holiday hours, introduce new providers and staff, as well as important medical information like updates regarding flu season, or information from medical societies. Expand your content to include tips, useful articles, expert opinions and even a little fun, and it can also your best tool for promoting your practice and strong sense of community with your patients.

Second is the use of scribes. Medical scribes are trained in transcribing medical documentation. Scribes assist physicians by sitting in on patient visits and entering notes into the EMR. This requires a thorough analysis of your workflow to ensure the cost-benefit is worth the investment of staff time, training, and workflow redesign, but the increased physician productivity (and happiness!) is usually worth the investment. 10. Telemedicine and Virtual Visits A rapidly growing area is the use of telemedicine and virtual visits to eliminate barriers to access of care, particularly for patients who are home-bound or in rural communities. The technology and security of networks has dramatically improved, as has the diagnostic equipment used to provide virtual visits (for example, listening to heart and lung sounds using an electronic/digital stethoscope). It?s important to check with your Payers to determine if they are covering these services (many will only do so through third party companies), but there are now several companies helping physicians to offer these services to patients that are looking to pay directly for the convenience of a virtual visit. According to the American Telemedicine Association, some examples of telemedicine include:

8. AutoVoice Recall Another way to save time, paper and money is to ditch the reminder postcards and utilize auto voice recall systems. These systems generate an automatic call to patients who have upcoming scheduled appointments and reminder calls for those with chronic conditions who need to schedule follow up appointments. As this process is automated through your EMR, it prevents patients from slipping through the cracks, ensuring more optimal care and maximizing revenue by increasing follow up visits. The staff time required to phone patients individually or, the even more expensive route of sending reminders by mail, can be reduced substantially.

Primary care and specialist referral services may involve a primary care or allied health professional providing a consultation with a patient, or a specialist assisting the primary care physician in rendering a diagnosis. This may involve the use of live interactive video or still diagnostic images, vital signs and/or video clips along with patient data for later review.

9. Electronic Dictation and Notes The chief complaint of many providers who struggle with their EMRs is the time it takes to enter information into the record. Many providers find the physical process of typing while seeing the patient intrusive, requiring them to multitask as they try to provide the best care and bedside manner possible. Others struggle with their typing speed and are unable to keep pace with their visits as the EMR slows them down. To help with that, there are a couple of options providers can explore. The first is voice recognition software, such as Dragon, where the provider wears a headset and verbally enters notes

Remote patient monitoring, including home telehealth, uses devices to remotely collect and send data to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation. Such applications might include a specific vital sign, such as blood glucose or heart ECG or a variety of 28

indicators for homebound patients. Such services can be used to supplement the use of visiting nurses. Consumer medical and health information includes the use of the internet and wireless devices for consumers to obtain specialized health information and access online discussion groups that provide peer-to-peer support. Medical education provides continuing medical education credits for health professionals and special medical education seminars for targeted groups in remote locations.

Technology is Only a Tool Technology provides useful tools to deploy in your practice, but can never be the solution to providing the best care. By streamlining processes within the practice, you and your staff can eliminate mundane tasks and focus on higher-level processes such as care coordination, chronic care management, and other processes required to transform you into a higher functioning patient-centric practice. In addition, utilizing technology may help to differentiate your practice by providing patients with information at their fingertips in an easily accessible format. Patients experience technologically-enabled tools at every other service point in their lives ? they expect it from you too. And these tools can help your practice save time and money by automating costly processes that used to require staff time. Who wouldn?t want to improve service and decrease costs at the same time?

? CHECK UP ? Chip Hart | Director Physicians Computer Company

ELECTRONIC MEDICAL RECORDS ARE HERE TO STAY. And that?s a good thing.

There's no official measure, but the last year or so marked the moment when the use of EHRs became the norm in independent pediatric practices. [http://www.medscape.com/viewarticle/837655] Sure, many of you have charted digitally for a decade or more, but you were ahead of a curve that promised more than it has delivered...but how many are ready to go back to the "good ol' days" of looking for lost charts, trying to decipher handwriting, or reading your charts from home (or your phone!)? The future may have under-delivered, but it has delivered. Before your EHR even has the time to catch up on time lost to MU and all of its particular unfulfilled promises, look what's coming: telemedicine, wearable technology, even your fridge talking to you about your vaccines. When will it stop? When will you be able to take control of all the change? Never. The change will not stop. There will always be undelivered promises. Which is actually why it's important to embrace the change. Because change is going to happen whether you participate or not. Because participating means you might make it less painful and more 30

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valuable. Because the good ol' days weren't as good as you like to remember. And, most of all, participating in the inevitable change is good for you and your patients. Before your EHR, how did you identify the kids who needed immunizations or well visits? You really never missed a chance to vaccinate? And you remembered everything about the kids your partners usually saw? In the next few years, it won't be called "telemedicine" - it will be just be called medicine. The opportunity to communicate with your patients after hours or from a distance may intrude on your existing notion of what you do for a living, but that will be outweighed significantly by an improvement in the quality of your diagnosis and the consistency and speed of your contact. Those first-year college students who need ADHD med management? That rash-on-vacation family? Or, most importantly, getting paid for the hundreds of hours of free phone care you give every year? Those are the benefits of progress. Now, in 2016, almost everyone reading this can send a text or email to the 70% of teens who need to finish their HPV series. How do we know it's 70%? Because of the data we can gather from EHRs around the country, something unheard of even less than a decade ago. This is something to embrace. What else can we look forward to? All those Fitbits and Apple Watches your patients can somehow afford will soon begin feeding vital

information to you and your office. Blood sugar levels from your diabetics, respiratory data from your asthmatics. You won't need to wait for your patients to call and depend on their accuracy and honesty to know how they are doing...and there are resources already out there to help with that patient triage. For better or worse, your patients' information is going to follow you around now. Your cell phone or internet access is all you will need to have all of your charts at your fingertips - and we are ? albeit slowly ? seeing little signs of actual interoperability out in the wild. Imagine actually learning when each of your patients visited the ER or used one of your referrals? Soon, your office will catch up the "Internet of Things." That fancy thermostat at home that you can talk from your office to check the temperature (or turn on the A/C!)? Or that security camera you can watch from your phone? The same will happen in your office. Your EHR will talk to your fridge to coordinate your vaccine inventory or even hand you the vaccines for the patients in front of you. The real question I have for myself is, "Will this article be outdated in the short time between writing it and it appearing in the 4th issue of Viewpoint?" A year from now, how will the landscape, and our attention, have changed? Anyone who makes a specific promise about that is just guessing, but there are two things I know for sure: things will change and some of them will even get better. A lot better.

?SPOTLIGHT ?

ON INNOVATION

?SPOTLIGHT ?

GAUTUM GUL ATI , FROM CL I N I CI AN TO I N N OVATOR

BRAN DON BETAN COURT, M ARK ETI N G M AVEN IN TH IS ISSUE, W E TURN OUR SPOTLIGH T ON

3 INNOVATORS IN H EALTH CARE. CLICK ON EACH PH OTO TO ACCESS TH EIR STORIES

TODD W OL YN N BI G K I D, BI G I DEAS

? HR MATTERS ?

RenĂŠe Hartleib | Writer & Researcher

I S A PEO RI GHT FOR YOUR PRACTI CE? Her e's a pr im er t o help you decide.

Tired of spending too much time on activities that don?t create revenue for your practice? If you feel like your valuable time and energy is being drained by aspects of your business that you have little interest in, let alone training for, you?re not alone! It?s one of the reasons so many practices are looking for help in the form of professional employer organizations (PEOs). These firms take care of tasks such as recruiting and training new employees, payroll, and the administration required for benefits, safety and risk management, and worker?s compensation. There is no shortage of PEO firms. Nearly 1000 PEOs provide services to between 156,000 and 180,000 small and mid-sized businesses in the United States alone. That?s not counting the PEOs that are springing up across Europe. Before jumping on the PEO bandwagon though, let?s have a look at all the facts, taking into account both the benefits and the potential drawbacks.

What is a PEO? Professional employer organizations exist to provide HR solutions for small and mid-size companies. The theory is that most business owners have not been trained in payroll, accounting, or human resources, and likely don?t possess 34

knowledge of regulatory compliance and risk management. Rather than spending time on steep learning curves, hiring a PEO will allow you to focus on the skills that prompted you to launch your business in the first place. PEOs don?t just offer their expertise. PEO firms actually become your employees??employer?in an outsourcing arrangement that is sometimes called ?joint employment?or ?co-employment.? When it comes to daily operations, you are still the boss, but the PEO pays your employees and is responsible for benefit plans, workers compensation coverage, and tax filing.

What a PEO isn?t! A PEO is not a temporary staffing service or an employee leasing company. PEOs enter into a co-employment arrangement with a business client and supply HR services for existing employees. They will not supply labor to your company.

Who uses a PEO? According to the National Association of Professional Employer Organizations (NAPEO), any business can find value in a PEO relationship. However, the average NAPEO client is a business with 19 worksite employees. The reason PEOs seem to make the most sense for small businesses is that they often don?t have dedicated human resources staff or the time to commit to the necessary administrative tasks associated with having employees. Companies often hire a PEO when administration begins eating away at productivity. While this is individual to each company, experts say this usually occurs somewhere around the 10 to 15 employee mark.

PEO perks NAPEO?s stats, taken from a study by two noted economists, point to big advantages for companies using a PEO. They claim that small businesses that use PEOs grow 7-9 percent faster, have 10-14 percent lower employee turnover, and are 50 percent less likely to go out of business. Add to that, the benefit for employees. On their website, NAPEO contends that through a PEO, ?the employees of small businesses gain access to big-business employee benefits such as: 401(k) plans; health, dental, life, and other insurance; dependent care; and other benefits they might not typically receive as employees of a small company.? 35

As a private practice owner, other benefits might include:

Improved Retention/ Recruitment. Enhanced employee benefits, professional human resource services, training, employee manuals, safety services, and improved communications are just some of the ways that PEOs have been known to help with retaining valuable employees and recruiting new talent.

More time. When you?re not focused on employee management tasks, you have more time, energy, and resources to actually improve and grow your practice. No costly mistakes. Let?s face it, a trained expert is less likely to make mistakes when it comes to payroll, benefits, and tax reporting. Not only will you prevent expensive errors, but you?ll spend less time pulling out your hair on frustrating tasks.

Those in the pro-PEO camp would tell you that freeing up precious time and energy by hiring an expert allows you to focus on what you love about being in business for yourself. And that can only enhance the vitality of your practice, including your bottom line.

Competitive and affordable benefit packages. As a small company, you might not be able to negotiate a competitive benefits package for your employees. PEOs will do the legwork and help you find the best, most affordable plan.

Sound too good to be true? It just might be. That?s why it?s important to do your own research. There are potential drawbacks, in addition to the benefits PEOs claim to provide. Here is a list of things to think about before you make any hard and fast decisions:

Lawsuit Protection. Employee discrimination, workers?compensation, unlawful termination, benefit/pension violations - the list of potential lawsuits is long. Partnering with a PEO will provide you with sound advice, tips on avoiding legal hassles, and possibly even an in-house legal advisor.

Are you ready to relinquish control over parts of your business? If your business feels like your ?baby,? it might be hard to let go of certain aspects of

control. Although you will be still be ?the boss? when it comes to your actual business operations, someone else will be in charge of most of your employee-related activities. How does this feel when you try it on for size?

COM PLI M ENTARY W EBI NAR HIPAA Compliance for Pediatric Practices

Have you thought about what effect this will have on employees? Some employees might feel uncomfortable with a third party, off-site human resources contact. How will your employees respond to a more ?impersonal?approach?

Thursday March 24 at 11:30CST Join Paul Vanchiere, MBA with PMI as he shares with you: The specific compliance programs every practice needs to have in place ? Locations of self-paced tools to maintain compliance ? Discussion of third-party resources available to help you ensure compliance.

Have you done your homework? Each PEO has a different pricing structure. Make sure you find out what you are paying for and ask for a full outline of all fees and services, in writing. You don?t want to get burned by hidden costs.

REGI STER NOW : http://bit.ly/22m WoY4

Are you clear about liability? PEOs do assume some of your liability as the employer (for taxes, payroll, and benefits), but not all. It's important to know the facts. Ask any PEO you are considering working with for details on liability, in writing.

naturally good at. Who doesn?t want more time in a day? Who doesn?t wish for more energy to do the things that really matter?

If the claims are true, a PEO might be the answer to your prayers, freeing up time to focus on growing your practice and thereby creating more revenue. Plus, you?ll be granted a permanent reprieve from tasks you may not enjoy or be

But, finding the right fit for your practice and asking the proper questions is critically important. Take a close look at bundled services, watch out for hidden costs, get the low-down on liability, and ask for agreements in writing.

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-PAYER NEW S -

Susanne Madden, MBA

THE EVOLUTI ON OF PAYERS How Value Based Paym ent s Ar e Wor king in Pr im ar y Car e

If you haven?t yet heard about ?value based payments?it?s time to get up to speed. This doesn?t only apply to CMS (Medicare and Medicaid) business: many of the commercial insurers are moving aggressively to transition provider payments from solely fee-for-service based payments to value-based payments, estimating that as much as 80% of their networks will be value-based by 2018. Even for those of you who are up to speed on the concept, it is likely still some vague and nebulous thing. So let?s take a look at what the Anthem group of Blue Cross Blue Shield companies are doing for primary care doctors and this may all become a little clearer.

Blue Distinction Total Care The Anthem group of Blue Cross Shield companies spans across at least 14 states and services millions of customers. In California alone, the Blue Cross company has more than 38 million enrollees! As part of Anthem?s efforts to transition to a value-based payment system, it has taken advantage of a BCBS sponsored system called Blue Distinction Total Care. This system 38

The Good

provides the framework for each region to develop it?s own set of parameters to work jointly with the providers in those local networks. For example, in California the program is called Personal Enhanced Care, in Virginia it?s called Accountable Care. But whatever the name, the goals are the same - to better coordinate care, to have participating providers reach certain quality metrics, and to reward those participants with ?per member per month?payments and opportunities for sharing in savings. There are currently 450 local programs with more than 118,000 providers participating, with savings ranging from $6 to $9 dollars per ?attributed?patient.

These programs are, for now, all ?upside?meaning that there are financial rewards but no penalties. So if you fail to perform well, you are not facing take-backs or other financial losses. That said, it?s important to note that you may be dropped from the program over time if there is no improvement.

The Bad (Sort Of ) You have to adhere to certain processes and you have to better coordinate care. The BCBS companies have made available many tools and resources, including staff at the local plan level who will perform outreach on patients that physicians have identified as needed a higher level of care coordination. However, this may result in having to perform processes and services that your practice is not currently doing, meaning more labor and potentially higher costs. That said, the additional work may benefit your practice by being more patient-centric and proactive ? actively recalling patients that may be overdue for care (which also improves your bottom line as it may mean additional, but appropriate, visits), following up on patient tests and records ahead of time, and making sure that patients are receiving the best care can all help move your practice from reactive workflows (Where are the test results? Did Mr. Smith come back for his med check?) to proactive ones.

The incentives work like this: -

image courtesy of khunaspix/ freedigitalphotos.net

Patients are attributed to primary care physicians. An attributed patient is one that is under a commercial plan (most self-funded plans are excluded) that has seen the physician within a certain period of time for preventive care or care management services. The physician is paid a ?per member per month?(PMPM) amount for each of his or her attributed patients. Certain targets are set in terms of adhering to evidenced based medical guidelines and other measures such as HEDIS scores. Meeting those targets may result in a reduction in the overall cost of care for a panel or group of participants, in which case a percentage of those savings are shared back to the participants to reward them for reducing the cost of care.

The Numbers If you happen to have 3,000 attributed members and are receiving $1.50 PMPM, that?s an additional $50,000 in revenue a year for the practice. Shared savings are a bit harder to quantify ? if you don?t produce savings across your panel (or group of practices to which you?ve been assigned) then no additional revenue is forthcoming. 39

Should You Sign Up? If you are approached to participate by a BCBS plan, you will need to sign an agreement with them. These are typically only one year in duration and often have termination provisions that allow you to opt out with X number of days notice. Because of this, and because we believe that the patient-centered approach can bring benefits to your practice as well as to your patients(we have seen many times!), we recommend that you at least try out the program and see how you do. You may very well be glad you did. There are several case studies available online as well as details about the Blue Distinction Total Care framework. Click on the links below to learn more: Blue Distinction Total Care

Case Studies Anthem Blue Cross and Blue Shield Blue Cross and Blue Shield of Kansas City Blue Cross and Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue Shield of Michigan Blue Cross and Blue Shield of Minnesota Blue Cross Blue Shield of North Dakota Blue Cross and Blue Shield of South Carolina BlueCross BlueShield of Tennessee Capital BlueCross CareFirst BlueCross BlueShield Florida Blue Highmark BlueCross BlueShield Horizon Blue Cross and Blue Shield of New Jersey Premera Blue Cross

SEARCH MEDICAL POLICIES ANYTIME, INSTANTLY. BE INFORMED ABOUT HIGH IMPACT POLICY CHANGES, AUTOMATICALLY. Here at The Policy Authority, we make it our business to know health care insurance company policies inside and out. We track changes and advise our clients on the impacts to their revenues, operations and physicians so that you don't have to.

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? FRONTLINES ?

Susanne Madden| CEO & Founder

RELATI ONAL MARKETI NG: MI CRO I NNOVATI ONS I N PRACTI CE An int er view wit h Brandon Bet ancour t

Susanne: Brandon, Thank you for joining me today to discuss innovation in healthcare. When thinking about who to talk to about innovation at the small pediatric practice level, I thought there?s no better person than Brandon Betancourt ? you write a blog, you manage Salud Pediatrics, and you?re just the sort of person who can't help but think of innovation when tackling problems and challenges. I?d like to talk to you today about micro and macro innovations, big and small. What does that look like at the pediatric practice level where you have 2 doctors and 1 nurse practitioner? What does that conjure up in your mind in relation to all of the things that you have to deal with daily and weekly there? Brandon: Really, when I think about innovation one of the things that first comes to mind is frustration, quite frankly. If you look at some of the other industries and you look at the advancement that we've seen with smartphones, web applications, and apps, ? we are really, really far behind [in medical practices]. A lot of the cool things that many people are doing aren?t accessible to us ? we?re limited by a number of things. One challenge is finding the time and resources, but 42

also in order to execute some of these innovations in a way that serves our patients, the technology that is available to us is locked up, or the functionality isn?t there. I'm talking specifically about our EMRs and our practice management systems. That's the first thing that comes to mind.

marketing and engage with your patients in the practice management industry as it is in other industries? Brandon: I think it's a lot more difficult than traditional marketing. It's not like you can just create a promotion, a ?2 for 1?sort of deal, or ?3 months free?if you sign up. There are all these incentives that traditional businesses can offer to create customer loyalty and have people coming back [for more]. In the medical field, we don't have that, right?

Having said that there are, of course, a lot of things that we can do. I?m always looking for ways that we can use innovation, and really what I?m talking about is innovation in relationship to technology. I?m always thinking about what is available to us. What can we utilize to not only make our jobs easier, in terms of patient flow, or automation? A lot of tasks can now be automated to some extent. There are also great opportunities to reach out to patients. Patient engagement is now largely taken care of by technology.

That said, one of the marketing advantages we do have is the ability to communicate more on an emotional level. People love their pediatricians. In terms of specialties, I think we pediatricians have one of the best relationships with patients ? with maybe the exception of the OB/GYN crowd. We spend many years with a family so there's a level of trust and even a level of friendship that gets created over the years. As all pediatricians know, you don't just have a relationship with the kid; you have a relationship with the family.

Susanne: I hear you saying a couple of things. One being that if only the technology were better we could innovate faster and smarter, but there are limitations in terms of the ability to innovate due to the constraints that you're experiencing with EMRs and practice management systems. I hear that loud and clear. Then, of course, there's regulation that plays into that too. You have to be so mindful about protected health information. On the other side, I'm also hearing you say there's great opportunity to engage with patients in a different way, utilizing what technology there is available or some of the exciting new technologies and platforms that are springing up around this idea that patients are becoming much more involved in their healthcare.

It's not just a stuffy nose, or a sore throat. Some of the challenges have to do with social issues. My wife Joanna, the founder of Salud Pediatrics, was recently explaining to someone that there is so much more to pediatrics training than just the scientific and medical training. There are all these social components to consider, such as advice about the effects of stress on kids, under performing because of emotional issues, and things of that nature. My point is, you can capture that emotional offering that pediatricians have that a lot of other specialties may not. One of the best ways to explain it is by comparison to the non-profit world ? they?re very much in the same category as us. They can't offer

Brandon: Yes, absolutely. Susanne: How do you tackle that proactive patient engagement? I know you have a background in marketing. Do you find that it is as easy to engage in Yellowstone, photo by Dr. Scott Schams

any type of traditional or retail-type promotions. What do they do to make their appeal to people? They do it from an emotional level, and that's what we try to do. When we think about what we're marketing, it's not just the usual "We're open weekends," or "Accepting new patients.?Of course we're accepting new patients, why else would we advertise? There is that bond or a connection that we have with patients that we carry over to the marketing and advertising side. Tying it back to technology and innovation, the web has afforded us the opportunity to do some amazing stuff ? from a marketing standpoint, from an innovation standpoint, from a practice management standpoint, really from any way you want to look at it. The web has really democratized communication. Anybody with a voice can essentially communicate to a pretty large crowd. That wasn't accessible to us just a few short years ago. There are various ways of doing it: through blogs, through Facebook, through some of the other social media platforms that are out there. And there are new ones coming out all the time. Just last month we were with Dr. John Moore and he was talking about Snapchat. It's important to keep an eye on the new things that young kids are doing. Susanne: What's important is really that innovation doesn't just need to be technology. You're really saying that the technology can be the tools. That can be the means to make the connections but the innovations here are really understanding who are you reaching, and what do they care about. You really can't create that ?stickiness?with your patients if the message is just generic.

To conti nue readi ng th i s i nterv i ew go to: Frontl i nes

OVERHEARD at The Verden Group

"Not only are the doomsayers wrong, but pediatricians are actually in a better situation than most think." - Chip Hart (as overheard by Brandon Betancourt) Click below to read more from Brandon's post-PMI conference wrap up:

Let 's Talk About What Happened in Vegas...

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? NCQA UPDATE ?

Julie Wood | Co-Founder, PCS

PRE-VALI DATI ON WI THI N THE NCQA-PCMH PROGRAM What it m eans f or Pract ices and EMR Vendor s

The NCQA Pre-validation Program also known as Auto-credit is where an IT Vendor applies to the NCQA for credit for functions within their EHR?s or Practice Management Systems. These are functions that are common to all practices with the same version of the product? the NCQA will either agree or not agree with the vendor; should they agree then the practice can take credit for those Factors without supplying any documentation for that factor as proof (you do, of course, need to make sure you are using the technology the way it is meant to be used ? sometimes you may need to check with the vendor to explain this). It is essential to use the technology in the way that the vendor has received its auto-credit. A couple of examples of how it would affect whether you can claim the auto-credit points are as follows: the vendor demonstrated to the NCQA that they have templates set-up in the EHR for Pediatric Well Visits based on the Bright Futures Guidelines ? using these templates the way they are in the system, or with just minor edits/additions ? in this case you could take the auto-credit points; another example would be a test tracking module in the EHR that has received auto-credit for ordering and tracking of test results ? if you are not using this module to track tests you cannot take the auto-credit for the factors. 46

The number of points that Vendors have gained auto-credit for range from 2 to 32.12 points. Think about this. If your vendor has gone to the trouble to get you 32.12 out of a possible 100 points for PCMH Recognition, you undoubtedly should make use of it! That amounts to over one third of the points you need to reach a Level 3 Patient Centered Medical Home.

Approval Table, NCQA Letter of Product Auto-credit Approval as well as a Letter of Product Implementation from your vendor(s), indicating which pre-validated tool(s)/modules approved for auto-credit have been implemented at the practice. 3. Crosscheck against the Standards and cross those items that you will be able to take auto-credit for off of your to do list. Keep in mind, if a process is a requirement of the Factor you will still need to provide this but no supporting documentation is required.

Just to give you an idea about how much this costs Vendors, here is the link to the pricing and process for Vendors: as an eye opener, to get 32.12 points the Vendor had 14 scoreable Elements and a fee of close to $30,000 to achieve this auto-credit for its clients.

4. Upload the vendor Prevalidation Summary Approval Table, the NCQA Letter of Product Auto-credit Approval and Product Implementation Letter from the vendor into the ?Organizational Background?section of the ISS Survey Tool.

To view Vendor Pre-validation pricing click here. If you are a Vendor reading this article then here is where you go to start the application process and see exactly what is involved:

5. In the Organization Background section under Pre-validation Tab of your ISS Survey tool, complete the site attestation under question 2B by checking the box. By doing so, you attest to the implementation and use of an NCQA Pre-validated health IT solution for associated auto-credit points as specified in your attached NCQA Pre-validation Summary Approval Table. You will enter the name of the pre-validated health IT solution you are using in question 1.

NCQA Application Process Does your EHR or Practice Management System have auto-credit points? The first step is to check the listing of pre-validated products/companies: Pre-Validated Products/ Companies Secondly, contact your vendor for a final determination if your products are pre-validated, as we have found that this list is not 100% accurate. That said, it is a great starting place, pay special attention to the versions and specific modules of the software as this does matter.

6. Under each Element in the ISS Survey Tool there is a text box. You will want to make note in the text box which Factors you are taking the auto-credit for. For example ?Factor 3 = pre-validated with x EHR?. 7. When you have completed everything in your ISS Survey tool, submit it.

So now that you have determined that the products you use in your practice are pre-validated, what do you need to do and how do you utilize it in your application?

To r eview t he applicat ion pr ocess and see exact ly what is involved click her e.

1. A practice or practice group must have implemented the PCMH pre-validated product throughout the entire practice for a minimum of 3 months before submission of the PCMH ISS Survey Tool.

For Vendor Pr e-validat ion pr icing click her e.

2. Obtain the NCQA-issued Pre-validation Summary 47

" I f your V endor h as gone to th e troubl e to get you 32.12 out of a possi bl e 100 poi nts f or PCM H Recogni ti on, you undoub tedl y sh oul d mak e use of i t! Th at amounts to ov er one th i rd of th e poi nts you need to reach a Lev el 3 Pati ent Centered M edi cal Home." .

Overall pre-validation is fantastic. The process is easy both for us as Consultants guiding you through this process and also for practices that are doing it on their own! That said, some vendors have looked inwards within their products to see how they can improve their product capabilities with regard to meeting the NCQA-PCMH Recognition Standards without giving the NCQA oodles of money. Improving reporting capabilities for the nuances of the PCMH Standards can be one of the biggest struggles with some IT products ? especially for Practices without an IT department ? so it is really great when vendors step up to the plate for this program and its practices. With that, of course, comes the other twist. Many of these vendors turn around and charge the practices for these modules and reporting capabilities, and many are not very affordable or have ongoing costs. From our experience, the ease of getting to some of these reports and the ability to track Quality Improvement measures makes it well worth the investment to have this capability. The alternative is spending the money on people-hours in trying to re-create these on your own. The Verden Group applauds those vendors that create these capabilities without passing on the charge to their clients! You'll find more information for both Vendors and Practices on the NCQA.org Pre-validation page. 48

Welcome to our third issue of ViewPoint magazine! Each issue will deliver our take on the latest news and developments from the health care industry, tips and success stories from our clients, blog recaps and reports from the conference trail. This third issue brings even more content to VerdenViewPoint.com to compliment what is in these pages. View videos, listen to audio clips and get inspired by stories about what other practitioners are doing.

Want to stay connected and be the first to know all the latest news? Visit www.theverdengroup.com and click on CONNECT at the top of any page on our site. With just one click you're connected to all of The Verden Group's social media feeds. LinkedIn, facebook, and twitter plus a whole lot more. The TVG team will keep you up to date on events, conferences and training sessions that your practice needs to know about.

www.TheVer denGr oup.com The Verden Group is an innovative consulting firm focused on shaping the landscape of advocacy by empowering medical practices to navigate through the increasingly complex business of healthcare, and to advocate on their own behalf with insurers and regulators. The Verden Group delivers expert services and advice to meet needs across your practice. From contract management to social media management, start ups to super groups, PMCH to research studies, we are your Partner In Practice. To learn more about our services visit www.theverdengroup.com Subscribe to ViewPoint to stay on top of all our news and views on the business of health care. Using a smart phone or tablet? Just scan the QR code to subscribe now, or visit www.TheVerdenGroup.com 49

VIEW POINT ViewPoint is a seasonal publication, distributed digitally ÂŠ The Verden Group 2016 Editor-In-Chief: Susanne Madden | Editorial, Design and Production Manager: Heidi Hallett | Cover Design: Scott Hodgson Contributors: Susanne Madden, Julie Wood, Jose Lopez, Robert Goff, Chip Hart, Heidi Hallett, RenĂŠe Hartleib, Photography by: Susanne Madden, Heidi Hallett, Julie Wood, Joseph Madden, www.Ver denViewPoint .com 50