ESCAMBIA COUNTY MEDICAL SOCIETY
President’s Message
MAY/JUNE2011 Volume 41, No. 3
The Real Cost of Medical Errors by Michelle Brandhorst, MD
Upcoming Events Thursday | July 7 Location: Hancock Bank on Creighton Road 5:30 pm Speaker: Dr Timothy McDonald Topic: Medical Errors 1 hour CME Sponsored by: Hancock Bank
RSVP: 478-0706 ECMSinfo@bellsouth.net Founded in 1873
As many of you are aware, the Florida Legislature recently sent to Governor Scott’s desk medical malpractice reform legislation (HB 479) which
feel that a trial attorney, thanks to their prolific advertising, is their first
requires expert witnesses from other states to obtain a certificate prior to giving testimony and gives the Florida Board of Medicine the authority to discipline witnesses that give false testimony. The Florida Medical Association, which we support, is to be congratulated on this achievement as well as their ongoing efforts to make Florida a state where physicians want to practice and thus insure Florida citizens access to quality medical care. This reform bill as well as recent amendments that capped attorney fees and awards for non-economic damages are helping stabilize, if not reduce, medical malpractice premiums. A bill in the U.S. House was recently introduced that caps malpractice and attorney fees and even though this will not likely survive in the U.S. Senate, it does give us hope that further improvements may come. Our ultimate goal is to provide access to medical care to as many Floridians as possible and provide that care, without causing harm. High malpractice premiums and a litigious environment make it difficult to attract or retain physicians that will provide this care. Adverse outcomes are a part of patient care, but medical errors that cause adverse outcomes should not be. Lawyers seem to believe that the fear of litigation and its associated cost will drive the health system toward safety ala McDonald’s coffee. The opposite of course is true. It may enrich some members of the trial bar and some of their clients but the adversarial, highly emotion environment of a law suit is not conducive to system improvement and improving patient safety. Medical errors are a reality. Recent articles in The Wall Street Journal indicate that medical errors result in 98,000 American deaths each year and increase health care cost by $19.5 billion per year. One can argue the validity of these individual studies but, medical errors occur too frequently and there is a perception that the medical profession tries to hide or cover up these errors. Thus, some patients may
contact when they feel they have been a “victim” of a medical error. Dr. Michelle Brandhorst Our ultimate goal should be to create an environment in which preventable adverse outcomes and near misses are openly reported and corrective action taken to prevent a reoccurrence of the error. As physicians, we can agree that the court room is not the place to investigate possible medical errors. We can agree to develop personal, professional and system changes to investigate adverse outcomes and to insure that errors that result in preventable adverse outcomes do not reoccur. The question in the details of do we achieve this and how do we also insure that patients are reasonably compensated when preventable adverse outcomes occur? Given this recent press regarding the cost of medical errors and the recent victories in making the med-mal process more difficult it is a golden opportunity for organized medicine to address this issue and indeed we should feel obligated to address this issue. We must show patients that we take this issue seriously and that patients can trust medical professionals as their first contact in the event of an adverse outcome, preventable or not preventable. Patients do not just want to enrich themselves and their attorney. Studies have shown that when preventable adverse events occur, patients and families want to know what happened, receive an apology, care and just compensation and be confident that steps are being taken to insure that no one else will be harmed in a similar way. With this background, this summer, in conjunction with Sacred Heart Hospital, the Escambia County Medical Society will offer two lectures by Timothy McDonald, MD, JD, Chief Safety and Risk Officer at the University of Illinois Hospitals in Chicago. Dr. McDonald is board certified in both pediatrics and Continued on page 3
ECMS Bulletin The Bulletin is a publication for and by the members of the Escambia County Medical Society. The Bulletin publishes six times a year: Jan/ Feb, Mar/Apr, May/Jun, Jul/Aug, Sept/Oct, Nov/Dec. We will consider for publication articles relating to medical science, photos, book reviews, memorials, medical/legal articles, and practice management. Editors Norman Vickers, MD Holly Strickland, Executive Director
AD PLACEMENT Contact Holly Strickland 478-0706 Ad Rates Full page: $600 • ½ page: $300 • ¼ page: $150
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2011 ECMS Officers President Michelle Brandhorst, MD President-Elect George Smith, MD Vice President Wendy Wozniak, MD Secretary /Treasurer Susan Laenger, MD
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Vision for the Bulletin: -Appeal to the family of medicine in Escambia and Santa Rosa County and to the world beyond. - Collaborate with the Alliance to bring together Escambia and Santa Rosa County medical families. To know the needs of the community and promote the healthcare needs. - A powerful instrument to attract and induct members to organized medicine. Views and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the directors, staff or advertisers.
For more information, contact Shelly Hakes, Director of Society Relations at (800) 741-3742, Ext. 3294.
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Membership We Are Pleased to Announce Two NEW Member Benefits for 2011! DOCBOOK is FREE for Everyone with ECMS!
Introducing... The Healthcare Attorney On Call Members can call after hours with a specific legal issue or question and receive a response no later than noon the next business day. This Service is now available for all members at no charge. Hotline number is 561-306-5699 Provided by Florida Healthcare Law Firm www.FloridaHealthcareLawfirm.com
Send Your Vote on ECMS Mission and Vision ECMS has been in the process of creating a mission and vision for several months. The Board has agreed on a mission and vision statement for ECMS. We are now allowing the membership to comment through the end of June 2011. You may make suggestions or cast your vote through email at ECMSexec@bellsouth.net Mission: The mission of the Escambia County Medical Society is to promote the art and science of medicine in order to improve the health of our community . Vision: Tradition – Honoring the history of medical care in Escambia and Santa Rosa counties. Service – Serving the needs of our community through the service of our members in the practice of medicine. Leadership – Meeting the challenges of the future and safeguarding our community’s health through organized collaboration on the local, state, and national level.
Connect with members on the go! I’d like to introduce our new ECMS Mobile application, which we believe is a revolutionary design to connect with members. Our intention is to create a simple but effective way for our community of physicians to communicate across hospitals and above physician directories. ECMS has partnered with DocBook to help keep our community of physicians up-to-date with the latest physician and pharmacy information. We’ve worked hard to create an electronic directory that is a living document. This application has a great design which allows physicians the ease to search for important information on the fly. A quick reference tool located in your pocket everywhere you go. By design this app gives our physicians a platform structure to create their own personal communication outcomes. We have loaded the ECMS Mobile app with physician information that can be tailored to each physician’s communication preference. You may opt to text, email, or call your fellow physicians. Our primary goal is to also keep physician information private and secure. Therefore, DocBook uses the highest form of encryption and verification for safety. The information provided is secure in our database and the information you store on your personal IPhone or Android is limited to your use. This application is currently a benefit of membership; therefore a physician must apply for membership, receive member number, and sign up for the application. Only MDs and DOs are eligible for the benefit.
Corrections to the Directory James Patrinely, MD
Henry Porter, MD
Robert Camreon, MD
17 East Main Street, Ste 100 Pensacola, FL 32502 Phone: 473-0900 Fax: 473-0790
9400 University Parkway, Ste 109 Pensacola, FL 32514 Phone: 438-1136 Fax: 438-1148
4541 N Davis Hwy, Ste A Pensacola, FL 32514 Phone: 494-9000 Fax: 474-4123
President’s Message, continued from page 1 anesthesiology and has been a licensed attorney since 1997. He has been instrumental in developing a principled approach to adverse outcome investigation. This approach involves investigation of adverse outcomes which consists of seven “pillars.” 1. Reporting 2. Investigation 3. Communication and disclosure 4. Apology and remediation 5. System improvements 6. Data tracking and performance evaluation 7. Education and training. This principled approach seeks to address preventable adverse outcomes fairly, care for patients and families affected, and support and
educated care providers involved with the goal of improving patient safety and preventing a recurrence of a preventable adverse outcome. If an adverse outcome was not preventable that information is also shared with patients, families and staff. The patient, staff and the therapeutic relationship between the patient and staff, are all still supported. If an adverse outcome was judged not preventable, and litigation ensues, the case will be vigorously defended. The Medical Society will also recognize in the next newsletter safety initiatives currently being implemented by physician groups and hospitals. Please submit your Safety Pearls and initiatives so that they can be shared with your colleagues. I look forward to seeing you at our meetings and working with you while we strive to provide safe and effective medical care and to preserve the patient-physician relationship.
Practice Management Preventing Allegations of Sexual Misconduct By the Risk Management Experts at First Professionals Insurance Company Of all the allegations that can be raised against a physician, sexual misconduct is no doubt the most devastating. Professional, as well as personal integrity is attacked. Moreover, the stigma of such allegations may linger long after vindication. While most claims alleging sexual misconduct lack merit, careers get ruined and private practices destroyed. Personal relationships with family, friends, and colleagues often become strained and irreparably harmed. Exposure to criminal prosecution is created. In terms of loss prevention, an understanding of the difficulty in defining sexual misconduct is necessary. Sexual misconduct between a physician and patient may include sexual behavior or involvement with a patient, including verbal or physical behavior that may reasonably be interpreted as romantic involvement, regardless of whether such involvement occurs in the professional setting or not. Courts have interpreted sexual misconduct to include behavior or actions reasonably interpreted by the patient as being sexual. This could include a patient not actively receiving treatment from the physician, which results from the use or exploitation of trust, knowledge, influence, or emotions derived from the professional relationship. Generally, sexual behavior or involvement with a patient excludes verbal or physical behavior that is required for medically recognized diagnostic or treatment purposes when such behavior is performed in a manner that meets the standard of care appropriate for the diagnostic or treatment situation. The fact that a person is not actively receiving treatment or professional services from a physician may not be determinative, and depending on local statutes, may extend even after the physicianpatient relationship has ended. The actual definition of sexual misconduct is unclear. Legal definitions vary by venue. In the context of medical malpractice, sexual misconduct in the practice of medicine means violation of the physician-patient relationship through which the physician uses the relationship to induce or attempt to induce the patient to engage in sexual activity outside the scope of the practice or scope of generally accepted examination or treatment. The Ad Hoc Committee on Physician Impairment’s report on sexual boundary issues defines sexual misconduct as behavior that exploits the physician-patient relationship in a sexual way. Regardless of the definition, sexual behavior on any level with a patient within a professional relationship is prohibited in virtually every instance. Engaging in a sexual relationship with a patient outside of medical treatment or after the professional relationship is ended is still a question of ethics and places a physician at risk for allegations of sexual misconduct. Although the patient or physician may have “officially” terminated the physician-relationship, courts will often consider the patient’s underlying vulnerability and dependence on the physician. Although allegations of sexual misconduct are among the most difficult to defend, they are the easiest to avoid using two basic risk management tenets: utilize a chaperone whenever possible, documenting the record to that effect, and avoid statements or behavior that could be misinterpreted by the patient. Some patients may feel that the presence of a chaperone is intrusive or otherwise violates their privacy. This is understandable. Patients have an absolute right to decline a chaperone. In such
cases, document the record. A physician has the right to refuse an examination without a chaperone being present. Patients should be advised in this regard and asked to comply with your policy. Patients that refuse to comply should be given a referral to another healthcare practitioner. Before starting an examination, advise the patient. Describe what the examination will entail, and give the patient an opportunity to ask questions. Ask the patient’s permission before physical examination is conducted. Explain your actions if you need to examine one part of the body when the symptoms are felt in another and when intimate physician examination must be conducted. Claims of sexual misconduct can be complicated and uncertain in terms of professional liability coverage. Generally, sexual misconduct constitutes an intentional act. Intentional acts are excluded by most liability policies. In addition, if the alleged sexual misconduct is not related to a professional service, coverage under most professional liability will not apply. However, most allegations of sexual misconduct assert the unwanted touching or manipulation of private parts during medical examination, when unwarranted and without medical purpose. Even seemingly benign behavior may be the basis of a claim of sexual misconduct. Generally, these types of claims entail a questionable “line crossing” in the physician-patient relationship: using the patient’s first name instead of last name, engaging in personal conversations during examination or professional encounters, personal contact, social interaction external to the medical office. Such behaviors increase a physician’s exposure to allegations of misconduct. Courts have also interpreted sexual misconduct to include behavior or actions reasonably interpreted by the patient as being sexual. In some instances, patients encourage inappropriate interaction. When patients come to accept that a physician has no romantic intentions, their feelings of rejection and anger are channeled by unfounded allegations of misconduct. While there is no set waiting period after termination of the physicianpatient relationship before allowing a romantic relationship, less than one year increases exposure for sexual misconduct. However, the official position of the American Psychiatric Association is that such relationships are never appropriate. Claims of sexual misconduct may also arise from inappropriate behavior or romantic involvement with co-workers and staff. It is not uncommon for allegations of sexual harassment and sexual misconduct to be initiated by a scorned individual. Such allegations involve non-patients and arise outside the scope of professional services. Therefore, most medical malpractice insurance policies will generally not respond to such claims. Risk Management Guidelines • Consider terminating the physician-patient relationship should inappropriate signals be sent by the patient • Avoid statements or signals that could be misunderstood by the patient • Refrain from overly social, informal behavior • Do not accept inappropriate gifts • Do not be recalcitrant. Firmly, but politely respond to inappropriate gestures or conduct Continued on page 5
Medical/Legal National Pilot Program Paves the Way for Payment Bundling By Laurel H. Thorpe In an effort to address unsustainable levels of health care spending, legislators included a variety of cost containment strategies in the Patient Protection and Affordable Care Act. The National Pilot Program on Payment Bundling is one proposed approach. The Pilot Program, set to begin no later than January 1, 2013, is intended to improve the coordination, quality, and efficiency of health care services throughout the country. During the five year pilot, CMS will assess whether Medicare can save money by paying one fee for a single “episode” of care. An episode of care is currently defined as the period of time beginning three days prior to a hospital admission, the length of the hospital stay, and the 30 days following discharge. Only certain conditions and procedures will be included in the Pilot Program. These have not been determined. They will include a mix of chronic and acute conditions as well as a mix of surgical and medical conditions. In determining which conditions to include the Secretary will consider whether there is evidence of an opportunity to improve quality while reducing cost. CMS will accept bids from integrated care entities and negotiate rates accordingly. The total payment will be made to the entity which will then distribute it among all of the providers involved. Each year participating entities will be required to submit data on quality measures. The comprehensive bundled payment will be the total remuneration for all goods and services provided during that particular episode of care. It will include all services related to coordination of care, transitional services, and other patient-centered activities. The bundled payment scheme is not an entirely new concept. Similar initiatives were developed in the Netherlands. In 2007 a pilot program was established by the Dutch minister of health and in 2010 it was fully implemented for certain chronic diseases. The system created a new legal organization and principal contracting entity. The entity serves as a “general contractor” that “subcontracts” with providers. The parties freely negotiate the price for the services provided. The plan covers chronic conditions such as diabetes and COPD. In 2009 CMS launched its own demonstration project focusing on cardiovascular procedures and hip and knee replacements. Five hospitals participated in the program. Hospitals and providers formed collec-
tive entities managed by the hospitals. The hospitals submit bids to Medicare and receive one comprehensive payment for each episode of care. A lot can be learned from these early initiatives. It is vital that prices be set appropriately from the beginning. Physicians who are part of participating entities may need to aggressively advocate for fair allocations of funds. Primary care physicians and those in smaller practices may be particularly vulnerable as business deals are negotiated. As implemented in the Netherlands, a wide range of prices for similar services developed as a result of free negotiations between groups and among providers. By necessity a bundling of payments leads to a greater definition of roles among providers. In order for integrated care entities to succeed under bundled reimbursement, providers must fully understand their role in the patient’s care and be paid according to their participation. The hoped for result is increased collaboration among providers. The preliminary findings from the Netherlands suggest that one consequence of expanding bundled payment programs was a decrease in patient choice. As groups developed relationships with preferred providers, patients lost some freedom to choose among providers and facilities. Many are encouraged by the success of previous initiatives and it is clear that CMS views bundled payment programs as a key provision for Medicare cost containment. Supporters state that such programs can help to shift the financial incentive to the provision of cost-effective, high quality care. Better treatment protocols will be developed and there will be a greater adherence to standardized medicine. Many uncertainties remain. For example, it is unclear how the Pilot Program will account for coexisting conditions, how it will avoid shifting costs outside the bundled services, and how it will impact the overall cost of care. Additionally, there are still questions about how agreements between parties will avoid violations of fraud and abuse and antitrust laws. Although the Pilot Program will be conducted over a five year period, it may be expanded any time after that period. Expansions are likely if the initial assessments suggest that spending can be reduced and quality of care increased or maintained. Further, private insurers are poised to follow suit in the event that bundled payment programs meet the goals of cost containment and improved quality of care.
Sexual Misconduct, continued from page 4 • When necessary, clarify the boundaries in your physician-patient relationship • Exercise the same, if not heightened caution, when examining or treating employees • Require that patients disrobe in private and are provided cover gowns • Utilize a chaperone whenever examining patients of the opposite sex • Never examine a new patient, of the opposite sex, without a chaperone present • Document the identity of the chaperone present
• Do not rule out the need for a chaperone just because the patient is the same gender. Allegations of inappropriate behavior have been made by patients of the same sex • Exercise caution relative to romantic and intimate relationships with coworkers and staff For more information regarding this and other medical professional liability insurance risk management issues, please contact the risk management consultants at First Professionals Insurance Company at (800) 741-3742, ext. 3016 or send an e-mail to rm@fpic.com.
Membership
Health Fair i n i M MAY 10, 2011
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Foundation Go Seniors! Transportation Vouchers and Epi-Pens for Escambia County Schools ECMS Foundation has received TWO grants in 2011. As part of our mission to promote improved methods of healthcare and pursue the protection of public health we are proud to help our physicians and the community. By Holly Strickland On May 1, 2011, Escambia County Medical Society Foundation (ECMSF) implemented a new program that will provide Yellow Cab of Pensacola vouchers to eligible seniors. The program is Go Seniors! for Escambia and Santa Rosa residents. Funded by the Fellows Memorial Fund, the $30,000 grant is designed to encourage independent community mobility for seniors who need transportation assistance that may find the cost of transportation prohibitive to meet healthcare needs. Fellows Fund was founded in 1961 under the will of the late Earle W. Fellows-Williamson, widow of the beloved Pensacola physician, Dr. J. Hugh Fellows. The Fellows Memorial Fund assists in providing loans for students in the field of medicine, nursing, medical technology, and ministry, as well as fund programs around the elderly at risk population in our community. The ECMS Foundation is involved in providing services to at risk populations and currently supports the WeCare program focused
on providing specialty physician care to the working poor. With financial support of the Fellows Memorial Fund and physicians the Go Seniors! program will help provide door- to-door transportation for healthcare related needs. Go Seniors! transportation vouchers will be distributed by ECMS physicians, Health and Hope Clinic, St. Joseph’s Clinic, Good Samaritan Clinic, and the Escambia County Community Clinic. To be eligible, a person must be 60 years of age and be certified by a healthcare professional as needing door-to-door assistance. For more information call Escambia County Medical Society Foundation (850) 478-0706. I am grateful to our ECMS members. Thank you for supporting ECMS, me, and your dedication to our community. See the Go Seniors! Taxi Adventures below.
Rachel Holt, MD & Hillary Norris Jack Kotlarz, MD & Ruth Lewis
William Belk, MD
John Lanza, MD & Michelle Brandhorst, MD
Paula Montgomery, MD
Carol Willis & Wayne Willis, MD
On May 10, 2011, ECMSF was notified we received a $2,000 grant from the Partnership For Public Health, Inc. This grant was written to provide Epi-Pens to all of the Escambia County Schools. We are very grateful to all the Partnership For Public Health for supporting our goal of safety of students in life-threatening situations of allergic reactions.
Membership 2011 FSU Match Day Results Few events hold more drama, or have more impact, in the life of a medical student than Match Day. For many, the sealed envelope holds the key to the future. The residency match is conducted annually by the National Resident Matching Program. It’s the primary system for pairing graduating medical students across the United States with residency programs at teaching hospitals. Graduating medical students across the country received their match information at the same time on the same day. FSU College of Medicine’s ceremony took place, March 17, Ruby Diamond Concert Hall, Tallahassee, FL. Student Blick, Jessica Brown, Jennifer Chandler, Ashley Elliott, Mark
Institution Name Vanderbilt University Medical Center Madigan Army Medical Center Virginia Tech Carilion School of Medicine University of Florida College of Medicine
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Escobar, Vanessa Golden, Erin Harris, David Hunter, Abby Lagergren, Emily March, Bradford Martin, Tashara Martinez, Eric McGlynn, Kathleen Murphy, Kelli Newell, Ashley Nguyen, William Peters, Gregory Schultheis, Caitlin Spencer, Natasha Vollmer, Tiffany
Halifax Medical Center Mayo School of Graduate Medical Education Thomas Jefferson Hospital Wake Forest Baptist Medical Center Wake Forest Baptist Medical Center Rhode Island Hospital/Brown University Greenville Hospital System/U. of South Carolina University of Texas Medical School St. Johns Mercy Medical Center Naval Medical Center University of Alabama Medical Center Einstein/Montefiore Medical Center Wake Forest Baptist Medical Center University of Florida College of Medicine University of Alabama Medical Center Thomas Jefferson Medical College
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Residency Program IM - Neurology - Pediatrics Family Medicine Surgery - General Surgery - Orthopaedic Family Medicine IM - Neurology IM - Neurology Pediatrics Surgery - General Radiology - Diagnostic Pediatrics Surgery - General Obstetrics/Gynecology Internal Medicine Pediatrics Psychiatry Emergency Medicine Obstetrics/Gynecology Obstetrics/Gynecology Pediatrics
InThe Community Baptist Hospital
Hospital News Sacred Heart News Sacred Heart Hospital Among Top 5 percent in the Nation for Women’s Health Sacred Heart Hospital in Pensacola is the recipient of the 2011 Women’s Health Excellence Award™ and is ranked among the top five percent in the nation for women’s health, according to a study released by HealthGrades®, the nation’s leading independent source of hospital quality ratings. HealthGrades analyzed hospital complication and mortality rates among women ages 65 and older in 16 of the most common diagnoses and procedures in two primary areas: cardiac care and bone and joint health. Its findings are based on an analysis of more than five million Medicare patient records from 2007 to 2009 from nearly 5,000 hospitals across the nation. Sacred Heart was one of only 170 hospitals in the nation, and the only hospital in the Mobile-Pensacola area, to be honored with this distinction. New President of Sacred Heart Women’s and Children’s Hospitals Sacred Heart Health System welcomes Dana Bledsoe as the new President of Sacred Heart Women’s and Children’s Hospitals. Dana began her new role in Pensacola in late April and is responsible for both Women’s and Children’s Services, including the Ann Baroco Center for Breast Health. Dana began her healthcare career as a nurse and has spent the past 19 years in leadership roles at pediatric hospitals. She has served for the past seven years as VP, Patient Care Services, and CNO for Children’s Hospital of Orange County, a 238-bed pediatric facility in Orange, Calif. Dana brings a wealth of experience, a commitment to excellence and a high degree of enthusiasm to this new role. Please join us in welcoming her and her family to our community.
Baptist Hospital announces new leading-edge digital OR. BHC is the first in the region to complete the first of five new hybrid i-Suite® operating rooms (ORs) designed to support minimally invasive surgeries as a part of Baptist Hospital’s new 42-bed Center of Innovation. Features include larger rooms, ceiling mounted equipment, high def medical video system and Integrated surgical environment capability displays. This $1.1 million investment is part of Baptist Hospital’s current $39 million construction project. The remaining four ORs are estimated to be complete by late 2011. Advances in pulmonary lobectomy at Baptist enhance patient outcomes. Baptist now offers da Vinci S HD® Surgical System pulmonary lobectomy, a minimally invasive procedure to treat lung cancer that reduces pain, complications, incision size and recovery time. BHC is the first health care system in northwest Florida offering this advanced procedure. For more information, call 850.857.1734 or visit eBaptistHealthCare. org/RoboticSurgery. Baptist Medical Group practices offer patient-care partnership solution for fellow community physicians. Physicians now have a new way to care for their patients when planning time away from their office. Many Baptist Medical Group practices will partner with local physicians to provide walk-in care services or same-day appointments for their patients while his/her office is closed. Upon the doctor’s return, BMG physicians gladly provide documentation on the care provided to ensure continuity of care. To find a physician willing to help while you’re away, visit BaptistMedicalGroup.org or call 850.437.8600.
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