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Dr. J. Carson Rounds, 2005-06 NCAFP President

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The Skinny on Milk, Cheese and Yogurt 3-A-Day of Dairy Increases Weight Loss When Part of a Reduced-Calorie Diet Research continues to support the relationship between dairy foods and weight management. In a clinical trial, people on a reduced-calorie diet who consumed 3 servings of milk, cheese or yogurt each day lost significantly more weight and body fat than those who just cut calories while consuming little or no dairy.1 How It Works Cell culture and animal studies provide a strong potential framework to explain dairy’s weight loss effect, part of which has to do with the role that dietary calcium, and potentially dairy protein, may play in lipolysis and lipogenesis. Low-calcium diets have been shown to increase a key calcium-regulating hormone, which in turn increases intracellular calcium concentrations in human adipocytes and results in increased fat storage. Conversely, a high-calcium intake inhibits production of the hormone, thereby decreasing intracellular calcium and ultimately the fat content of fat cells. Moreover, studies in animals and humans show that dairy foods promote substantially greater loss of body weight and fat than calcium supplements.

Benefits Beyond Weight Loss The newly released Dietary Guidelines for Americans also acknowledges the important role of dairy products’ unique nutrient package.The guidelines recommend people consume 3 servings of fat-free or low-fat dairy foods every day as part of a healthy diet. It also recommends dairy products like lactose-free milk or yogurt first for individuals who are lactose intolerant.

Dairy Foods Accelerate Loss of Abdominal Fat1 Results after six-month study 0.0 Change in Waist Circumference (inches)

A Motivating Benefit: Losing Inches in the Waist Research also indicates that including 3 daily servings of dairy in a reduced-calorie diet may help patients lose more inches and burn more fat in the abdominal region.1 Visual results can help motivate patients to decrease a high waist circumference, a trait that indicates abdominal obesity and an increased risk for the metabolic syndrome, hypertension and cardiovascular disease.

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Low Calcium (400-500 mg daily)

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High Calcium (1200-1300 mg daily) High Dairy (1200-1300 mg daily)

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Motivate patients with what they find important. Adults may lose more inches in the waist when including 3 servings of milk, cheese or yogurt each day as part of a reduced-calorie diet.

To learn more about the body of research supporting dairy’s role in weight loss and to download a free Healthy Weight Education Kit with patient education materials, visit nationaldairycouncil.org.

Also encourage your patients to assess their diet at assessyourdiet.webmd.com.

Zemel MB, et al. Dietary calcium and dairy products accelerate weight and fat loss during restriction in obese adults.

Obesity Research. 2004; 12(4): 582-590.

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© 2005 America’s Dairy Farmers. The 3-A-Day of Dairy logo is a mark owned by Dairy Management Inc. ®

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3 servings of dairy a day in a reducedcalorie diet supports weight loss.

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NCFP

Ta b l e o f C o n t e n t s Vol 2 • No 1

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Inaugural Message

12 Member News

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Study shows 25% of Physicians in North Carolina have Implemented Electronic Health Records...Where are you?

14 Obesity Initiative to Focus on Physician-Agent Networking in 2006

winter 2006 PUBLISHED BY THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS The North Carolina Family Physician is published quarterly by the NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS P.O. Box 10278 Raleigh, NC 27605 919.833.2110 • fax 919.833.1801 www.ncafp.com 2006 NCAFP Board of Directors NCAFP Executive Officers President J. Carson Rounds, MD President-Elect Michelle F. Jones, MD Vice President Christopher S. Snyder, III, MD Secretary/Treasurer Elizabeth B. Gibbons, MD Board Chair Karen L. Smith, MD, FAAFP Executive Vice President Sue L. Makey, CAE Past President (w/voting privileges) Conrad L. Flick, MD The District Directors District 1 Donald Keith Clarke, MD District 2 Robert Lee Rich, Jr., MD District 3 Victoria S. Kaprielian, MD District 4 William A. Dennis, MD District 5 Sara O. Beyer, MD District 6 Thomas J. Zuber, MD District 7 Shannon B. Dowler, MPH At Large R.W. Watkins, MD At Large Richard Lord, MD IMG Physicians Constituency Ofelia N. Melley, MD Minority Physicians Constituency Claudia E. Gonzalez, MD New Physicians Constituency Jessica J. Burkett, MD Resident Director Jennifer L. Mullendore, MD, GAHEC Resident Director-Elect Parker McConville, MD, GAHEC Student Director Oritsetsemaye Otubu, UNC Student Director-Elect Mary Jean Deason, UNC AAFP Delegates and Alternates AAFP Delegate L. Allen Dobson, MD AAFP Delegate Conrad L. Flick, MD AAFP Alternate Mott P. Blair, IV, MD AAFP Alternate George H. Moore, Jr., MD FP Department Chairs and Alternates Chair (WFU) Michael L. Coates, MD Alternate (Duke) J. Lloyd Michener, MD Alternate (ECU) Mark Darrow, MD Alternate (UNC) Warren P. Newton, MD, MPH NCAFP Council Chairs Child & Maternal Health Shannon B. Dowler, MD Governmental Affairs Advisory Robert Lee Rich, Jr., MD Health Promotion & Disease Prev.

Mott P. Blair, IV, MD Mental Health Robert E. Gwyther, MD Albert Mooney, MD Professional Services Brian Forrest, MD Health Disparities Karen L. Smith, MD NCAFP Editorial Committee Chair William A. Dennis, MD Shannon B. Dowler, MD Elizabeth B. Gibbons, MD Richard Lord, MD David C. Luoma, MD

CREATED BY: Virginia Robertson, President vrobertson@pcipublishing.com Publishing Concepts, Inc. 14109 Taylor Loop Road Little Rock, AR 72223 FOR ADVERTISING INFORMATION: Adrienne Freeman adrienne@pcipublishing.com 501.221.9986 • 800.561.4686 edition

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Abstract: Mercury Toxicity

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Essentials of Documentation

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Foundation News

14 AAFP Studies Retail Health Clinics, Releases Evaluative Criteria 15 Shared Maternity Care: Do We Deliver?

10 Academy Names Dr. Joyce copeland 2005 Family Physician of the Year

NCAFP Strategic Plan Vision Statement The vision of the North Carolina Academy of Family Physicians is to be the leader in transforming healthcare in NC to achieve optimal health for all people of NC. Mission Statement The mission of the North Carolina Academy of Family Physicians is to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity.

Strategic Objectives 1. Health Promotion & Disease Prevention (Health of the Public): Assume a leadership role in improving the health of North Carolina’s citizens by becoming proactive in health promotion, disease prevention, chronic disease management and collaborating in other public health strategies.

2.Advocacy: Shape healthcare policy through interactions with government, the public, business, and the healthcare industry.

3. Workforce: Ensure a workforce of Family Physicians which is sufficient to meet the needs of patients and communities in NC. 4. Education: Assure high-quality, innovative education for family physicians, residents, and medical students that embodies the art, science, and socioeconomics of family medicine.

5. Technology & Practice Enhancement: Strengthen members’ abilities to manage their practices, maintain satisfying careers, and balance personal and professional responsibilities.

6. Research: Develop and promote new medical knowledge and innovative practice strategies through information technology, primary care research and assessment of the practice environment.

7. Communications: Promote the unique role and value of family medicine, family physicians and the NCAFP to the public, business, government, the healthcare industry and NCAFP members.

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The 2006 Inaugural Address Delivered by Dr. J. Carson Rounds, 2005-06 NCAFP President

The cover of the US News and Report in my reception room caught my eye – the one screaming “WHO NEEDS DOCTORS? Your next physician might not be an M.D. – and you may be better off.” I looked inside to see if I had no future or if, like Mark Twain, the report of my death had been exaggerated.

The article began with a description of increasing paperwork, decreased payment, and general strain in the doctor-patient relationship. The final line in the opening paragraph was a quote from AAFP President Mary Frank: “Family physicians are getting stressed to the max.” I read on, hoping to find what the headline told me I would not: the rest of what Mary told them, about the Future of Family Medicine project, about the commitment all of us share to the sacred relationship of doctors and patients, about the need for reform of the whole health care system. Instead, I found an apologetics for what US News called The New Healers – nurse practitioners, nurse anesthetists, pa’s, optometrists, psychologists, and pharmacists.

The information on physicians was almost uniformly negative except for a sidebar about Rachel Remen and her efforts to help physicians battle burnout. Dr. Frank, AAFP Executive Vice-President Dr. Doug Henley, and AAFP Communications Director Cynthia Stapp later met with the editor of this series of articles to share our vision of the future of health care, “a message of hope and vision and how family physicians are ideally trained to deliver on that vision.” What a paradox: stressed to the max but articulating a vision of hope for the Future of Family Medicine, indeed, all of medicine.

There is no question that Mary’s remark about our stress is true. We are stressed to the max. We work more, are paid less, and face an ever increasing number of demands and challenges to our traditional roles as Family Physicians. How can we respond? A response to the invitation to our NCAFP 2004 Leadership Retreat from a member shows one response – “Like John Gault (referring to the protagonist in Ann Rand’s book Atlas Shrugged) I will no longer participate in a system that devalues me.” He has since left Family Medicine. Another response is learned helplessness – acquiescence to “the system,” a belief that nothing will change, and a conscious decision to continue doing

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what is not working for us, and worst, not working for our patients. Too many of them have access problems, poorly controlled chronic illnesses, and no one to serve as their champion in an increasingly fragmented, impersonal, “system” of healthcare that is really no system at all.

My first priority this year is to advocate for a different response. I believe there is a better way to respond. We stand at a crossroads, a place in time as ripe with opportunity as the 1960’s when the specialty of Family Medicine was born, midwived by our General Practice ancestors. The “Future of Family Medicine” report has given us all a gift, a compass, a vision of a brighter future for us, and more importantly, our patients.

The initial report, detailing the process and the vision, was published as a supplement to the Annals of Family Medicine in March 2004. The other important piece of the puzzle – the financial implications of the vision – was published as a supplement to the Annals in October 2004. Embracing and implementing this vision should be our response.

I think it is important to understand the process that resulted in the FFM report. The national Family Medicine organizations – the American Academy of Family Physicians, the AAFP Foundation, the American Board of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors, the North American Primary Care Research Group, and the Society of Teachers of Family Medicine - started with the premise that Family Medicine as currently practiced in this country could not be sustained as a meaningful, viable, specialty. The core of Family Medicine was clearly viable, and offered the best and brightest future for the foundation of a health care system in the US that would truly be the best in the world. A national research study was commissioned conducted by independent researchers working collaboratively with a national strategic branding firm. In a nutshell, they found that people wanted what we provide, they just didn’t know we provided it. Patients want their primary care physician to meet 5 basic criteria: to be in their insurance plan, to be in a convenient location, able to schedule an appointment in a reasonable time frame, to

have good communication skills, and to have a reasonable amount of experience in practice. Given those basic criteria are fulfilled, “patients value the relationship with their physician above all else, including service.” The project leadership concluded that family medicine continues to meet a fundamental public need and our problems “do not include irrelevance or obsolescence”, but there is a need to “rearticulate our vision…while at the same time substantially revising the organization and processes by which care is delivered.” A New Model of Family Medicine was articulated, a “basket of services” described, and a comparison of traditional versus New Model practices was described. At your seat today, we have provided you with the tables from the report that summarize the New Model, the Basket of Services, and the comparison.

Task Force 6, the group charged with developing a financial model assessing the impact of the New Model of care, followed a similar process, engaging experts in health care economics and policy. They concluded that “full implementation of he New Model of care within the current fee-for-service system of reimbursement would result in a 26% increase in compensation for prototypical family physicians who maintain their current number of work hours.”

Changes in the payment system that included incentives for e-care, case management, and performance improvement could increase income even more. Assuming that all patients who currently use a sub-specialist for their primary care began to get their primary care from primary care physicians, national health care expenditures would drop by $67 billion in 2004, despite increased payment to primary care physicians, and health out comes would be improved. Sounds like a win-win to me.

I urge all of you to read the FFM report, the report of Task Force Six on the financing of the FFM, and begin to consider how you could adopt these recommendations into your own practice. Many of you have already adopted some of the recommendations, but I doubt many of us have truly transformed our practices into the “New Model” described in the FFM report. Your Academy has been working with a number of other organizations around a project called IPIP, which Warren

North Carolina Academy of Family Physicians

Newton spoke about yesterday. This project, if done correctly, could be a major resource for you as you begin to look at practice redesign. If done correctly, practice redesign should lead to better community health, better individual health, and a better life for each of us. Alan Dobson’s public policy lecture updated you on Community Care of North Carolina. If you have not affiliated with the CCNC network in your area, I also urge you to do so. Many of the principles of the New Model are being implemented, and it offers the network structure that appears to be necessary for us to move forward with improving health in our communities.

Individual doctors, individual patients, all in the context of a concentric circle of teams – your office team, your community team, your state team, your national team.

These systemic changes will take some time to come to fruition. It will take all of us working collectively to begin to change the healthcare system and deliver on the promise of the FFM. How do we keep from burning out now, before these changes can be made?

How do we survive the transition? A recent study demonstrates that as our satisfaction decrease so does the quality of healthcare we deliver. I believe there are two things each of us can do individually that will have both short and long term impact on our satisfaction My other priority this year is to lead each of us to making our own physical, emotional, and spiritual health a priority. There is no better way to prevent burnout and no better example we can set for our patients. There is ample data from businesses that productivity suffers as work hours increase. We need to exercise, eat right, , get enough sleep, play enough, pray enough, see our Family Physician and follow their advice. It amazes me that it is illegal for a commercial pilot to fly more than 110 hours in a month but I can (and have) work 110 hours in a week without anyone saying a word. William Osler said Nothing will sustain you more potently in your humdrum routine, as perhaps it may be thought, that the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain toil-worn women, of their loves and their joys, their sorrows and their griefs.

Rachel Remen’s work was highlighted in that US News article. Her writing and life’s work has a meaningful place in my life. I would commend her book Kitchen Table Wisdom to you. She founded the Institute for the Study of Health and Illness. One outgrowth of that Institute is Finding Meaning in Medicine. Groups of physicians come

together to establish self-sustaining, replicable story-telling and discussion groups.

Physicians can serve as resources to one another, helping each other maintain a sense of service and meaning to our work. Topics such as grief, joy, mystery, loss, and hope serve to help us focus on the stories from our practices. I recall leaving the home of a terminally ill cancer patient this year after a visit with her and her family and realizing that I was not focused on the managed care issues that had frustrated me that day but feeling good about the relationships my practice affords me. Sharing these stories from our practice or from literature or art are what Finding Meaning in Medicine is all about.

Www.findingmeaninginmedicine.com is the website for this organization, and it also describes how to start a group. At your place is an article Dr. Remen wrote about these groups. I am also available to you to help you start a group. We are developing a webpage on the members only section of NCAFP.com with information on local resources for physicians who are struggling with burnout, information on burnout, resources and seminars on burnout prevention, and links to helpful websites. My cell phone number is 9196063209 and is available to you at any time. I may be attending to my health and ask you to leave a message – please use your local crisis line if you are truly in crisis – but I would be more than happy to talk to another “wounded healer” or “recovering doctor.”

Thank you for this honor. I pledge my focus, my passion and my time to you this year. You are my heroes for what you do every day. We can change the culture of American medicine. A subculture that changes will change the larger culture. Like Frank Leak said in his inaugural address in 1989, “we have come a long way since 1969.

There are many reasons for this. The major reason we did was through just plain ‘stupidity.’ We are so stupid that we are unable to understand the word “can’t.”…

There are still plenty of ‘can’t do’ problems that our Academy faces but we still can’t understand that word. We have a compass – the Future of Family Medicine – and we have sustenance – Finding Meaning in Medicine. The report of our death is greatly exaggerated. The American people still need doctors, Family doctors, now more than ever before. Join me in showing the American people that we are, in fact, what they need and what they want, and let’s lead them out of this wilderness.

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Study Shows 25% of Physicians in North Carolina have Implemented Electronic Health Records…

Where Are You? A Rand Corporation study published this year found that in 2002 between 10 percent and 16.4 percent of the nation’s physicians had adopted electronic medical record technology. However, preliminary results from a joint survey between the North Carolina Academy of Family Physicians (NCAFP) and The Carolinas Center for Medical Excellence (CCME), formerly Medical Review of North Carolina, shows that over 25 percent of primary care physicians in North Carolina have already implemented electronic health records (EHR). An additional seven percent of physicians stated that they plan to implement a new EHR system in the next 12 to 24 months.

If you have not considered moving to an EHR yet, where are you? EHRs allow physician offices the freedom and flexibility to provide top quality care to their patients while operating with increased office efficiencies which enable providers to reap rewards such as increased personal time, increased coding accuracy, increased staff satisfaction, remote access to patient records and numerous other things.

CCME is offering assistance with transitioning your office to compete with the 25 percent of physician practices that have already made the move to EHR. Technology has become a part of our daily lives and your patients will come to expect it in their medical care, we can help you meet their demands.

The Doctor’s Office Quality – Information Technology (DOQ-IT) program offers free consultation, tools and resources to assist your practice in moving to an EHR. Your government is paying the cost for this service. The federal government has contracted with each state quality improvement organization (QIO) to help physician offices like yours make this switch. Program availability is limited. Take advantage of this resource today. Visit www.mrnc.org/doqit or call Ann Lefebvre at 919-380-9860 ext. 2102 for more information.

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Health Promotion & Disease Prevention Council

ABSTRACT: MERCURY TOXICITY-PAST EXPERIENCES, PRESENT CONCERNS AND FUTURE CONSIDERATIONS Authors: Marc Peter Guerra, Tony Wilson, and Melissa Guerra Mercury’s potent neurotoxicity has been documented throughout the ages. Organic mercury (example: dimethylmercury, methylmercury, and ethyl mercury/thimerosal) possess lipophilic properties allowing them to cross the blood brain barrier, placental barrier, and thereby potentiating their toxicity. Furthermore, organic mercury bioaccumulates in fat over time. Acrodynia, a disease of the 1950’s with characteristic neurotoxicity and many autistic-like characteristics, was eradicated when mercury was removed from teething powders. The Karen Wetterhahn case exemplifies the potent neurotoxicity of dimethylmercury. This case describes a young organic chemist from Dartmouth who, through her gloved hand, absorbed a drop of dimethylmercury. Five months later she died, comatose, from its neurotoxicity in a nursing home. Minamata disease exemplifies methylmercury’s potent neurotoxicity through fish ingestion. A coastal Japanese community ingested methylmercury tainted fish and suffered a constellation of neurologic mercury induced illnesses. In 2001, the EPA and the Agency For Toxic Substances and Disease Registry issued a public health warning regarding consumption of fish with high mercury (methylmercury) levels. It states that women of child-bearing age, pregnant women and children should not eat fish that have been found to have high levels of mercury. At that time, king mackerel, swordfish, shark and tile fish were the identified species; however, many other fish caught off of our own North Carolina coast have also been found to contain high mercury levels, example: yellow fin tuna, blue fin tuna, grouper, and amberjack. Ingestion of mercury tainted fish is felt to be the number one cause of mercury exposure at this time. In fact, North Carolina has over 1800 miles of coastline that is under a mercury advisory making it the third highest state in the union.

In 2002, it was estimated that 300,000 children were born with mercury levels above safe parameters high enough to cause neurologic symptoms or decreased IQ levels. In 2005, it is estimated that 630,000 children are born with elevated mercury levels high enough to cause neurologic abnormalities, learning disabilities, and decreased IQ’s. The EPA states that one in every six women of child-bearing age has serum mercury levels above advisory points. It is most concerning to consider where these statistics will be in five years or in ten years if we do not take action now. The American Academy of Pediatrics, the American Nurses Association, and other health care professionals have joined in a class action suit against the EPA as to how it is handling mercury emissions in the United States. Coal burning power plants remain the main source of mercury emissions in this country. A recent community study from the University of Texas, San Antonio, correlates childhood autism and learning disability to concentrations of mercury emissions across Texas.

The Associated Press recently confirmed that swordfish sold in grocery stores and checked at a UNC-Chapel Hill chemistry lab were found to have substantially elevated mercury levels. A research survey of grocery stores in North Carolina confirms that mercury warnings universally are not available to warn high-risk populations and the general public from mercury ingestion and toxicity. In lieu of the facts, what do we tell a young pregnant woman with 2 preschoolers who are sitting down at a local restaurant ready to enjoy the grouper special (55 mcg mercury/serving).

This research project is the fruit of three undergraduate students exhaustive and revealing inquiries on mercury’s toxicity through its past experiences, present concerns and future considerations. They have worked with numerous health care and chemistry experts to ascertain

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data and facts. A resolution regarding Mercury In Food As A Human Health Hazard has been synthesized and presented to the North Carolina Academy of Family Physicians and the North Carolina Medical Society for discussion, consideration and national referral.

Bibliography 1. Agency for Toxic Substances and Disease Registry (ATSDR), 2001, CERCOA Priority List of Hazardous Substances US Department of Health and Human Services, Public Health Service Atlanta, GA. 2. USEPA, Mercury Study Report to Congress, Volume 7: Characterization of Human Health and Wildlife Risks From Mercury Exposure in the United States, 1997.

3.USEPaA, Mercury Report to Congress Report 3 Fate in Transport of Mercury in the Environment, 1997.

4. USEPA, Mercury Update. Impact On Fish Advisories, June 2001.

5. USEPA, Fact Sheet: National Listing of Fish Advisories, August 2004.

6. Aschner, M, Walker, S.J. 2002. The Neuropathogenesis of Mercury Toxicity. Molecular Psychiatry 7.

7. Bernard, S. 2001. Autism: A Novel Form of Mercury Poisoning.

Medical Hypothesis 56, 462-471.

8. Bernard, S. The Role of Mercury in a Pathogenesis of Autism Molecular Psychiatry 7, 42-43.

9. Grandjean, Milestone Development in Infants Exposed to Methylmercury From Human Milk. Neurotoxicology 16, 27-33.

10. Grandjean, P. 2003. Neurotoxic Risk Caused By Stable and Variable Exposure to Methylmercury From Seafood. Ambulatory Pediatrics 3, 18-23.

11. Harada, M., 1978. Congenital Minamata Disease: Intrauterine Methylmercury Poisoning. Teratology 18, 285-288.

12. Kiser, J. 2000. Mercury Report Backs Strict Rules. Science 289, 371-372.

13. Landidrigan, P. 2002. Chronic Effects of Toxic Environmental Exposures On Children’s Health. Journal of Toxicology-Clinical Toxicology 40, 449-456.

14. Mercury Policy Project (MMP), 2004.

15. National Academy of Sciences, 2000. Toxicologic Effects of Methylmercury. National Academy Press, Washington, DC. 16. Ostrowski 2003. Agency for Toxic Substances and Disease Registries 1997 Priority List of Hazardous Substances. Latent Effects-Carcinogenesis, Neurotoxicology and Developmental Deficits in Humans.

17. Ramirez, G. 2000. The Tagum Study: Analysis and Clinical Correlates of Mercury in Maternal and Cord Blood, Breast Milk, Meconium, and Infants’ Hair. Pediatrics 106 (4), 774-781.

18. Ramirez, G. 2003. Tagum Study II: Follow-up Study At Two Years of Age After Prenatal Exposure to Mercury. Pediatrics 111 (3).

19. Rice, D. Critical Periods of Vulnerability for the Developing Nervous System: Evidence From Human and Animal Studies.

Environmental Health Prospectives 108, 511-533.

20. How Toxic Mercury Contaminates Fish in US Waterways, Environment Colorado Research and Policy Center October 2004.

The Poison Paradox National Geographic May 2005.

21. Environmental Mercury Release, Special Education Rates, and Autism Disorder: An Ecological Study of Texas; R. Palmer, Health and Place 2005 What to Tell Patients About Eating Fish; J. Hayes, The Clinical Advisor, February 2005.

North Carolina Academy of Family Physicians

Essentials of Documentation or Family Physicians, the main goals of documentation are to accurately show what you have done to and for the patient, and to receive appropriate pay for the office visit. The purpose of this article is to discuss the latter – specifically, Medicare documentation requirements to support the various levels of evaluation and management (E&M) codes.

The Medicare documentation guidelines from HCFA in 1997 require that you document the complexity of the office visit. These guidelines categorize complexity in three major areas: the History, Physical Exam (PE) and Decision-Making (DM). Let us look at each of these in more detail, beginning with the History.

Documentation of each office visit must start with a chief complaint (CC) – in the patient’s own words when possible. Next is the history of present illness (HPI). For chronic problems, this means from the last office visit to the present; for acute problems, this is from the onset of illness to the present. The HPI may include any or all of the following: location, quality, severity, duration, timing, modifying factors, context, and associated signs and symptoms.

Medicare counts each of these facts as an “element” of the HPI, and counts elements in determining the E&M level for which a physician can code. We should also include the appropriate Review of Systems (ROS) and, if medically necessary, appropriate facts from the Past, Family, and/or Social History (PFSH). The increasing complexity of the History should be shown by the increasing number of the above elements included in the HPI, ROS and PFSH. Table 1 provides specifics for each E&M code level for an established patient.

The PE also varies in its degree of complexity. The more elements of the PE the physician performs, the more complex the office visit becomes. That sounds easy, and can be—if we document all we do in an exam, instead of omitting the pertinent normal findings. For example, start with at least three vital signs or, “vital signs noted,” and a statement of the general appearance of the patient. Then document!

Can you look at the oropharynx without seeing the teeth? Can you look at the tympanic membrane without seeing the external ear? Can you auscultate the lungs without noting the respiratory effort? We review all of these, but often omit them in our documentation because the findings are normal. The Medicare (and medicolegal) rule of documentation states: if it’s not in the chart, it wasn’t done. By not documenting all of the elements of our exam, we make it appear less

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By George T. Wolff, MD

complex, and so lose our ability to render an appropriate charge.

The third part of documentation is the DM, which is composed of three parts: 1) Diagnosis; 2) Data; and 3) Risk. Diagnosis consists of both number and type. Many patients have several chronic illnesses that must be evaluated on each visit. Not only the illness, but the type of each should be noted. There are 3 types: 1) established and stable; 2) established and worse; and 3) new and stable or needs work-up.

Obviously, these are in increasing order of complexity, and correspondingly higher levels of care. Also remember, Medicare counts a known diagnosis as less complex than an unknown.

Documentation of the Data portion of the DM should include any of the following: ordering and reviewing labs and x-rays; discussing results with the performing physician; or ordering a summary of old records or additional history. The more done here, the more complex the visit becomes.

The Risk area has three components to consider: problems or diagnoses; procedures; and management. The more problems, the more complex; the more procedures, the more complex. Under management, if you write or renew a prescription, that is a level 4 or moderate complexity. In the Risk area, the most complex component drives the other two. So a written prescription in the management area will make the Risk portion a level 4 or moderate complexity level of care, even if there is only 1 diagnosis.

Similarly, in the DM area, only 2 of 3 of the parts are needed to determine the level of care. For example, a new problem or diagnosis and a written prescription can represent a moderate complexity, or level four, even if no labs or x-rays are ordered or reviewed. Table 3 gives more details on how to determine the DM level.

Table 1 shows the components required for each level of care.

Note that 99211 is generally used for Nurse visits, and level 99212 is generally for brief rechecks, such as for an Otitis. Also, as noted, if you charge by time spent in counseling – the time must be face to face and represent more than half of the total visit time, and must be documented in your chart.

As shown in Table 2, the requirements for a new patient are higher than for an established one. (A new patient is defined as one never seen by the physician or anyone in their practice, or not seen for 3 or more years.) For example, a new patient may be a Level I (99201) with a brief CC and HPI, a one area PE and straightforward DM. A

Table 1: Established Patient Requirements (1997)

Table 2: New Patient

E&M Code: 99211 99212 99213 99214 99215 History /CC N/A Required HPI elements N/A 1-3 4 or 3 chronic disease ROS elements N/A N/A 1 2-9 10 + PFSH elements N/A N/A N/A 1 2+ PE* N/A Exam 1-5 6-11 12-18 18 + DM N/A StraightLow Moderate High forward Complexity Complexity Complexity Time in 5 10 15 25 40 minutes** *There are 14 systems and 59 exam items in the guidelines. **Half or more of the time must be face to face and documented.

E&M Code: 99211 99212 99213 99214 99215 History /CC Required HPI elements 1 1 4 or 3 chronic diseases ROS elements 0 1 2 10 10 PFSH elements 0 0 1 3 3 PE* 1 6 12 18 18 DM StraightLow Moderate High forward Complexity Complexity Complexity Time in 10 20 30 45 60 minutes** **Half or more of the time must be face to face and documented.

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Level II (99202) requires a CC, HPI & one ROS. The PE must have at least 6 areas examined and documented; while the DM is straightforward.

Level III (99203) requires a CC, & HPI of 4 elements or 3 chronic Diseases, 2 ROS and 1 PFSH. The PE requires 12 areas examined and documented. The DM is now low complexity. Level IV (99204) requires the same CC, HPI as level III, plus 10 ROS and all 3 PFSH. The PE now requires 18 areas

and the DM: moderate complexity. Level V (99205) History is the same as Level IV, and the PE is the same as Level IV. However, the DM is high complexity.

The different DM levels are essentially the same as the requirements for an established patient. In most cases, unless a new patient is very complex, the level of care will probably be a level III (detailed).

Figure 1 is a schematic, generic outline of the requirements. It is a skeleton, and the

Table 3: Decision-Making Requirements for Established Patients Level II Level III Level IV Level V (Straightforward) (Low Complexity) (Moderate) (High Complexity) Diagnoses

1 minor problem or 1 estab & stable

2 estab & stable 1 estab & worse 1 new & stable

2 estab & worse 3 estab & stable 1 new, needs workup

Data

1 lab/ xray

2 lab/ xrays

3 labs/ xrays

Problem

1 minor problem

2 out of 3

Risk*

Procedures

Management

Time**

10 minutes

1 lab or x-ray 2 labs/ xrays Advise

2 minor problems 1 estab & stable 1 acute systemic

3 estab & worse

4 labs/ xrays

2 estab severe or & stable life1 new threatening uncomplicated 1 new undiagnosed 1 acute systemic invasive studies with risk

minor surgical non CV contrast xray OTC prescription parental medication therapy or major surgery with risk factors

15 minutes

25 minutes

Figure 1: Requirements Skeleton CC, HPI, how many elements Hx

ROS & how many systems PFSH – how many required

PE

How many areas required

How many Diagnoses Type DM

Data

40 minutes

* Use whichever is the most complex area – problem, procedures or management – to define level. **Must include diagnoses, description of counseling/coordination, total time, persons present, and be 50% of visit time.

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muscle is found in the rest of this article. I have made no attempt to discuss the ICD-9 codes in view of the length required.

However, you should use the most specific code available to avoid questions that delay payments.

After studying the facts outlined here, the appropriate documentation and charge should be readily achieved. So, document all you do in an office visit, and charge appropriately for the visit. Be ready to defend your documentation and charge when Medicare or an insurance company tries to down code your care and charges.

Dr. Wolff is former program director and currently part time faculty at the Moses Cone Family Medicine Residency Program, in Greensboro, North Carolina, in affiliation with the Greensboro Area Health Education Center (AHEC) and the Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill.

Correspondences regarding this article should be addressed to: Dr. George T. Wolff 1125 N. Church St. Greensboro, NC 27401 Phone: 336-832-8132 Fax: 336-832-7078 E-mail: george.wolff@mosescone.com

Risks

labs x-rays consultants

established – stable established – worse new – stable new - needs work-up

How many problems procedures management

North Carolina Academy of Family Physicians

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FOUNDATION NEWS 2005 SILENT AUCTION CELEBRATES 10 YEARS!!

The NCAFP Foundation’s 2005 Silent Auction celebrated its 10th anniversary at the Winter Family Physicians Weekend in beautiful Asheville!! Begun in 1995, the NCAFP Foundation’s Silent Auction has become a tradition. Members, exhibitors, and guests who attend this yearly meeting at The Grove Park Inn Resort & Spa continue to look forward to bidding on items while mingling with friends and associates. Items ranged from symphony tickets to sports memorabilia and tickets, weekend getaways, artwork, handcrafted items, electronic equipment, and more. Our Academy and Foundation Boards, as well as exhibitors, contributed items to the auction, making this year’s function extremely successful. With everyone’s contributions and participation, the 2005 Silent Auction brought the Foundation a grand total of $10,758.50!

We’d like to extend a special “thank you” to our Silent Auction Sponsors – Onslow Memorial Hospital and University Health Systems of Eastern Carolina (Platinum Sponsors) and Lenoir Memorial Hospital and Union Regional Medical Center (Silver Sponsors). We’d also like to extend a heartfelt “thank you” to Martini Print Media, Inc., who donated their services to produce the Silent Auction booklets. Marlene Rosol, Development Coordinator, did a superb job of organizing the auction. A special thank you to Silent Auction Co-Chairs Dr. James G. Jones and Judy Mann for their leadership. We also want to thank the NCAFP Academy staff, especially Jenni Fisher whose assistance was invaluable, all our volunteers, and Bobbi Abram of the AAFP Foundation. The Silent Auction continues to hold a special place for the NCAFP Foundation, and we greatly appreciate our members’ support and involvement!

A NEW YEAR IS UPON US! The NCAFP Foundation extends a Happy New Year and a special “thank you” to all our members who made individual contributions in 2005! Through your generous support, we continue to make a difference in the lives of continued on Page 13

Flu Season is Here s the new year begins, the influenza season is just getting started. The average flu season in North Carolina runs from October through April and often peaks in February or March. Unfortunately, after the Thanksgiving holiday, demand for flu vaccine diminishes. The good news is - you can still help prevent this deadly disease.

Please continue to encourage your patients and all health care workers to receive a flu shot if they have not gotten one already. At this time, vaccine is available for anyone who’d like a shot. However, the Advisory Committee on Immunization Practices (ACIP) has recommended several primary target groups receive vaccination on an annual basis.

These target groups are at greatest risk for complications from the flu and include: • Persons aged 65 years and older, with and without chronic health conditions • Residents of long-term care facilities • Persons aged 2–64 years with chronic health conditions • Children aged 6–23 months • Pregnant women • Health-care personnel who provide direct patient care • Household contacts and out-of-home caregivers of children aged less than 6 months • Help your patients understand that the flu vaccine is safe and effective, and that the flu shot cannot give them the flu. What it CAN do is protect them from a serious illness.

Please, this flu season, protect your patients. Protect yourself. Encourage them to get a flu shot today (and get one yourself).

For more information about the 2005-2006 influenza season, please visit www.cdc.gov/flu/ or www.immunizenc.com.

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Health experts warn that flu season can cause serious illness in February, March and even April.

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Anyone who doesn’t want to catch the flu, adults 50 and older, individuals with chronic medical conditions, pregnant women, residents of nursing homes, babies 6-23 months and health care workers.

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Academy Names Dr. Joyce Copeland 2005 Family Physician of The Year n December 2, 2005 in Asheville, the NCAFP presented its 2005 Family Physician of The Year award to Duke University’s Dr. Joyce A. Copeland of Efland, NC. Copeland was recognized for her careerlong commitment to her patients and their families, as well as to the specialty’s future physicians: family medicine residents and medical students. This powerful and unique combination has enabled her to touch the lives of thousands and to instill her care philosophy on many of North Carolina’s practicing family physicians.

A Busy Physician and Active Educator Dr. Copeland practices at Duke Family Medicine in Durham, NC and like many family physicians, she has served multiple generations within the same family and has forged close personal relationships with many of her patients. But while she’s a physician that her patients and colleagues respect, admire and look up to, she’s also one that occupies an important academic role at the university.

Copeland mentors and teaches medical students and residents and has excelled in doing so since 1986. Her work in this area

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has led her to be honored with several leadership and teaching awards by her peers and made her a sought-after lecturer in both the residency and medical school. She even ‘wows’ her residents and colleagues with her technology acumen. Juggling these two duties – physician and educator - so effortlessly is remarkable and one that makes her stand out.

Copeland completed her undergraduate studies at Barton College in Wilson and subsequently entered medical school at UNC Chapel Hill. She completed her residency at the Duke Watts Family Medicine Residency in Durham, and served as Chief Resident there in 1978. At Duke, she has oversaw and led many key efforts related to resident and student development, including serving as Director of Pre-Doctoral Education in the Family and Community Medicine Department, Co-Director of Obstetrical Training and Director of the Family Medicine Clerkship. In each of these roles, Copeland has been able in influence the clinical practice habits and help mentor of many of Durham’s and North Carolina’s leading family physicians.

In an effort to gauge Dr. Copeland’s perspectives on her work, life and the specialty, we sat down with her and conducted the following interview.

What led you to study medicine? Was anyone in your family a doctor? Any special memories from childhood?

When I was in the 3rd grade, I decided I would be the first woman astronaut, the first woman president or a doctor. The latter seemed to fit the best, though the second is still available. I had two wonderful examples of “Family Doctors” before there was an organization.

I remember old Dr. Hoggard’s office...small and intimate...with the smell of sulfa tablets greeting you at the door. He literally started as a horse and buggy doctor.

When he passed away, an entire community mourned. I had never seen such a large crowd at a funeral in my very young life.

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North Carolina Academy of Family Physicians

I also remember the role my parents played in my development. They are a farmer and his wife...honest as the day is long and always there for me and my siblings. They never tried to point me in a direction but supported me in my decisions to pursue medicine as a career. I was the first of my extended family to attend college and my parents were there through thick and thin.

They still are.

I have learned a lot about how to be a better doctor from them as they try to negotiate the medical system in their elder years. The need for advocacy and communication is a critical component of care as well as the need to be mindful of the home environment and resource needs. This is the essence of Family Medicine…knowing the medical needs and identifying the “caring” needs.

Your professional experience has been coupled with a large academic role at Duke and you seem to have made extra efforts in teaching and mentoring of medical students. How has this impacted your perspectives on your practice of medicine?

The teaching role was not one I had thought of when I chose medicine, but it has become a passion. The teacher has a chance to multiple their influence on health care exponentially by impacting the career of the next generation of health care providers.

Medical students and PA students are usually a joy to work with. They make work fun.

I have found that my patients generally like the idea of contributing to the education as well. It is certainly a challenge to keep up with changes in care and the field of knowledge. Students motivate me to learn.

It is a great pleasure to teach a student or resident and then, years later, get a return

Billing for Copying and Preparing Medical Records

Thomas J. Zuber, MD, MPH, MBA

When patients request a transfer of their medical records to another medical provider, the initial holder of the records may charge patients a reasonable fee for the cost of reproducing and mailing the records.

While many offices find it easiest to set a standard fee for this service, there is legislation limiting what can be charged under certain circumstances. North Carolina General Statue (90-4110 lists the maximum fee as 75 cents per page for the first 25 pages, 50 cents per page for pages 26-100, and 25 cents per page for pages in excess of 100. The statute states that the limitation of fees applies only to liability claims for personal injury, and for claims for social security disability. The entire statute can be found online at http://www.ncleg.net/EnactedLegislation/Statutes/-

on the investment by seeing them become the stars of their small towns and their large communities. It is a source of great pride to watch their careers grow. I look at the past presidents and leaders of NCAFP and see many of my former students provide the framework of our profession.

Students increase my awareness of the little things that make a difference. They see me walk into a patient’s room and have a command of years of knowledge about what makes that person tick. They learn the “art” of medicine and I learn that evidence based must be patient specific.

Any thoughts to share with other physicians?

We all take the Oath of Hippocrates. That oath charges us with the responsibility to care for our patients and to share our knowledge with the next generation. You can change a life and/or an attitude by sharing your world with a student.

It is also important to be aware that “Little Pitchers have Big Ears”. What you do is as important as what you say. Our professional demeanor should serve as a positive model for our students.

Given your unique perspective regarding medical students, what do you think is the biggest challenge facing the specialty with regards to student interest?

There are many challenges ranging from economics to popular culture. Family Medicine can be intimidating when the student looks at the breadth of skill and knowledge required to be a Family Doctor.

Gone are the days of Marcus Welby…the t.v. doc of my day…and here is the sexy world of E.R. and surgery. The visibility of our specialty is critical to recruiting. Fair reimbursement for our services is also

HTML/BySection/Chapter_90/GS_90-411.html. The N.C. Industrial Commission (GS 97-26.1) also limits payment for medical reports and medical records for worker-related claims.

The above payment limitations do not apply to most non-disabled patient transfers of records. A set fee can be applied by medical practices for such transfers. Alternately, a professional fee can be charged by the physician for a narrative summary of the patient’s medical record, given that a summary is requested by the patient or the patient’s representative.

The North Carolina Medical Board (NCMB) has a position statement regarding access to patient medical records as well. The NCMB position is that a summary of the record should only be provided if the patient agrees in advance to the summary. The NCMB position does not provide guidance on the fees that can be charged for records copying and mailing, but

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important.

What do you feel would attract a greater number of students to family medicine?

I would love to see more exposure to Family Medicine throughout the pre-doctoral years. The accrediting bodies for medicine are coming around in promoting ambulatory care and who is in a better position to teach ambulatory care than us?

Where should the specialty be adapting?

Any thoughts or ideas?

Student buddy programs that extend beyond academy meetings. Identification and mentoring of students prior to matriculation into college or medical school. High school programs in health careers with family doctor role models. Early identification and mentoring of medical students who might be interested in the field. Better reimbursement for the care we provide. High visibility of family doctors in the community and academic centers: volunteering as preceptors and “guest faculty” in patient assessment and longitudinal courses. A t.v. show featuring family doctors would help as well….remember Marcus? We cannot dismiss popular culture. Community health and population based medicine programs and education as the cutting edge of medicine…an area we can become the “experts” in. Our own attitude as a “speciality” that focuses on people and community becoming infectious because of our enthusiasm.

When you look back on all this, what do you think will be your greatest professional achievement?

Making a difference in the lives of my patients and my students and, if I am lucky, the community I serve.

simply suggests that a physician may charge a “reasonable fee.”

The NCMB policy is that medical records should not be withheld because a patient’s account is overdue or a bill is owed. In addition, the medical records should not be withheld until fees for the record are paid. Patients can complaint to the Board for violations of these policies, and physicians can be sited for ethical violations. While action against a physician’s license is unlikely, failure to transfer records in a timely fashion can result in warning letters from the Board.

A complete copy of the Medical Board’s position statement on this issue can be found online at www.ncmedboard.org. Click on “For Physicians” and then “Board Position Statements.”

Further questions on this or other statutes affecting healthcare should be directed to Greg Griggs at the NCAFP Help Desk, (919) 833-2110.

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Academy’s Annual Meeting Draws Record Numbers The NCAFP’s Winter Family Physicians Weekend – dubbed the ‘Celebration in The Mountains’– drew record attendance and hosted several organized medicine dignitaries in Asheville on December 1 – 4th. Special guests included AAFP Immediate Past President Michael Fleming, MD of Shreveport, LA, NCMS President Chuck Wilson, NCMS Executive Director Robert Seligson, Old North State Medical Society Past President George L. Saunders, III, M.D and NC DHHS Assistant Secretary for Health Policy and Medical Assistance, Dr. Allen Dobson.

Program Chair Dr. Robert E. Gwyther, MBA, presented an excellent lineup to topics that blended clinical information with topics on public policy, quality improvement and clinical procedures.

In addition to the lectures, the event’s fun social activities reached their high point on Saturday night with motivational humorist and internationally recognized speaker Ken Futch, a native of Burgaw.

Honors & Awards The NCAFP presented its 2005 Family Physician of the Year Award to Dr. Joyce A. Copeland, of Efland, NC. Dr. Copeland is a key member of Duke’s family medicine staff and also occupies a major academic role at the school (see related story). She gave a gracious acceptance speech that was both inspirational and motivating.

In other honors, the 2005 NCAFP Lifetime Service Award was awarded to Dr. Dean Patton, former Chair of the Department of Family Medicine at the Brody School of Medicine at East Carolina University. Patton has served the specialty in a variety of capacities since 1972, including operating a independent family medical practice in West Virginia, serving as President of the West Virginia family medicine association and through numerous academic roles at ECU and West Virginia University. During his ten-year tenure as family medicine chair at ECU, the department attracted national attention for its research and academic training programs and its efforts in the areas of health disparities and obesity prevention.

Patton currently oversees special projects for the medical school. A native of Beckley, WV, Patton graduated from Marshall University in 1968 and finished medical school at West Virginia University in 1972. He subsequently conducted his family medicine residency training at West Virginia in 1977. Patton practiced at Total Life Family Practice Center in Princeton, WV before he assumed a teaching role at ECU. He currently resides in Winterville with his wife of thirty-three years, Deanna The Academy also recognized Drs. Conrad Flick of Cary, NC and Warren P. Newton of Chapel Hill, NC with the 2005 Distinguished Service Awards. Flick is a principal with Family Medical Associates of Raleigh and was cited for his legislative advocacy efforts. Newton is presiding chairman of the Department of Family Medicine at UNC Chapel Hill and was recognized for his work promoting innovative primary care practice models within organized medicine.

2005 Outstanding Residents Named Fourteen third-year residents were recognized as the Outstanding Resident at their residency program for demonstrating compassionate patient care and maturity in interpersonal relationships in the specialty of family medicine: Soo Lee, MD - Cabarrus Michael Shusko, MD - Camp Lejeune Lauren Hull, MD - CMC Eastland Takie Hondros, MD - CMC Union Maya Carter, MD - Duke Susan Keen, MD - ECU Rustan Adcock, MD - MAHEC Asheville Jessica Ankney, DO - MAHEC Hendersonville Adam Kendall, MD - Moses Cone Slade Suchecki, DO - New Hanover Jeremy Ackermann, DO - SRAHEC Rebecca Burchfiel, MD - UNC David Lee, MD - WFU Micaiah Kuzma, MD - WOMACK

2005 Community Teaching Award Recipients Each medical school’s Family Medicine Interest Group recognizes a family physician for their dedication to teaching medical students. The award is in recognition of dedicated service to medical student education by advancing the principles and ideals of family medicine: Mark Heffington, MD - UNC John Burkard, MD - Duke Wilton Gay, MD - ECU Stephen Bissette, MD - WFU

2005 Research Poster Contest This year’s poster contest saw a number of high-quality presentations. The winners in the student and resident categories were as follows: Student Category: Nicole Gaskins Resident Category: Tim Daaleman, DO, MPH

NCAFP 2006 CME CALENDAR Mark your calendar for NCAFP's 2006 CME Meetings 2006 Spring Weekend: The CME Lowdown Charleston Dr. Gregory Pleasants - Program Chair 24+ Credits with Evidence-Based Topics April 6-9, 2006 Embassy Suites Charleston, Charleston, SC 2006 Mid-Summer Family Physicians CME Vacation Dr. Sarah Beyer - Program Chair July 2nd-8th, 2006 Kingston Plantation, Myrtle Beach 2006 Winter Family Physicians: Extravaganza in Asheville Dr. Kevin Burroughs - Program Chair 20+ Credits Nov 30 - Dec 3, 2006 Asheville, NC

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North Carolina Academy of Family Physicians

FOUNDATION NEWS continued from Page 9 the people of North Carolina. Our preventive medicine initiatives, Tar Wars, Into the Mouths of Babes, and the Adolescent Obesity and Inactivity Project were successful in educating and bringing quality healthcare to the population of our state. With programs such as the Student Scholarship Program, Student Activities Endowment Fund, and Family Medicine Interest Groups, our students and residents saw firsthand how the specialty of family medicine is a worthwhile choice.

Did you know that you can make your contribution in honor or memory of a colleague or loved one? Look for the special designation on our 2006 appeals.

Please consider “ringing in the new year” with a Foundation donation. For more information on any of the Foundation’s projects, please contact Marlene Rosol, Development Coordinator, at (919) 8332110, (800) 872-9482 [NC only], or mrosol@ncafp.com. Thank you – Happy New Year!!

FOUNDATION SCHOLARSHIP PROGRAM

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North Carolina medical students are eligible to apply for one of four scholarships in 2006. Applications are available through the four FMIG programs or you can download them on the NCAFP website (www.ncafp.com). For more information on student scholarships, or how you can make a donation to the Scholarship Program, please contact Christy Ayscue, Programs Coordinator, at (800) 872-9482 [NC only], (919) 833-2110, or cayscue@ncafp.com.

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Obesity Initiative To Focus on PhysicianAgent Networking in 2006 he Adolescent Obesity & Inactivity Project (AOI), funded by the NC Health and Wellness Trust Fund, has now completed its second year. Physician and cooperative extension teams were established in 20 counties throughout North Carolina. The trainings in these counties are now near completion. The cooperative extension agents serve as a referral source for family physicians to send their obese and at risk adolescent patients. The agents have been trained in a curriculum called Families Eating Smart Moving More (FESMM), which is available in all counties and to anyone in the community.

This year, the AOI project has taken to the road and visited many of these physician-agent teams. These meetings resulted in an array of ideas on how to collaborate their efforts to combat childhood obesity. For example, in New Hanover County Dr. Belinda McPherson and Dianne Gatewood, the New Hanover agent, decided to kick-off Healthy Weight Week in January with an event in Dr. McPherson’s office. This program is planned for an evening and will consist of a cooking presentation and tasting, height and weight measurements and a demonstration with the Fast Food and Families CD-ROM. The participants will be recruited from Dr. McPherson’s and her partners’ patient base.

In October, Dr. Karen Smith in Hoke County hosted an educational event in her clinic for some of her adolescent patients and their families. During this, her patients were weighed, measured, and then given a healthy snack and a Fast Food and

T

Families CD-ROM. In Nash County, Dr. Nadine Skinner has plans to participate in a program already established throughout the school system. The program, Friends Unraveling Nutrition (FUN), is continuous for 12 weeks and any student with interest may join. Dr. Skinner is looking forward to speaking at some of these sessions and presenting the health consequences of poor nutrition and inactivity.

She will also be available to these students for more in-depth and personalized one-on-one conversations.

Dr. Tamara Babb in Craven County continues her involvement within the schools in her county. She has been working with school nurses, physical education teachers and others to encourage involvement with the AOI project. The project will be presented at the Craven County Health Expo in May 2006.

During 2006, the project will seek to strengthen the relationships between the county physicians and their local cooperative extension agents. Activities for the coming year include FESMM sessions held in physician offices, programs to kick-off Healthy Weight Week and dissemination of education tools, such as the Fast Food and Families CDs. Prescription pads will be available to participating physicians with specific dates and times of educational programs.

In addition, generic prescription pads with specific goals for eating healthy and increasing physical activity will be printed for general use. Dr. Mott Blair continues to serve as the physician consultant with the project.

AAF P Studies Retail Health Clinics, Releases Evaluative Criteria n response to the rapid proliferation of retail-based health clinics, a special AAFP Board of Directors workgroup has released a set of “Desired attributes for Retail Health Clinics.” The workgroup was established in response to Resolution 212 of the 2005 Congress of Delegates and is led by President-elect Dr Rick Kellerman of Kansas.

Currently, the strategy at the national and state levels is to provide each chapter and member the most accurate information about the clinics, to promote family medicine as the “medical home,” and to encourage the clinics to operate in accordance with the workgroup’s desirable criteria.

Numerous clinics have opened across North Carolina recently, including several in Raleigh and Charlotte; and more are expected.

These developments have been discussed at length within NCAFP’s Professional Services and Governmental Affairs councils, as well as at the Board level. At this point, the chapter is continuing to evaluate the impact of the clinics and looks favorably on AAFP’s guidance.

The criteria released by the workgroup are closely aligned with key Future of Family Medicine (FOFM) goals and are being made available so chapters and member physicians may evaluate the companies and any collaborative opportunities within their service areas. The emerging retail model is seen as the market’s response to number of factors, including consumerism, consumer-directed health plans, and retailing, and that promoting support for the criteria is in the

I

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best interests of all patients.

The five attributes the workgroup identified as desirable are: 1. Scope of Service —Retail clinics must have a well-defined and limited scope of clinical services.

2. Evidence-based Medicine — Clinical services and treatment must be evidence based and quality improvement oriented.

3. Team-based Approach — The clinic should have a formal connection with physician practices in the local community, preferably with family physicians, to provide continuity of care. Other health professionals, such as nurse practitioners, may only operate in accordance with state and local regulations. Ideally, other health professionals should be part of a “team-based” approach, with physician supervision, as prescribed by the Future of Family Medicine report.

4. Referrals — The clinic must have a referral system to physician practices or to other entities appropriate to the patient’s symptoms beyond the clinic’s scope of work. The clinic should encourage all patients to have a “medical home”.

5. Electronic Health Records — The clinic should include an EHR system sufficient to gather and communicate the patient’s information with the family physician’s office, preferably one that is compatible with the Continuity of Care Record supported by AAFP and others.

North Carolina Academy of Family Physicians

Maternal & Child Health Council

SHARED MATERNITY CARE: DO WE DELIVER?

By Dr. Shannon Dowler I love taking care of pregnant women. Way back in medical school one of the things that factored into my decision to become a family doctor was my desire to care for women and children throughout the spectrum of their lives. When I was a resident it became abundantly clear that being on Labor and Delivery was deleterious to my health. I would sit rapt with attention, analyzing the tracings on the computer from all 13 labor rooms, watching for decelerations while the other residents were fast asleep in their call rooms. I would pounce on the diagnosis of failure to progress so we could proceed to a “safe” c-section. When I, myself, was four months pregnant I nearly fainted while repairing a third degree tear. Clearly, I was not meant to be in labor and delivery.

On the other hand, I looked forward with great anticipation to the prenatal visits in the outpatient clinic. I loved standing by to receive the newborn baby. Well child checks were my favorite type of visit. As I began job hunting, I wanted to find a way to have it all without having to do it all.

I found the perfect opportunity right here in Asheville where I could be a provider of “shared maternity care.” Shared care is the division of maternity care between either a family doctor or a midwife and a collaborating community obstetrician. This model is practiced everywhere from England to Australia to Florida. It allows the patient to stay in their “medical home” throughout their pregnancy, whether that is a private practice or a public clinic.

Our health department has a unique relationship with the MAHEC OB/FM residency programs in which we provide comprehensive prenatal care and they provide the hospital services.

One of our collaborators, Dr. Hytham Imseis, the residency director and senior perinatologist for the MAHEC OB-GYN Residency program, has this to offer, "The key to successful collaborative care is ongoing 2-way communication and mutual trust--the keys to any successful relationship."

Our model of shared care in Buncombe County differs slightly from some shared care models in other states in which the patient has one visit with an OB at 18-20 weeks (usually for their ultrasound) and several visits at term. Our model allows me to follow my patients throughout their pregnancies and to provide postpartum care to the mom and the baby after delivery and for subsequent pregnancies. I have a thriving population of young, healthy women and children without the barriers associated with delivering babies.

The most significant problem with this model is that the patient will not have continuity at delivery. However, in this world of mega-groups and shared call continuity at delivery often does not happen anyway.

The positives are numerous and I will delineate how they have the potential to benefit all parties involved. In our times of outrageous malpractice premiums and decreased hospital privileging, a shared maternity care arrangement can offer family doctors the opportunity to provide full spectrum care without the cost and time associated with deliveries. This model also provides

additional delivery experience for the family medicine and OB residents in training without overwhelming their outpatient clinics.

When we encounter challenges, this model allows our patients “specialty consultations,” as the perinatologists and obstetricians are always open to our calls and questions.

How does this benefit your community obstetrician? They will experience decreased office visits for low paying clients (Medicaid or uninsured), higher reimbursement for the delivery and hospital time, the same cost of liability coverage and more time to pursue high risk patients and gynecology patients in the office. By creating a trusting relationship with your community specialist in which you agree on the standard of care for prenatal patients, you become an extension of them, which is mutually beneficial.

How does this benefit your family doctor? It decreases malpractice costs, provides a better quality of life with less call time and hospital time, and an opportunity to provide care to more children and young, healthy patients. While you lose those sleepless nights on L&D (which I know some of you actually like), you gain a population of young women and children that in a clinic full of patients with multiple comorbitities can be priceless.

Most importantly, how does this benefit the patient? The patient gets a well-rounded family doctor who will provide long term care for their family, potentially decreased costs of prenatal care and the convenience of staying with their “medical home”. In our community, by coming to the health center, the patients receive their care at a fraction of the cost of a private obstetrics practice.

The vast majority of our patients are Medicaid, uninsured and often do not speak English as their first language. Going to an outside provider would be cost prohibitive for many of these patients and likely result in limited prenatal care and possibly worse outcomes.

A perennial topic at the Maternal-Child Health Council meetings is the question of how to provide maternity care in a time when the barriers are mounting. This alternative model may be a great way to do this for certain communities. I am not suggesting that family doctors should abandon the delivery room altogether.

As we look for ways to find our niche in medicine and to be fulfilled both personally and professionally this is a time when we all need to share our positive experiences with our colleagues in family medicine.

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The North Carolina Academy of Family Physicians, Inc. P.O. Box 10278 Raleigh, NC 27605

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