In June 2007, the American Medical Association (“AMA”) released a report entitled “Medical Travel Outside the U.S.,” that tried to explain why people are going abroad for medical care. According to the AMA, the primary reasons that Americans are traveling for treatment are the ever escalating-cost of healthcare and the lack of affordable health insurance. On June 16, 2008 the AMA re-entered the conversation with Guidelines on Medical Tourism. These guidelines address important issues of patient safety, transparency, financial incentives, after care, and legal liability. The AMA’s contributions to the medical travel industry at such an early stage is notable and important. Many American doctors strongly disapprove of patients who seek care abroad and few will agree to provide follow-up care for returning medical travelers. Those doctors are understandably concerned about incurring liability for another physician’s malpractice. Widespread resistance in the medical community led many to believe that the AMA would either ignore or actively oppose the development of the medical travel industry. Instead, most were surprised by the AMA’s desire to get out in front of the issue and announce guidelines that some view as a traveling patient’s bill or rights. As the health insurance industry and employers begin to explore the cost savings and benefits of medical travel, the AMA’s contributions promote patient safety and protection. The AMA has legitimized a nascent industry with only limited support from mainstream healthcare networks. Since the AMA entered the discourse, more and more health insurers are evaluating whether medical travel makes sense today, tomorrow or sometime soon. At this stage, AMA does not seem intent to stamp out medical travel. This may be due in part to the movement’s consumer-driven nature and the reality of restricted resources at home. Instead, the organization of medical professionals will propose model legislation to all states that protects patients who go abroad for treatment. 2. The Guidelines and Who Will be Impacted The AMA’s Guidelines on Medical Tourism are enumerated below. Each addresses important components of patient decision-making, safety, protection and recovery. a. Medical care outside of the U.S. must be voluntary. b. Financial incentives to travel outside the U.S. for medical care should not inappropriately limit the diagnostic and therapeutic alternatives that are offered to patients, or restrict treatment or referral options. c. Patients should only be referred for medical care to institutions that have been accredited by recognized international accrediting bodies (e.g., the Joint Commission International or the International Society for Quality in Health Care). d. Prior to travel, local follow-up care should be coordinated and financing should be arranged to ensure continuity of care when patients return from medical care outside the US. e. Coverage for travel outside the U.S. for medical care must include the costs of necessary follow-up care upon return to the U.S. f. Patients should be informed of their rights and legal recourse prior to agreeing to travel outside the U.S. for medical care. g. Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the U.S. h. The transfer of patient medical records to and from facilities outside the U.S. should be consistent with HIPAA guidelines. i. Patients choosing to travel outside the U.S. for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities. Generally, these guidelines appear to be directed to health insurers and employers incorporating foreign providers into healthcare plans and to a lesser extent medical travel experts coordinating the patient travel experience. The Guidelines seek to protect patients from being pressured by healthcare payers to accept lower quality care without recourse in the event of a bad outcome. The AMA repeatedly stresses the importance of informing patients of their rights and recourse, the hospital and doctor’s credentials, and potential risks associated with combining travel activities with surgical procedures. 3. Implementing Key Guidelines a. Patient Safety The majority of the AMA’s Guidelines are aimed and ensuring patient safety. The Guidelines call for treatment abroad to be voluntary and for financial incentives to not restrict treatment options. This measure is meant to avoid patient coercion and withholding important information about available alternatives. The AMA also requires that institutions treating patients be accredited by recognized international accreditation bodies. This rule tries to ensure that patients are treated in safe and clean facilities that meet international standards of patient care, infection control and hygiene. The AMA also requires that patients be informed of the risks of combining surgical procedures with travel activities. The Guideline’s proscription against transferring patient medical records in violation of HIPAA aims to reassure patients that their privacy rights will continue to be safeguarded abroad.
In these days of economic uncertainty, career change is a hot button issue. As baby boomers retire and leave the work force, employers are concerned about the shortage of skilled workers. In addition, corporate cost cutting, off-shoring, layoffs, and forced career changes leave many workers with difficult choices. Gone are the days of one job and one employer for life. Following a career path today can mean maneuvering many twists and turns, setbacks, side roads, and blind alleys. Where is the roadmap to a new career that provides enrichment, stability and growth potential? One of the best ways to ease some of the uncertainty and increase your marketability quotient is to broaden your skill set. Since continuing education is often required to maintain licenses and certifications, make those education hours do double duty. The right training can mean more opportunities in your current field, and serve as a stepping stone to a new career. But which industries offer the best chance for job stability and advancement? It is predicted that expanding healthcare and healthcare-related industries will require many additional skilled workers in the coming decade. According to Forbes Magazine, “As well-heeled baby boomers age, look to the health care industry… (B)etween 2004 and 2014, seven of the 10 fastest-growing jobs in the U.S. will be in health care.” In addition to careers directly involved in patient care, demand for support professionals such as medical records and health information technicians, therapists, counselors, and medical transcriptionists will increase. A basic requirement for entry into almost any healthcare-related career is a command of medical terminology. The ability to recognize, understand, spell, and pronounce basic medical terms, identify medical abbreviations, and decipher unfamiliar words using roots, suffixes and prefixes is a necessary tool to perform well in any medical setting. Medical terminology courses are widely available in online, home study and instructor-led formats. Because medical technology advances rapidly, medical terminology evolves to keep pace. To stay on top of new terminology, consider taking the course again if you’ve taken it in the past. The Department of Labor database lists seven nontraditional careers that require medical terminology: Medical Transcriptionists – To understand and accurately transcribe dictated reports, medical transcriptionists must understand medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. They also must be able to translate medical jargon and abbreviations into their expanded forms. Medical Records and Health Information Technicians – In addition to general education, coursework requirements for medical records and health information technicians includes medical terminology, anatomy and physiology, legal aspects of health information, health data standards, coding and abstraction of data, statistics, database management, quality improvement methods, and computer science. Surgical Technologists – Surgical technologists receive their training in formal programs offered by community and junior colleges, vocational schools, universities, hospitals, and the military. In 2006, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) recognized more than 400 accredited training programs. Programs last from 9 to 24 months and lead to a certificate, diploma, or associate degree. Programs provide classroom education and supervised clinical experience. Students take courses in anatomy, physiology, microbiology, pharmacology, professional ethics, and medical terminology. Other topics covered include the care and safety of patients during surgery, sterile techniques, and surgical procedures. Students also learn to sterilize instruments; prevent and control infection; and handle special drugs, solutions, supplies, and equipment. Most employers prefer to hire certified technologists. Occupational Therapist Assistants and Aides – There were 126 accredited occupational therapist assistant programs in 2007. The first year of study typically involves an introduction to health care, basic medical terminology, anatomy, and physiology. In the second year, courses are more rigorous and usually include occupational therapist courses in areas such as mental health, adult physical disabilities, gerontology, and pediatrics. Students also must complete 16 weeks of supervised fieldwork in a clinic or community setting.
Medical Transcription is the process of converting voice dictation (typically either cassette or digital format) into a permanent written record utilizing word processing equipment and software. Each day in hospitals all over the country, thousands of patients are admitted and discharged. Examinations are conducted, procedures are performed and recommendations are made. It is not uncommon for multiple physicians to be involved in a simple procedure for a single patient. Radiologists, Pathologists, Anesthesiologists, Surgeons, and a host of other medical specialists must all coordinate their efforts to ensure that patient care is both adequate and appropriate. Underpinning all of these activities is a complex web of medical and patient information. Each patient-related activity and procedure must be meticulously documented and then added to the patient’s permanent record. Physicians and medical record handlers alike must be extremely careful to ensure that detailed patient identification information accompanies each procedure and examination report to avert potentially disastrous mix-ups. Over time, all of this information accumulates in a centralized medical records repository where it serves as a critical resource for patient care – facilitating accurate diagnoses and appropriate treatments. Indeed, timely patient care often hinges on the ability of Radiology, Pathology, and other specialty departments to quickly conduct their examinations and report their findings. Evolution and History of Medical Transcription In the past, patient medical charts consisted of a series of abbreviated handwritten notes that were funneled into the patient’s file for interpretation by the primary physician responsible for diagnosing ailments and prescribing treatment. Ultimately, this hodge-podge of handwritten notes and typed reports was consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department. Whenever the need arose to review the records of a specific patient, the patient’s file would be retrieved from the filing cabinet and delivered to the requesting physician. To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy. In recent years things have changed considerably. Walls of filing cabinets have given way to desktop computers connected to powerful mainframe systems where patient records are prepared and archived digitally. This digital format allows for immediate remote retrieval by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. While the transition from a paper based to an electronic format will take years to complete, considerable progress has been made. Handwritten reports are largely a thing of the past. Verbal dictation is now by far the most common method for documenting and reporting the results of examinations and procedures. Physicians generally use either a cassette based voice dictation system or a digital voice dictation system to record their findings. Dictating reports verbally not only allows physicians to be more thorough in their reporting, it also saves them a great deal of time. The Wall Street Journal recently reported the results of a study conducted by the Association of Legal Administrators suggesting that verbal dictation is the fastest way to create a document. The study states that “a 245-word document takes 9.34 minutes to create with an electronic dictaphone, compared with 16.46 minutes on a personal computer and 16.49 minutes by hand.” (WSJ, Tuesday, October 22, 1996, page A1, column 5). Given the salaries of most physicians, the cumulative productivity savings associated with these technological enhancements is considerable. The process of converting voice dictation to a typewritten format is known as transcription. Traditionally a staff of skilled medical transcriptionists working in the medical records department of the hospital has accomplished the work of transcribing medical records. In the early years of medical transcription it was not uncommon for very large hospitals to have staffs of 40 or 50 medical transcriptionists working one or more shifts. A transcription supervisor, who in turn reported to the Medical Records Director, generally oversaw these transcriptionists. The Medical Transcription Outsourcing Trend Increasingly, traditional hospitals are coming under competitive attack by more efficient managed care organizations. In an effort to remain competitive, many hospitals have turned to outsourcing as a means of cutting costs. Many of the processes that were previously performed internally are now being contracted out to third parties. Medical transcription is no exception. The outsourcing of transcription and other functions relieves hospitals of the administrative headaches and overhead burdens associated with internal production and allows them to focus their attention on improving service and lowering costs. This new competitive climate has driven many hospitals out of business. Those organizations that have survived have done so by becoming more efficient and cost-conscious. There is considerable evidence to suggest that contracting out medical transcription is a much less costly alternative to producing reports internally. Most savvy healthcare providers today understand this and are responding appropriately. The significant cost-cutting pressures which continue to drive the industry toward consolidation, managed care and capitation virtually guarantee that the outsourcing trend will not only continue but accelerate in coming years. This proliferation of outsourcing agreements has spawned a new generation of small medical transcription companies intent on carving out a piece of the pie. Interestingly, in spite of its rapid growth, the medical transcription industry is still considered a cottage industry. While there are a few truly national players, the industry is at this point still dominated by the hundreds of small local transcription companies located wherever hospitals are found. Opportunities in Medical Transcription The outlook for quality medical transcriptionists have never been greater. Lucrative opportunities abound today in hospitals, clinics, HMO’s, and in the hundreds of Medical Transcription contracting companies located throughout the country.
Expired medications are commonplace and inertia notwithstanding, many of us tend to rely on an intuitive sense of their value in continuing to store and use them. Such drugs can be harmful to health in several ways; they can be unpredictable in effectiveness, simply ineffective, or even toxic. The formal way of classifying a medication as having expired is through it’s labeled expiry date. This date is often set based on a combination of the common properties of the dosage form as well as the stability and expiration studies of the product that have been conducted by the manufacturer. Importantly, this expiry date is contingent on specific storage conditions of the product. Although a medication may pass it’s labeled expiry date, it may not necessarily be any less effective or dangerous to consume depending on the product itself, the storage conditions and the circumstances leading up to expiry. When most medications pass their expiry date under appropriate storage conditions, they are generally taken to have become so variable in effectiveness as to have become unsuitable for use. This often comes about as a result of the degradation of the active ingredients of the medication with exposure to physical, chemical or microbiological variables like temperature, pressure, humidity, light, bacteria as well as other components of the product known as excipients. Creams may “crack” once their expiry date is passed, leading to a separation of the components and hence provide a non-uniform delivery of active ingredients. This can lead to the poor control of conditions like eczema or acne. Tablet medications can mechanically “powder” off, change in consistency with exposure to water vapor or even experience the contained drug itself becoming ineffective on prolonged exposure to air as occurs with glyceryl trinitrate, an emergency medicine that can easily become ineffective in relieving acute symptoms of chest pain. With common injections, should the acidity change to fall outside a fairly narrow range, significant pain and tissue damage can result from use. With most eye drops, an expiry date of one month after opening is accepted to minimize the potential for dangerous bacterial contamination. With any medication, once a specific threshold of remaining active ingredient is passed, the medication can no longer be relied upon to deliver accurate doses. This loss of reliability is often exacerbated by the fact that the active ingredients can degrade into various combinations of active, inactive or toxic breakdown products. The common aspirin is for instance, known to react with moisture to breakdown into salicylic acid, which is active, and acetic acid, which is inactive and can lead to toxicity in excess. While the expiry date provides a useful gauge of when to stop using a medication, there are also many other factors that can informally accelerate the expiry of a medication and make it dangerous to use, chief among which is how the medication is stored. It is oftentimes not just the medication that is affected by storage conditions but also the storage container. Under inappropriate storage conditions, certain containers can leech material into liquid medication preparations, or medication particles can stick to the container rather than remain separated. On average, a 10 degree rise in temperature doubles the rate of chemical reactions that occur to a medication product and can accelerate the rate of bacterial contamination several fold. Just like an ice cream can simply melt or a loaf of bread becomes mouldy much quicker if not refrigerated, many medication products can easily expire much faster when not stored appropriately. With oral liquid and topical medications, potentially dangerous changes associated with expiry can at times be detected by color or consistency changes, component separations, altered smell or taste (oral preparations). Should a suspicion of expiry arise, a medication expert should be consulted regardless of whether or not the labeled expiry date has been passed. “Expiry” should also be understood to occur once a supply of medications is no longer used appropriately for it’s intended purpose. Consultation with a medication expert is always advised to prevent the inappropriate use of existing medication supplies. Inappropriate use can often occur with self-medication and is harmful. An unfinished supply of a previously used antibiotic may be tried to treat a new infection that is actually untreatable by or resistant to that antibiotic. This practice may not only delay recovery but can also encourage the proliferation of “super bugs” that have resistance to many antibiotics. Another incorrect purpose involves sharing medications and this can be especially harmful if another is allergic to the shared medication or a child or pet is medicated with an adult’s medication. Children often require dose adjustments to accommodate their size while many human drugs are often unsuitable for pets. Even a simple food like chocolate that we may enjoy can easily be toxic to a pet dog. Another mechanism whereby medication expiry is dangerous occurs when an unfinished supply is used despite new information that points to increased precautions associated with the medication or that has led to it’s recall. An example is obtaining pain relief from a previous supply of a painkiller like Vioxx (rofecoxib) or Celebrex (celecoxib) in spite of an existing heart condition that is now known to relate to an increased risk of fatality under those circumstances of consumption. Expired medications that are kept instead of discarded not only take up space but can actually discourage the appropriate use of new supplies in the treatment of illness. A medication cabinet, if not tended to regularly, could eventually contain more expired medications than viable ones and this can lead to the accidental consumption of an expired medication in place of a viable one. It is definitely advisable to clear the medication cabinet of expired medicaitons at least annually if not more often. A further danger however, lies in how expired medications are disposed of. Expired medications and pharmaceutical byproducts can be harmful to the environment especially when they end up in our rivers and drinking water supply. Hormonal compounds like estrogen from birth control pills and patches as well as antibiotics have been linked to being flushed by individuals and institutions into sewage, draining largely unchanged and collecting in rivers and streams, then returning in tiny amounts into drinking water. Traces of antibiotics could worsen bacterial resistance while estrogens and other steroids are known to change the reproductive characteristics of fish. Even trace amounts of chemotherapy medications have emerged in tap water and this could be severely detrimental to the unborn babies of pregnant women who drink such water. The long-term impact on human health of medications in our rivers and drinking water is as yet unknown but no one would want to wait to find out. We can all play our part by inquiring on and using pharmacy or state-run programs for the disposal of expired medications instead of sending them down the sink or the toilet bowl. A pharmacist is the expert of choice to approach in handling medication expiry and should be consulted if in doubt. As a general rule, it is always best to safeguard your own health and that of those around you by expeditiously and appropriately discarding all expired medications.
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