Medical Association of Georgia Journal

Vol. 105, Issue 3 2016

HIT: How it may now help you and your patients

A Q&A with MAG’s CME Committee chair Physicians and advertising Valacyclovir and acute renal failure Legal discusses chaperones & how a CMS telehealth proposal might affect rural areas

How does telemedicine impact your coverage?

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Experience the MagMutual PolicyOwner difference, call 800-282-4882 or visit MagMutual.com SM

Since inception, MAG Mutual Insurance Company has declared $175 million in dividends to our policyholders. Dividend payments are declared at the discretion of the MAG Mutual Insurance Company board of directors. Insurance products and services are issued and underwritten by MAG Mutual Insurance Company and its affiliates.

TABLE OF CONTENTS VOLUME 105, ISSUE 3

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12

YOUR AD HERE 16

18

IN EVERY ISSUE

FEATURES

3 President’s Message

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4 Editor’s Message 6 Executive Director’s Message 16 Medical Ethics 22 Legal: Chaperones are more important than ever 26 L egal: CMS telehealth proposal could aid rural beneficiaries 29 MAG Member Profiles 30 Patient Safety: Health care − A rich new environment for cybercriminals 32 County, Member & Specialty News 35 Prescription for Life

HIT: How it may now help you and your patients

12 Education: A conversation with MAG’s CME Committee chair 14 Case Report: Valacyclovir and acute renal failure 18 GCMB: Georgia’s physician advertising law

PRESIDENT’S MESSAGE

Here comes MACRA – ready or not John S. Harvey, M.D.

johnharveymd@gmail.com

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fter a decade of having Congress kick the can down the road and the constant threat of double-digit pay cuts hanging over our heads, the Medicare SGR is history.

But what we got in exchange is predicated on a zero-sum gain.

That means that there will be winners and losers, so it is essential for physicians and their staff to take the time to really understand the new payment system.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – the bipartisan legislation that replaced the SGR – was designed to “modernize and streamline Medicare and tie payments to quality patient care for hundreds of thousands of physicians and other clinicians.”

MACRA offers strong incentives for physicians to participate in either a Medicare risk-sharing Alternative Payment Model (APM) or the Merit-based Incentive Payment System (MIPS), which will employ a number of metrics that are linked to quality, resource use, health information technology, and clinical practice improvements.

The federal government will begin to use this single payment platform in 2019. But what physicians and applicable practice staff need to understand and embrace today is that the Centers for Medicare & Medicaid Services will use 2017 numbers as the basis for the initial reimbursement.

The MIPS system will employ a 100-point MIPS Composite Performance Score (CPS) – and your Medicare pay will be tied to that CPS score. The MIPS bonuses and penalties will range from four percent in 2019 to nine percent in 2022 and beyond.

The majority of Georgia’s physicians will end up in the MIPS model, which will continue to pay on a fee-for-service basis – but which will also combine the existing Medicare quality reporting programs (PQRS, EHR Meaningful Use, and valuebased payment modifier) into a single program.

On the APM track, practices will assume some level of financial risk and reward for their patient populations – in addition to quality, cost, and EHR standards (i.e., similar to MIPS).

Practices that meet the APM criteria will not be subject to MIPS, and they can earn an annual lump-sum bonus of five percent of their total Medicare payments from 2019 to 2024, with higher fee-schedule updates in 2026 and beyond.

But whether it’s MIPS or APM – and whether you’re in a solo practice or large group – the odds are that MACRA is going to touch your practice.

Adrienne Mims, M.D., MPH, is the vice president and chief medical officer for Medicare Quality Improvement for Alliant Quality (the Medicare Quality Innovation Network-Quality Improvement Organization for Georgia), a MAG member, and a leading authority on Medicare pay. When she appeared on MAG’s ‘Top Docs Radio’ program in August, Dr. Mims encouraged physicians and medical practices to…

• Review their Medicare Quality and Resource Use Reports (QRUR) as soon as possible • Use the Medicare PQRS system to begin to report their quality measures • Use an electronic health records (EHR) system That is some great advice – and I could not agree more.

And whether it comes to identifying high-cost patients or achieving better patient engagement or reducing readmissions and adverse events or coordinating care and managing resource use or accurately reporting quality measures to the various registries and payers, I also believe that we as physicians will need to make better use of health information technology so we can prosper in the post-SGR world.

With that in mind, I encourage you to read the feature article that begins on page 8 of this edition of the Journal, which addresses the relationship between health information technology and the new MACRA payer metrics.

I also encourage you to visit www.healtheparadigm.com to see how you can get connected to a new physician-led health IT solution that is being offered by MAG and KaMMCO Health Solutions that will enable you to generate sophisticated patient data reports that you can use to improve outcomes and fulfill the new payer metrics.

I believe that HealtheParadigm will enhance and transform Georgia’s health care system – and I also believe that HealtheParadigm is going to appeal to a lot of independent, community-based physicians and other health care providers who aren’t currently using a health information exchange given the less-than-physician-friendly options that are currently available.

Editor’s note: Go to http://go.cms.gov/1Gb6GDL for the MIPS/ APM website and go to www.mag.org/resources/TopDocs to listen to a recording of Dr. Mims’ ‘Top Docs’ show. Also contact Dr. Mims at Adrienne.Mims@AlliantQuality.org for free assistance with PQRS reporting or with any questions related to the Medicare QRUR. www.mag.org 3

EDITOR’S MESSAGE

The Medical Association of Georgia 1849 The Exchange, Suite 200 Atlanta, Georgia 30339 800.282.0224 www.mag.org MAG’s Mission To enhance patient care and the health of the public by advancing the art and science of medicine and by representing physicians and patients in the policy-making process.

Editor Stanley W. Sherman, M.D. Executive Director Donald J. Palmisano Jr. Publisher PubMan, Inc. Richard Goldman, rgoldman@pubman.net 404.255.5603, ext. 1 Editorial Board Janis S. Coffin, D.O., Augusta Jay S. Coffsky, M.D., Decatur Mark C. Hanly, M.D., Brunswick Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee John S. Harvey, M.D., President Steven M. Walsh, M.D., President-elect Manoj H. Shah, M.D., Immediate Past President Madalyn N. Davidoff, M.D., First Vice President S. Mark Huffman, M.D., Second Vice President Rutledge Forney, M.D., Chair, Board of Directors Frederick C. Flandry, M.D., Vice Chair, Board of Directors Andrew B. Reisman, M.D., Secretary Thomas E. Emerson, M.D., Treasurer E. Frank McDonald Jr., M.D., Speaker of the House Edmund R. Donoghue Jr., M.D., Vice Speaker of the House Michael E. Greene, M.D., Chair, Council on Legislation S. William Clark III, M.D., Chair, Georgia AMA Delegation Advertising PubMan, Inc. 404.255.5603 or 800.875.0778 Fax 404.255.0212 Brian Botkin, bbotkin@pubman.net Subscriptions Members $40 per year or non-members $60 per year.

Foreign $120 per year (U.S. currency only).

The Journal of the Medical Association of Georgia (ISSN 0025-7028) is the quarterly journal of the Medical Association of Georgia, 1849 The Exchange, Suite 200, Atlanta, Georgia 30339.

Periodicals postage paid at Atlanta, Georgia, and additional mailing offices. The articles published in the Journal of the Medical Association of Georgia represent the opinions of the authors and do not necessarily reflect the official policy of the Medical Association of Georgia (MAG). Publication of an advertisement is not to be considered an endorsement or approval by MAG of the product or service involved.

Postmaster Send address changes to the Journal of the Medical Association of Georgia,1849 The Exchange, Suite 200, Atlanta, Georgia 30339.

Established in 1911, the Journal of the Medical Association of Georgia is owned and published by the Medical Association of Georgia. © 2016.

4 MAG Journal

MAG’s summer legislative conference

Stanley W. Sherman, M.D.

I

f you did not attend MAG’s ‘Summer Legislative Conference,’ I want to make sure that you know just what you missed. Derek Norton, MAG’s new director of Government Relations, greeted us at registration. It was opportunity to meet him and know that our organization is transitioning smoothly and is in good hands.

Our first session dealt with out-of-network billing and the inadequacy of increasingly narrow networks. Many of our fellow members gave examples of poor patient care and the difficulty they have collecting payment for services that have already been provided to patients. Members of the Georgia House and Senate Health and Human Services committees and the State House Insurance Committee composed the panel that listened to physicians’ concerns. In some areas of our state, hospitalists are listed as primary care providers – which makes networks appear adequate. We also discussed “any willing provider” solutions. If you have experienced network problems, what better way do you know to be heard and, hopefully, let those with the power to correct these problems truly understand them?

Our second session involved covering the uninsured. We heard a presentation on the magnitude of the problem. There is an estimated 485,000 to 560,000-person coverage gap in Georgia, where 110 of our 159 counties are rural. Gov. Deal refused the “Obamacare” Medicaid expansion because he believes the solution to this problem must be affordable and sustainable and simplified. And hopefully, the solution will involve helping move patients from welfare to work coverage.

The ACO delivery systems do not seem to be an answer – especially since 17 of 23 ACOs failed and only three have been profitable. Arkansas and Indiana have a waiver system that seems to be working. Georgia legislators are studying these systems in hopes that the waiver approach will keep our tax money here, rather than helping other states solve their problem.

The third session was on the insurance mergers. We were given the great news that the U.S. Department of Justice had filed an anti-trust lawsuit to block the mergers. The consensus from Georgia Insurance Commissioner Ralph Hudgens and our legislative panel was that this would not be good for our patients – which was good to hear. Please read MAG CEO Donald J. Palmisano Jr.’s in-depth discussion about this on page 3.

Congressman Buddy Carter gave attendees an update on health care from a federal standpoint. He presented Rep. Paul Ryan’s and the GOP’s health care proposal known as “A better way.” This includes 1) the repeal of “Obamacare” and 2) provides patients with more choices, lower costs and greater flexibility and 3) protects patients with preexisting conditions and complex problems and 4) spurs innovation in health care, like the “21st Century Cares Act” and 5) protects and preserves Medicare.

I must say that I cannot imagine a better forum for our representatives to hear our views about issues that affect our practices and hear examples (e.g., problems with Medicaid) that they can clearly resolve. If you could not attend this year’s meeting, please plan to attend in 2017.

For the first time that I can remember, this edition of the Journal includes a timely supplement on a symposium on pulmonary embolism that was presented by Emory, Piedmont and WellStar physicians to update us on the evaluation and management of this common problem.

The Journal’s feature article and Dr. John Harvey’s editorial deal with the Medicare Access and Chip Reauthorization Act, its implementation, and MAG’s new HealtheParadigm solution to document compliance. We also highlight MAG’s Education Committee with a Q&A on CME with the committee chair, Dr. Darrell Dean.

Lawyers from Polsinelli review new Center for Medicare & Medicaid Services’ proposals on telemedicine. Dr. John Antalis from our State Medical Board addresses controversies surrounding our physician advertising laws.

MAG Mutual Insurance Company informs us how to protect health care information from cyberattack. Andy Grant, CPA,

gives us tips to maintain a practice’s financial security.

Given the recent investigative reports in both The Atlanta Journal Constitution and national news of physician sexual misconduct, Daniel Huff’s article on guidelines for chaperone use is especially timely. Our medical ethics article reiterates the need for good physical exams, not just a quick check of a box in EMR. And we include a case report on an unexpected reaction to a patient’s use of too much Valcyclovir.

Finally, a big “Hooah” to Dr. Coffsky for his editorial.

Enjoy your fall with its cooler weather. And keep letting us know what problems you and your practice are experiencing so that MAG can help you find solutions.

MAG’s ‘Summer Legislative Education Seminar’ on Jekyll another big success

One of the panel discussions that took place during MAG’s ‘Summer Legislative Education Seminar’ on Jekyll Island on July 30 addressed out-of-network health insurance billing issues. The panel featured (from the left) Sen. Dean Burke, M.D., Rep. Sharon Cooper, Rep. Chuck Efstration, Rep. Lee Hawkins, Rep. Darlene Taylor, and Sen. Ben Watson, M.D. Jay Smith, M.D. (standing) served as the panel moderator.

Among the dignitaries who attended MAG’s 2016 ‘Summer Legislative Education Seminar’ were (from the left) Georgia Composite Medical Board Chair John Antalis, M.D., MAG President John Harvey, M.D., Saundra Harvey, and Georgia AMA Delegation Chair William Clark, M.D.

MAG Government Relations Director Derek Norton kicked off MAG’s 2016 ‘Summer Legislative Education Seminar’ with an overview and introductions. More than 50 MAG members had the opportunity to meet 25 legislators during the two-day event.

www.mag.org 5

EXECUTIVE DIRECTOR’S MESSAGE

A big, big victory Donald J. Palmisano Jr.

dpalmisano@mag.org

A

etna/Humana and Anthem/Cigna have repeatedly assured us that their pending mergers would be good for all. But physicians in Georgia did not bite on that line for one moment. And both physicians and their patients scored a huge win on July 21, when the U.S. Department of Justice (DOJ) and multiple state attorney generals (AG) – including Georgia’s Sam Olens – filed a lawsuit to block the mergers.

DOJ and the AGs said that the “transactions would increase concentration and harm competition across the country, reducing from five to three the number of large, national health insurers in the nation.”

This was also fortuitous timing, as the office of Georgia’s insurance commissioner had scheduled meetings to consider the mergers – meetings that were “continued” pending the outcome of the aforementioned lawsuit.

This victory can be largely attributed to the advocacy efforts of the Medical Association of Georgia (MAG) and the American Medical Association (AMA). That and, of course, the grassroots efforts of individual physicians who made phone calls and sent emails (including more than 600 in Georgia alone) to explain why these deals would have such disastrous results. In fact, I view this as MAG’s biggest “win” in the 11 years I’ve been with the organization.

When the mergers were first announced in 2015, a lot of people accepted the deals as done. But rather than accept the outcomes as a foregone conclusion, MAG’s Board of Directors decided to take a stand. They decided that opposing the mergers should be MAG’s number one priority – keeping in mind that just a handful of other state medical societies assumed a comparable position.

AMA deserves a lot of credit here, too. MAG – along with the Colorado Medical Society – asked AMA for resources to fight the mergers at the state level during AMA’s interim meeting in Atlanta in 2015. (AMA had met with DOJ, but little was being done to fight the mergers at the state level at the time.)

AMA responded in a big way. It promised (and delivered) the resources that were needed in the states that held the most strategic value, including Georgia. It also initiated a series of conference calls of a coalition of 17 states that were dedicated to fighting the mergers.

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Georgia was seen as pivotal because Aetna only needed two states to reach its goal of 20 states that okayed the mergers to withstand regulatory scrutiny at the national level.

And make no mistake about it, the effects of the mergers would be especially negative and pronounced in Georgia.

MAG determined that just two companies would control 90 percent of the individual health insurance market in the state – not to mention 80 percent of our group health insurance markets. What’s more, Aetna/Humana would be the only health insurance option for seniors in certain Medicare Advantage markets.

In addition to a joint letter that was sent to DOJ, an important part of MAG and AMA’s combined advocacy effort was conducting a joint survey of physicians in Georgia.

The results of that research clearly showed that physicians are opposed to the mergers – as many said they believe that the deals would ultimately limit the accessibility of medical care in the state. The county and state specialty medical societies in the state also deserve our collective thanks and applause for encouraging their members to take this survey.

And it is worth noting that MAG also formed a coalition of hospitals and other health care groups to oppose the mergers in Georgia. The Georgia Pharmacy Association consequently sent a letter to Georgia’s insurance commissioner to oppose the mergers. And a national consumer group contacted MAG to get its perspective to include in its advocacy efforts to oppose the mergers.

MAG members should be proud knowing that MAG President John S. Harvey, M.D., and the rest of their leadership team never strayed from their objective. So it was especially rewarding when we found out that DOJ and the AGs filed their lawsuit.

In terms of next steps, separate trials are scheduled to get underway in federal courts in December and January. Rest assured that MAG will continue to assist DOJ as it prepares for these trials.

This is undoubtedly one of a number of important battles that will take place on this front, but make no doubt about it: This was an important victory. And perhaps more importantly, it demonstrated what the medical profession can accomplish when it speaks with a unified voice.

Are You Ready

for the Transformation of Health Care?

To get started today call 678.303.9290 or visit www.HealtheParadigm.com.

HealtheParadigm is a private health information network endorsed by the Medical Association of Georgia. HealtheParadigm offers a suite of health information technology tools to help health care professionals across the state of Georgia to CONNECT, ANALYZE, ENGAGE and TRANSFORM in the midst of the MACRA/MIPS evolution.

HIT: How it may now help you and your patients

By Tanya Albert Henry

T

he answer to whether physicians will win or lose in the context of the new physician payment system will largely depend on what kind of technology they employ in the post-SGR era.

And the extent to which physicians and medical practices in Georgia are prepared for this new world is a fair question. But what’s not in doubt is whether technology will play a huge role in how they deliver patient care and get paid going forward.

In addition to getting rid of the dreaded SGR, the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) is supposed to enhance our health care system, including higher quality, greater efficiency, and lower costs.

For physicians and other providers, that means the payment system is moving away from the traditional fee-for-service system and toward a “merit-based” system.

“Technology is the primary tool that physicians and other health care providers will use to fulfill the new payer requirements,” explains Medical Association of Georgia (MAG) Executive Director and CEO Donald J. Palmisano Jr. “And assuming they use the right technology, it will enable them to root out waste and provide the best care for their individual patients – as well as their patient populations as a whole.”

Palmisano says that data, data sharing, and analytical reports can help prevent physicians from ordering tests that have already been ordered by another physician, it can help physicians identify patients who are 8 MAG Journal

not managing a chronic condition properly, and it can enhance their communications with patients and their peers.

MAG President John S. Harvey, M.D., believes that the time has come for physicians to take a more active and assertive role in the development of the technologies they employ.

“Physicians understand how the right technology can result in better, more efficient patient care,” Dr. Harvey says. “So I believe that we need to get off the sideline and become more engaged.”

The North Atlanta surgeon explains that, “It is no secret that the medical profession has largely relinquished control of the development of the technologies we use to insurers and other commercial entities and government bureaucrats. For the sake of our profession and our patients, that has to change – especially since technology will be such an important factor in the new payment system.”

This reality prompted MAG to enter into a partnership with KaMMCO Health Solutions – which is a subsidiarity of the Kansas Medical Mutual Insurance Co. and an affiliate of the Kansas Medical Society – to form a new physician-led health IT solution, HealtheParadigm, that will enable physicians to connect to a health information network that they can use to generate sophisticated patient data reports to improve outcomes and fulfill the new payer metrics.

Dr. Harvey says that, “I genuinely believe that HealtheParadigm will enhance and transform Georgia’s health care system, and I also believe that it is going to appeal to a lot of independent, communitybased physicians and other health care providers who aren’t currently

using a health information exchange given the less-than-physicianfriendly options that are currently available.”

He believes that this will be especially true when they find out that HealtheParadigm has formed an advisory committee that consists of a diverse group of physicians who live and practice in Georgia.

MACRA/MIPS When Congress passed MACRA, its goal was to change the U.S. health care system from a fee-for-service system to a performancebased one – and do so as quickly as possible.

The law did away with the Medicare SGR, which had subjected physicians to the threat of double-digit pay cuts every year for more than a decade.

MACRA offers strong incentives for physicians to participate in either a Medicare risk-sharing Alternative Payment Model (APM) or the Merit-based Incentive Payment System (MIPS), which will employ a number of metrics that are linked to quality, resource use, health information technology, and clinical practice improvements.

The federal government will begin using this single payment platform in 2019. But it is worth emphasizing that the Centers for Medicare & Medicaid Services will use 2017 data as the basis for the initial reimbursement.

The MIPS system will employ a 100-point MIPS Composite Performance Score (CPS), and Medicare pay will be tied to that CPS score. The MIPS bonuses and penalties will range from four percent in 2019 to nine percent in 2022 and beyond.

In explaining how MIPS differs from the system that is in place today, the American Medical Association (AMA) says that…

• “Quality” will replace the current Physician Quality Reporting System (PQRS) program

“Under MIPS, I believe that physicians can play a leadership role in overhauling and improving the Medicare system from patient outcomes and cost standpoints,” he said. “I also believe that we can begin to reduce what we all know are some unreasonable administrative burdens.”

So what should I be doing today?

According to Adrienne Mims, M.D., MPH – the vice president and chief medical officer for Medicare Quality Improvement for Alliant Quality (the Medicare Quality Innovation Network-Quality Improvement Organization for Georgia) and a MAG member and a leading authority on Medicare pay – key short-term objectives for physicians and medical practices should be…

• Reviewing their Medicare Quality and Resource Use Reports (QRUR) as soon as possible • Using the Medicare PQRS system to begin to report their quality measures • Using an electronic health records (EHR) system Dr. Walsh agrees, and he also encourages physicians to take advantage of the new HealtheParadigm solution.

He says, “This new entity will establish a private, statewide health information network that participating physicians can use to share key patient data. It will help physicians and other health care providers – including accountable care organizations – improve patient outcomes and fulfill the metrics that are now being required by the new performance-based payment models through the use of data analytics and business intelligence tools.”

Dr. Walsh also explains that, “Physicians can use the system to generate reports that they can use to address high-risk patients and chronic disease populations while improving patient outcomes through enhanced care coordination.”

• “Advancing Care Information” will replace the EHR Meaningful Use program

In addition, he believes that, “There is a clear need for HealtheParadigm based on the feedback that we have received from physicians and other stakeholders across the state who want a proven technology for connectivity that also delivers actionable intelligence while providing patients with access to their own health data.”

In addition, AMA says that MIPS will establish a “Clinical Practice Improvement Activities” component.

And Dr. Walsh stresses that this new health information tool will provide physicians with “seamless, real-time access to a patient’s full longitudinal medical record at the point of care.”

• “Resource Use” will replace the current Value-Based Modifier (VBM) program and

The physicians and practices who meet the APM criteria, meanwhile, won’t be subject to MIPS – and they can earn an annual lump-sum bonus of five percent of their total Medicare payments from 2019 to 2024, with higher fee-schedule updates in 2026 and beyond.

It is also worth noting that in addition to quality, cost and EHR standards (i.e., similar to MIPS), physicians and practices that follow the APM model will assume some degree of financial risk (and could receive a reward) for the overall health of their patient populations.

“But whether a physician falls under MIPS or APM, it will be imperative for them to be able to secure and submit the data they need to demonstrate that they are delivering quality care and fulfilling the required metrics,” Palmisano explains.

MAG President-elect Steven M. Walsh, M.D., an Atlanta-area anesthesiologist and the chair of the aforementioned HealtheParadigm Advisory Board, believes that physicians have a real opportunity to influence how the new payment system will ultimately look and work.

He points out that, “It has an analytic capability that allows physicians to improve clinical outcomes and community health by using the data to identify trends in care, uncover gaps in care and reduce inefficiencies, to name a few uses.”

Meanwhile, Dr. Harvey says that some of the factors that set HealtheParadigm apart from the other, more traditional health information exchanges in the state include…

• It has been endorsed by MAG’s Board of Directors • Provider governance of data utilization • It is connected to other health information networks across the country • Physicians and hospitals can use its data warehouse capabilities to manage their chronically ill patient populations and generate patient and public health and other analytical reports (continued on page 10)

www.mag.org 9

(continued from page 9)

• It is “agnostic” when it comes to EHR vendors • It has a “personal health record” feature that is automatically populated, which promotes better patient engagement (e.g., patients have access to a portal that includes their personal health records from every participating provider and they receive emails whenever new information becomes available) How HealtheParadigm works Dr. Walsh explains that HealtheParadigm allows EHR systems to communicate with one another “whether the care is being provided in a hospital or a clinic or in Georgia or California or somewhere in between.”

What’s more, he says, “The critical patient data can flow back and forth – no matter what electronic medical record system a particular hospital or physician is using to enter patient information.”

And according to Dr. Walsh, HealtheParadigm…

• Built a data warehouse that can be used to create custom reports, registries and benchmarks • Is a web-based system that does not require participants to download any software • Allows physicians to email patient health information in a safe and secure way • Reduces the amount of staff time that is required to fax or mail patient records • Helps demonstrate EHR meaningful use • Provides an audit trail for medical records • Facilitates better and quicker communications between physicians and patients

Dr. Walsh also points out that this system has a proven, five-year track record in Kansas.

Joe Davison, M.D., with West Wichita Family Physicians, P.A., remarks that, “I really love the fact that I can look at my patient population and see those patients who are in trouble.”

He adds that, “I may not have known they were in trouble, but when I look at the analytic reports that represent my panel of patients, I see I have a certain number of patients who have poor to no control of their diabetes for example. I can identify those patients. I can develop a list of those patients. Then I can act on that information.”

Dr. Davison has discovered that, “This kind of health information, specifically with analytics, is a hugely powerful tool.”

Dr. Walsh is excited knowing that, “MAG leveraged a proven technology and worked with KaMMCO to design a solution specifically for physicians and other health care providers in Georgia, and I can assure you that physicians from Georgia will continue to play the central oversight role in its ongoing development.”

Palmisano concludes that, “HealtheParadigm is a game-changer. It’s a dynamic and powerful patient-focused health care solution that is fully aligned with MAG’s mission and values.” ¨ Resources Physicians and other health care providers who have questions about HealtheParadigm can contact Susan Moore at 678.303.9275 or smoore@mag.org.

Also visit www.healtheparadigm.com for information on HealtheParadigm.

Finally, go to www.mag.org/resources/TopDocs to listen to a recent MAG ‘Top Docs Radio’ show that addressed HealtheParadigm.

Washington’s perspective on the future of interoperable health systems Government officials say that they are working with physicians – and making real strides – to develop an interoperable health system that will “empower individuals to use their electronic health information to the fullest extent [and will] enable providers and communities to deliver smarter, safer and more efficient care and promotes innovation at all levels.”

In a talk that he gave during AMA’s annual meeting in Chicago in June, CMS Acting Administrator Andy Slavitt said that [physicians] have an historic opportunity “to change how Medicare pays for care.”

He added that, “I am also here to talk about something bigger…[which is] reversing a pattern of regulations and frustration and ultimately unleashing a new wave of collaboration between

10 MAG Journal

the people who spend their lives taking care of us and those of us whose job it is to support that cause.”

Officials in the Office of the National Coordinator for Health IT (ONC) have created a “roadmap” that identifies what it believes physicians and others need to do in the near-term to create/ build an interoperable health system.

ONC envisions a “learning health system” where providers can seamlessly access and use health information from different sources and where an individual’s health information includes data from an array of sources to create a “longitudinal picture of a patient’s health and not just episodes of care.”

Making this information more readily accessible will also allow public health agencies and researchers to

learn, develop and deliver cutting edge treatments, ONC says – adding that is expects to have a system in place by 2024.

In terms of a key milestones, ONC expects to see the following…

• 2015-2017: The ability to send, receive, find and use priority data domains to improve health care quality and outcomes • 2018-2020: An expansion of data sources and users in the interoperable health IT ecosystem to improve health and lower costs • 2021-2024: Achieve nationwide interoperability and establishing a “learning health system” where the person at the center of a system can continuously improve care, public health and science by accessing real-time data

Are you ready to succeed in the post-SGR world?

T

he Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was designed to rapidly transform the U.S. health care system by promoting performance-based payment models across the full range of government and commercial payers – and it is replacing the Sustainable Growth Rate (SGR) formula as the basis for Medicare pay.

MACRA provides strong incentives for physicians to participate in either a Medicare risk-sharing Alternative Payment Model (APM) or the new Merit-based Incentive Payment System (MIPS), which are tied to quality, resource use, advancing care information, to include patient engagement and health information technology, and clinical practice improvement performance metrics.

Adrienne Mims, M.D., MPH, the vice president and chief medical officer for Medicare Quality Improvement for Alliant

Quality – which is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Georgia – explains that, “Beginning in 2019, the government will employ a mandatory single payment platform – but the Centers for Medicare & Medicaid Services will use 2017 as the basis for the initial reimbursement.”

• Use the Medicare PQRS system to begin to report their quality measures • Use an electronic health records (EHR) system

She also notes that the new MIPS system will employ a 100-point MIPS Composite Performance Score (CPS): “And there is going to be a direct relationship between a practice’s CPS score and its Medicare pay.”

Finally, Medical Association of Georgia President John S. Harvey, M.D., emphasizes that, “Whether it is identifying high cost patients, enhancing patient engagement, reducing readmissions and adverse events, coordinating care and managing resource use or accurately reporting quality measures to various registries and payers, we will as physicians need to make better use of health information technology so our practices can prosper in today’s environment.”

Keeping in mind that there will be winners and losers in the zero-sum MIPS world, Dr. Mims suggests that medical practices…

Contact Dr. Mims at Adrienne.Mims@gmcf. org with questions related to the MACRA requirements or MIPS.

• Review their Medicare Quality and Resource Use Reports (QRUR) as soon as possible

Go to http://go.cms.gov/1Gb6GDL for the Medicare MIPS website.

Dr. Mims stresses that, “This does not mark the end of the Medicare fee-for-service system for small practices.”

The new physician-led HealtheParadigm solution allows physicians to…

CONNECT • Join the HealtheParadigm health information network • Longitudinal, real-time patient EHR data • Secure messaging between physicians • Enhanced physician/patient communications • Public health reporting and disease registries ANALYZE • Web-based dashboards • Risk stratification reports • Chronic disease management • Readmissions management ENGAGE • Share EHR across providers • Better care coordination • Secure patient communications TRANSFORM • Improved patient outcomes • Population health management • Fulfill new payer requirements Contact Susan Moore at smoore@mag.org or 678.303.9290 to find out how MAG’s new HealtheParadigm solution can help you and your practice.

HealtheParadigm Advisory Group Steven M. Walsh, M.D. – Chair Anesthesiology Roswell Thomas E. Bat, M.D. Family Medicine Alpharetta Frank McDonald Jr., M.D. Neurology Gainesville Donald J. Palmisano Jr. Medical Association of Georgia Doug Patten, M.D. Georgia Hospital Association Joseph W. Stubbs, M.D. Internal Medicine Albany

www.mag.org 11

EDUCATION

A conversation with MAG’s CME Committee chair

D

arrell Dean, D.O., is the chair of the Medical Association of Georgia’s (MAG) Committee on Continuing Medical Education (CME). He recently addressed a number of important CME issues in a conversation with the Journal.

Q. What is the role of MAG’s Department of Education?

A. MAG accredits 39 organizations that are authorized to offer physicians AMA PRA Category 1 (CME) Credit(s)TM that meet Georgia and Tennessee license renewal requirements. This includes hospitals, voluntary health organizations, and specialty societies.

Q. Where does MAG get its authority to accredit CME providers?

A. MAG receives its authority to accredit intrastate CME providers from the Accreditation Council for Continuing Medical Education (ACCME). I should also stress that MAG’s Department of Education abides by all ACCME polices and standards.

Q. How did you get involved in CME? A. I was a member of the CME committee at a hospital where I had privileges. So when MAG advertised that it needed a CME surveyor in 2011, I felt like I could make a contribution – and I thought it could be a personally rewarding experience.

Q. What can CME providers do to make CME presentations more appealing?

Darrell Dean, D.O. Q. Are there other key considerations?

A. I encourage CME providers to really think about their audience. Is the topic one that will be relevant for the majority of physicians who will be in the room? This can be especially important when you are talking about physicians who practice in the broader specialties. It is equally important for the physicians who attend a CME program to understand the subject matter that will be addressed and whether that is truly applicable to their practice and their patients.

Q. How many hours of CME are physicians in Georgia required to take?

A. Physicians in Georgia are required to take 40 hours of CME every two years. But, again, I would encourage physicians to make sure they are taking the right CME versus just checking off the box because CME should ultimately result in better physicians and better patient care.

Q. What are your thoughts on a physician’s ongoing professional development?

A. I believe that we have a professional obligation to a lifetime of learning. That is especially true given the rapid pace of change in medical care.

Q. What are your thoughts on maintenance of certification and licensure?

Q. What are some of the typical concerns that physicians have about CME?

A. This is one of the more difficult and contentious topics for physicians. I believe that physicians should be held accountable to maintain their skill set in the context of their specialty and scope of practice. The rub is defining what is reasonable when it comes to demonstrating or proving one’s competence and knowledge. I don’t believe that there is a single perfect or comprehensive solution here, but I would support efforts to form an independent physicians’ committee to develop a flexible system that could be reviewed and updated as needed on a rolling basis that the profession views as reasonable and credible.

A. The time they are away from their practice is a common concern due to loss of income, as well as the actual CME program cost. It’s also not unusual to hear that a CME presentation is boring, especially when it comes to programs that are offered at the local level.

Editor’s note: Dr. Dean became the chair of MAG’s CME Committee at the beginning of 2016. Go to www.mag.org/affiliates/ accreditation or contact Andrew Baumann at abaumann@mag.org for additional information. MAG members who have an interest in volunteering to serve on the committee should contact Baumann.

A. I would encourage CME providers to look at quality and patient care data at their hospital. CME programs can then be aligned with specific issues – and they can then track their progress going forward. If you demonstrate that CME is driving better patient outcomes that will encourage more physicians to attend your CME programs. I also believe that more diverse CME programs, such as a panel discussion on a quality issue or a specific procedure, will help to increase CME attendance.

12 MAG Journal

MAG’s Department of Education

MAG accredits 39 organizations that are authorized to offer physicians AMA PRA Category 1 Credit(s)™ that meet Georgia and Tennessee license renewal requirements. This includes hospitals, voluntary health organizations, and specialty societies.

MAG’s CME Committee

Darrell Dean, D.O. (Chair) Wayne Mathews Jr., M.D. James Rawson, M.D. William Silver, M.D. MAG’s Top Free CME Resources

MAG recruiting CME committee volunteers

The MAG Committee on CME is a “[special committee that is] charged with the responsibility of accrediting organizations that desire to provide accredited CME activities to Georgia physicians. [It] reviews and approves applications for accreditation and reaccreditation, establishes accreditation policies, provides supervision and guidance to surveyors and holds periodic training sessions for staff of accredited organizations. [It] keeps all accredited organizations updated concerning MAG, Accreditation Council for Continuing Medical Education (ACCME) and American Medical Association (AMA) requirements and policies related to CME.”

Medscape www.medscape.org

The committee’s chair, Darrell Dean, D.O., says that, “This is an easy and rewarding way to make a contribution to the medical profession in Georgia. The primary role of this group is to ensure that the CME providers that MAG accredits offer interesting and relevant CME programs.”

MedPageToday www.medpagetoday.com/cme

He also stresses that, “Of course, this is ultimately a great way to enhance patient care.”

freeCME.com www.freecme.com

Dr. Dean says that the time commitment is nominal – as the committee generally only meets by conference call four times a year.

MyCME www.mycme.com Have questions?

Go to www.mag.org/affiliates/accreditation or contact Andrew Baumann at abaumann@mag.org or 678.303.9286.

MAG’s accredited CME providers American Academy of Pediatrics – Georgia Chapter 404.881.5067 Athens Regional Medical Center 706.475.7525 Children’s Healthcare of Atlanta 404.785.7624 Covenant Health 931.459.7037 DeKalb Regional Health System 404.501.1628 Emory Regional Perinatal Center 404.616.4219 Floyd Medical Center 706.509.5789 Georgia Academy of Family Physicians 404.321.7445 Georgia Chapter of the American College of Cardiology 770.271.0453

MAG members who are interested in serving on the committee should contact Andrew Baumann at abaumann@mag.org or 678.303.9286.

Georgia Hospital Association Research and Education Foundation 770.249.4517

Northeast Georgia Medical Center & Health System, Inc. 770.219.7715

Georgia Psychiatric Physicians Association 404.298.7100

Northside Hospital 404.236.8418

St. Francis Hospital 706.660.6058 St. Joseph’s/Candler Health System 912.819.7646 St. Mary’s Health Care System, Inc. 706.389.2655

Gwinnett Hospital System 678.312.4341

Phoebe Putney Memorial Hospital 229.312.1426 Physicians’ Institute for Excellence in Medicine 678.303.9287

Hamilton Medical Center 706.272.6056

Piedmont Healthcare 404.605.2750

The Medical Center 706.571.1179

Houston Healthcare 478.542.7963

Saint Joseph’s Hospital of Atlanta, Inc. 678.843.5105

The Southeast Permanente Medical Group, Inc. 404.504.5591

South Georgia Medical Center 229.259.4131

Tift Regional Medical Center 229.353.6805

Southern Alliance for Physician Specialties CME 770.613.0932

University Healthcare System 706.774.5786

Georgia Society of Ophthalmology 404.299.6588

John D. Archbold Memorial Hospital 229.228.2768 Mag Mutual Insurance Company 404.842.5681 Memorial Health Care System 423.495.4759 Memorial Health University Medical Center 912.350.8168

Southern Regional Health System 770.991.8353

Tanner Health System 770.812.5973

WellStar Health System 470.956.6431 West Georgia Medical Center, Inc. 706.845.3326 www.mag.org 13

CASE REPORT

Valacyclovir and acute renal failure

By Marilyn Chavannes, M.D., Rohit S. Doad, Gurinder J.S. Doad, M.D., PhD, FAAFP, with Southwest Georgia Family Medicine Residency, and Muffaddal F. Kheda, M.D., with Southwest Georgia Nephrology

H

erpes labialis is endemic throughout the world with prevalence ranging from 20 percent to 40 percent of the population. After primary infection with the Herpes simplex virus (HSV-1), which usually occurs before the age of 20, the virus recedes via sensory nerve into respective ganglion – where it lies latent throughout an individual’s lifetime.

Stimuli such as fever, menstruation, sunlight, stress and even upper respiratory tract infections (URI) can reactivate the virus. In contrast to the primary infection, during which all oral mucosa can be affected, relapsing infections are limited to the mucosa of the hard palate or to the lips in older children and adults.1 The number of relapses decrease after the age of 35.2 Multiple over the counter3 and prescription4 treatments are available. Valacyclovir, taken at 2 gm twice a day for one day, is a well-tolerated treatment with decreased episode duration and time to lesion healing. Side effects are rare. However, the following is an account of a male who developed acute renal failure after taking 4 gm of Valacyclovir at once when he tried to improve his episode even faster.

Case study

A 42-year-old caucasian male with a diagnosis of Herpes labilais presented to the emergency room after he took 4 gm of Valacyclovir at one time to help resolve his lesions and symptoms faster. The Valacyclovir had been prescribed previously by another physician.

Two to three hours after ingesting the medication, the patient experienced nausea, flank pain, and lightheadedness. The patient had no fever, chills, vomiting, abdominal pain, urinary urgency, frequency, dysuria, hematuria or penile discharge.

He had been eating and drinking normally and he had not been out in the sun. He had no recent use of NSAIDs. The 14 MAG Journal

patient had a history of hypothyroidism for which he took Synthroid. His labs included Hgb at 14.1, platelet count at 116, sodium at 140, potassium at 4.7, chloride at 108, bicarbonate at 20, BUN at 47 and serum Cr at 5.6. His glucose level was 92, calcium was at 8.0, PT at 15.0, INR at 1.16 and APTT at 32.6. Urinalysis tested positive for blood with microscope 0-3 wbc, 25-50 rbc, and it contained moderate amorphous sediment.

Renal ultrasound was unremarkable without renal calculi. The patient was started on IV hydration, after which his renal function normalized over a period of four days.

Discussion

Valacyclovir is a pro-drug of acyclovir with bioavailability three to five times greater than acyclovir.

It is rapidly excreted in the urine and reaches high concentrations in the tubular lumen.

Acyclovir is relatively insoluble in urine, particularly in the distal tubules where urine flow declines. Urine may show birefringent needle-shaped crystals under polarized light.

These characteristics may explain why 4 gm of Valacyclovir may have increased blood concentration of acyclovir with intra-tubular precipitation of acyclovir crystals in the kidney, which led to the patient’s flank pain, nausea, elevation of serum creatinine, and urinalysis with hematuria and pyuria.5 This case highlights the importance of educating patients on taking medications as prescribed.

The authors practice in Albany.

References 1

Esmann J. J Antimicrob Chemotherp 2001; 47 (SupplT1): 17

2

Straus SE, Rooney JF, Sever JL, Seidlin M, Nusinoff-Lehrman, Cremer K. Ann Intern Med.1985;103(3):404

3

Opstelten W, Knuistingh- Neven A, Eeekhof J. Can Fam Phy. 2008; 54: 1683

4

Chon T, Nguyen L. J of Fam Prac.2007; 56 (7):576

5

Parazella MA. Amer J of Med.1999; 106(4):459

MEDICAL ETHICS

Is the physical exam dying as a clinical and teaching tool?

By Laura Lowrey, third-year medical student, and Richard L. Elliott, M.D., Ph.D., professor and director of medical ethics and professionalism, Mercer University School of Medicine

I

magine that you are sitting in a doctor’s office full of people. There is a bad infomercial playing on TV at a volume just loud enough to keep you from focusing on anything else. Phones are ringing and people are coughing on either side of you. You check your watch to see that your appointment should have started 30 minutes ago. Finally, your name is called and you are led to an exam room. You tell the nurse why you are here.

She tells you the doctor should be in shortly as she leaves the room. Twenty minutes later, the doctor comes in and sits directly in front of a computer. During the encounter your physician is busy clicking boxes on the computer screen and barely looks at you.

Once your history is documented, your doctor finally moves away from the computer to conduct the physical exam. However, much to your surprise this portion of the exam is done in under a minute. You leave the office with prescriptions for your ailment…frustrated that you had to wait so long, and baffled because your doctor barely examined you during the encounter.

Unfortunately, this scenario is increasingly becoming a ‘typical doctor’s visit.’ The physical exam, once viewed as an art form, is now considered by some physicians to be less relevant.1 It is being replaced by sophisticated lab tests and imaging studies, so much so that a physician’s first encounter with a patient is often through the electronic medical records (EMR), where the chief complaint, review of systems, and laboratory data are available. The patient becomes the “ePatient.”

And, as EMR has emerged, doctors are confronted with and frustrated by greater documentation requirements that encroach on their time with patients. This forces doctors to decide what is most important during the patient encounter, and sometimes a good physical exam is not a priority.

As a third-year medical student, this realization has me perplexed. Throughout the first two years of medical school, students are taught how to perform a physical exam. We are told that clinical findings have almost as much value as a patient’s history in making a diagnosis. We are tested on our clinical skills, and we stress over our ability to perform the exam correctly.

16 MAG Journal

When we enter the hospital in our third year, we are finally able to put our clinical skills to the test. Like most new clinical clerks, I [LL] was eager to practice my newly acquired skills and to pick up tips from attendings and residents who are much more experienced with physical exams.

To my dismay and sometimes disbelief, I have realized that a lot of physicians do not see the art in the physical exam.

The exam no longer has a sense of power and significance, but is seen as something that is done if time allows. The exam is fading, and some would say it is a lost art.

I was shadowing a resident as we examined a woman whose chief complaint was shortness of breath. She had a past medical history of asthma, and allergies were exacerbating her symptoms. After the resident finished taking the history, she told the patient that we would be giving her medications to help with her asthma and allergies. The resident then looked at me, nodded toward the door, and said goodbye to the patient as we left to present to our attending. We never touched the patient – or any other patients – that morning. Even more disturbing, my resident described our physical exam findings as normal during our presentation to the attending. When he asked if the patient’s lungs contained any wheezes, the resident responded by saying, “No, they were normal.”

This encounter made me feel very uneasy as a medical student. I left the clinic that day asking myself if this is the new normal. How often do physicians completely neglect the physical exam? How often is the physical exam reported as normal when it is actually disregarded completely? Is it really still an art, and what about the two years that I spent learning to perform physical exams? And given the demands on attendings and residents to complete documentation on the computer, what can be done to improve the quality of bedside teaching?

It would seem that the value of the physical examination is incontrovertible as a bedrock of medical practice. But given less time to spend with patients and the growth of telemedicine, there are some who have argued that the physical examination may be unnecessary 50 to 70 percent of the time.2 It is probably also true that a lot of complaints (e.g., UTI) can be diagnosed and treated based on a brief, accurate history.

However, this ignores three factors. First, there is often value in going beyond the chief complaint. A physician who sees a patient for a UTI might notice something unrelated (e.g., a skin lesion, abnormal gait, or shortness of breath).

Perhaps for financial reasons the patient ignored his or her condition or did not see it as sufficient reason for an office visit. Second, the skills that are necessary to conduct a clinical examination are perishable and must be practiced with regularity to be maintained. Examining a patient with an otherwise straightforward complaint gives physicians an opportunity to practice their skills. And, finally, aside from providing essential clinical information a physical exam offers a unique advantage in that it enables the physician to build a personal relationship with their patients.

At what point in a physician’s career is the decision made to falsely document or report information? Do the pressures of time constraints and EMR requirements eventually cause physicians’ ethical practices to be colored? Whatever the causes, patients and other physicians trust us to be skilled in our examinations and honest in our reporting.

Danielle Ofri, M.D., wrote that, “Countless times, I have found that it is only during the physical exam that patients reveal what is truly on their mind…there is something about touch that changes the dynamic.”3

References

Touch personalizes the encounter. The physical acts of touching – of listening to their bodies with our stethoscopes – conveys to our patients that at that moment our sole attention is on them, and that they are not mere data points to be entered into a computer. These physical interactions encourage a trusting relationship between physicians and their patients, and many physicians still agree that the most sensitive historical information is revealed during a physical examination.

While the loss of the physical exam is troubling, false reporting of information through EMR or reports to attending physicians may be worse. Yet practices like copying and pasting progress notes are commonplace. O’Donnell et al. found that 70 percent of physicians at one academic medical center used copy and paste functions all the time or most of the time when they wrote progress notes, despite the high prevalence of inconsistencies associated with the practice.4 Although we are not aware of any credible data, we can safely assume that this kind of short cut undermines the accuracy of EMR. As a medical student and future physician, I was concerned by the lack of examinations that were performed and the false reporting that went on, but I did not know how to respond. I recalled the Oath of Geneva:5 “I solemnly pledge to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude that is their due; I will practice my profession with conscience and dignity; the health of my patient will be my first consideration…”

This oath reminds physicians to dedicate their lives to serve the health of their patients and that we should do so with integrity and honesty. As medical students we are trained to document only what we actually discuss with our patients and what we perform during the exam.

In conclusion, we believe that no physician should forget the art and value of the physical exam – and the duty we have to report the results of the examinations we perform in an honest and accurate way. The exam is crucial to patient care, and if we want patient care to be our first consideration then we must not let the physical exam become a fading art.¨

1

Verghese A. Culture shock – Patient as icon, icon as patient. N Engl J Med 2008;359(26):2748-51

2

See, for example http://evisit.com/physical-exams-why-they-can-be-unnecessary-ineffectiveand-costly/

3

Ofri D. The physical exam as refuge. New York Times, July 10, 2014

4

O’Donnell HC, Kaushal R, Barron Y, et al. Physicians’ attitudes towards copying and pasting in electronic note writing. J Gen Int Med 2008;24(1):63-8

5

http://www.wma.net/en/30publications/10policies/g1/

A DVA N C ES & CO N T ROV ERS I ES in

CLINICAL NUTRITION

6

th ANNUAL

December 8-10, 2016 Rosen Shingle Creek Orlando, Florida

#ACCN16 www.nutrition.org/meetings/ www.mag.org 17

GEORGIA COMPOSITE MEDICAL BOARD

Georgia’s physician advertising law

By John Antalis, M.D., Georgia Composite Medical Board

H

.B. 1043, which was passed during the 2016 session of the Georgia General Assembly, addressed two key issues – including physician advertising, in the context of their board certification, and vaccine protocol agreements. This article addresses the way physicians position their board certification in their ads.

Effective July 1, the law prohibited physicians from advertising that they are board certified in any specialty or subspecialty unless the certifying board is a member of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).

H.B. 1043 amended Article 2 of Chapter 34 of Title 43 of the Official Code of Georgia Annotated, which is titled “Prescribing Medicine Without a License.” Article 2 had previously required physicians to possess a valid license to hold himself/herself out to the public as being engaged in the diagnosis and treatment of any disease or injury of human beings or to suggest, recommend, or prescribe any treatment.

And without a valid Georgia license, the law had prohibited a person from receiving any fee, gift or compensation for their services or using the titles of “M.D.,” “Oph” (Ophthalmology), “Surgeon,” “Doctor,” “D.O.,” “Doctor of Osteopathy,” “Osteopathic Physician” or “Physician” or setting up an office to receive, examine and treat patients who are ill or injured.

Article 2 also originally contained just nine exceptions to practicing medicine without a Georgia license, including providing gratuitous emergency service (free care), allowing military or civilian federal physicians to perform their medical duties, approving licensed out-of-state physicians to consult on special cases, using physician assistants who are approved by the Georgia Composite Medical Board (GCMB) to perform medical acts, and allowing other qualified persons who are under a physician’s authority to perform a necessary ancillary patient care function (e.g., RN, LPN, MA).

It also allowed medical or physician assistant students to perform medical acts when they are enrolled in a medical school, osteopathic medical school, or a physician assistant training program that is approved by the GCMB. But over the last several years – as patient demand for cosmetic procedures, as well as the corresponding lucrative rewards, increased – a wider array of physicians (beyond plastic or cosmetic surgeons) began to claim that they could perform these surgeries. And instead of taking the time to become proficient in these procedures through a fellowship, a lot of these physicians would simply take a weekend or week-long course and then market themselves as being competent to perform plastic surgery or cosmetic surgery.

Invariably, the rates of disfigurement and death that followed these 18 MAG Journal

John Antalis, M.D. procedures increased. These stories raised an alarm bell throughout the medical community, but especially with the members of the Georgia Society of Plastic Surgery (GSPS).

The GSPS, with the help of American Society of Plastic Surgery (ASPS), consequently submitted an amendment to the Georgia General Assembly to ensure that the physicians who perform plastic or cosmetic surgery are required to clearly state their specific board certification in any advertisement or publication. The GSPS website stated that, “Because physicians lacking sufficient training in plastic and/or cosmetic surgery will no longer be allowed to represent themselves as experts, this law stands to advance one of ASPS’ and GSPS’ primary goals – greater patient safety and better outcomes.”

One physician organization, the American Board of Cosmetic Surgery (ABCS), has raised a concern since H.B. 1043 was amended. It believes that the law does not adequately recognize those physicians and surgeons who super-specialize in a field and who do not get additional training beyond their American Board of Medical Specialties (ABMS) residency – such as Accreditation Council for Graduate Medical Education (ACGME), ABMS, or AOA-approved fellowship or preceptorship. ABCS argues that these residency-trained physicians should be included in the law without additional training and that they have been accepted with open arms in communities in Georgia. Residency-trained physicians besides those in plastic surgery include general surgery, OB-GYN, oral and maxillofacial surgery, otolaryngology, oculoplastic surgery, and procedural and Mohs dermatology.

Therefore, ABCS may submit a bill to further amend the law during the 2017 General Assembly.

ABCS says that the reason it has not applied for ABMS membership is that the ACGME is funded by Medicare, which will not fund additional training for elective cosmetic surgeries.

And another organization – the Georgia Chapter of the American College of Physicians – has also expressed concern about the potential impact that the law will have on physicians who choose to recertify with boards other than ABMS. The Medical Association of Georgia’s House of Delegates (HOD) is an excellent forum for physicians to debate this issue.

GCMB supports H.B. 1043 because it believes that there is a need for all physicians to be transparent about their credentials in their advertisements.

As GCMB’s new chair, I hope that this issue will be resolved at the HOD meeting in Savannah in October. This will give further direction to both the Georgia General Assembly and GCMB in the event there is a need to further modify this law.

Dr. Antalis served as MAG’s president in 2004-2005.

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LEGAL

Chaperones are more important than ever

By Daniel J. Huff, Esq., Huff, Powell & Bailey, LLC

T

his summer The Atlanta Journal-Constitution (AJC) published the results of its widespread investigation into the sexual abuse of patients by physicians. The AJC expose was widely read, and it even received national attention on NBC’s Today Show.

The investigation revealed that thousands of doctors in the U.S. had raped, molested or sexually exploited their patients while performing medical examinations over the past two decades. The scope and publicity of this investigation has led to additional victims coming forward, more investigations, and some arrests.

With this in mind, interactions between physicians and their patients will be viewed with greater scrutiny by law enforcement, the Georgia Composite Medical Board (GCMB) and, most importantly, patients. The purpose of this article is not to highlight or reiterate the impropriety of these unprofessional and improper acts. It is, instead, to highlight the important ways that you can protect yourself and your patients from inappropriate conduct and false allegations of inappropriate conduct.

So, let’s review the rules and standards regarding physical examinations and chaperones.

 Increased attention on physician misconduct will not only lead to more victims coming forward, but it will also lead to false allegations of misconduct.

You can protect yourself from false allegations by adhering to patient privacy standards and having some chaperone guidelines in place.¨ 

GCMB rules

Rule 360-3-.02 defines unprofessional conduct warranting GCMB to take action against one of its members. Unprofessional conduct includes: (12) Conducting a physical examination of the breast and/or genitalia of a patient of the opposite sex without a chaperone present.

Beyond performing an examination of the breast and/or genitalia of a patient of the opposite sex, the GCMB published the following guideline regarding other examinations in May 2016: For all other examinations the Board recommends that physicians aim to respect the patient’s dignity and to make a positive effort to secure a comfortable and considerate atmosphere for the patient; such actions include the provision of appropriate gowns, private facilities for undressing, sensitive use of draping and clear explanation on various components of the physical examination. The physician should have a policy that patients are free to 22 MAG Journal

make a request for a chaperone. This policy should be communicated to patients, either by means of a welldisplayed notice or preferably through a conversation initiated by the intake nurse or the physician. The request by a patient to have a chaperone should be honored. It is recommended that an authorized health professional should serve as the chaperone whenever possible. In their practices, physicians should establish clear expectations about respecting patient privacy and confidentiality to which chaperones must adhere. If a chaperone is to be provided, a separate opportunity for a private conversation between the patient and the physician should be allowed.

The “unprofessional conduct” rule only requires a chaperone for the examination of the genitalia of a patient of the opposite sex. In practice, limiting chaperones to patients of the opposite sex may not be appropriate.

Let the nature of the examination and your patient dictate whether a chaperone should be present – even if you and the patient are both the same sex.

Protecting yourself and your patient begins at the outset of your interaction with the patient. The patient should understand the nature of the examination that is going to be conducted, and consent to do that examination should be obtained.

The nature of any physical examination should be explained to the patient or the guardian of a minor patient in detail.

Specifically, what will be done and why it’s necessary. The examination itself, particularly with respect to a private area of the body, should be done with the minimum amount of physical contact necessary to perform the examination. The examiner as well as the chaperone should avoid making sexual comments or provocative statements to a patient, but this is especially true during an intimate examination.

Every practice should respect a patient’s privacy consistent with common sense and GCMB guidelines. Modesty should be respected during an examination to expose only that part of a patient’s body that is necessary. Patients should be allowed to dress and undress in private unless the patient is having difficulty or requires assistance. (continued on page 24)

HUFF, POWELL & BAILEY, LLC

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www.mag.org 23

(continued from page 22)

When an examination of the breast and/or genitalia is going to be performed and the patient is of the opposite sex, a chaperone must be present. For the benefit of you and the patient, a chaperone should be present during an “intimate examination” of a patient regardless of the patient’s sex. This is not required and there are exceptions where this need not happen, but it is an excellent standard for you and your practice.

Here are some additional guidelines regarding chaperones…

• The patient must consent to having a chaperone and should agree with the individual who will serve as the chaperone prior to the examination • The chaperone should be an impartial observer to the examination and not a relative or friend of the patient • If a chaperone is not available or the patient does not consent to the choice of a chaperone, the examination should be postponed unless this would impact the patient’s care • It should be documented in the patient’s medical record that a chaperone was present for any intimate examination Creating a culture that respects patient privacy and safety

Take any complaint from a patient about anything inappropriate seriously. Likewise, listen to feedback from your employees about patients’ and co-workers’ behavior. Be diligent about concerns that are raised regarding provider and patient contact.

Consensual relationships can develop between patients and their health care providers. These situations must be identified

24 MAG Journal

and addressed when they arise. Be on the lookout for signs that the normal barriers between a patient and a provider are not in place. For example, if an employee is seeing a patient outside of normal hours or away from the office, the employee should be confronted about the relationship. [Huff will address these and other patient-provider relationship issues in the fourth quarter issue of the MAG Journal.]

Some bars and restaurants check their customers’ IDs regardless of age – even if they are in their 70s. And, clearly, there are some people who do not need their ID to be checked to confirm they are older than 21 years of age. Nevertheless, these bars and restaurants have the privilege of saying “we ID everyone.”

So, having a chaperone culture to promote patient safety and privacy in your office should not be considered an inconvenience.

It should be an important part of your overall goal of making your patients more comfortable. You should strive to protect your patients from the possibility of inappropriate contact by one of your employees – as well as protect you and your employees from false allegations of inappropriate conduct by one of your patients.

Increased attention on physician misconduct will not only lead to more victims coming forward, but it will also lead to false allegations of misconduct. You can protect yourself from false allegations by adhering to patient privacy standards and having some chaperone guidelines in place.¨ Huff is a founding partner at the Atlanta law firm of Huff, Powell & Bailey, LLC. Huff and the members of his firm defend civil lawsuits on behalf of hospitals, physicians, product manufacturers, businesses, corporations and other professionals. Huff and his firm try several jury trials each year. Huff can be contacted at dhuff@huffpowellbailey.com.

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www.mag.org 25

LEGAL

CMS telehealth proposal could aid rural beneficiaries

By Laura Little, J.D., M.B.A., and Sidney Welch, J.D., M.P.H., Polsinelli PC

T

he latest proposed changes from the Centers for Medicare & Medicaid Services (CMS) hint at its willingness to encourage practitioner’s adoption of telehealth to expand the accessibility of quality care for rural beneficiaries.

On July 7, 2016, CMS released the CY2017 Physician Fee Schedule Proposed Rule1, which in addition to updating payment rates would marginally expand the list of telehealth services that are eligible for Medicare reimbursement.

Additionally, CMS is calling for modifications to its current policies on place of service (POS) coding – and it wants to clarify its payment policies for the telehealth services that are rendered in hospitals. Comments on the proposed rule are due on September 6, 2016.

Medicare telehealth services list Starting in CY2017, CMS is proposing to add several services to the list of telehealth services that are eligible for Medicare reimbursement when the services are provided in accordance with all pre-existing legal requirements2, including: • ESRD-related services: CMS has proposed adding end-stage renal disease (ESRD)-related services that are provided via telehealth to patients of all ages (represented

by CPT codes 90967 through 90970) to the list of telehealth services eligible for Medicare reimbursement.

Five ESRD services are currently included on the list.

It is important to note that, as proposed, CMS would only reimburse physicians for such services when they are provided via telemedicine if the required clinical examination of the catheter access site is performed on a ‘hands on’ basis by a physician, clinical nurse specialist, nurse practitioner or physician assistant (not via an interactive telecommunications system).

• Advance care planning services: CMS has also proposed adding two advanced care planning services to the telehealth list, noting their similarity to the annual wellness visits that are already on the Medicare telehealth list: HCPCS code G0438 (for an initial 30-minute, face-to-face advanced care planning session by a physician or other qualified health care professional with a patient, family member, or surrogate regarding advanced directives and related forms and completion of such forms) and HCPCS code G0439 (for each additional 30 minutes of advance care planning).

26 MAG Journal

• Critical care consultations furnished via telehealth: CMS is proposing two new Medicare G-Codes (GTTT1 and GTTT2) that would grant Medicare reimbursement for intensive telehealth consultation services at a slightly lower rate than the full reimbursement rate (as compared to existing rates for the evaluation and management of critically ill/injured patients). CMS rejected requests to reimburse eligible practitioners for teleICU, telestroke, and teleneurology services under existing CPT consultation codes because it noted that those codes, as bundled payments, mandate that various services must be provided in-person and cannot be furnished via telemedicine. CMS consequently said that reimbursement under existing CPT codes for services rendered via telehealth would be excessive and inappropriate. But to encourage providers to offer telestroke and teleneurology services, CMS has proposed a compromise: to create two new codes (GTTT1 and GTTT2) that will reimburse eligible practitioners for initial and subsequent intensive telehealth consultation services that are rendered to critically ill patients at higher rates than those who are paid for typical, less complex patient consults.

As proposed, CMS would reimburse eligible practitioners for such consults when they are 1) provided via telemedicine to critically ill/injured patients and 2) a qualified health care professional has in-person responsibility for the patient and 3) the patient could benefit from the additional services provided via the distant site consultant and 4) the distant site consultant is trained in critical care services.

Reimbursement would be limited to one service per day, per patient.

Like other telehealth consultations, the services would be reimbursed at the equivalent rate for the evaluation and management (E/M) service when they are provided inperson (not via telehealth). CMS is seeking public comment on this proposal in particular.

CMS ultimately rejected requests to add the following CPT codes to the list of eligible telehealth services: • Observation codes: Repeating its CY2005 determination, CMS elected not to add various observation codes to the telehealth list (CPT codes 99217 through 99236). CMS stated that the significant (continued on page 28)

• • • •

www.mag.org 27

(continued from page 26)

differences in patient acuity between these services and the others on the telehealth list precluded it from adding these on a category one basis, and it said that requesters failed to present specific evidence that demonstrated that the telehealth services provided a clinical benefit to warrant adding them under a category two basis.

• Emergency department E/M services: Likewise, CMS elected not to add various emergency department E/M services (CPT codes 99281 through 99285) to the list of Medicare telehealth services. CMS rejected arguments that the codes are similar to the outpatient visit codes that are already on the telehealth list, noting that the work is distinctly different in pace, intensity, and acuity when a patient presents to an emergency department versus an outpatient setting – so Medicare reimbursement is, therefore, inappropriate under the codes.

• Psychological testing: CMS refused to add CPT codes for psychological and neuropsychological testing to the Medicare telehealth list of reimbursable services, indicating that these services require close observation of how a patient responds in testing – which may not be accomplished via telehealth.

• Physical therapy, occupational therapy, and speechlanguage pathology services: CMS, again, refused to add physical therapy, occupational therapy, and speechlanguage pathology services to the list of reimbursable telehealth services for Medicare. Since existing law3 does not recognize physical therapists, occupational therapists or speech-language pathologists as authorized practitioners of telehealth, and since such services are predominantly provided by such individuals, it is unlikely that CMS will reimburse for these services in the future – barring Congressional action.

Place of service (POS) code suggestions Although a CMS POS workgroup establishes policies for POS code usage, CMS has proposed various modifications to the existing POS code policies for reporting telehealth services to allow for possible future POS workgroup decisions governing appropriate coding, which might occur before January 1, 2017. Specifically, CMS is calling for practitioners who furnish telehealth services to be required to report the POS code that they would use if the services were furnished in-person (i.e., the patient location) to indicate that the services were provided via telehealth. CMS also proposed that on receipt of such a claim it would use the facility practice expense relative value units (PE RVUs)

28 MAG Journal

to reimburse eligible practitioners for the telehealth services that are reported. CMS also is suggesting that POS code use for the originating site remain unchanged (i.e., the originating site should continue to bill for the facility fee and continue to use the POS code that is applicable for the patient’s location [facility or non-facility] in order to receive the correct reimbursement rate [either facility PE RVU or non-facility PE RVU]).

Policy clarification – hospital telehealth services Finally, CMS has proposed revising the regulations to clarify that when telehealth services are furnished in a hospital and the hospital is not being paid for such services, payments under the physician fee schedule should be made at the facility rate (facility PE RVUs). This policy is not new, but it underscores CMS’ existing stance on appropriate billing in such scenarios. ¨ Welch is the chair of Health Care Innovation at Polsinelli PC. Little is an attorney with Polsinelli’s Health Care practice.

They counsel physicians, physician practices, and health care technology clients in transactional, regulatory, administrative law, and litigation matters on a national basis. Go to www. polsinelli.com/professionals/swelch for additional information.

Contact Welch at 404.253.6047 or swelch@polsinelli.com.

References 1

Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for Calendar Year (CY) 2017 (proposed July 6, 2016) available at https://www.cms.gov/ Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-RegulationNotices-Items/CMS-1654-P.html.

2

See 42 U.S.C. § 1395m(m); See also 42 C.F.R. § 410.78.

3

See Section 1834(m)(4)(E) of the Social Security Act as defined by Section 1842(b)(18)(C) of the Social Security Act.

Paid editorial submission

MAG MEMBER PROFILES

Masoumeh Ghaffari, M.D. Rome Internal Medicine MAG member since 2015 I’m a MAG member because…

I wanted to have a stronger voice for myself and my profession. Being a MAG member allows me to support and advance a common cause. As an individual, I have relatively little power to effect change. But by joining MAG, with like-minded professionals, I have the opportunity to become an advocate who can address the issues that matter.

As a MAG member, I’m a leader…

I represented the Cobb County Medical Society at MAG’s HOD meeting in 2015 – and I also expect to serve as a delegate in 2016. I recently joined the VA/Residency Academic Team, where I’m able to take care of patients, educate residents and students, and see the positive effect I’m having on my community.

My greatest moment as a physician…

When I began working as a physician in my home city in Iran, I was involved in efforts to eradicate polio and control infection. After I completed my training as a surgeon, I returned to my home city as its first female surgeon. To me, being a physician is not a job – it is a great responsibility to serve your community.

Biggest challenge facing physicians…

The rapidly changing health care environment, the increasing costs of providing the care, maintaining the quality of the care we deliver, physician workload, and the increasingly heavy burden of dealing with information technology.

John A. Johnson, M.D., M.B.A. Atlanta Internal Medicine MAG member since 2015 I’m a MAG member because…

MAG is an outstanding, physician-led organization that is committed to staying abreast of the dynamic landscape within the health care industry.

As a MAG member, I’m a leader…

I currently serve on the Medical Association of Atlanta (MAA) Board of Directors and work closely with MAG leadership. I represented the MAA at last year’s House of Delegates meeting. I am a member of the MAG Medical Reserve Corps (MRC) – and I serve as a regional physician coordinator for the MRC in the Atlanta area. I am the lead clinician at WellCare of Georgia.

My greatest moment as a physician…

In 2010, I was fortunate to serve as a member of a military humanitarian mission that went to Haiti after the earthquake. After seeing such poverty and devastation, I felt honored to be able to utilize my clinical skills as a doctor to help mankind. The people of Haiti showed so much hope, gratitude and resilience.

Biggest challenge facing physicians…

The ability to successfully practice medicine given the recent and dramatic changes within health care. Physicians have always been expected to deliver excellent care, improve health outcomes, and enhance patient satisfaction – but it is becoming increasingly difficult for physicians to navigate through the new federal requirements and sustain an operational practice model.

www.mag.org 29

PATIENT SAFETY

Health care: A rich new environment for cybercriminals

By Rebecca Summey-Lowman, MBA, RD, LD, CPHRM, CPPS Manager, Risk and Patient Safety, MAG Mutual Insurance Company

C

riminal attacks are the leading cause of data breaches in health care.1 In 2014, the Federal Bureau of Investigation (FBI) sounded an alarm to the health care industry – warning of increasing cyber threats against health care systems and medical devices. In an April 2014 “Private Industry Notification,” the FBI described the health care industry as “a rich new environment for cybercriminals to exploit.”2

While the retail and banking industry has become more secure, health care systems have emerged as a prime target. Many health care organizations are underfunded and understaffed. In an article that was posted on iHealthBeat.com, Lisa Gallagher, a HIMSS cybersecurity expert, said that “health care organizations should be spending at least 10 percent of their information technology (IT) budget on cybersecurity, yet the industry average is just three percent.”6

Cybercriminals have discovered new opportunities for financial gain from the virtual “treasure trove” of information that is contained in electronic medical records (EMR) and medical devices. According to one report, the health care industry is more than 200 percent more likely to encounter data theft and 340 percent more likely to see security incidents and attacks than the average industry.3

Compounding the problem is the amount of money that medical records can fetch through illegal trading. According to Raytheon Websense, medical information that is contained in EMR can command up to 10 times more money than financial information.7

Large data breaches have been well-publicized in the media. On February 18, 2016, the Los Angeles Times reported that Hollywood Presbyterian Hospital paid a $17,000 ransom in bitcoin to a hacker who seized control of the hospital’s computer systems.1 The incident occurred when the hackers used malware to lock the hospital’s computers, preventing hospital staff from being able to communicate from those devices. The attack forced the hospital to temporarily return to paper record keeping. The malware locked the hospital’s systems by encrypting the files. The hospital paid the ransom because administrators felt that it was the quickest and most efficient way to obtain the decryption key and restore their systems. The hospital subsequently alerted authorities, and it was able to regain control of its computer systems with the assistance of technology experts.4 The medical office setting is not immune to cyberattacks. Twentyfirst Century Oncology, a Fort Myers-based practice that offers cancer care services, revealed in a statement on its website that 2.2 million patients may have had personal information stolen when the company’s system was breached in October 2015. According to the notification, the breach was discovered in November 2015, but the FBI discouraged the company from making a public announcement until March – as the investigation was ongoing.

Though there is no evidence that the data has been used in any way, the hackers did have access to patient names, Social Security numbers, doctor’s names, diagnosis and treatment information, and insurance information.5 The health care industry has become a target for cybercriminals for many reasons. In recent years, there has been a push to transition from paper records to an electronic format. The transition has not been easy primarily due to EMR adaptability problems with the clinical workflow. Health care organizations have focused on adapting to the workflow while moving data security to the back burner. For the cybercriminal who is eager to exploit these vulnerabilities, it is like “leaving the key to the house under the doormat.”

30 MAG Journal

Medical devices can also be a target for cyberattacks. In June 2013, the FDA issued a safety communication for the purpose of recommending that medical device manufacturers and health care facilities take steps to assure that appropriate safeguards are in place to reduce the risk of a cyberattack. The alert warned of the introduction of malware into medical equipment or unauthorized access to configuration settings in medical devices and hospital networks.8 The U.S. Department of Homeland Security warned that hard-coded passwords that normally allow service technicians to gain access to machines could be used to make nefarious changes if they fall into the wrong hands.9

Practical strategies for preventing a cyberattack • Train your staff. Employees can be the most significant risk to an organization’s security. HIPAA requires this training for all employees and that it is tailored to meet the organization’s needs • Perform a security risk analysis, which is a key requirement of the HIPAA Security Rule • Develop an incident response policy to utilize in the event of a breach • Back up your operating system and all of its contents to an external hard drive every day. It is less likely that you could be held hostage from a ransomware attack if data can be recovered from back-up files • Be careful what you click on. Do not open attachments that are contained in unsolicited emails or click on any link that contains free software • Use reputable anti-virus software and a firewall. Make sure your software is up-to-date • Keep current with “patching” to minimize exploits and vulnerabilities • Require your IT department to perform upgrades. Ransomware attacks often come in the form of fake ads for upgrades to products such as Windows, Java, and Adobe

• Use strong passwords on systems that contain sensitive information (e.g., mix eight or more upper and lower case letters, numbers, and special characters)

Cyber liability resources HealthIT.gov

• Enable your pop-up blocker on your browser to prevent suspicious ads

Privacy security training games http://bit.ly/2bcvs8v

• Use virtual browsing sessions whenever possible so everything is deleted – including malware – when the session is closed

EHR practice integration http://bit.ly/2bixlEa

• Avoid clicking on links to suspicious websites. A common technique that attackers use is to distribute ransomware through fake websites

Top 10 tips for cybersecurity http://bit.ly/2bzvdtb

• Keep sensitive information physically secure.

• Keep mobile devices (laptops, smartphones, tablets, USBs, etc.) within your sight or locked up at all times

Your mobile device and health information privacy and security http://bit.ly/2aOVgM8

• Immediately notify your IT department, the FBI, and your insurance carrier if you believe that you have been a victim of a cyberattack

American Hospital Association www.aha.org/advocacy-issues/cybersecurity.shtml Office of the National Coordinator or Health Information Technology (ONC) Security Risk Assessment Tool

• Consider purchasing cyber-liability insurance

Immediate actions to take if a data breach occurs

HIPAA risk assessment tool https://www.healthit.gov/providers-professionals/ security-risk-assessment

In the event of a data breach, seek the assistance of IT and insurance experts. Early recognition and intervention may help to mitigate damages and prevent the loss of data. Preserve any evidence and perform a breach assessment that includes the following: • The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification

HIPAA guidelines and resources www.hhs.gov/hipaa/index.html Food and Drug Administration Guidance on medical devices www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ ucm356423.htm

• The unauthorized person who used or had access to the protected health information or to whom the disclosure was made • Whether the protected health information was actually acquired or viewed • The extent to which the risk to the protected health information has been mitigated If the risk assessment confirms that a breach of unsecured protected health information occurred, you are required to notify the affected individuals and the Department of Health and Human Services (HHS). If more than 500 individuals are affected, you may be required to notify the media. Go to www.hhs.gov/ hipaa/for-professionals/breach-notification for information and guidance from HHS.¨ The MagMutual Patient Safety Institute (MMPSI) is a wholly owned subsidiary of MAG Mutual Insurance Company (MagMutual).

Its mission is to identify, develop and implement effective patient safety and risk reduction strategies. The risk and patient safety consultants, made up of clinicians with a multidisciplinary background, are experts at risk management, patient safety and performance improvement. The MMPSI collects and analyzes data in a way that facilitates the reporting of patient safety events, errors and near misses, and it works to help clinicians eliminate them – leading to better care. The expertise and resources that are available from the MMPSI reinforce MagMutual’s commitment to promote collaboration and ongoing advancements in health care.

The information presented in this article is intended as general information of interest to physicians and other health care

professionals. The recommendations and advice published herein do not reflect or establish a standard of care and do not establish rules for the practice of medicine. The publication of this information is not intended to serve as an offer to insure such conditions or exposures or to indicate that MAG Mutual Insurance Company will underwrite such risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies that are issued.

References 1

Ponemon Institute, LLC. Sixth Annual Benchmark Study on Privacy & Security of Healthcare Data. Research Report, Traverse City, MI: Ponemon Institute, LLC, May 2016

2

U.S. Department of Justice Federal Bureau of Investigation. Health Care Systems and Medical Devices at Risk for Increased Cyber Intrusions for Financial Gain. Private Industry Notification, Washington, DC: United States Department of Justice Federal Bureau of Investigation, 2014.

3

Raytheon Websense. 2015 Industry Drill-Down Report Healthcare. Websense Security Labs, 2015.

4

Winton, Richard. “Hollywood hospital Pays $17,000 in Bitcoin to Hackers; FBI investigating.” Los Angeles Times, February 18, 2016.

5

21st Century Oncology. “Notice to Patients Regarding Security Incident.” 21st Century Oncology. n.d. https://www.21co.com/securityincident (accessed July 18, 2016).

6

iHealthBeat. June 3, 2015. http://www.ihealthbeat.org/articles/2015/6/3/health-careorganizations-underfunding-cybersecurity-efforts (accessed February 4, 2016).

7

Raytheon Websense, 2015.

8

U.S. Food and Drug Administration. Cybersecurity for Medical Devices and Hospital Networks: FDA Safety Communication. Silver Spring, MD: U.S. Food and Drug Administration, June 13, 2013.

9

Department of Homeland Security. Alert (ICS-ALERT-13-164-01) Medical Devices HardCoded Passwords. Washington, DC: Department of Homeland Security, 2013.

www.mag.org 31

COUNTY, MEMBER & SPECIALTY NEWS

COUNTY MEDICAL SOCIETY NEWS Bibb County Medical Society

Go to www.bibbphysicians. org for information on the Bibb County Medical Society.

Coffee County Medical Society

Go to www. coffeemedicalsociety.com or contact Charles Miller, M.D., at wcmiller@windstream. net for information about the Coffee County Medical Society (CCMS) or contact Dawn Williams at 678.303.9261 or dwilliams@ mag.org to join CCMS. DeKalb Medical Society

by Hank Holderfield, Executive Director The DeKalb Medical Society (DMS) hosted a legislative reception for its members and state lawmakers from DeKalb County at the Petite Auberge restaurant in Atlanta on September 8. On October 5, DMS will host a membership meeting – which will also take place at Petite Auberge – that will feature a program from MAG Mutual Insurance Company, ‘Closing Gaps in the Continuum of Care: Best Practices in Care Transitions.’

The meeting is being sponsored

by MagMutual and American Health Imaging. Go to www. dekmedsoc.org or contact Hank Holderfield at hholderfield@ pami.org for more information or to join DMS. Dougherty County Medical Society

Go to www.dc-ms.org or contact Susan Workman 32 MAG Journal

at 229.436.8191 or dcms. director@gmail.com for information on the Dougherty County Medical Society.

11. Contact Ca Rita Connor at gamedsoc@bellsouth.net for details on this meeting or with questions related to GMS.

Floyd-Polk-Chattooga County Medical Society

Hall County Medical Society

Physicians who are interested in serving as an officer or joining the Floyd-PolkChattooga County Medical Society should contact Kate Boyenga at 678.303.9263 or kboyenga@mag.org.

by Hank Holderfield, Executive Director MAG Executive Director Donald J. Palmisano Jr. gave a “Navigating the Changing Health Care Environment” talk at the Hall County Medical Society (HCMS) meeting in May. Georgia Gov. Nathan Deal was the keynote speaker at the HCMS meeting that took place at the Chattahoochee Golf Club in Gainesville on September 15. New Northeast Georgia Medical Center staff was recognized at the meeting.

Contact Hank Holderfield at hholderfield@pami.org with HCMS questions.

Georgia Medical Society

by Ca Rita Connor, Executive Director Georgia Medical Society (GMS) President Kelly A. Erola, M.D., welcomed third-year medical students from the Medical College of Georgia at Augusta University at an event that took place at the Savannah Golf Club in July. She discussed the roles of GMS and the Medical Association of Georgia (MAG) – as well as the history of the medical profession in Savannah. And in August, GMS President-elect Joshua T. McKenzie, M.D., gave a similar talk to firstyear medical students at the Mercer University School of Medicine’s Savannah campus.

GMS passed out GMS and MAG membership applications at both meetings. GMS held its annual ‘Super Meeting’ at the Alee Shrine Temple in Savannah on September 13. It featured a talk by Tony Buettner, who is an author and the vice president of Blue Zone Development. He discussed “How to live to be 100” and “Making Savannah a Blue Zone City.” Finally, GMS will host a meeting that will feature state legislators from the Savannah area in Savannah on October

Muscogee County Medical Society

by Dan Walton, Executive Director The Muscogee County Medical Society (MCMS) will hold a beer tasting event at the Rivermill Event Centre in Columbus on Thursday, September 22. It is being sponsored by Columbus Bank and Trust Company and the Columbus Diagnostic Center. Go to www. muscogeemedical.org or call 706.322.1254 for additional information or to join MCMS. Ogeechee River Medical Society

by Michelle Zeanah, M.D. The Ogeechee River Medical Society (ORMS) held its annual ‘Legislative BBQ’ in July. The lawmakers who attended the event included

House Majority Leader Rep. Jon Burns, Reps. Jan Tankersley and Butch Parrish, and Sen. Jack Hill. John Gerguis, M.D., and his wife, Angie Gerguis, hosted the event at their home. Contact Michelle Zeanah, M.D., at doctor@zeanah.com with questions related to ORMS. Richmond County Medical Society

by Dan Walton, Executive Director Attorney James Painter gave a talk on the role of electronic medical records in medical malpractice cases at the Richmond County Medical Society (RCMS) meeting in May. In July, SunTrust Bank sponsored a lecture on variable annuities. RCMS also held its second annual leadership conference in August – an event that focused on opioid abuse and addiction. Go to www.rcmsga.org or call 706.733.1561 for additional information or to join RCMS. Troup County Medical Society

Physicians who have questions about the Troup County Medical Society should contact Kate Boyenga at 678.303.9263 or kboyenga@ mag.org.

Walker-Catoosa-Dade County Medical Society

Physicians who are interested in attending a Walker-Catoosa-Dade County Medical Society (WCDCMS) meeting or who have questions related to WCDCMS should contact Michael E. Wilson, M.D., at tenwilsons@gmail.com.

MEMBER NEWS The Longstreet Clinic, P.C., recently announced that two of its physicians – Betsy Grunch, M.D., and James Reeves, M.D. – performed the “first motion preserving disc replacement in Georgia in lieu of spinal fusion to treat chronic lower back pain.”

Ten physicians from The Longstreet Clinic, P.C., were also recently honored by Atlanta magazine as ‘Top Doctors in metro Atlanta.’

This includes Alexander D. Allaire, M.D., Amy BullensBorrow, M.D., Michael P. Connor, M.D., Jeff Reinhardt, M.D., Eugene Cindea, M.D., Marti Gibbs, M.D., Richard J. LoCicero, M.D., Holmes B. Marchman, M.D., Rob Richard, M.D., and Karl D. Schultz Jr., M.D.

SPECIALTY SOCIETY NEWS Georgia Academy of Family Physicians

by Morgan Mahone, Communications and Marketing Manager The Georgia Academy of Family Physicians (GAFP) will hold its annual Scientific Assembly at The Westin Buckhead Atlanta on November 10-12.

The event will offer up to 27.5 CME credits. GAPF Chair Wayne Hoffman, M.D., says that, “These activities were developed for family physicians and are appropriate for other primary care clinicians, advance practice providers, office staff, and other health care professionals who

Georgia Chapter of the American College of Cardiology

The Longstreet Clinic and MAG member physicians Betsy Grunch, M.D., and James Reeves, M.D., were part of the team that performed the first motion preserving disc replacement in Georgia.

are interested in improving patient care.” GAFP President Mitzi Rubin, M.D., adds that, “Upon completing these activities, participants should be able to identify family medicine practices that are relevant to the well-being of their patient population and be able to recognize and describe current diseases and offer proper diagnosis, management and treatment options to patients and their families and be able to apply evidence-based treatments to effectively manage patient care.” The meeting will cover key conditions and diseases.

It will feature two mini-tracks that are devoted to women’s health and chronic kidney disease. There will also be a one-day workshop on cardiac stress testing, which will cover the basics for cardiac ECG exercise stress testing (EST) – including indications, contraindications, limitations, alternatives, equipment, and personnel needs. The event will also offer four Knowledge Self-Assessment Modules or KSAs (which were formerly known as SAMs) – including

the new Medical Genomics module. Other topics will include cancer survivorship, adult immunizations, direct primary care, and management strategies for long-term COPD patients. Go to www.gafp.org to register or call 800.392.3841 with questions.

Georgia Association of Pathologists

by Dan Walton, Executive Director The Georgia Association of Pathologists (GAP) is recruiting new members and reminding its current members to renew their membership at www. gapathology.org. GAP is also working with other pathology societies in the state to schedule what will hopefully become an annual meeting.

GAP members who would like to participate in the planning process for the meeting should contact Stacie McGahee at 706.738.3119 or smcgahee@medicalbureau. net. Go to www.gapathology. org to join/renew GAP or for additional information.

by Hank Holderfield, Executive Director The Georgia Chapter of the American College of Cardiology will hold its annual meeting at The RitzCarlton at Lake Oconee on November 18-20. Chapter President Charlie Brown, M.D., says that more than 150 cardiologists and 50 exhibitors will be on hand for “what many consider to be the best state meeting in the country.” Arthur Reitman, M.D., and Sheila Robinson, M.D., are heading up the Program Steering Committee. The event will feature special symposia on ‘Atrial Fibrillation, Innovations in Cardiology and Chronic Heart Failure’ and workshops on ‘Imaging, Women in Cardiology, Congenital and Structural Heart and Valve and Sudden Cardiac Death.’

ACC President Richard Chazal, M.D., will give a national issues update. The meeting will also feature a unique track for surgical specialists, a program for fellows in training and early career professionals, poster presentations from fellows in training and an array of outstanding speakers that will address a number of aspects of contemporary cardiovascular medicine.

The Chapter will honor Ken Dooley, M.D., from Children’s Healthcare of Atlanta with its Lifetime Achievement Award for “a long career of service (continued on page 34)

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(continued from page 33)

to the specialty, the medical profession, and organized cardiology.” Call 770.271.0798 or go to www. accga.org for additional information.

Georgia Chapter of the American Academy of Pediatrics

by Kasha Askew, Director of Membership & Education The Georgia Chapter of the American Academy of Pediatrics held its ‘Pediatrics by the Sea’ summer CME meeting on Amelia Island in June. The meeting chair was Charles Linder, M.D., of Augusta. Nearly 200 physicians from 23 states

attended the event. Ben Spitalnick, M.D., from Savannah was installed as the Chapter’s president. Other officers for the year include Vice President Terri McFadden, M.D., from Atlanta, Secretary Iris Basilio, M.D., from Columbus, and Treasurer Minor Vernon, M.D., from Macon. The Chapter also hosted a webinar on the Zika virus in June. It featured the Chapter’s Infectious Disease Committee Chair, Harry Keyserling, M.D., Georgia Department of Public Health (DPH) Director of Health Protection J. Patrick O’Neal, M.D., State Epidemiologist Cherie Drenzek, and Angela Campbell, M.D., MPH, and Janet Cragan, M.D., MPH,

MAG’s ‘Top Docs Radio’ show tops 7,500 listeners

from the Centers for Disease Control and Prevention.

The Chapter’s Fall CME Meeting – ‘Pediatrics on the Perimeter’ – will be held at the Westin Atlanta Perimeter North on September 22-24.

Emory University’s Judson Miller, M.D., will serve as the program chair. The event will include preconference seminars on nutrition, developmental and behavioral pediatrics, hospital medicine, and cardiology. The Chapter will also give out its annual awards during the meeting.

And it is worth noting that the Chapter is working on a number of webinars that will address pediatric care that it will unveil in the coming months. Visit www.gaaap. org or call 404.881.5091 for additional information on the Chapter.

Georgia Chapter of the American College of Physicians

From the left are Rep. Sharon Cooper, the chair of the Georgia House of Representatives Health and Human Services Committee, MAG ‘Top Docs Radio’ host C.W. Hall, and MAG Executive Director Donald J. Palmisano Jr. discussing key legislative issues on the ‘Toc Docs’ show in January.

MAG hosts the ‘Top Docs’ program on the Business Radio Network on the second and fourth Tuesday of every month. The program now has more than 7,500 listeners from all 50 states and more than 80 countries.

The show has addressed key insurer/payer issues, state legislation, chronic diseases, financial planning, fraud and abuse, regulatory compliance, practice management, and opioid drug abuse.

Go to www.mag.org/resources/TopDocs to listen to recordings of ‘Top Docs’ shows.

34 MAG Journal

by Mary Daniels, Executive Director The Georgia Chapter of the American College of Physicians will hold its annual meeting – ‘Fostering Excellence in Internal Medicine’ – at the Chateau Elan Winery & Inn in Braselton on October 21-23. The event will feature a hospital medicine track and faculty development course. Monitor www.gaacp. org for details. Contact Mary Daniels at mdaniels@gaacp. org with questions.

Georgia Gastroenterologic and Endoscopic Society

by Dan Walton, Executive Director The Georgia Gastroenterologic and Endoscopic Society

(GGES) will hold its annual meeting at the Atlanta Marriott Buckhead on Saturday, September 17.

Topics will include small bowel enteroscopy, nonalcoholic steatohepatitis, colon cancer in Georgia, and ERCP. Go to www. georgiagi.org for registration and other information. The meeting typically offers about six CME credits – and active members can attend the meeting for free, so they should go to www. georgiagi.org to complete a membership application for the year as soon as possible if they haven’t already done so. Contact Stacie McGahee at 706.738.3119 or smcgahee@medicalbureau. net with questions.

Georgia Society of Dermatology and Dermatologic Surgery

Go to www.gaderm.org for information on the Georgia Society of Dermatology and Dermatologic Surgery.

Georgia Society of Rheumatology

Go to www.garheumatology.org for information on the Georgia Society of Rheumatology.

Please submit your county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag. org. Also contact Kornegay with corrections, which will run in the next edition of the “Journal.” The “Journal” reserves the right to edit submissions for length and clarity. Bolding recognizes the physicians who are active MAG members at the time the “Journal” was prepared. Go to www.mag.org to join MAG.

PRESCRIPTION FOR LIFE

Hooah and 26,000 oversights Jay Coffsky, M.D.

W

hat would you call a person who was doing pretty much the same job they did when they entered the workforce more than 55 years ago? Dull, drone, monotonous, or unambitious come to mind.

Yet other than the advances in technology – like digital workstations instead of hard copy analog films, ultrasound, CT, MRI, mammography, and isotope imaging – that pretty much describes me to a “T.” I am essentially still doing what I did back in 1962 when I started my residency…evaluating and interpreting images of individual patients, one by one.

Back then we were trained to evaluate a couple of hundred films a day.

Now we evaluate tens of thousands of images a day using CT, ultrasound, MRI, and tomogram technologies – to name a few.

Yes, I have held administrative positions like medical staff chief and president of our group. But these were administrative positions that had nothing to do with my training or my medical professional career. I actually prefer practicing medicine over the administrative positions.

Although there’s debate over its origin, the word “Hooah” is a military term that means any kind of exclamation of a positive response – anything except no. It’s usually meant to mean heard, understood, acknowledged, and will do.

I think it is a great term. How nice Hooah would sound as a response when you ask someone to perform a favor or deed. It’s the law of affirmative action. If you are going to do something, do it with a positive attitude.

The closest I would have come to yelling Hooah is the night I graduated from medical school. It is the greatest feeling I have had in my life.

Now, how could a person who’s been performing the same tasks for 55 years – the same job of interpreting all these body imaging modalities – still be excited about what basically is an entry-level position? In addition to this, consider that I have seen the medical records of more than 2.6 million patients with often hundreds of images per case – bringing the total number of images into the hundreds of millions. (This is the first time I have tried to reconstruct these numbers…and it is staggering!)

But thinking about the number of images makes me think of how many misses, oversights, and incorrect interpretations I must have made. If the number of errors is only one percent – and studies show it’s more likely four percent or more – that is at least 26,000 errors for me, if I am in the best percentile.

Maybe I am a failure after all. How would you like to know that you made that many errors even if you were really good and not average in your professional career?

Most oversights are not of serious consequence (e.g., healed rib fractures or cervical ribs), but what if there was a billboard that said, “See Dr. Coffsky. He has only made 26,000 oversights in his career.” The internet chatter would be enormous.

I was recently doing some bathroom reading and the magazine was addressed to Mr. Jay Coffsky. That got me thinking about retirement and the fact that I am really not ready to get out of dodge. I still think that I am one of the richest people in the world. I’ve been fortunate to live and work in the greatest country ever when it comes to freedom and opportunity. I have a great wife of 57 years who still loves me (I think), a plateful of kids, grandkids, and a great grandson all who seem to enjoy being around us. And I’ve had the same job for 50 years in a great honorable profession with great colleagues.

Our chief of medicine in medical school used to say that he pinched himself on a daily basis surprised that they allow him to practice medicine – and pay him to do it. I now know what he meant, and I feel the same.

When an oversight comes to light, I still have the same emotional pain and suffering as I did the first day I started. If I was indifferent, I would surely retire.

One of my professional friends for more than 40 years, retired pathologist Dr. Frank Matthews, comforted me by saying the main difference in good and bad doctors is that bad doctors make more mistakes then good ones.

I hope I am in that good doctor category. Despite all the negative trends happening in medicine, I would do it again, and I would say HOOAH. Dr. Coffsky and his wife, Sandy, have been married for 57 years and have three children and eight grandchildren. He is in his 50th year at DeKalb Medical. His email is m3wejr@bellsouth.net.

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Take Two Steps MAG is encouraging its members to take two steps …

1 2

Submit your email address to dwilliams@mag.org to ensure you receive MAG’s e-News from MAG and e-News from the Capitol newsletters Open at least one electronic communication from MAG each month (e.g., alert, survey, newsletter) to ensure MAG’s email server doesn’t suppress your email address

Contact Kate Boyenga at kboyenga@mag.org or 678.303.9263 with questions.

36 MAG Journal

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