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Each has unique potential to enhance the doctor–patient relationship and to increase physician liability cheap clarinex 5mg online. Key Words: E-medicine; e-mail; risk reduction; telephone; online medical communication; Internet; guidelines for online communi- cations; electronic medicine buy cheap clarinex 5mg line. INTRODUCTION E-medicine buy generic clarinex 5 mg on-line, or electronic medicine clarinex 5mg, refers to the use of electronic communication and information technology by physicians in the care of patients. Therefore, e-medicine encompasses various services includ- ing telephone, Internet, telemedicine, and electronic medical records. Each of these services has the unique potential to enhance the patient– physician relationship. As with all services that impact patient care, each also has the potential to increase physician liability. TELEPHONE-BASED CARE The use of the telephone in the treatment of patients is neither new nor controversial. However, it does represent a legitimate form of patient care that has clear benefits as well as clear liabilities. When the tele- phone first emerged as a popular form of communication in the early 20th century, it was looked on with concern by many in the medical establishment. Warnings were given to doctors that the role of the tele- phone should not replace a face-to-face office visit and that telephone- based care could lead to suboptimal clinical outcomes and liability. Although the use of the telephone has become an essential compo- nent of medical care, particularly in the outpatient setting, it has largely been relegated to an administrative tool for setting appointments, refill- ing prescriptions, billing, and related administrative requests and ques- tions. Physicians generally are not reimbursed for providing telephone-based care and, as the demands of physicians have increased with the advent of managed care, patient frustrations related to poor telephone access to their doctor has increased. Numerous national stud- ies, including a national survey of patients done by Harris Polls, confirm growing patient frustration in their inability to communicate with their physicians via the telephone. Telephone: Value and Appropriateness of the Service It is hard to imagine running a physician’s office without a telephone. Yet the use of the telephone varies widely among physicians, even Chapter 7 / E-Medicine in the Physician’s Office 77 within a single specialty. Some physicians are willing to spend large amounts of time on the phone with patients, whereas others rarely speak to patients outside of the exam room, opting instead to have most calls from patients returned by an office staff member. Whatever the protocol of the office, the physician is responsible for care delivered, regardless of whether it is delivered directly or through a member of the staff. In addition, the ability of a specific patient or caregiver to use telephone- based communication should be considered, as should the appropriate- ness of using the telephone to communicate sensitive clinical information. Telephone: Patient Expectation The growing frustration among patients regarding an inability to speak to their doctor on the phone only partially results from increased demands on the physician’s time and a lack of reimbursement for tele- phone-based care. A substantial portion of this frustration stems from inadequate expectation management. It is guaranteed that patients or caregivers will want to telephone their doctor at some point, likely when a need arises and stress levels may be high. It is also guaranteed that doctors who spend entire days on the phone providing unreimbursed care to patients will quickly find their practices in financial trouble. The gap between patient expectation and practical limitations must be filled with disclosure and expectation management, preferably done ahead of the telephone ring, and in writing. Physicians are well advised to develop written protocols associated with the appropriate use of the telephone in their practice. These pro- tocols should be used to set patient expectations and to set office procedures that should be followed by all—physician and office staff alike. The procedures should be reviewed annually, and patients should be reminded of these protocols on a regular basis. The physician should consider posting protocols in areas where office staff has frequent access, as well as in employee handbooks. It is also advisable for the physician to be notified when and if a patient or caregiver has shown anger or frustration related to telephone-based communication. These concerns should be addressed by the physician and the practical and clinical issues associated with the office protocol should be reviewed directly with the patient. Telephone: Standards of Care The standards of care as they relate to telephone-based patient– physician communication do not vary significantly with specialty and 78 Fotsch practice setting.

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The large cells with low nuclear/cytoplasmic ratios and “ugly” nuclei seen in LSILs are less frequently missed cheap 5mg clarinex with visa. Hyperchromatic crowded groups of cells are often difficult to accu- rately classify generic clarinex 5 mg with visa. They may be normal endometrial cells or benign basal cells seen in atrophy cheap clarinex 5mg without a prescription, but abnormal cells from HSILs can also mimic this appearance purchase 5mg clarinex free shipping. In 1996, new technologies and techniques were emerging that were designed to improve recognition of missed cells, increase the sensitiv- ity of the Pap smear, and reduce false-negatives. These included liq- uid-based cytology, automated processing and screening, automated and manual rescreening of both negative Pap smears and smears show- ing ASC-US, and rapid rescreening. However, these techniques were expensive, and because the increased costs were not offset by higher reimbursement, few laboratories were able to provide them. Some pathologists expressed concern that even if reimbursed, the higher cost may reduce both access to the Pap smear and its frequency, whereas others wondered if a higher “community standard” for the frequency of false-negative Pap smears would increase the public’s expectation of perfection and thereby increase liability. Failure to Recognize Unsatisfactory Pap Smears CLIA 88 prohibits making a diagnosis of “negative for intraepithe- lial lesion or malignancy” on an unsatisfactory Pap smear. However, a Pap smear with abnormal epithelial cells must never be interpreted as “unsatisfactory for evaluation. The fact that CLIA 88 prohibits making a diagnosis on unsatisfactory Pap smears assures liability if a woman with cervical cancer had a prior Pap smear Chapter 13 / Pap Smear Litigation 173 diagnosed as “negative for intraepithelial lesion or malignancy” that on retrospective review is found to be unsatisfactory. For these rea- sons, every laboratory should have written policies defining specimen adequacy; today these should be based on the 2001 Bethesda System recommendations. These criteria include the presence of at least 10 well-preserved endocervical or squamous metaplastic cells and 8000– 12,000 squamous cells (5000 for liquid-based preparations) (8). For computerized labs, “edits” should be created to assure that diagnoses are not assigned to unsatisfactory smears. INTERPRETATION ERRORS Interpretation errors account for the other 50% of laboratory false- negatives. ASC-US is a poorly defined diagnostic category and represents the pathologist’s interpretative “gray zone. Expert members of the CAP Cytopathology Com- mittee reached 80% consensus on the diagnosis of ASC-US on only 20% of cases reviewed; there was not 100% consensus on any case. Approximately 2 million Pap tests in the United States are diagnosed as ASC-US each year. Therefore, finding ASC-US on retrospective review of a “negative” Pap smear should never be the sole basis for judging a false-negative Pap smear to be below the standard of prac- tice. However, because about 26% of women with ASC-US are sub- sequently diagnosed with SILs (up to one in four as HSILs), rescreening of all ASC-US cases is recommended as a quality assur- ance (QA) procedure. Furthermore, when atypical cells are found on a Pap smear, it is important that they not be characterized with terms such as “non-neoplastic” or “benign. Use of the 2001 Bethesda System terminology (8) is an appropriate way to deal with this situation (i. Misinterpretation of an “epithelial cell abnormality” as “negative for intraepithelial lesion or malignancy,” (e. Failure to look carefully for abnormal cells in the “neighborhood” of parakeratotic cells. Because abnormal cells tend to occur in linear streaks, pathologists must look carefully at screened smears with lines of dots or look to either side of dotted abnormal cells for other abnormal cells. Include a “statement” in the Pap smear report reminding the clinician (and patient) that the Pap smear is a screening test with an irreducible false-negative rate, the consequences of which can be minimized by obtaining an annual Pap smear. It is important to educate the public, primary care physicians, and gynecologists about the limitations of the Pap smear so that they have realistic expectations about its sensitivity and understand why it is important to obtain a Pap smear annually. Provide the referring physician with patient information cards explain- ing in easy to understand lay terms that although the conventional Pap smear’s accuracy in detecting abnormalities is about 70–80%, it is not perfect, and, therefore, an annual Pap smear is important. The patient may be asked to sign the card to indicate that it has been read.

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