[G-DRG version 2007: a short overview]

Just as in the year before, the structure and regulations of the new GDRG version 2007 was successfully agreed on a mutual basis by the national self-governing bodies in the German health care system. Although some problems in high-specialized medicine or day clinic care will remain, the current developments demonstrate once more the learning aptitude of the G-DRG-system. Some beneficial and major changes have been made in 2007, but most of them do not touch dermatology. Additional procedure-based payments have been introduced in 2007 including the parenteral administration of such expensive agents as etanercept and itraconazole. A statistical analysis of cost weights of the year 2006 versus 2007 for two university clinics suggests that in dermatology, the increasing complexity of the G-DRG system partly leads to lower cost weights. Overall in 2007 a remarkable increase of complexity and differentiation throughout the DRG-system can be identified as well as a careful expansion of procedure-based payments.

Legal Issues in Dermatology: Informed Consent, Complications and Medical Malpractice

Legal considerations can arise in almost any aspect of a dermatology practice. A full textbook on health care law would be required to adequately cover the varied legal issues as they relate to dermatology. This article will focus on the relationship between informed consent and the development of complications that may lead to a cause of action based on negligence. Because it is the lack of informed consent that may form the basis of a medical malpractice claim, the issues of what constitutes a medical malpractice claim will be fully described.

Dermatology: litigation and the NHS Redress Bill

This article considers an allegation of failure to diagnose a patient's condition by the consultant dermatologist and considers the likely repercussions if the NHS Redress Bill currently going before Parliament is passed and implemented.

Legal ramifications of off-label filler use

Dermal fillers are often used in an off-label manner. Most off-label use is not only legal, but represents an appropriate physician standard of care. This chapter will first explore what is and what is not considered off-label. Then the chapter will explore manufacturer promotion of off-label use of both drugs and devices. Finally, the legal ramifications of off-label dermal filler use will be discussed.

Dermatology: obtaining patient consent in clinical trials

This article considers the law which applies to the conduct of research on health service patients. It considers the ethical approvals which are required and the necessity to obtain consent from the patient. It must be made clear to the patient that a refusal to participate in a research project should have no adverse effect on their ongoing care and treatment.

[The new German educational law for medical schools: the Hamburg concept in dermatology and venereology]

Medical school graduates are required to deal with complex situations in their future work which require profound theoretical knowledge as well as many practical skills. The University of Hamburg used a new educational law (AappO 2002) as catalyst to define learning objectives relevant for practice and to guarantee a close connection between theory and practice. A newly founded curriculum committee with twelve members developed a strategy and structure for the new clinical curriculum (KliniCuM) in weekly sessions. The subject dermatology and venereology is taught in the thematic block "The Internal and External Human Being" in integrated courses with the subjects internal medicine, pathology and pharmacology. The teaching modules (introductory lectures, symptom-oriented lectures, problem-based tutorials and bedside-teaching) are practice oriented and teach diseases and skills of dermatology which are important for "general medicine". Written and practical exams take place at the end of the block. Although there is more required attendance and increased demands on students' time, dermatology has received very positive evaluation results. Students consider their gain in knowledge and skills as very high. The new curriculum in Hamburg could provide helpful orientation for other medical faculties in changing their curricula for the subject "dermatology and venereology" according to the new educational law.

Medicolegal aspects of neoplastic dermatology

Medical malpractice litigation is rising at an explosive rate in the US and, to a lesser extent, in Canada. The impact of medical malpractice litigation on health care costs and the cost of insurance is dramatic. Certain specialist categories are becoming uninsurable in some parts of the US, while in others, clinicians are retiring early, restricting or changing practice or changing states of residence in consequence of medical malpractice claims and of the cost and availability of insurance. This, in turn, has had the real effect of denying care to patients in some communities in the US. Some 13% of all medical malpractice claims relate to one area of neoplastic dermatopathology, specifically, melanocytic neoplasia. Certain steps can be taken by pathology laboratories to reduce, but never completely eliminate, the risk of medical malpractice claims. In this review, attention is paid to the source of medical malpractice claims and an abbreviated approach to specific strategies for risk management is presented.

[Current regulatory aspects: ambulatory surgery and dermatology]

Recently the catalogue for ambulatory surgery in hospitals has been updated presenting a successful integration into the classification of EMB 2000plus. A fundamental reconstruction resulted in changes to the specifications of health care services which are covered by the catalogue. The agreement became effective in April 2005. According to the new catalogue for ambulatory surgery, the procedure codes of the OPS classification and their transitions to a specified EBM-figure or category are relevant for the reimbursement of ambulatory services provided by a hospital or in private practice. Moreover, the regulations to avoid unnecessary bed days of hospital care and the criteria of the German appropriateness evaluation protocol (G-AEP) have to be considered carefully in terms of inpatient admissions. In the following the revised catalogue for ambulatory surgery is reviewed in detail with special relevance to dermatology.

An analysis of recent antitrust issues affecting specialty practice: is dermatology immune?

In the healthcare industry, the rules of regulation and competition often collide. Despite the view of Medicine as a "learned profession", it is clear that physicians will be subject to the same legal restrictions against sharing price information as those in place for any other industry. Thus, the relevant provisions of antitrust law will apply to most activities of physicians. Although recent case law has involved actions undertaken by physicians in other specialties of Medicine (e.g. oncology) the activities reviewed will likely be applicable to Dermatologists as well.

[Off-label use in dermatological practice. The conflict between professional duty and legal requirements]

When making therapeutic decisions, doctors often find themselves faced with a dilemma regarding ethical, professional, legal liability, social and service aspects of their duties. These conflicts may be enhanced when medications have to be prescribed for non-approved usages, known as off-label prescribing, because existing therapy options have been exhausted. This option become considerably more difficult since the German Federal Social Court decision of March 2002 which limited off-label use to a number of very strictly defined circumstances. In order to clarify the basis for taking decisions in a given situation, an oncology expert commission has been formed under the coordination of the Department of Health and Social Security. However, this is no solution for the great variety of uncommon dermatological diseases which often require off-label medication usage.

Interstate dermatopathology interpretations—50 separate licenses?

The increasing bureaucracy of health care has had a serious negative impact on physicians and patients for the last fifteen years. We report an example of this trend involving the interstate interpretation of dermatopathology specimens, which resulted in a significant interruption of diagnostic services to a large number of dermatologists. Temporary and long term solutions are discussed with the hope that dialogue and political consensus-building can bring resolution to the problem.

[New dermatologist's procedure. Research plans for improving secondary prevention of occupational dermatoses]

The dermatologist's procedure was introduced in 1972 by employers' liability insurance funds in the industrial, agricultural, and public sectors of Germany's statutory occupational accident insurance as a "procedure for early detection of occupational skin diseases." So far, it is still the most relevant tool for secondary prevention in occupational dermatology in Germany. According to the intention of this procedure, insured persons with a skin disease in which an occupational etiology is suspected must be offered preventive measures and, if necessary, given appropriate treatment to avoid job-loss. To improve the efficiency of the "classic" dermatologist's procedure, in 1999, on the initiative of the Central Federation of Industrial Professional Associations, a study group was founded in cooperation with the Task Force on Occupational and Environmental Dermatology of the German Dermatological Society and the Professional Organisation of German Dermatologists. In October 2002, a controlled intervention study started in North-western Germany to scientifically evaluate the "optimised" dermatologist's procedure, which was proposed by the study group and compare it to the standard ("classic") procedure. The study results should allow detailed suggestions for an improved dermatologist's procedure before it is introduced nationwide.

Medical malpractice and cancer of the skin

BACKGROUND

A litigation crisis exists in this country, and it may be better understood through analysis of lawsuits. Verdict summary analysis has been used for this purpose.

METHODS

Ninety-nine jury verdict reviews from 1986 to 2001 were obtained from a computerized database. Reviews compiled data on defendants, plaintiffs, allegations of wrongdoing, cancer cell types, sites, outcomes, and case summaries. Data was entered into a spreadsheet for analysis.

RESULTS

Failure to diagnose was alleged in 54%; of these, 48% alleged biopsies were inappropriately omitted. Allegations were highest for failure to diagnose in dermatologists and general practice physicians, for misdiagnosis in pathologists, and for complications in surgeons. Young patients and those with poor outcomes received more and larger awards. Trauma appears to have support for a role in causation of skin cancer in some courts.

CONCLUSIONS

The study of skin cancer suits may help develop risk management and prevention strategies.

Photographic images, digital imaging, dermatology, and the law

BACKGROUND

Patient photographic images play an important role in dermatological record keeping and training. An assessment of the legal implications of image taking is necessary to use images properly.

OBSERVATIONS

Images are parts of the medical record and must be treated with the same care as written medical records. Because multiple digital images are sometimes taken and digital images can be easily manipulated, they present novel issues in this regard. Images can be used as evidence in court. Issues regarding digital images include (1). authentication, (2). manipulation, (3). audit trail verification, and (4). data compression. The Health Information Portability and Accountability Act requires that health care providers control and track those who have access to identifiable digital medical information. This should facilitate the use of digital images as evidence because the provenance of digital images can be established. The Health Information Portability and Accountability Act covers the use and disclosure of protected health information, such as "full-face photographic images and any comparable images." To publish identifiable digital images (images of the face), it seems prudent for patients to waive in writing their rights to this protected health information. Conclusion Images will continue to enhance dermatological care, and understanding and accounting for the legal underpinnings of their use is prudent.

G-DRG Version 2004: Veranderungen aus Sicht der Dermatologie. G-DRG Version 2004: Changes in view of dermatology

In the year 2004 the obligatory introduction of the new hospital funding system based on a Diagnosis Related Groups (DRG) system will become reality for all German hospitals. After all fundamental items of the new G-DRG version were made generally known, the possible consequences had to be considered. The first mandatory German case-based lump sum catalogue differs importantly from the previous payment models and requires intensive study. Economic considerations will increasingly play a role in the daily routine of hospitals and influence treatment patterns. Therefore, comprehensive knowledge of basic principles of G-DRG is essential. In the following aspects of the reimbursement system with special relevance to dermatology are reviewed in detail. Additionally, the revised classification system versions OPS-301 SGB V and ICD-10-GM 2004 and the German coding standards version 2004 must be appropriately applied for dermatologic purposes.

Legal claims in Scottish National Health Service Dermatology Departments 1989-2001

BACKGROUND

An area of current National Health Service (NHS) interest is risk management as it is one of the requirements of clinical governance. If there are aspects of dermatological practice prone to mishap or dispute then a review of legal claims in dermatology may highlight these areas. This would then allow input into these specific areas of practice to try and minimize future risk.

OBJECTIVES

To review all legal claims relating to NHS Dermatology in Scotland and characterize the main areas of risk.

METHODS

Staff at the Central Legal Office in Edinburgh reviewed all legal claims in NHS Dermatology between 1989 and 2001. Details provided were general, and claimants, staff, hospitals and regions of Scotland could not be identified.

RESULTS

Thirty claims were identified relating to five main areas of dermatological practice: (i) phototherapy (eight claims); (ii) therapeutics (eight); (iii) cryosurgery/cryotherapy (six); (iv) surgery (four); and (v) misdiagnosis (three) and one alleged neurological problem after fainting. As well as consultants, nurses featured in phototherapy claims and junior medical staff in cryosurgery claims. Twelve of the 30 (40%) claims have reached settlement; three claims are presently outstanding.

CONCLUSIONS

Given the numbers of patients seen annually at Scottish NHS Hospital Dermatology units the absolute number of claims is low. Five main areas within dermatology were highlighted as at risk of litigation and this has implications for all U.K. dermatology departments with regard to funding, staff training and patient information and consent.

Under the microscope: doctors, lawyers, and melanocytic neoplasms

Misdiagnosed melanoma remains one of the most common causes of lawsuits in histopathology. Reasons for this are discussed in conjunction with relevant literature, common errors in diagnosis, and strategies to avoid them.