Round up Magazine February 2015

IN EVERY ISSUE: From the Exec. Director Announcements Marketplace Board of Directors Meeting Minutes To learn more visit www.mcmsonline.com

Page 4 Page 10 Page 34 Page 36

MCMS Members: Join us for cocktails and hors d’oeuvres as we celebrate the Society’s building facelift with an Open House on March 12. Details on page 3.

Celebrating 60 Years

- 015 1955 2

round-up Volume 61

•

Number 2

•

February 2015

Providing news and information for the medical community since 1955.

Dr. Paul Berggreen is keeping pace with technology.

Page 16

PRESIDENT’S PAGE: Technology has transformed a physician‘s ability to discover, diagnose and treat their patients.

However, with great advancements come great responsibility.

Page 8

PUBLIC HEALTH: The causes of childhood obesity are many, and as such, more than one approach to treating it is important.

Page 12

A CLOSER LOOK: We bring you a summary of a recent initiative led by the AMA to help improve the cumbersome EHR certification process for physicians.

Page 25

FEATURE ARTICLE: Senator Bill Frist, MD shares his thoughts with Round-up readers on how our nation’s health IT framework needs to adapt.

Page 26

TECHNOLOGY: The legal pitfalls of documentation shortcuts when using EHRs and steps to take to ensure that your practice is properly securing electronic records.

Pages 28 & 32

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Thursday, March 12, 2015 • 5-7 pm 326 E. Coronado Rd., Phoenix, Arizona 85004

RSVP by March 9th mcms@mcmsonline.com • 602-252-2015

from the executive director

What’s Inside?

Medicine and technology go hand in hand these days, most would agree. Either by innovation or by government mandate, it’s now a vital part of the practice of medicine.

Jay Conyers, PhD MCMS, Executive Director E: jconyers@mcmsonline.com P: 602-251-2361

But physicians and scientists have been innovating for centuries. Ben Franklin developed the flexible catheter more than a quarter of a millennium ago and the stethoscope celebrates its 200th birthday this year. As for the x-ray – well, it’s been around since before the turn of the 20th century after a German physicist, Wilhelm Röntgen, first introduced it to the world. At the time, many couldn’t believe his reports, with the New York Times even mocking his, “alleged discovery of how to photograph the invisible.” Fortunately, they were wrong, and Röntgen received the Nobel Prize in Physics in1901 for his technological breakthrough.

These days, discussions about technology in medicine commonly focus on electronic health records (EHRs), telemedicine, and mobile health, among other things. But would you believe that telemedicine is a relatively old concept? Scientists in the 1920’s were predicting the use of the radio and television to, “touch their patients from miles away.” One such report, in the February 1925 issue of Science & Innovation, described the Teledactyl, a futuristic medical device that would allow the physician to feel his patient from a distance.

In that article, the author, Hugo Gernsback, predicted the future of medicine when he wrote: The busy doctor, fifty years hence, will not be able to visit his patients as he does now. It takes too much time, and he can only, at best, see a limited number today. Whereas the services of a really big doctor are so important that he should never have to leave his office; on the other hand, his patients cannot always come to him.

This is where the teledactyl and diagnosis by radio comes in.

I was curious to know just how right Gernsback was, specifically the timing of his prediction. So I asked my good friend Dr. Jay Sanders, an Emergency Medicine physician at Johns Hopkins who founded the American Telemedicine Association (and served as its first President) and is widely considered by many to be the father of telemedicine. Dr. Sanders and I used to visit every so often at a little sleepy coffee shop outside of Washington, DC – prior to my relocation to Arizona in 2013 – and he’d tell me amazing stories about early examples of telemedicine.

When I asked him about the first example he could recall, he explained: In the early 70’s, there was a nurse who ran a clinic on an island off the coast of Maine and she was connected to the dermatology clinic at Dartmouth-Hitchcock Medical Center via telemedicine. It

4 • Round-up • February 2015 • A monthly publication of the MCMS

from the executive director

was noted after about a year of the system being operational that her requests for dermatology consults were going down, and the question was, why? Of course, everyone initially thought that she was having trouble with the system; that it was too difficult to set up, coordinate appointments, etc. To everyone’s surprise, when she was asked why, she said that she had learned so much from the previous consultations that now she was able to diagnose and treat a lot of the dermatologic problems that came into her office. This educational component of telemedicine for the local practitioner is not emphasized enough.

But enough with the history, and on with what’s inside this issue of Round-up…

We bring you most of our usual content, but with a focus on technology. MCMS President Dr. Ryan Stratford writes about some of the pitfalls of technology adoption in medicine in his editorial, and Dr. Sy Hasan brings us an in-depth report on childhood obesity in our public health section.

Our physician profile looks at Dr. Paul Berggreen, President at Arizona Digestive Health and developer of a mobile app that makes it easier for patients to prepare for surgery. We enjoyed getting to know Dr. Berggrreen, and hope you do, too.

We also bring you “A Closer Look” of a recent initiative led by the American Medical Association (AMA) to help improve the cumbersome EHR certification process. They spearheaded a coalition of 36 physician groups that penned a letter to the Office of the National Coordinator for Health IT recommending changes to the meaningful use program.

We include an op-ed from Senator Bill Frist, MD, a well-respected heart and lung transplant surgeon and former Majority Leader of the U.S. Senate. I had the pleasure of doing some work with Senator Frist during my time in Washington, DC and was excited when he agreed last month to share some of his writing with us this year. We hope you enjoy his thoughts on how our nation’s health IT framework needs to adapt.

February 1925 Cover - Science and Innovation Magazine.

And lastly, from the business side of practicing medicine, we have two great articles on the legal pitfalls of documentation shortcuts when using EHRs and steps to take to ensure your practice is properly securing electronic records.

Moving ahead, what better to focus on after technology than public health? Next month in Round-up look to read about one of the nation’s leading population health experts and Phoenix resident, Diana Petitti, MD, MPH. Until then, ponder the words of Pulitzer Prize-winning American author Richard Rhodes, who once wrote, “Arguably the greatest technological triumph of the last century has been the public-health system, which is sophisticated preventive and investigative medicine organized around mostly low- and mediumtech equipment ...fully half of us are alive today because of the improvements.” ru

A monthly publication of the MCMS • February 2015 • Round-up • 5

round-up

february 2015

Providing news and information for physicians and the healthcare community since 1955.

Published by the Maricopa County Medical Society.

4

8

10 12 16 25 26 28

32

what’s inside president’s page Technology in medicine.

announcements Society call to members. Volunteer your time and get involved! public health Childhood obesity – some good news.

member profile Dr. Paul Berggreen is keeping pace with technology.

a closer look Physicians outline improvements to EHR certification process.

feature article Time to advance a new oversight framework for health information technology. technology Electronic health records – legal risks of documentation shortcuts.

technology Securing and protecting electronic medical records.

In every issue Marketplace ....................................................................................................................................................................34 MCMS Board of Directors Meeting Minutes ................................................................................................................36

Cover photo: Denny Collins Photography www.dennycollins.com • 602-448-2437 6 • Round-up • February 2015 • A monthly publication of the MCMS

Connect with your Society.

Letters and electronic correspondence will become the property of Round-up, which assumess permission to publish and edit as necessary. Please refer to our usage statement below for more information.

Editor: Ryan R. Stratford, MD, MBA • rstratford@mcmsonline.com

Managing Editor: Jay Conyers, PhD • jconyers@mcmsonline.com Round-up Staff

Editor-in-Chief Ryan R. Stratford, MD, MBA Editor Jay Conyers, PhD

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To subscribe to Round-up Magazine please send a check for one-year subscription of $36 to Round-up Magazine, 326 E. Coronado Rd., Phoenix, AZ 85004 or visit mcmsonline.com/subscribe.

MCMS 2015 Officers President

Ryan R. Stratford, MD, MBA President-Elect

Adam M. Brodsky, MD Vice President

John L. Couvaras, MD Secretary

Kelly Hsu, MD Treasurer

Mark R. Wallace, MD

Immediate Past-President Miriam K. Anand, MD Board of Directors 2013-2015

R. Jay Standerfer, MD

Steven R. Kassman, MD Shane Daley, MD

Anthony Lee, MD 2014-2016

Lee Ann Kelley, MD May Mohty, MD

Richard Manch, MD Anita Murcko, MD 2015-2017

Ross Goldberg, MD

Jennifer Hartmark-Hill, MD Tanja L. Gunsberger, DO Marc M. Lato, MD

Celebrating

60 Years - 015 1955 2

Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at roundup@mcmsonline.com.

All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned.

The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Roundup considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content.

Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission.

No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.

A monthly publication of the MCMS • February 2015 • Round-up • 7

president’s page

Technology In Medicine

By Ryan R. Stratford, MD, MBA

ew would argue that technology has not revolutionized the practice of medicine, despite the under-the-breath complaints I am certainly guilty of making about the requirement to adapt EMR. The truth is technology has transformed our ability to discover, diagnose and treat our patients, and has given us the ability to manage previously untreatable conditions with ever-increasing speed. However, with great advancements comes great responsibility.

F MCMS President 2015 Ryan R. Stratford, MD, MBA Dr. Stratford specializes in Urogynecology/Pelvic Reconstructive Surgery.

He joined MCMS in 2005.

Contact Information: The Woman's Center for Advanced Pelvic Surgery 4344 E. Presidio Street Mesa, AZ 85215 P: 480-834-5111 E: rstratford@mcmsonline.com

Physicians in my subspecialty recently faced the dilemma of how to adapt new technology. Female Pelvic Medicine and Reconstructive Surgery (Urogynecology) is a newly formed subspecialty recognized by the American Board of Medical Subspecialties. It took years of effort, a foundation of substantive research, and significant compromise between two distinct fields of obstetrics/gynecology and urology to finally reach the distinction of becoming a unique subspecialty. However, in the same year that the first board exam was offered for the subspecialty, the subspecialty received a black eye from what has been considered an unregulated adaption of new technology — trocar-guided transvaginal mesh for the treatment of pelvic organ prolapse.

For the past two years there have been multiple television adds recruiting patients for class action lawsuits dealing with complications associated with placement of transvaginal mesh. As an example of the many settlements to end the tide of law suits, American Medical Systems (AMS) settled a group of lawsuits last year for $830 million. The impact on those who are involved in the industry has been profound and the rippling effects yet unknown.

The quick adaption of trans-vaginal mesh for the treatment of prolapse occurred because of a perfect storm of events. In the mid-1990’s, a mid-urethral sling for the treatment of stress urinary incontinence was developed in Denmark. By the early 2000’s, careful scientific studies began showing significantly improved long-term outcomes using mid-urethral slings for the treatment of stress urinary incontinence. Because prolapse is a commonly occurring condition with urinary incontinence and surgical treatments for prolapse historically had poor long-term outcomes, a ground swell of enthusiasm began building around the use of mesh for the treatment of prolapse using a similar, trocar-guided technique. Industry quickly developed multiple different options and physicians quickly adapted the new technology after attending short cadaver courses to learn how to place the mesh. New mesh kits were introduced to market almost every month. During the fervor to

8 • Round-up • February 2015 • A monthly publication of the MCMS

president’s page adapt, it seemed for a time that I had an industry representative in my office nearly every week touting a new, more effective “mesh kit.” Like most new technologies, the purpose and intent was two-fold: to improve patient outcomes and to make a profit. However, trans-vaginal mesh for the treatment of prolapse did not undergo the same level of scrutiny and premarket science that was applied to procedures such as mid-urethral slings.

Adding another wrinkle to this story, the FDA’s classification of trans-vaginal mesh did not require human testing prior to approval because trans-vaginal mesh kits for prolapse were considered similar to trans-vaginal mid-urethral slings — something already being placed in human subjects with good outcomes. Thus, no outcomes testing was required; physicians did not demand it, and industry didn’t complain. The products were quickly pushed to market.

Unfortunately, although not all outcomes were poor, the number of complications grew as the number of performed procedures increased. As a result, the FDA issued statements of concern regarding those complications and within a short time multiple class action law suits were filed.

Looking back, there are many lessons that can be learned.

Hopefully, lessons that will prevent similar miss-steps.

Today’s general gynecologists face a similar dilemma. In the last eight years surgeons have had to grapple with how to adopt the technology of robotic surgery. Originally developed by the military to allow surgeons to operate off-site from the battle field on wounded soldiers, the daVinci robot was sold to industry because the military found little use for intracavitary robotic surgery with the advent of improved body armor, reducing the number of bowel and abdominal wounds. The owners of this new technology were clever in how they marketed the technology. They drove demand by marketing directly to patients. The enthusiasm for robotic surgery grew quickly creating a fervor among competing hospitals to obtain a daVinci robot. Shortly after the adoption of robotic surgery, I had patients coming to see me asking me if they could have robotic surgery regardless of what surgery was needed to treat their condition. In addition to pressure from patients, company representatives encouraged surgeons to “practice” by performing the majority of their hysterectomies with the robot despite whether it offered benefits over other surgical routes.

Now, after wide-scale adoption of the technology, the utility of robotic surgery for hysterectomies is in question.

“We all have to grapple with this issue.

Technology affects every aspect of our practices, whether it is prescribing a new medication; finding a new way of communicating with patients through online portals, blogs, or emails; or accepting new surgical technology.”

– Ryan Stratford, MD

In early February, United Healthcare released their plan to require greater medical documentation by physicians in order to authorize a hysterectomy by any route other than vaginally. Although many physicians, and especially Intuitive Surgical, the producers of the daVinci robot, are up in arms, the new requirements from United Healthcare are in line with long-held recommendations from the American College of Obstetrics and Gynecology that the vaginal approach is the preferred route of hysterectomy.

Each of us can recount ways technology is requiring that we make decisions on how and when to adopt. I was told when I finished fellowship that I would have to decide how I would adopt new technology. Was I going to be a fast or slow adopter? How would that affect my ability to treat patients?

We all have to grapple with this issue. Technology affects every aspect of our practices, whether it is prescribing a new medication; finding a new way of communicating with patients through online portals, blogs, or emails; or accepting new surgical technology.

In each case, there are many factors that affect our decision about whether to adopt a new technology. I do not pretend to know what is best in every case. I certainly am amazed by technology and find it exciting and appealing.

Even more, I greatly appreciate how technology has made me better able to help patients as a physician. However, I believe that careful scrutiny is needed and scientific evidence required before supporting adoption of new technology. In my mind there is a place for both fast and slow adopters, but there should be no place for unscrutinized adoption.

The same principle applies to my oldest two children who I sometimes see at social gatherings texting the person sitting across the room from them rather than talking with them directly. It is not the technology but how it is adopted that affects us most. With greater advancements in technology comes greater responsibility. ru

A monthly publication of the MCMS • February 2015 • Round-up • 9

announcements

We Need You! Volunteer to Serve on a Committee!

The Maricopa County Medical Society has numerous committees designed to carry out specific missions that help support the practice of medicine.

These committees help bring our members together, provide educational materials and announcements, and advance strategic initiatives that serve the physician community.

Interested in policy making? We have a policy committee. Is quality and education your passion? If so, we have a committee for that, too! What about philan-

Philanthropy

Public Health Policy

Membership Mentorship Social Finance

thropy? Yep, a committee for that as well. Our committees include membership, public health, finance, social, philanthropy, mentorship, education & quality, and policy.

We're looking to involve more members in our committee activities, so please consider joining one today.

How much time does it take? Not much, actually.

Most of our committees have a teleconference once a month or once a quarter, and usually need an hour or less to discuss business.

Education & Quality

The Society staff carries out much of the work directed by the committees, so the time required by you will be little.

Signing up is easy!

Email us at mcms@mcmsonline.com (include your name, email and committee interest) or call the Society membership office at 602-252-2015. ru

Let the Lawmakers Know How You Feel About Pending Legislation!

Did you know that your support of or opposition to any bill can - and will - be seen by our legislators as they cast their votes?

Did you know that many bills are considered each legislative session that have an impact on the way you practice medicine?

The Arizona Legislature has a very simple-to-use platform that allows citizens to track bills, provide comment in support or opposition of a bill, and easily sign up to speak on behalf of a bill. All you need to know is a bill number.

Your Society is helping physicians register for the online portal and hopes that you can take a minute or so to email us at mcms@mcmsonline.com and provide us with a name and email address.

We'll get your account created and activated, and then email you the easy instructions for logging on and tracking bills. Even if you only track and comment on a single bill, it's worth it! ru

10 • Round-up • February 2015 • A monthly publication of the MCMS

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Join us for our 24th year of quality engaged learning! This activity has been approved for AMA PRA Category 1 Credit™ and AOA Category 1A Credit.

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public health

Childhood Obesity – Some Good News

By K.S. Hasan, MD

he previous three decades have witnessed a dramatic increase in obesity in the general population. You have read the grim stats – prevalence of childhood obesity in the United States remains high.

According to CDC’s National Health and Nutrition Examination Survey (NHANES) 2011-2012 data, approximately 17% (or 12.7 million) of children and adolescents aged 2-19 years had obesity.1

T K.S. “Sy” Hasan, MD Dr. Hasan is a board certified pediatric endocrinologist and owner of Pediatric/Adult Endocrine Gilbert.

He served as National Finance Committee Member for President Barack Obama and Doctors for Obama.

Contact Information: 1760 E. Pecos Rd. Suite 231 Gilbert, AZ 85295-3207

Hey, but wait, there is some good news. Efforts by pediatricians and other health care advocates have resulted in an obesity rate decline in kids between 2-5 years old.

Obesity means having too much body fat. It is not the same as overweight, which means weighing too much. Overweight and obesity are better expressed as body mass index (BMI). BMI is calculated by dividing the body mass in kilograms by the square root of the height in meters2. The resulting number is then compared to CDC growth charts to determine comparative percentiles to other children of the same age and sex. If a child is in the 85th percentile or higher, they are considered to be overweight. If a child’s BMI falls higher than the 95th percentile, they are considered obese.

There are clearly thermodynamic bases of obesity and these can be simplified by an energy balance equation: Energy Storied = Energy Intake — Energy Expenditure or Gain In Weight = Calories In — Calories Out

P: 480-821-2883 F: 480-237-5799 E: info@pegilbert.com

It is clear from this equation that the approach to weight reduction, therefore, needs to address ways of increasing expenditure over consumption.

www.pegilbert.com

GENETIC STUDIES OF OBESITY

Animal models have provided some insight into the genetics of obesity.

There are many protein gene products involved in the pathogenesis of obesity. The first to be identified was the product of the ob gene termed leptin (pathway 1).

12 • Round-up • February 2015 • A monthly publication of the MCMS

public health The leptin-leptin receptor axis represents one of a number of systems that is being explored as a possible way to treat human obesity and overweight.

Overweight and obesity impacts the conditions treated by all pediatric specialists. As a pediatric endocrinologist, my colleagues and I have seen a dramatic increase in what were previously “adult” diseases. These include diabetes mellitus, type-2 diabetes (T2DM) and polycystic ovarian syndrome (PCOS).

By far, in the general population, the major type of diabetes is type-2 diabetes and was previously referred to as adult-onset diabetes mellitus (AODM).

The terms type-1 and type-2 refer to the underlying mechanism of diabetes, that is, autoimmunity (Type-1) vs. insulin resistance (Type-2). Type 2 Diabetes Mellitus (T2DM), a result of insulin resistance, usually occurs in adults and is associated with obesity.

The symptoms of T2DM can be subtle to dramatic. The typical three P’s – polyuria, polydipsia, polyphagia – that are seen in type 1 diabetes may be seen in T2DM. Often a child presents with significant hyperglycemia resulting in glucose toxicity and “ketosis prone Type-2 Diabetes.”

PCOS is the most common cause of androgen excess in adolescent girls and women. The hormone mechanism in PCOS is due to elevated ovarian androgens. These include androstenedione, testosterone and dehydroepiandrostenedione. The typical clinical picture leads to menstrual irregularities, acne and hirsutism.

Stein and Leventhal gave the “classic” description of PCOS in 1935. The women described had bilateral polycys-

Pathway 1.

The leptin-leptin receptor axis is shown to have influence on body weight.

Corticosterone, insulin and other peptides play a role in satiety and hunger.

Thermogenesis by burning of brown fat (activation of beta 3-adrenergic receptor) is regulated by leptin secretion. Pharmacotherapy that targets steps in this pathway may prove to prevent or treat obestity.

Insulin from pancreas

Leptin from fat cell Corticosterone from adrenal gland Feedback

Binding to leptin receptor in hypothalamus

Corticotropin rel. hor.

(CRH) levels

Neuropeptide Y (NPY) levels

Sensation of fullness food intake

Gut peptides influence intake

tic ovaries, amenorrhea, anovulation, hirsutism and obesity. These women often underwent surgery to remove the ovarian cysts.

Insulin resistance correlates strongly with PCOS. There is evidence that a high insulin state can alter local insulin-like growth factor (IGF 1) within the ovary. Additionally studies investigating the effect of insulin sensitizers on the disease have shown ben-

efit. Furthermore PCOS is a well detailed predictor of the future development of T2DM.

Therapy for PCOS is aimed at restoring the hormone imbalance. The most effective strategy is a combination of estrogen and progestin to override the pituitary-ovarian axis. The combination pill suppresses LH and FSH, the agents that stimulate the ovary and shut off androgen production by the ovaries.

A monthly publication of the MCMS • February 2015 • Round-up • 13

public health Metformin and other insulin sensitizers have also been effective. Furthermore, the most widely used agent, metformin, has weight loss as an added benefit.

Spironolactone at a dose of 50 to 100 mg b.i.d. for several months may be helpful to reduce the androgen effect at the hair follicle. This therapy requires a long-term commitment due to the slow response. Immediate cosmetic measures can be used such as bleaching, waxing, shaving or other means to reduce unwanted hair. Furthermore, weight loss alone has been shown to reverse many of the abnormalities associated with PCOS.

“... The likelihood of losing weight as an adult is less than that for children.

It is obvious that addressing this increase in incidence of obesity needs to be done early in childhood. Evidence has shown that the younger siblings who come to office visits and have normal BMIs are tuning in to discussions. It is among children between 2 and 5 years old that obesity has declined, based on CDC’s National Health and Nutrition Examination Survey (NHANES) data.”

– K.S. “Sy” Hasan, MD

METHODS OF WEIGHT REDUCTION/ MAINTENANCE

In a young child whose weight is above the normal curve for age, weight reduction per se is not necessary. If the child can maintain his weight or even reduce the rate of weight gain, the weight will eventually enter the normal curve as the child ages. As the linear growth continues, his/her body mass index will decrease with stable weight.

Programs that couple calorie restriction with exercise

have been shown to be far better in promoting weight loss/maintenance. Sedentary time should be limited to no more than 1-2 hours. A rigorous exercise regimen will not likely be effective for the long-term. Incorporation of exercise that reduces time of inactivity is far more likely to have a long-term effect. A moderate amount of anaerobic exercise has been shown to have good compliance especially in teenage boys. Experimenting with various types of activity may result in one that the child favors. Playground equipment may be more suitable for one child while enrolling in swim lessons is more preferred by another child. Asking children to perform chores around the house with a built in reward system can lead to a reduction of inactive time.

It is essential to incorporate the entire family in the goal of improving the child’s health. A child is more likely to succeed in weight loss if other members of the family participate in the program.

Limiting eating out, and especially fast food restaurants that serve “super sized” high calorie items is recommended.

A mirror or a sign on the door of the refrigerator or pantry can serve as a reminder of the goal of weight control. Keeping a diary or written log of weekly success is helpful. Also, taking water, salad or other vegetables first at mealtime can provide a sensation of fullness. In addition, eating slower, using smaller plates and preparing foods with less oil and butter may improve the likelihood of success.

Unfortunately 80% of overweight adolescents maintain this problem as adults. The likelihood of losing weight as an adult is less than that for children. It is obvious that addressing this increase in incidence of obesity needs to be done early in childhood. Evidence has shown that the younger siblings who come to office visits and have normal BMIs are tuning in to discussions. It is among children between 2 and 5 years old that obesity has declined, based on CDC’s National Health and Nutrition Examination Survey (NHANES) data.

Lifestyle interventions are regarded as the therapy of choice in children with obesity. The efficiency of lifestyle intervention for childhood obesity has been proven by several randomized controlled trials and meta-analyses. Even a stable weight in a growing child with obesity is associated with an improvement in cardiovascular risk factors and comorbidities of obesity. In particular, children aged 5-12 years and children who are overweight rather than obese profit from lifestyle interventions.

14 • Round-up • February 2015 • A monthly publication of the MCMS

public health The Arizona Academy of Pediatrics3 (AzAAP) urges clinicians to use the 5-2-1-0 message: 5 – Servings of fruits and vegetables per day.

2 – Less than 2 hours of screen time per day (computers, TV, video games, cell phones).

1 – At least one hour of physical activity per day.

0 – Zero or almost zero sweetened beverages such as soda, and sports or energy drinks.

The Obama administration recognizes the public health implications of childhood obesity. Michelle Obama launched Let’s Move! in 2010 with the goal of the action plan to reduce the childhood obesity rate to just five percent by 2030 – the same rate before childhood obesity first began to rise in the late 1970’s.

As physicians, we should continue to champion for children struggling with overweight and obesity. This includes demanding proper reimbursement for the care provided. This

started with policy adoption at the American Medical Association’s 2013 annual meeting of obesity as a disease. The ICD-10 diagnosis codes roll out expected in October of this year will include E66.0 codes for overweight and obesity.

We will be able to get better reimbursement for obesity and its comorbid conditions.

The causes of childhood obesity are multifactorial. A multi-faceted approach to success is important. Lifestyle interventions are regarded as the therapy of choice in children with obesity. Getting parents and siblings involved along with the healthcare team is essential. The message is working especially in the 2-5 age range. If this trend continues we will have a brighter future for our children. ru

References:

1. http://www.cdc.gov/obesity/data/childhood.html

2. Growth charts can be downloaded from the Centers for Disease Control web site:www.cdc.gov/growth

3. The AzAAP has created a clinician toolkit that can be viewed at: www.azwaytogo.org 22

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Maricopa County Medical Society members are eligible to join A monthly publication of the MCMS • February 2015 • Round-up • 15

member profile

Paul Berggreen, MD

By Round-up Staff

Article photos by Denny Collins Photography www.dennycollins.com 602-448-2437

W

ith new advances in technology overwhelming the market every day, and Meaningful Use requirements looming large in the forefront of our minds, it is no wonder that we are looking to see how these trends will affect the practice of medicine.

Dr. Paul Berggreen, a leader and innovator in his field, has played a pivotal role in the new technology currently available.

Berggreen specializes in Gastroenterology, and serves as the president of Arizona Digestive Health, where he has worked hard to establish an environment in which technology truly serves as a valuable asset to physician and patient prep and communication.

Round-up sat down with Dr. Berggreen to discuss his take on technology in today’s medical field.

16 • Round-up • February 2015 • A monthly publication of the MCMS

member profile

Altruism and Independence

When asked what led him to medicine, Dr. Berggreen said he was motivated by, “the opportunity to put altruism and idealism to work on a daily basis. Intellectual stimulation and independence are fringe benefits,” he said.

Technology also played its part from the beginning, and helped Berggreen select his specialty. While studying at LSU Medical School, Berggreen observed physicians performing endoscopy at Charity Hospital in New Orleans and was immediately impressed with the technique.

“I thought, it’s like going to work and playing video games all day,” he recalls.

He was hooked. After LSU, he decided to come west to Phoenix to complete his residency in internal medicine at Banner Good Samaritan. He then stayed to complete a Gastroenterology fellowship at the combined Phoenix VA-University of Arizona program. Originally, Berggreen planned to pursue an academic career after fellowship, and even interviewed in Oregon for a faculty position. But when the ideal position opened up unexpectedly in Phoenix he jumped at the chance to stay.

“The New West appealed to me for its possibilities,” he said about his choice to settle in Arizona. “There was a huge influx of new residents, the social infrastructure was in tran-

sition, and it was a dynamic environment where a person really could shape their own destiny in a way that is much more challenging elsewhere. Also, the sunshine didn’t hurt.”

After graduating, Berggreen joined with other physician partners to lead the construction of the Arizona Endoscopy Center, which allowed them to establish a practice founded on their own philosophies.

“When I made the decision to go to medical school, the vast majority of physicians were independent,” he explained.

“That was and remained very appealing to me, and has shaped my career.”

In 2007, Berggreen would form another group, Arizona Digestive Health (ADH), a gastroenterology supergroup where he is the president today. When it began, the group initially comprised 35 members. It has grown to include 59 physicians and over 300 employees, with 9 affiliated endoscopy centers and a full service pathology lab.

Technology and Innovation

Throughout his career, Berggreen has consistently embraced technology early on, beginning with electronic medical records. ADH made the switch soon after EHR’s hit the marketplace. While a positive change in many ways, Berggreen recognizes this was not without its operational and economic costs.

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A monthly publication of the MCMS • February 2015 • Round-up • 17

member profile The quest to establish real value through technology in medicine is a driving factor in Berggreen’s career, and he believes the impact of technology on practices everywhere will only continue to grow.

Smart Clinic is a patient-facing application that aids in procedure prep through notification reminders and other communications.

“Configuring an EMR to be a true assistant to clinical practice rather than just a tool to justify a billing code is challenging, and typically requires a significant time investment by a committee of IT-savvy physicians,” he explained.

In addition to standard record-keeping practices, physicians at ADH use a GI registry through the American College of Gastroenterology (ACG), which allows them to upload quality measures to a national database and benchmark their individual practice against their peers.

“Our physicians use a variety of online and mobile tools to assist in daily chores, from tracking hospital patients to checking for drug interactions,” he said.

When asked to comment on how this will affect healthcare in Arizona, Berggreen explained, “Aggregation of data, benchmarking results, standardizing care protocols and measuring compliance are all ramping up across the country, and Arizona is no exception. These trends are positive for our profession and rather than resist, we need to direct their adoption and usage.”

“The operational aspects of this can be painful,” he acknowledged. “But groups that fail to move in this direction will find themselves at a distinct disadvantage when health systems and insurers start demanding quality data, a move that will accelerate rapidly as new payment models stressing quality outcomes take hold in Arizona.”

Far from sitting back and allowing the technology wave to pass him by, Berggreen has taken his involvement a step further. Two years ago his group developed a smartphone app designed to assist with procedure preps. Before taking the app live, ADH conducted studies to determine if the application truly improved the quality of the process. When these results proved remarkably positive, the application concept was presented nationally and a second round of tests were conducted to confirm the original positive findings.

“We have to adopt better tools if we want better results, and the most significant tool to be developed in the past decade is the smartphone. That’s what we are calling patient engagement, but it really just means better communication.”

– Paul Berggreen, MD 18 • Round-up • February 2015 • A monthly publication of the MCMS

member profile

Dr. Berggreen talks to a patient at Arizona Digestive Health.

One year later, Berggreen took the positive results and innovative thinking a step further and developed the mobile communication platform called Smart Clinic, a patient-facing application that connects to a physician web portal. The app then sends push notifications, texts, or emails reminding patients of upcoming visits and procedures. The app also aids in procedure prep by delivering all preparation steps for the patient and allowing the office to confirm patient prep and medication courses. Patients can also access their clinical summary, procedure, biopsy, or labs results directly through the app in a secure and HIPPA compliant environment.

Smart Clinic is iOS and Android compatible, and can also send surveys or condition specific questionnaires to enhance patient – physician communication. While it began as a GI application, it has expanded to include functionality for physicians in all specialties.

“Smart Clinic is not only first to market, it is still the only app of its kind,” Berggreen said. “Although it is a young

company, it is now the official mobile communication platform of the ACG and is in use in practices in several states, as well as Australia and South Africa.”

“It’s free, simple to use, and secure, and the feedback for the past six months has been remarkably positive from all age groups,” he said. “Although fitness trackers are popular, their data is not terribly useful and certainly not in a format a physician would want.”

When asked if he would recommend the use of particular apps to physicians, he said there a great many mobile apps for various functions, and it would be difficult to select just one.

“TigerText and Wickr bill themselves as HIPAA compliant texting services between physicians. Other services are focused on hospital systems to facilitate local network formation, so that a group such as a large medical group, a heath network, or an ACO (Accountable Care Organizations) can

A monthly publication of the MCMS • February 2015 • Round-up • 19

member profile

On the Personal Side 1. Describe yourself in one word.

Driven.

2. What is your favorite food, and favorite restaurant in the Valley?

Pizza. Pomo Pizzeria Napoletana. Authentic certified Neapolitan pizza, great neighborhood restaurant in Scottsdale.

3. What career would you be doing if you weren’t a physician?

University professor teaching History of Western Civilization.

4. What’s a hidden talent you have that most wouldn’t know about?

My hobby has always been creative writing. I published short stories when I was younger and I actually wrote three novels. Unfortunately, only one of them came close to being printed by a major publisher and it didn't work out in the end. Then I started private practice and had kids, and that was the end of that.

5. Best movie you’ve seen in the last 10 years?

I'm a huge fan of J.R.R. Tolkien, so the Lord of the Rings trilogy is number one, hands down.

6. Favorite Arizona sports team (college or pro)?

Since I went to LSU I'm not allowed to root for any other college teams, so I'll have to say in pro football: the Cardinals are my favorite.

7. Do you participate in any sporting activities?

Cycling is a great sport. You can be as competitive or as social as you like. Several partners in our group formed the Arizona Digestive Health Cycling Team, and we'll do rides or races together. Staying healthy through sports like cycling sets a good example for our patients.

20 • Round-up • February 2015 • A monthly publication of the MCMS

communicate seamlessly,” he said.

“Nationally, the most popular reference app for doctors is Epocrates, which is very useful for drug reference.

PubMed4Hh is a free app from the National Library of Medicine useful for article lookup.”

With the innovation of so many different communication and tracking technologies, much has been said and written concerning patient engagement. Specifically, how the use of Mobile Health can help reduce patient readmissions.

When asked for his take on improved patient engagement through technology, Berggreen agreed that medical and tech literature are brimming with studies that confirm mHealth’s role in improving compliance and communication.

“In medical school… we were taught that patients forget 80% of what they are told in a visit within 24 hours,” he explained. “More recent data confirms that this number has not changed in 30 years, and the reason is that we are using the same tools — verbal communication and paper documents.”

“We have to adopt better tools if we want better results, and the most significant tool to be developed in the past decade is the smartphone,” he said.

“That’s what we are calling patient engagement, but it really just means better communication.”

According to the Nielsen research group, 71% of U.S. adults use a smartphone. Considering this, and the likelihood that number will only continue to grow, Berggreen believes the medical profession needs to fully embrace the use of smartphones to provide the best benefit to their patients.

member profile Despite the conveniences these innovations offer, not all discussion and reactions to technology in medicine are positive. Recently, a coalition of specialty societies led by the American Medical Association submitted a letter to The Office of the National Coordinator for Health Information Technology (ONC) recommending changes to EHR certification requirements tied to Meaningful Use. When asked to describe his take on this, Berggreen explained that Meaningful Use Stage 1 was relatively simple for practices to accomplish, but that Stage 2 is proving to be more of a challenge.

Meaningful Use Stage 2 requires that a provider have a set percentage of his or her patients utilize an online personal care tool or electronic personal health record.

“While MU2 is in full swing and causing significant heartburn amongst doctors and practice managers, it’s really just an attempt by government planners to force adoption of new tools for communication,” Berggreen explained.

While the ONC recently delayed their previous requirement percentage for use of a patient portal, the 5% use requirement is in full effect for 2015.

“The requirements for an EMR company to provide the ability for their customers to achieve MU2 is going to drive a significant number of the 600+ ambulatory EMR companies out of business in coming years, thus spurring market consolidation,” Berggreen explained. “Having begun this process for Smart Clinic, I can attest to the remarkably complex set of rules and testing requirements involved.”

Meaningful Use Stage 3 has yet to come into effect, and Berggreen describes it as a moving target. He asserts that Stage 3 will require EMR vendors to continue development, and that these costs will inevitably be passed on to physicians.

“While the ultimate goal is laudable, the devil is in the details and implementation will be painful,” he said.

Berggreen also believes that EMR interoperability is another popular discussion point, and already a hurdle for readily accessible patient records.

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A monthly publication of the MCMS • February 2015 • Round-up • 21

member profile

“Historically, physician groups have supported community outreach, education, and fundraising efforts directed toward patients and their care: all important and appropriate goals. However, more is needed. We must become politically active to advocate not just for our patients, but for our pro– Paul Berggreen, MD fession.”

“While the ONC and other organizations are pushing the issue, the large EMR companies continue to jealously guard ‘their’ data,” he explained. “Without true interoperability, the entire effort at communication and standardization is bound to fall short.”

Involvement and Activism

In addition to innovating and implementing new technology, Berggreen believes that part of what is necessary to combat these growing challenges and hurdles is increased physician involvement and activism.

In addition to serving as president of ADH, Berggreen is heavily involved in other physician organizations. He serves on the board of the Digestive Health Physicians Association, which is a national group that advocates for the preservation of the independent, integrated model of medicine. He also serves as a member of the AMSURG National Physician Advisory Board, and has served as site director of the GI fellowship program at Banner Good Samaritan for 16 years.

In addition to his leadership in these organizations, he is also an active member of the American College of Physicians, the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy, and the Phoenix GI Society. And, of course, the Maricopa County Medical Society.

Berggreen said that historically, physician groups have supported community outreach, education, and fundraising efforts directed toward patients and their care: all good things he considers important and appropriate goals. However, he thinks more is needed.

“We must become politically active to advocate not just for our patients, but for our profession,” he stated.

“Our profession has neglected the political aspect of medicine - the macro forces that have shaped medicine - often without much of our direct involvement. From the managed care movement of the last decades, the broken medical liability situation, and more recently the ACA and its ramifications, the majority of physicians have watched from the sidelines as we work 12 hour days caring for our patients.”

Because the Affordable Care Act (ACA) is so new, he thinks it may have little immediate effect on day-to-day patient care, and will do little to control cost, for now. The main impact he is seeing is in the confusion of managing patients signing up for health exchanges of all varieties.

“What it and other government initiatives will do is to continue to promote consolidation of power in large healthcare systems and make it more difficult for physicians in small practices to survive and thrive,” he said.

“Since recent research shows that hospital-employed physicians deliver significantly more expensive care than private practice physicians, that bodes ominously for the future of health care costs.”

Berggreen believes physician voices in the political arena are the key to preserving not only physician independence, but also the highest quality of patient care.

“It’s not much fun and not nearly as gratifying as saving someone’s life, but if we neglect this aspect we become pawns in a process dictated by money and politics, controlled by people who never took the Hippocratic Oath,” he said.

“It’s helpful to remember the mantra, The world is run by those who show up.” ru

22 • Round-up • February 2015 • A monthly publication of the MCMS

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a closer look

Physicians Outline Improvements to EHR Certification Process Published with permission. Originally printed on January 22, 2015.

Released by the American Medical Association (AMA Wire). hysicians can’t meet meaningful use requirements without certified electronic health records (EHR), but the current EHR certification program ties EHR design and testing too closely to the meaningful use program.

Medical associations recommended three broad changes to improve the EHR certification process and make it easier for physicians to use EHRs and care for patients.

P

In a letter to the Office of the National Coordinator for Health IT, 36 physician groups said there are many issues with EHRs, but addressing EHR certification is an improvement that can be made in the short-term to guide further efforts in the long-term.

“Ensuring patient safety is a joint responsibility between the physician and technology vendor and requires appropriate safety measures at each stage of development and implementation,” the letter said. “Ultimately, physicians must have confidence in the devices used in their practices to manage patient care.”

In 2014, regulators made some improvements to the meaningful use program, including allowing physicians to use new, old or a combination of both versions of certified software to meet meaningful use. But the changes didn’t go far enough, and only about three percent of physicians and other eligible providers had attested to Stage 2 of meaningful use in 2014, highlighting the difficulty of the program.

To make improvements to the EHR certification process, physician groups told ONC it should focus on three areas:

1. Usability. The method used to test EHR usability is underdeveloped, and testing doesn’t often mimic real-world medical practice. More rigorous testing to include a variety of different scenarios, including test cases that represent the

needs of medical specialists, would help to improve how the technology is used in real-life workflows. EHRs should also demonstrate their ability to handle input errors, bad data or system malfunctions. For optimal performance, an EHR should be able to flag and manage erroneous data entered by mistake to protect patients from unsafe events.

2. Interoperability. “The act of two computers sending and receiving data does not constitute functional interoperability—the ability for information to be exchanged, incorporated, and presented to a physician in a contextual and meaningful manner,” the letter said. Rather, efforts should be placed on ensuring the necessary health information follows patients during transitions of care. For example, currently EHRs exchange lengthy documents that provide little value if they’re simply imported in to a patient’s record.

ONC must clarify and standardize how these documents should be exchanged and create tests to verify their conformance to those standards.

3. Security. Protecting the privacy and security of patient information is crucial, yet current methods for accessing data, like passwords and tokens, are cumbersome and can still be compromised. Health IT regulators and EHR vendors should look toward advancements in consumer electronics and developing identification solutions to reduce many of the authentication difficulties medical professionals face.

Last year, the AMA released a blueprint outlining ways to improve the meaningful use program and a framework that details eight priorities for moving toward more usable EHR systems.

Read more about EHR improvement at AMA Wire® (www.ama-assn.org). ru

A monthly publication of the MCMS • February 2015 • Round-up • 25

feature article

Time to Advance a New Oversight Framework for Health IT

By Senator Bill Frist, MD

nnovations in digital technology have changed the way we live our everyday lives, and we are finally, just now, seeing them change the way that we deliver healthcare and manage our own health.

I Sen. Bill Frist, MD Dr. Frist, senator from Tennessee from 1995 to 2007, is a nationally acclaimed heart and lung transplant surgeon, former U.S. Senate Majority Leader, and chairman of the Executive Board of the health service private equity firm Cressey & Company.

Currently Frist serves as an adjunct professor of Cardiac Surgery at Vanderbilt University and clinical professor of Surgery at Meharry Medical College, and chairman of both the Hope Through Healing Hands foundation which focuses on maternal and child health and SCORE, a collaborative K12 education reform organization that has helped propel Tennessee to prominence as a reform state.

Now new technology makes it possible for us to track and improve our health and wellness by logging our personal habits like physical activity, food intake, and sleep, as well as helping us keep track of important health information like medications and blood pressure. Americans are also using social networks for much more than socializing. Through online communities patients and caregivers are sharing their stories and advice, getting emotional support, and even logging and sharing side effects of specific treatments and interventions. In addition, price transparency tools are emerging to help the consumer-patient make better informed decisions about the quality and costs associated with many medical choices.

Given the pace of technology in every other field, it is embarrassing to report that we are just now seeing a significant penetration of online communication between doctors and patients. However, it is imperative to the efficient delivery of modern medical care. In addition to moving medicine into the 21st century with online portals and secure emailing, we are also seeing the rise of telehealth. Telehealth or connected health has been aided by the slow but eventual uptake of electronic health records by the nation’s physicians and hospitals. We can now access patient data and support on best practices at the point of care between physician visits. As we combine this type of health information access with genomic information, we move one step closer to truly personalized medicine.

However, new innovation is always met with the age-old problem of existing regulation. Laws are understandably written with existing technology in mind and without flexibility for an evolving and unforeseeable landscape. What Congress envisioned 40 years ago is simply no longer relevant. To support invention and innovation we need a flexible, risk-based oversight framework that protects patient safety and reduces regulatory duplication.

To address this need the Bipartisan Policy Center has engaged hundreds of stakeholders and experts to develop a set of principles and recommendations for a new oversight framework for digital technologies in healthcare. The BPC frame-

26 • Round-up • February 2015 • A monthly publication of the MCMS

feature article work — reflecting agreement among leaders across every sector of healthcare — calls for higher risk health information technology (IT) to be subject to oversight via public-private partnerships promoting adherence to a set of voluntary consensus standards and patient safety reporting. This framework would better support rapid response, learning, and improvement. Advancing and implementing this framework was discussed during an event I kicked off at the Bipartisan Policy Center last week.

The good news is this is on the radar for Congress, the administration, and the private sector alike, with everyone agreeing we need a risk-based framework for health IT. During BPC’s December 2014 event, Representative Marsha Blackburn (R-TN) confirmed that an updated version of the Sensible Oversight for Technology which Advances Regulatory Efficiency (SOFTWARE) Act of 2013, which has 38 co-sponsors on both sides of the aisle, would be part of the 21st Century Cures package scheduled to emerge from the House Energy and Commerce Committee in January 2015. Sens. Michael Bennet (D-Colo.) and Orrin Hatch (R-Utah) introduced the Medical Electronic Data Technology Enhancement for Consumers’ Health (MEDTECH) Act, which provides greater certainty regarding regulatory expectations, limiting the Food and Drug Administration’s role related to low risk medical software and mobile apps in alignment with the BPC framework.

“We demand online and digital access 24 hours a day to most of the other information in our lives and employ digital technologies and devices to make frictionless our daily business and leisure activities. Why should something as important as our health be any different? Sure there are barriers and privacy considerations, but we can overcome them. We know how right now. So, it is time to move on bringing health information technology up to speed with the rest of our lives. No more excuses.”

— Sen. Bill Frist which reflects many of the principles and recommendations outlined in the BPC report.

With growing agreement among and action by Congress, the administration, and the private sector we are on the cusp of evolving a regulatory environment that would reward innovation, protect patient safety, create jobs, and improve health and healthcare in this country. But we cannot stop now.

We demand online and digital access 24 hours a day to most of the other information in our lives and employ digital technologies and devices to

make frictionless our daily business and leisure activities. Why should something as important as our health be any different? Sure there are barriers and privacy considerations, but we can overcome them. We know how right now. So, it is time to move on bringing health information technology up to speed with the rest of our lives. No more excuses. ru ©2015 Capitol Hill Publishing Corp., a subsidiary of News Communications, Inc. Reprinted with permission; http://thehill.com/opinion/oped/226680-time-to-advance-a-new-oversight

And the administration is also onboard with the release in April 2014 of the FDASIA Health IT Report: Proposed Strategies and Recommendations for a Risk-Based Framework,

A monthly publication of the MCMS • February 2015 • Round-up • 27

technology

Electronic Health Records: Legal Risks of Documentation Shortcuts

By Kylie Mote, JD

Kylie Mote, JD Kylie Mote is an associate attorney at Milligan Lawless, P.C., in Phoenix. Her practice includes the representation of physicians, physician groups, and healthcare organizations in a variety of healthcare matters.

She can be reached at 602-792-3523 or kylie@milliganlawless.com.

The use of electronic health records (EHRs) by physicians, hospitals and other providers has dramatically increased in recent years. The federal government reports that 78% of officebased physicians are now using some type of EHR, up from only 18% in 2001. Additionally, while only 9% of hospitals had adopted EHRs in 2008, more than 80% are now meaningfully using the technology.

While the widespread adoption of EHRs may offer certain benefits to healthcare providers, including the increased quality and efficiency of patient care, providers should be aware that certain EHR documentation practices may expose them to serious legal implications. Specifically, providers must be cautious that the use of certain EHR documentation tools and shortcuts does not result in the creation of records that are inconsistent or inaccurate.

This article will provide an overview of certain documentation shortcuts that can expose providers to legal consequences. In addition, it will offer some suggestions for reducing the risks associated with EHR documentation.

28 • Round-up • February 2015 • A monthly publication of the MCMS

technology

Copying & Pasting

One particularly dangerous EHR documentation shortcut is copying information recorded during a previous patient encounter and pasting it into the record as current documentation. This shortcut, also referred to as “cloning” or “carrying forward,” is a common practice among providers. According to a 2013 report issued by the American Health Information Management Association (AHIMA), up to 90% of physicians use the copy and paste function when using EHRs. While copying and pasting can save valuable time, it can also result in documentation errors that compromise patient safety and the integrity of a patient’s record.

The literature abounds with stories that illustrate the safety risks posed by this documentation practice. In one case, a patient was nearly subjected to an unnecessary change in medication after providers failed to update the information in his EHR to show that his abscess had been drained. In another case, providers continued to copy and paste a note stating that a patient was receiving vancomycin, despite the fact that the patient had been taken off the antibiotic. When the patient developed symptoms of an infection, a hospitalist read the inaccurate note and mistakenly determined that the patient was already receiving proper treatment.

Copying and pasting can also lead to the creation of records that overstate the level of service provided to a patient. For example, when providers copy and paste notes from a previous patient encounter, during which the patient had undergone a complete physical, they can create a record that appears as if the same exam were performed during the current visit. Third

party coders, who rely on the documentation to assign a CPT code to the visit, may unintentionally “upcode” the visit as a result of this practice.

Templates & “Documenting by Exception”

Another potentially-risky EHR documentation practice is the use of autofilled templates to “document by exception.” These templates expedite the documentation of a patient’s condition by providing pre-stored data specific to a particular specialty or health complaint. Rather than starting from scratch, a provider who is seeing a patient with a UTI, for example, can rely on an auto-filled template that will populate single or multiple sections of the patient’s record with findings or other information commonly found in patients with the condition in question. If certain auto-filled data does not apply to a specific patient, as is the case with a patient who does not have the abdom-

inal pains commonly associated with UTIs, the provider must edit the record to remove or modify the auto-filled data. This approach is called documenting by exception.

The use of auto -filled templates is another EHR feature that can save providers valuable time. However, when providers fail to review and edit the auto-filled data to ensure the accuracy of the information entered into the record, they can create serious documentation errors. For example, a provider using an auto-filled template specific to patients with hypertension may create a record that improperly notes a recommendation to take daily aspirin – a common recommendation for patients with hypertension - despite the fact that the patient is taking a medication that is a contraindication for aspirin-use. Similarly, a provider using an auto-filled template that inputs a negative review of systems, despite the fact that the provider did not review a par-

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A monthly publication of the MCMS • February 2015 • Round-up • 29

technology ticular system with a patient, may inadvertently create a record that documents a higher level of service than the provider actually performed.

Legal Risks of Documentation Shortcuts

Errors caused by risky EHR documentation practices can expose providers to multiple legal problems. If these practices result in errors that cause injuries to patients, providers may face malpractice lawsuits and licensing board investigations. CRICO, the medical malpractice insurer for Harvard’s medical community, recently conducted a study showing that cloning and templates are major factors in EHR-related malpractice lawsuits. Indeed, in a recent malpractice case filed against a New York hospital, the plaintiff blamed her son’s death on an ED physician’s improper use of an EHR template.

In addition to issues relating to quality of patient care, providers who fail to exercise caution in their use of EHR features may expose themselves to allegations of fraud and abuse. Although the federal government has pushed providers to implement EHR systems in their practices, certain federal agencies have expressed concerns that EHR documentation shortcuts may result in improper claims and billing. For example, the Office of the Inspector General, which has repeatedly identified copying and pasting as a major fraud and abuse concern, has called for greater scrutiny of EHRs in order to determine whether this documentation practice has resulted in up-coding and overpayments. Additionally, the Centers for Medicare and Medicaid Services has instructed auditors to pay close attention to EHR templates, particularly templates with check boxes and pre-defined answers, in order to ensure that providers who use this tool are not submitting false claims resulting from inaccurate records.

Documentation Best Practices

In order to reduce the risks associated with EHR documentation practices, providers should consider the following suggestions when using EHRs:

• Be cautious when using EHR templates with check boxes, pre-defined answers, pull-down menus, and limited space to enter information.

• Make certain that any automatically-populated information accurately depicts the patient’s condition and the level of service provided during the current visit.

• Train staff on proper EHR documentation.

• Verify the accuracy of all records prior to their submission.

When used appropriately, EHRs can assist providers in delivering quality healthcare. However, in order to maximize their benefits, providers should exercise caution when using certain EHR documentation shortcuts that can potentially result in serious errors and legal consequences. ru

Sources

Hsiao CJ, Hing E. “Use and characteristics of electronic health record systems among office-based practices: United States, 2001-2013”. NCHS data brief, no 143. Hyattsville, MD: National Center for Health Statistics.

2014.

Press Release, United States Department of Health & Human Services, Doctors and hospitals’ use of health IT more than doubles since 2012.

(May 22, 2013).

O’Donnell HC, Kaushal R, Barron Y, Callahan MA, Adelman RD, Siegler EL. “Physicians’ attitudes toward copy and pasting in electronic note writing.” J Gen Intern Med. 2009 January; 24(1): 63-69. Published online 2008 November 8.

O’Reilly K. “EHRs: ‘Sloppy and paste’ endures despite patient safety risk.” American Medical News, February 4, 2013. Available at http://www.amednews.com/article/20130204/profession/130209993/2/.

Bowerman D. “Ten techniques to redeem copy-and-paste documentation.” ACP Hospitalist, July 2014. http://www.acphospitalist.org/ archives/2014/07/EHRS.htm.

Ruder D.B. “Malpractice Claims Analysis Confirms Risks in EHRs.” Patient Safety Qual Healthcare. Jan-Feb 2014:20-33.

• Confirm that any copied and pasted information accurately reflects the current patient encounter.

Bowman v. St Luke’s-Roosevelt Hosp. Ctr., No. 150213/09 (N.Y. Sup Ct. Oct. 17, 2011).

• Exercise extreme care when copying and pasting elements of a patient’s history or previous examination.

Hirsh MD. “EHR templates could cost providers reimbursement dollars.”

FireceEMR. Available at www.fierceemr.com/story/why-ehr-templatescould-cost-providers-reimbursement/2012-12-13

• Avoid copying and pasting whole notes.

Office of Inspector General, Department of Health and Human Services. “Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology.” Memorandum Report. (Dec. 2013).

30 • Round-up • February 2015 • A monthly publication of the MCMS

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Both of our creeds are “first, do no harm.”

Ongoing ACA International Training Program HIPAA Certified Agents Professional Collection Specialist (PCS) Certified Agents Free Account Evaluations

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We’ll collect unpaid debt while protecting your good name and preserving your relationship with the patient.

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technology

Securing and Protecting Electronic Medical Records

By Lizabeth F. Brott, JD

P Lizabeth F. Brott, JD Lizabeth F. Brott, J.D., is Regional Vice President for ProAssurance and oversees provision of Risk Resource services to ProAssurance’s northern and northeastern region states. She received her law degree from Thomas M. Cooley Law School.

She can be reached at lbrott@proassurance.com.

Copyright © 2014 ProAssurance Corporation.

This article is not intended to provide legal advice, and no attempt is made to suggest more or less appropriate medical conduct.

hysician practices that rely solely on paper medical records are increasingly rare. A recent National Center for Health Statistics report found slightly over seventyeight percent (78.4%) of office-based physicians use medical record systems that are all or partially electronic (excluding billing systems). This reflects an increase of more than thirtysix percent (36.4%) from 2008 to 2013. By state, 2013 electronic medical record (EMR) use estimates ranged from twenty-one percent to eighty-three percent; Arizona came in just under fifty-one percent (50.7%).1

If your office has adopted or is considering an EMR system, it’s important to address the privacy and cyber liability risks associated with this technology. Network security, internet viruses, and electronic data breaches present a growing threat for many medical practices. Failure to safeguard against these risks can result in dire consequences for medical practices and patients alike.

Concerns regarding EMRs and patient privacy are not unfounded. A recent study of large healthcare organizations found that ninety percent of respondents had experienced at least one data breach in the preceding 24-month period. The top three causes of breaches were: lost or stolen computing devices; employee mistakes or unintentional employee actions; and third-party error (e.g., by a business associate).2

Fortunately, there are steps you can take to reduce the likelihood of a data breach. Two crucial drivers of information security include having an effective security strategy in place and being proactive in using it.3 Implementing a strictly enforced electronic security/privacy policy is your first line of defense.

Consider including the following in your security policy:

• An initial risk assessment with periodic follow-up assessments (consider using external experts).

32 • Round-up • February 2015 • A monthly publication of the MCMS

technology

• Regular system testing and security updates.

• Nightly data backup.

• Comprehensive clinician and staff training on your security policies and procedures and the importance of protecting patient data.

• Specific policies for use of personal devices including laptops, home computers, mobile devices and social media.

• Use of passwords and encryption for personal devices.

• Agreements with business associates outlining data privacy and security requirements.

• An incident response plan.

• Varying levels of access for employees on a need-to-know basis.

• Complex passwords and frequent required password changes.

• Physical placement of computer screens with special attention to visibility of social security numbers.

• Root cause analyses of major data breaches.

In addition, interactions with your EMR should take place over a secure, encrypted network.

Taking proactive steps to secure your EMR will go a long way toward protecting patient data; however, even the best

managed system can be vulnerable to data breaches. Cyber liability insurance will help cover expenses associated with this risk. Most cyber liability policies include protection for: • Network and security privacy breaches - virus attacks, patient identity theft, online and offline data breaches.

• Regulatory fines and penalties - defense costs for governmental investigations (including HIPAA), and payment of regulatory fines and penalties.

• Patient notification and credit monitoring costs – payment of legal and other expenses incurred to notify patients of an information breach and payment of credit monitoring costs for persons affected by a breach.

• Data recovery costs – payment for costs of recovering or replacing data that is lost, erased, stolen, or corrupted. ru

References

1. Hsiao CJ, Hing E. “Use and characteristics of electronic health records systems among office-based physician practices: United States, 2001-2013.”

NCHS Data Brief. January 2014; No. 143. National Center for Health Statistics, Centers for Disease Control and Prevention.

2. Ponemon Institute. “Fourth annual benchmark study on patient privacy & data security.” Ponemon Institute Research Report. March 2014.

3. PricewaterhouseCoopers International Limited. “Eye of the Storm— Key Findings from the 2012 Global State of Information Security Survey®.”

PricewaterhouseCoopers International Limited. New York;

A monthly publication of the MCMS • February 2015 • Round-up • 33

marketplace RESIDENTIAL LOT FOR SALE Attractive wooded residential lot for sale in Pinetop.

On cul-de-sac, easy access main road, near two country clubs.

Architect’s prelim schematics for 2 car garage, 3-5 bedroom options, 2,495-2,567 sq. ft. design available. 0.31/ac, $109,500.

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LOCUM TENENS, SHORT AND LONG TERM EMPLOYMENT

PRACTICE FOR SALE

ESTABLISHED PRACTICE FOR SALE 1,830 sq. feet, 4 exam rooms, CLIA lab, e-MDs EMR/HR software, plenty of parking space. The clinic was established in 1970 and purchased by the second owner in 2006.

Located in downtown Scottsdale on McDowell Rd. Call 480-686-1635 or email akidane@akcrfr.com for more information.

Physician and Advanced Practitioner Recruitment and Placement Locum tenens short and long-term coverage for: CME, medical leave, vacations, sabbaticals, and retirement.

It’s more than just filling vacancies.

It’s about matching lifestyles, personalities and practice philosophies.

Call: 602-331-1655 or 800-657-0354 • www.catalinarecruiters.com

UROLOGISTS

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No surgery, or treatment and minimal paperwork.

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• Flexible Service Schedule Including On-Call Service • Trained Service Technicians • Tracking and Documentation • Regulatory Compliance • Approved Packaging Supplies

Contact Marla Zimmerman at 480-964-3013 or marla@prostatecheckup.com

Round-up Marketplace provides local classifieds for full-time or part-time jobs, office space for sale or lease, services, local community, and events.

To advertise your product or service, contact Candice Scheibel at cscheibel@mcmsonline.com or call 602-251-2363.

34 • Round-up • February 2015 • A monthly publication of the MCMS

marketplace OFFICE SPACE FOR LEASE

SHARED OFFICE SPACE FOR LEASE AT ARROWHEAD CORPORATE CENTER Established Endocrinologist office close to 101 and Bell Road. Beautifully furnished, large waiting area.

Four unfurnished exam rooms and three providers’ offices available.

Two (2) year agreement preferred.

Perfect for satellite office or primary practice.

Email matthias15396@hotmail.com or call Jodene Rainford at 623-241-9028, ext. 103 Monday-Thursday, 9 am – 5 pm.

MCCORMICK RANCH MEDICAL SPACE FOR LEASE w/in a 2 tenant Freestanding Class A Bldg. Great location-Via De Ventura & Pima blocks from 101 Freeway & close to Scottsdale Shea Medical Campus. Previous OB/GYN, Next to busy ENT Great Covered Parking, High End Bldg.

Move in Ready w/ Carpet/Paint Greg White, CBRE 602-735-5559 APACHE JUNCTION MEDICAL PLAZA Second generation PT and Oncology spaces available in this beautifully landscaped medical plaza. Join urgent care, general dentistry, lab and federally funded healthcare clinic in medically underserved Pinal County.

Excellent visibility and signage. Adjacent to Banner Goldfield Medical Center. Contact Marina Hammersmith, CCIM, Ensemble Real Estate Solutions, 602-954-8414

FREESTANDING BUILDING ANTHEM, AZ OFFICE, MEDICAL, OR DENTAL 9,211 RSF shell space. Newer building. Freeway visibility to the project.

Turnkey improvement. Aggressive rental rates and concessions.

Contact Margaret Lloyd, Plaza Companies (623) 344-4558 4,800SF MEDICAL OR OFFICE SPACE 101 & THUNDERBIRD, PEORIA Open floor plan vanilla shell.

2nd floor w/ views. Turnkey TI. Aggressive rates. Strong mix of medical, including imaging and Lab. Strong ownership.

Contact Margaret Lloyd Plaza Companies (623) 344-4558

HELP WANTED P/T PHYSICIAN NEEDED FOR PRIMARY CARE PRACTICE Internal/Geriatric Medicine physicianneeded part-time for established Sun City West practice. Contact Carl Carlson, MD at 623-546-5897.

PHYSICIANS - FT & PT Occ Med clinics in Phx & Tucson.

Excellent hours, CME, salary, benefits. Fax CV to Heather @ 602-773-0287 or e-mail h.wahl@mbiaz.com

LOCUM TENUM DOCTOR NEEDED Weekend shift for an urgent care, 8 am to 4 pm, $90/hr.

Please call 480-792-1025 or fax your resume to 480-792-1026.

MEDICAL OFFICE SPACE 6638 E. BASELINE RD., #101, MESA, AZ Are you looking for space to start a medical practice, but don’t want the overhead costs associated with opening an office?

Currently, I have an office with 4 exam rooms available, Mon., Tues. & Wed. Will supply front desk and back office staff. Just come in and see your patients. We have billing and coding available on site.

Office is convenient for Banner Gateway, Banner Baywood and Gilbert Hospital at Power and Baseline Roads. Short-term or long-term lease available. You decide how many rooms you need as well as number of days a week. Will allow 1/2 day usage.

Please call or text Kevin 480-200-4590.

MED. EQUIPMENT

Retired from surgical practice. Large assortment used surgical instruments (general and neuro) for sale. Like new condition. Contact Steve 602820-5522/ sdex491@gmail.com.

AFFORDABLE MEDICAL EQUIPMENT Low priced, high quality new & used equipment for: PHYSICIAN OFFICES, HOSPITAL RADIOLOGY We buy, sell, consign, service, and finance your CAPITAL MEDICAL EQUIPMENT NEEDS. Global Medical Solutions Contact: Don Creedon TEL. (480) 874-0333 Member AIUM www.igogms.com

A monthly publication of the MCMS • February 2015 • Round-up • 35

mcms board of directors meeting minutes The Maricopa County Medical Society

Board of Directors Meeting Minutes – January 20, 2015 IN ATTENDANCE

Board: Drs. Ryan Stratford, John Couvaras, Adam Brodsky, Kelly Hsu, Mark Wallace, Miriam Anand, Shane Daley, Ross Goldberg, Jennifer Hartmark-Hill, LeeAnn Kelley, Marc Lato, Anthony Lee, Anita Murcko, and Jay Standerfer were present. Staff: Jay Conyers was present. Guests: Dr. John Middaugh was present as a guest. By phone: Drs. Tanja Gunsberger and Richard Manch participated by phone.

Dr. Anand called the meeting to order at 6:32 pm and briefed the Board on last year’s accomplishments before passing the gavel to Dr. Stratford.

Dr. Stratford provided an introductory address to the Board, going through some of his plans for the year and what he envisions his role as president being. The Board went through introductions.

CONSENT AGENDA

A motion was made to approve the consent agenda, comprising December board minutes and the December membership report. The motion carried.

BYLAWS REVIEW

Dr. Stratford summarized for the Board the process required to present the single amendment to the membership for consideration. After closing of the polls, he confirmed that enough votes were collected to assign the Board the authority to make bylaws changes as needed, without going to the membership for full consideration. The Board openly discussed the current bylaws, which date back to 1992, and agreed that some immediate changes

can, and should, be considered in the coming months.

A motion was made to accept various topics for immediate ratification, pending review by a non-profit attorney. The motion carried.

The Board further agreed that membership categories, board composition, officers, dues, and committees would be focal points of discussion at upcoming meetings.

ORGANIZATION STRUCTURE

Dr. Stratford presented his vision for the overall organizational structure of the Society for 2015 and its associated businesses. The Board discussed the necessary committees and subcommittees, as well as the functions and responsibilities of each.

A motion was put forth designating Executive, Audit, Finance, Governance, and Board Development as permanent committees for inclusion in the bylaws. The motion carried.

A second motion was put forth designating Education & Quality (Mentorship subcommittee), Membership (Social & Annual Society Meeting subcommittees), Policy (Annual Policy Meeting subcommittees), and Public Health (Philanthropy subcommittee) as ad hoc committees for 2015. The motion carried.

STRATEGIC PLAN

Dr. Stratford presented a working strategic plan focused on four primary goals: Advocacy, Quality, Public Health, and Policy. The Board discussed organizational capacity to carry out these four, with defined strategies

36 • Round-up • February 2015 • A monthly publication of the MCMS

for each of the goals, and agreed that the plan would be further developed in the coming months.

FINANCIAL REPORT

Dr. Wallace presented the 2015 budget to the Board, and discussed each of the budget’s components. He explained the financial relationship between the businesses and the Society and pointed out variances from last year’s expenses. He also explained the various revenue lines (Maricopa County Business Services) and directed the Board’s attention to June, at which time Greater Arizona Central Credentialing Program (GACCP) revenue would decrease with the conclusion of the Arizona Medical Board contract.

There was discussion about the Public Relations budget intended to support social and education events. It was agreed that this component of the 2015 budget should be reduced by $6,000 with a target of one event every other month. A motion was put forth accepting the 2015 budget with the $6,000 reduction in the Public Relations budget. The motion carried.

NEW BUSINESS

Jay presented a Resolution to the Board designating new trustees for the Society’s 401(k) Savings Plan for employees of the Society and its businesses. A motion was put forth accepting the Resolution with the understanding that the three designated trustees have equal voting rights. The motion carried.

ADJOURNMENT

The meeting ended at 9:19 pm. ru

When you need a primary care physician or specialist

It’s good to have options When you need to find a doctor, not just anyone will do.

It has to be someone you and your family will feel comfortable with.

Someone with the right credentials.

Someone you can trust.

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Whether you need a routine check-up or require highly-specialized care, call us.

We’ll help you find a physician that meets YOUR needs.

Referral specialities include, but are not limited to: Cardiology Dermatology Family Medicine Gastroenterology

Call: 602-252-2844

Internal Medicine

Click: www.mymcms.com/providersearch/

ObGYN

Connect: mcms@mcmsonline.com

Ophthalmology Orthopedic Surgery Psychiatry Urology

Keeping Arizona families healthy for 123 years, and counting.

If you are a MCMS member and not receiving patient referrals, call the membership line at 602-252-2015 to get signed up today!

MICA MEMBERS RECEIVE

TH CONSECUTIVE DIVIDEND

MICA’s Board of Trustees is pleased to announce a $27 million dividend for the 2014 policy year.

This is our 10th consecutive dividend and our 24th dividend since MICA’s founding.

MEDICAL PROFESSIONAL LIABILITY INSURANCE (602) 956-5276, (800) 352-0402 www.mica-insurance.com Dividends declared for a given policy year reflect the Company’s financial performance during that year. Past performance does not guarantee future dividends.