The purpose of this post is not to give the typical background, etiology and treatment options for adult pharyngitis but for people to consider some alternative causes and avoid the “it’s ‘only’ a sore throat” mantra.

Sore throats can be caused by infectious agents such as viruses and bacteria and by non-infectious conditions such as reflux of acid from the stomach. If the treatable bacterial forms of pharyngitis are not properly addressed, patients can develop issues with their kidneys, arthritis, tonisllar abscesses and even potentially lethal blood clots.

Many people are familiar with the term, “strep throat.” Indeed, group A streptococcus (GAS) is one of the more common bacterial pathogens responsible for causing a sore throat. There is even a rapid strep test which can be performed and resulted in as little as 5 minutes time. However, there is some debate regarding the accuracy of rapid strep testing. (See this blog post by Dr. Robert Centor. Dr. Centor has studied strep pharyngitis extensively and often posts pearls regarding his experience and findings). The rapid testing can help to curb over-prescribing antibiotics for conditions clearly not warranting them. However, as we know, health care is not always so black and white. By the way, I always have the lab run a traditional throat culture when a rapid strep is negative due to the variability in rapid testing sensitivities. The rapid testing will not pick up the non-GAS bacteria.

I have seen some ill-appearing patients with a negative rapid strep throat ultimately have non-group A strep grow on a culture. I typically treated these patients with antibiotics upon examination and have seen them improve and have no sequella as a result. One of my most memorable cases of pharyngitis was a young ill-appearing adult ultimately diagnosed with Lemierre’s syndrome (with a negative rapid strep test). Lemierre’s syndrome is usually caused by the anaerobic bacterium Fusobacterium necrophorum, lead to a clot formation in the jugular vein, possibly leading to thrombosis and sepsis. This patient was ultimately hospitalized and recovered well but was required to be on blood thinners for a certain amount of time to avoid further clot formation.

Of course this was the exception to routine pharyngitis. However, if a patient is looking toxic or continues to complain of an increasing sore throat, don’t just write it off as viral. It warrants further and complete investigation to rule out the more serious causes.

Here is a differential diagnosis list for pharyngitis (partially from UpToDate):

• Group A Streptococcus
• Non-group A Streptococcus
• Fusobacterium necrophorum
• Infectious mononucleosis
• Primary HIV
• Neisseria gonorrohoeae
• Mycoplasma pneumoniae
• Chlamydophila pneumoniae
• Corynebacterium diptheriae
• Arcanobacterium haemolyticum
• Rhinovirus (post nasal drip)
• Gastroesophageal reflux
• Tumors

There are many potential causes for pharyngitis and as clinicians it is always important to take a complete history, perform an examination, and order the correct diagnostic tests. While I was told to “not look for zebras,” if the clinical presentation does not make sense, then its time to delve deeper into the investigation and consider other causes.

While subjective ratings hold some value, objective data would be just as important for someone wanting to find information in order to make an informed decision for selecting a provider or continuing to see that provider. For example, it would be extremely valuable to know the average hemoglobin A1c of a particular providers patient panel or to know the amount of preventable diabetic complications. Some other types of objective information could be the provider’s institution attended and training though I’m not sure how useful that is as a reflection of that provider. Perhaps patients would want to know what conferences or research the provider has been involved with to ensure that thy are up to date on the latest evidence.

Of course, the problem is that the objective data may not be a direct reflection of that provider’s ability. Since I define care as a partnership, the patient, their lifestyle, adherence, and socioeconomic background should be factors into the equation as well. Therefore, you see, there are challenges when it comes to simply rating a provider. Unfortunately, this is not as easy as rating a product on a website such as Amazon or rating a seller on eBay.

This takes us back to square one. That is, provider ratings are difficult to quantify and will remain a sore topic. Electronic health records should allow us to collect de-identified objective outcomes. However, it remains to be seen how this will fit into an overall rating algorithm.

Whether you buy into ratings or not, it is important for all providers to register on the sites and to regularly view their ratings since patients are using these sites. Here are some tips for what providers can do today on these ratings sites:

• Have a set time to view ratings on a weekly basis.
• Be open and upfront with your patients. Encourage patients to share any concerns about their care and experience.
• Inform patients about the site and encourage them to leave a rating.
• Create your own practice website listing your credentials, continuing education, etc.
• Consider having your own anonymous patient survey on sites such as Zoomerang or Surveymonkey to get feedback from patients to look for suggestions to improve their experience. Anonymous feedback may help to change something perceived as negative that the provider may be unaware of.
• Set up a Google Alert with your name to have an e-mail sent whenever anything is published about you on the searchable Web.
• Consider subscribing to a site like reputation.com that will help you to find reviews

Until provider ratings are perfected with incorporating more meaningful and useful data, patients will surely rely on some combination of them, word of mouth, and perhaps an in-network provider based on their insurance carrier recommendation. The bottom line is it is important for providers to be aware of these rating sites.

Recent market research suggests that sports, fitness, and wellness apps will grew to a $400 million market by 2016. Much of this growth will come from wearable devices that will communicate and be stored via the smartphone. Clinicians will be able to review the data with their patients and can potentially get much more accurate data such as blood pressure readings and blood glucose readings than the ones collected in their offices.

Three examples of very innovative apps that are meant for wellness/fitness are:

1. Macaw – is a free app that is acts a personal health monitor by tracking exercise via syncing with things like wireless pedometers and puts together a personal health profile.
2. GAIN Fitness – is a free app that acts as your personal trainer by putting together a custom work-out for you.
3. Lumoback – is a free app that interacts with purchased wireless sensors placed on your back to monitor posture throughout the day. When posture is incorrect, the sensors vibrate to signal you to change position to improve posture and thus reduce back maladies.

The technology is not stopping there. Helius, a system combining an ingestible pill with a built-in sensor, a wearable skin sensor, and a smartphone app will monitor when patients take medications and confirm that the correct medications were taken at the right time.

For any of these apps to be effective long-term, the gathered information must be reviewed with the health care team. Therefore, the team members must become familiar of this new wave of health monitoring in the ultimate hopes of improving quality and health care outcomes while spending health dollars more efficiently. The future of health information apps has arrived and it will be exciting to see the impact they have on our nations health.

Two of the larger insurance carriers for nurse practitioners include Nurses Service Organization (NSO) and Marsh. These two carriers are endorsed by the American College of Nurse Practitioners and the American Academy of Nurse Practitioners respectively. Of course, there are other malpractice insurance carriers out there and some Internet searching will give you more options. Most insurers offer deep discounts for students that make it inexpensive to maintain coverage while in school. After completion of school, rates do increase significantly.

A common question that is asked among nurse practitioners is “Should I have my own coverage if I am covered by my employer?” This is a tricky question and there is truly no universal answer that will cover every situation. I chose to carry my own policy despite the fact that my institution covers me as an employee. My reasoning was for an additional layer of security and peace of mind should something happen. In essence, I wanted someone representing me with my interests as their primary focus, not necessarily the institutions’.

Further, malpractice is one part of the risk management scenario. The other part includes professional misconduct and any charges that can be brought against your actual license at the state level and is different from malpractice. State boards have the authority to fine, suspend, and even revoke your license if professional misconduct was found to be committed. This is a good reason to have your own policy since most offer coverage in these events (It is also a reason to have coverage as an RN too since professional misconduct charges can be filed against RNs and other licensed professionals). It is a good idea to be aware of this type of coverage from your carrier at the outset. You can find more information on malpractice insurance for nurse practitioners on the ACNP website and on this Medscape article written by well known nurse practitioner, attorney, and author Carolyn Buppert.

An unfortunate reality that we can expect is that as more nurse practitioners are in practice, more malpractice claims will be filed. Therefore, it is important to review the malpractice data that is published by the carriers to get a sense of the liability landscape. Every state has their own claims data. In addition, each state sets minimum liability coverage. As a result, you will see different rates for different states based on the claims and the amount of coverage required.

Any discussion of malpractice is not intended to scare anyone from clinical practice but is the reality to be cognizant of in the litigiousness society in which we live. With this information, we can practice with some comfort in knowing that you have an advocate should an unfortunate incident occur.

Currently, nurse practitioner residency programs are sparse but that may be changing as more federal dollars are appropriated to this model of training and education. The first NP residency was established in 2007 in Connecticut as a program of the Community Health Center. Since then, the Affordable Care Act of 2010 set aside money to expand NP residencies, in mostly under-served and disparate areas, and NP education across the United States. The funding is slated to last for three years and was awarded mostly to universities and to 2 Federally Qualified Health Center (FQHC) networks. The California FQHC network are the Santa Rosa Community Health Centers while the other is located in Maine and is through Penobscot Community Health Care.

Other NP Residencies include one in Austin, Texas via the University of Texas and one through the Mayo School of Health & Sciences and affiliates.

The residency model is nothing new and is part of the medical education curriculum. In addition, it has been funded by federal dollars since Medicare was enacted in 1965. This allows the programs to be administered while offering the post graduates a salary and benefits while being trained.

It is great to see this model being further developed for nurse practitioners. New NP graduates will benefit from an intense immersion into primary care with the support of clinical faculty while being modestly paid with health benefits. These post graduate nurse practitioners will be experts in community based primary care – exactly what our health system needs as more Americans will be seeking health care under the Affordable Care Act and with an increasing emphasis on primary care.

What can one expect when applying to one of these 3 programs? For one, competition. Residency slots are very few and range from 2 – 4 graduates per year. Secondly, the NP graduates must be licensed in the state in which the practices are located. Finally, there are the typical applications, interview, and credentialing process that must be completed.

All of the above programs are actively recruiting for 2013-2014 placements so now is the time to get in touch with them to gather more information and apply. Just one note: the residencies are often limited to family nurse practitioners. However, check with each program as their requirements may differ. Since residency-type programs were mentioned in the historic 2010 IOM Future of Nursing publication, I predict that we will see more of these programs developed if the appropriate federal subsidized money is in place and it may even serve as a future model of post graduate NP training and education.

For more information on the rationale for the NP residency model, Dr. Margaret Flinter, nurse practitioner, is largely credited for being the pioneer of the model and wrote the recent article, From New Nurse Practitioner to Primary Care Provider: Bridging the Transition through FQHC-Based Residency Training.

As the healthcare industry is finally modernizing into the Information Age with electronic health records (EHR), the issue of medical identity theft has been pushed to the forefront. Medical identity theft “…tends to be focused on the use of someone else’s information to gain goods, services and health care, which can affect a victim’s medical record and future care” (Booz, Allen, and Hamilton, 2009). Electronic health records hold the potential to minimize medical identity theft altogether yet, if proper protections are not addressed, thieves may have an easier way for private information to be breached.

Medical identity theft is nothing new to the health care industry. For example, as a health care provider, there have been times that I have been asked to write prescriptions under another family member’s name since that member had health coverage and the patient that I was treating did not. This is often a precarious situation that I am placed in and will not partake in fraudulent practices, no matter how benign it seems to be. Another potential issue is that patients are not typically asked to show any form of photo identification when seeking health care. Most institutions are so focused on payment that they are quick to ask for one’s insurance identification card, but make little to no effort to ensure that the person holding the insurance card is the rightful owner. Fortunately, this trend is becoming increasingly recognized and institutions are putting steps and procedures in place, with the assistance of health information technology, to combat these practices. Mancilla and Moczygemba (2009) studied medical information theft in acute care facilities and identified the following themes: most cases involving theft occur through the emergency department, organizations are beginning to use photographic images to identify individuals, time constraints on registration staff may lead to poor organizational compliance to policy and procedures, biometrics are a possible solution, and avoiding the use of Social Security numbers (p.4-5). The authors concluded, “…stronger technology support may be needed particularly in the form of biometric identification verification” (p. 8). The use of such systems will help to mitigate fraud especially in the aforementioned example.

Conversely, automating health information and making it available via portals in cyberspace makes it a potential target for cyber criminals. The government attempted to address this via the Federal Trade Commission’s [FTC], Red Flag Rule (FTC, n.d.). According to the FTC (n.d.), “the Red Flags Rule requires many businesses and organizations to implement a written Identity Theft Prevention Program designed to detect the warning signs — or “red flags” — of identity theft in their day-to-day operations” (“Fighting fraud,” n.d.). Unfortunately, there were major issues with this ruling as it applied to health care professionals and institutions. The Rule was deemed too broad and over-reaching and was thus excluded from including physicians (Gallegaos, 2010).

Medical identity theft will continue to be an issue especially as more Americans will be insured under the Patient Protection and Affordability Act and as records become electronic. While the Health Information Portability and Accountability Act (HIPPA) attempts to safeguard protected health information (PHI), there is very little protection and enforcement at the organizational level to prevent medical identity theft. Therefore, it is necessary for health care providers and institutions to take the issue of medical identity theft very seriously and implement regular audits and updated polices to prevent its occurrence. Most Americans have an expectation that their personal health information is private and should be protected with the utmost security and handling. As the transition to EHRs is underway, time will tell if the health care system is doing an adequate job.

References

Booz Allen Hamilton (2009, January 15). Medical Identity Theft Final Report. Rockville, MD: Booz Allen Hamilton.

Federal Trade Commission (n.d.). Fighting fraud with the red flags rule. Retrieved from: http://www.ftc.gov/bcp/edu/microsites/redflagsrule/index.shtml

Gallegos, A. (2010, December 20). Congress exempts doctors from “red flags” rule. American Medical News. Retrieved from: http://www.ama-assn.org/amednews/2010/12/20/gvl21220.htm

Mancilla, D., & Moczygemba, J. (2009). Exploring medical identity theft. American Health Information Management Association, 6, 1-11. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804460/?tool=pubmed

1. Smartphone. A smartphone is essential for today’s clinician. As the amount of clinical data that we accumulate increases, smartphones can help us manage this data while serving as a handy resource for performing activities such as checking drug interactions. Back when I was in school, I utilized a PDA (personal digital assistant) in the form of a Palm Pilot (that was only 12 years ago!) and it is amazing how far the technology has come since then. It really didn’t have much functionality at the time other than ePocrates and some limited note taking. Today’s smartphone can access a patients electronic health record, order electronic prescriptions and even view diagnostic imaging  results in high resolution.

2. A small notebook. While I am very into technology, I am a bit old school when it comes to note taking. A small notebook that can fit in your lab coat pocket will make jotting notes very easy (and will make it seem that you aren’t fumbling with your smartphone and texting somebody). Most schools require you to keep a log of patients that you see during your clinical day (please remember to de-identify any patients personal health information). A notebook is a quick and easy way of taking those notes. To merge the old technology with the new, you can snap a picture of the notes using your smartphone and then use an app like Evernote to archive them and search them. Very cool.

3. Otoscope/Opthamlamscope. You can never look at enough tympanic membranes, retina’s and optic disks. And if you want to be the most popular person in your family, you can examine family members eyes and ears at family gatherings. You need not spend a lot of money on an otoscope/opthamalamscope setup since they make travel kits that have relatively good optics. Check out Welch Allyn products as the industry standard. This is money well spent and if you have young children, it’s always nice to be able to look in their ears when they are sick.

4. Stethoscope. Investing in a good stethoscope is also an essential tool. My stethoscope of choice is a Littmann Cardiology II. It is great for auscultating heart and lung sounds. The stethoscope has not been immune to technical advances. There are stethoscopes that are electronic with the ability to amplify heart and lung sounds while reducing background noise. Some even allow you to digitally save the audio files for playback. It’s probably not necessary to go the electronic route as a student but definitely is worth it to spend the extra money for a good stethoscope. Also remember that stethoscopes don’t last forever especially after sticking them in your pockets, around your neck and being exposed to the elements. So you should probably replace the diaphragm and ear tips every few years. Also be sure to clean your stethoscope between patients!

5. Student Membership to Your State’s NP Association. I previously blogged about why it’s necessary to be part of your state’s NP association. There are enormous benefits to students in the form of networking, mentoring, and other state-specific resources that will help your practice as an NP. Most associations offer student discounts on membership and it is a great time to become involved and familiar with issues that may impact your practice.

I hope you find the items as useful as I did and that it positions you for success. Good luck!

1. Nurse Practitioners Practice Under A Physician’s License. Nurse Practitioners hold their own licenses at the state level and are certified at the national level. In fact, nurse practitioners hold licenses both as Registered Nurses and Advanced Practice Registered Nurses (states have varying names when referring to nurse practitioners). While some states have a supervisory model between nurse practitioners and physicians, the NPs hold their own licenses and are responsible for the care that they provide.

2. The Nurse Practitioner’s Collaborating/Supervising Physician Is Ultimately Liable In Cases of Malpractice. NPs hold their own malpractice coverage and are on the hook if malpractice is committed. If the case involved the supervising/collaborating physician, then they might be held liable to some degree. Again, the nurse practitioner is responsible for the care that they deliver.

3. Nurse Practitioners Are “Mid-Level” Providers. Few other terms provoke the ire of nurse practitioners than “mid-level.” It connotes providing care that is “middle of the road” and sub par. What professional on earth would want to be considered “mid” anything? Not many that I know. Nurse practitioners hold advanced degrees, diagnose, and treat patients. In fact, studies have shown that nurse practitioners provide care that is of high quality. That doesn’t sound “mid” to me.

4.  Nurses Must Practice For At Least 5-10 Years Prior To Becoming A Nurse Practitioner. This is another one of those hot topics in the nursing community. Some will say that only experienced nurses should be eligible to become nurse practitioners. Nurse practitioners must become Registered Nurses first and have that experience to build upon. I have known nurses with little to no nursing experience to be wonderful clinicians. How can this be? It is largely because traditional bedside nursing is quite different than advanced practice. That’s not to say that the nursing experience isn’t helpful – but different clinical and critical thinking are used for advanced practice. A colleague has studied this phenomenon in so called second-degree students and found that students with backgrounds other than nursing had enhanced critical thinking skills. (These students were considered adult learners with life experiences in other fields).  These skills enabled the students to make better clinical decisions. A possible explanation is that their varied backgrounds allowed them to consider a wider range of alternative diagnoses.

5. Nurse Practitioners And Physician Assistants Are Exactly The Same. NPs and PAs have similar yet different backgrounds. Nurse practitioners are registered nurses first and then go on for additional schooling and training to become advanced practice nurses. For me, I found security in knowing that if I couldn’t find a job as a nurse practitioner, I could probably work as a nurse somewhere  until that ideal job came along.

NP education is built upon the foundation of patient advocacy and patient education in a whole person approach. Physician Assistants are usually taught in medical schools using the “medical model.” It is true that there are more similarities than differences among NPs and PAs. Very generally speaking, PAs tend to be more involved with surgical specialties and perform many procedures whereas NPs tend to be more in primary care and women’s health (again, from a very general view point).

I hope you find this list useful if you are a pre-nurse practitioner student and are considering entering the profession – and it is a wonderful profession and a great time to be a nurse practitioner.

According to HHS, a HIPAA Privacy Complaint can be filed with Office of Civil Rights (OCR) if there was believed to be a violation of health information privacy rights. HIPAA was enacted to protect a patients personal health information from improper access. However, HIPAA was enacted in a time period when EHRs were not even part of the healthcare landscape. Since that time, the American Recovery and Reinvestment Act (ARRA) has incentivized health care providers to adopt EHRs and increased the fines and penalties for HIPAA violations (Sarrico & Hauenstein, 2011). The regulations needed to be updated to reflect the transition of health records to the Digital Age.

The new jurisdictional penalties included under ARRA range anywhere from $50 000 to $250 000 fines and imprisonment from one to ten years for individuals or entities liable for information breaches (Withrow, 2010, p. 84). In addition, civil monetary penalty categories now include “violations that reflect increasing levels of culpability, requiring that a penalty determination be based on the nature and extent of the harm resulting from the violations” (p. 84). In the future, victims of privacy breaches may be able to collect financial restitution as a result of a privacy breach. Increased enforcement and regulation of privacy practices are attempting to catch up with the speed of technology innovation.

According to Withrow, “the two most commonly violated privacy provisions…are impermissible uses and disclosures of protected health information and lack of appropriate administrative, technical, and physical safeguards of protected health information” (p. 84).

Is your practice prepared to deal with potential HIPAA violations? Would you know what to do if a HIPAA violation was brought against your practice? How mindful of HIPAA when caring for patients? These are some beginning questions to ask yourself regarding patient privacy and protection in your practice. It is definitely a good time to brush up on your administrative safeguards, as well as physical and electronic safeguards, to protect your patients information.

References

Sarrico, C., & Hauenstein, J. (2011, February). Can EHRs and HIEs get along with HIPAA security requirements? Healthcare Financial Management, 65(2), 86-90.

Withrow, S.C. (2010). How to avoid a HIPAA horror story. Healthcare Financial Management Association, 8, 82-88.

1. Increased Utilization of Nurse Practitioners Throughout the Health Care System. Good data exists regarding the integration of NPs in the health care system. In fact, a study was recently published in Circulation: Cardiovascular Quality and Outcomes, entitled “Community Outreach and Cardiovascular Health (COACH) Trial: A randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers.” The study found that in the 12 month period following the intervention, the NP-guided group had improved total cholesterol, LDL cholesterol, triglycerides, systolic blood & diastolic pressure, hemoglobin A1c and perceptions of the quality of their quality of their chronic illness care. Utilization of NPs is not about replacing any other profession . It is about improving a very wasteful and inefficient healthcare system.
2. Increased Visibility. With the increased utilization of NPs, there will also be increased visibility. Following that same logic, there will also be more available jobs and likely increased salaries. With the good, there will also be some bad existing in the form of those trying to reduce the role and scope of the NP. It is fairly expected territory and should not discourage any practicing or future NPs.
3. Updated State/Federal Regulations that are Inclusive of NPs. Many regulations at the State and Federal levels were made when the profession was very young and little evidence existed regarding patient outcomes with NP utilization. There is a move to update these regulations to be inclusive of NPs to adequately reflect  our education and training. An example, is the Home Health Care Planning Improvement Act of 2011, which would allow NPs (as well as Physician Assistants, Certified Nurse Midwives and Clinical Nurse Specialists) to order home care services for patients. Antiquated regulations prevent patient access to care and just makes the system more inefficient and wasteful. At the State level, we have seen about 15 states transition to autonomous practice and many other states are in the process of examining their regulations to appropriately reflect scope of practice.
4. Increased use of Health Information Technology. The transition to electronic health records (EHRs) are well underway and all clinicians must become comfortable with electronic clinical data management.
5. More NPs will Graduate with Doctoral Degrees. NPs are choosing to return to school for a terminal degree to further enhance their practice and education. This is not limited to the Doctor of Nursing Practice (DNP) but also includes the PhD, DNS (Doctor of Nursing Science) and EdD (Doctor of Education). More doctorally prepared NPs will help educate future NPs and bring additional perspectives to clinical care.

It will be interesting following these trends and to see if they come true in the new year. Wishing you all a very Happy, Healthy, & Prosperous New Year.