Medical record Yo u r C ommu n ity R esourc e f or W hat ’s Happening in Healt h Car e
BERKS COUNTY MEDICAL SOCIETY
Mental Health Care
Primary Care Provider Dr. Maria Braun
in Berks County
BCMS Members Mentor Students’ Summer Research
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patient’s father asked me a thoughtprovoking question about a year ago. He was telling me that his 5-year old daughter preferred the freedom she had had in their village in Africa compared with living in the US. I replied that it was ironic that the country most associated with freedom didn’t seem free to his little girl. And then, in his deep, booming voice, he asked the question: “Are you free?”
Christina M. Ohnsman, MD, Editor
At that moment, I didn’t feel free at all. The responsibilities of my practice were weighing heavily on me that day, and outside of work, other responsibilities seemed equally heavy. My time wasn’t free to take a day off and do something just for the fun of it. For that matter, I wasn’t free to do some things that weren’t fun, but were further down my priority list. In that moment, I didn’t consider moving to Africa, but a few other options crossed my mind!
In this issue of the Medical Record, for those who are truly ready to be free of the concerns of medical practice, Dan Kimball has written an excellent article outlining the steps required for retirement. He offers guidelines and helpful references about your patients’ medical records, malpractice insurance, medical licensure, health insurance, and many other details that you may not have considered. As he aptly says, “One cannot just decide to retire and walk out of the office and close the door,” as tempting as that may sometimes be! On another note, you’ll find an article by Heath Mackey, MD, our district’s Trustee on the PA Medical Society Board, about consolidation of practices and hospitals into health systems, consolidation of insurance providers, and consolidation of health care networks and insurance companies. This is a growing trend as providers at all levels seek to continue caring for patients in a challenging economic environment. What are the tradeoffs in autonomy for physicians and patients when mergers take place? Will they improve or harm health care delivery? Many of these decisions seem out of our
control, but it’s good to know that PAMED is representing our interests and those of our patients, protecting our freedom to deliver good health care.
A month or two after I was put on the spot by that father, I had the honor of attending the 2014 Liberty Medal ceremony in Philadelphia. Malala Yousafzai, the girl who survived an assassination attempt by the Taliban, was the recipient. Coincidentally, she had just learned that she had won the 2014 Nobel Peace Prize, making her the youngest person ever to receive this award. I’ve attended a number of Liberty Medal ceremonies, but this one was the most moving by far. It seemed that there wasn’t a dry eye in the audience when Malala took the stage.
In her speech, this 16-year old girl powerfully reminded me that I am free, in the most important ways. Unlike the 57 million children around the world who do not go to school, I had had an excellent education. Unlike women in many countries, I am free to go where I want, work outside the home, own a business, pursue my interests, or not—yes, even practice medicine—as I choose. Unlike millions of people living under tyranny, I am free to openly disagree with my government. In fact, Malala reminded us, it is our responsibility to speak up. Malala was funny, passionate, and in the end, just an ordinary kid who is doing extraordinary things. She said that she is often asked why she risked her life, by outspokenly campaigning for the rights of girls to go to school and writing a blog for the BBC about life under Taliban rule. When asked, “Why you?” she replies, “Why not me?” She reminded us that “history doesn’t come down from the sky. It is we who make history.” And that was the message: we all have the capability—and the responsibility— to speak up for what is right. We may feel like we’re drowning in busy schedules, ICD10 transitions, A/R reports, etc., but here in America, in the ways that count, we truly are free.
What are you going to do with that freedom?
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Medical record BERKS COUNTY MEDICAL SOCIETY
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THE BERKS COUNTY MEDICAL RECORD Christina M. Ohnsman, MD, Editor
D. Michael Baxter, MD Lucy J. Cairns, MD Daniel B. Kimball, MD, FACP Betsy Ostermiller
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Table of Contents FALL 2015
Berks County Medical Society BECOME A MEMBER TODAY!
Go to our website at www.berkscms.org and click on “Join Now”
Access to Mental Health Care in Berks County
Charles Barbera, M.D., Chair of the Department of Emergency Medicine, RHS, Responses 12 How Many Psychiatrists Does It Take?
Thinking of Retiring Soon?
DOL Clarifies Worker Classification Test
Consolidation Here, There and Everywhere 21 BCMS Members Mentor Students’ Summer Research Guts & Glory Recap
Understanding Proposed 2016 Medicare Fee Schedule 34
Fall Golf Outing Recap
Editor’s Comments 3 Executive Director’s Message
President’s Message 8
Foundation Update 28
Legislative Update 30 Alliance Update 33
Events Calendar 38
Content Submission Medical Record magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Berks County Medical Society. Submissions can be photo(s), opinion piece or article. Typed manuscripts should be submitted as Word documents (8.5 x 11) and photos should be high resolution (300dpi at 100% size used in publication). Email your submission to email@example.com for review by the Editorial Board. Thank YOU! Cover Photo: Primary Care Provider, Dr. Maria Braun
Executive Director’s Message
Requiem for the Pancake Social Timothy J. (T.J.) Huckleberry, M.P.A. Executive Director
am going to level with you, the days of “pancake social” societies are over. A quarterly meeting and a parade float are simply not enough to sustain a meaningful professional society. I believe we all can agree that public interaction and fellowship has taken a backseat to our Netflix queue and Amazon wish lists. We are living in a world where it is increasingly easier to remain isolated in lieu of joining. As a whole, it has affected professional societies throughout the country and attracting and retaining young members has become increasingly difficult. Simply put, professionals need more, quickly, with little to no hassle, and less commitment.
As a millennial I count myself amongst these types of people. In fact as I am typing this I am also on Amazon searching for a particular office supply. As I am sifting through the seemingly millions of options for one product I am not focused on the cheapest, nor the most expensive – I am looking for the best value with the most features. It’s not good enough to just be run of the mill. And while I did not find the perfect Philadelphia Eagles post-it notes that I wanted, I truly believe that my method of shopping is akin to those contemplating membership in BCMS; are we getting the best value with most the features? Well, in order to address this question we should first define the nature of a value and a feature. Secondly let me show you what we are doing here at BCMS to ensure our values remain relevant.
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First let’s return to the example of the “pancake social.” This is a feature, an important extra that further adds to central value of why you join. In terms of collegiality these functions are invaluable and I plan on having many events like this throughout the year. But you did not join for the social aspect, you join in part because: • You are invested in your craft, your practice, and your community. • You are concerned that outside influences believe they know better than you when it comes to how you treat your patients. • You care about your fellow physicians and colleagues.
• You have a voice, an opinion, and expertise and you feel a duty to want to share it. • You are aware that your issues and concerns will get the proper attention they deserve on the state and local level.
These are just a few of the values that bring physicians into BCMS. But why does that make us the BEST value? Well, our best value is that we know you personally, we strive to understand your practice, and we are present in your community. To the Berks Medical Society you are not simply a membership card and dues statement... and we are invested in making your practice better not only because you are a member but because of who YOU serve; our co-workers, our neighbors, and our families. We have your back as you tend to those we care about.
That being said allow me to quickly transition to a key part—our outreach strategy. Over the past few weeks I have been scheduling outreach meetings with several physicians in order to get a better idea of the various issues they face as well as the values and features they are looking for in BCMS. These meetings have been invaluable and have already helped form BCMS’s ongoing community and advocacy strategy. These meetings will continue. We are currently looking to schedule dates in the fall to sit down with members and non-member physicians alike. I only meet for a half hour at a location that best suits the physician. If you want to meet at your practice, I am there. Over coffee? I am holding your vente pumpkin spiced latte in one hand and my notebook in the other. While jogging? I’ll be five paces behind you listening while trying not to blackout. In the fall, I will also be kicking off our new Breakfast Forums. These small group breakfasts will be held in locations close to your practice, and will be hosted by a member physician. You do not need to be a member to attend. During these informal gatherings I hope to get feedback on various topics that affect the physician directly. Ironically, pancakes may be on the menu. If you are interested in either of these opportunities or have any questions or issues that you would like to make me aware of, please do not hesitate to contact me at 610 375 6555, or email me at tjhuckleberry@berksCMS.org.
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he Berks County Medical Society continued its summer college intern program this year, selecting Sara Braun Radaoui to research and write about a health-related topic of local concern. Sara gained experience in the summer of 2014 as an intern in PAMED’s Marketing and Communication department. She then completed her undergraduate degree in Communication Arts and Sciences at Penn State University Park. Being raised in a medical family (her mother is BCMS member and Family Medicine specialist Maria Braun), Sara has a strong interest in health care issues. She decided to tackle the very important subject of access to mental health care in our community.
Lucy J. Cairns, MD, President
The field of mental health care is many-faceted. Those who may require the expertise of mental health professionals include people with developmental disabilities, major and minor psychiatric disorders, substance abuse and addiction, alcoholism, dementia, brain injuries, and strokes. In medicine, psychiatry is the specialty with advanced training in the diagnosis and treatment of mental disorders, but psychiatrists are joined by a wide variety of trained laypersons and non-physician professionals in working to meet the needs of this population. Counselors answering a crisis hotline, psychiatric clinical social workers, psychiatric nurse practitioners, and clinical psychologists with Master’s or Ph.D. degrees are a few of those in this mental health care workforce who help care for Berks County residents. The contributions of these non-physician providers are tremendous and absolutely vital to the well-being of our community, but in the interest of designing a project which could be completed in the few weeks available, Sara’s article focuses primarily on the unique role of psychiatrists in this complex system.
All psychiatrists have completed a four-year residency training program following their four years of medical school. Some then undergo additional training to subspecialize. Child and Adolescent Psychiatry and Addiction Psychiatry are two of the more popular subspecialties. The depth and breadth of knowledge psychiatrists thus acquire in the field of general medicine, in addition to the years of specialized training in psychiatry, is what results in the unique position of psychiatrists in the arena of mental health care. No other professional in the field is as qualified to understand mental illness in relation to physical health and to distinguish between physical and psychological causes of both mental and physical distress. Anyone who understands the unique contributions psychiatrists make to the health of a community will be alarmed by the evidence of the current shortage in this specialty, and by the near certainty that it will only get worse. This shortage is manifested in the long wait-times for appointments experienced by patients being referred for psychiatric care. The well-being of these patients is put at risk, and overburdened psychiatrists are more likely to experience burn-out.
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While psychiatrists play a unique and crucial role in mental health care, primary care physicians are central to this field. The majority of patients with mental health needs first present to their family physician, internist, or pediatrician, and often the presenting complaints are somatic (fatigue,
headache, insomnia, etc.). The primary care physician has the task of discerning the difference between physical distress and illness and mental distress or illness, and of recognizing the many instances in which the two are different sides of the same coin. Due to the stigma of mental illness, patients may be reluctant to acknowledge their condition, and it falls to their primary care physician to overcome this barrier to accepting appropriate care. Once a diagnosis is made and the patient educated regarding the need for treatment, the physician either undertakes the treatment themselves or refers the patient to a mental health specialist. According to sources cited in the American Academy of Family Physicians position paper Mental Health Care Services by Family Physicians, primary care physicians provide the majority of mental health care. But in those cases where a patient needs care beyond the scope of practice of their family doctor, it is too often difficult to access. Data from a nationally representative survey of physicians from 2004-2005 showed primary care physicians reported they were unable to access outpatient mental health services for patients at twice the rate they reported being unable to access other specialty care. This was before parity in insurance coverage for mental health was mandated by law, and 59% of physicians who reported being unable to access outpatient mental health services cited lack of or inadequate insurance coverage as a “very important” reason. This financial barrier is less important today, but a similar percentage of physicians also ranked lack of providers as “very important,” and this barrier remains. The shortage of both psychiatrists and primary care physicians is not likely to be addressed in the foreseeable future via increased federal funding for post-graduate medical education. In the meantime, initiatives to improve communication and collaboration between psychiatrists and other mental health specialists and primary care providers are moving forward and could alleviate the access problem to some extent. Facilitating communication and collaboration among physicians are the primary functions of physician organizations such as the Berks County Medical Society and PAMED, and I hope that by using the Medical Record to shine a light on the topic of access to mental health care we will encourage continued progress in improving health care in our community.
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Access to Mental Health Care in Berks County By Sara Braun Radaoui, BCMS Summer Intern Advisors: Lucy J. Cairns, M.D., and Daniel B. Kimball, M.D., F.A.C.P.
ental health includes our psychological, emotional, and social wellbeing. Mental health affects how we act, how we feel, and also how we think. While many people may not realize it, it helps us determine how we relate to others, make life choices, and handle stress. Mental health is important at every stage in one’s life, from childhood to adolescence through adulthood. Roughly 1 in 5 adults and 1 in 5 children ages 13-18 have some form of mental disorder that significantly limits or interferes with one or more aspects of their daily living. According to NAMI (National Alliance on Mental Illness), only 41 percent of adults and 50.6 percent of children with mental illnesses receive needed mental health services. Many different factors contribute to mental health problems such as life experiences, social and biological factors, and family history of mental health problems. Mental health disorders are extremely common, but the most important thing to remember is that help is available. People experiencing mental health problems should get treatment to improve their condition in order to lead happier and more productive lives. Serious mental illness costs America $193.2 billion in lost earnings per year.
According to the Kim Foundation, an estimated 26.2 percent of Americans ages 18 and older suffer from a diagnosable mental disorder in a given year. Mental illness is widespread throughout the population, but the main burden of illness is concentrated in only about 6 percent of the population. It is very possible for patients to suffer from more than one mental disorder at a time, and roughly about 45 percent of those with any mental disorder meet criteria for two or more disorders. There are several types of professionals who provide different mental health services, and finding the right one can be critical in the diagnosis, treatment and recovery process of the patient. A psychiatrist provides psychiatric and medical evaluations, treats mental disorders, and prescribes
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and monitors medications. Psychologists provide testing, evaluations, and treatment for mental disorders as well as behavioral problems. Social workers usually hold a bachelor’s degree or a master’s degree, with case management and placement services being within their realm of work. A Licensed Clinical Social Worker (L.C.S.W.) has earned a Master of Social Work degree and has undergone additional post-graduate training to become licensed in mental health counseling.
With a rising demand for mental health services in the community and statistics showing a serious shortage of mental health professionals, Dr. Kolin Good, head of the Psychiatry Department at the Reading Health System, believes that there will never be enough psychiatrists to meet the needs. She mentions that her department, however, is always trying to think of new and innovative ways to reach out. They are in the process of developing and putting together an education treatment protocol and training for primary care doctors. When asked if she envisioned a more collaborative effort with primary care physicians in the delivery of mental health care in our communities for the future, Dr. Good replied, “That’s my dream, to integrate the care between primary doctors and psychiatrists.” Primary care providers are the backbone of the healthcare system. In addition to their overall focus on a patient’s wellness and health, they are also playing a very important role in diagnosing and treating mental illnesses. According to The Bazelon Center for Mental Health Law, primary care providers now provide over half of mental health treatment in this country, and about 25 percent of all primary care patients have diagnosable mental disorders. Inadequate access to mental healthcare has taken a toll on American society. There are too many patients with an unmet need for mental health services. According to County Health
Rankings, 80 percent of Pennsylvania’s population lives in a county designated as a Mental Health Professional Shortage Area. This forces primary care physicians, who are already overwhelmed with tight schedules, to act as psychiatrists and counselors to their patients. The concern is that many primary care providers do not have the training to provide psychiatric treatment. In an interview with Dr. Maria Braun, a family practice physician for 23 years in Wyomissing, I learned that over 50 percent of the patients she sees on a day-to-day basis have some form of mental illness, the two most prevalent being anxiety disorders and depression. One of the biggest issues with access to the mental health care system is the long wait for appointments. It can take anywhere from 4 weeks to 3 months for a patient to get an appointment with a mental health professional. Dr. Braun mentioned that it is faster to get a patient seen by a mental health counselor or social worker (usually takes 2 to 4 weeks) as opposed to getting an appointment with a psychologist or psychiatrist. One of Dr. Braun’s concerns is the need to improve communication channels between mental health providers and primary care physicians. She mentions, “It is not in the best interest of the patient if there is zero feedback. The lack of communication impacts the follow-up care of these patients later on.” Dr. Braun believes that there needs to be a greater effort from the medical community in order to help demystify mental illness. It should be treated like any other chronic medical condition, such as diabetes or heart disease. They all need and deserve the same attention and ongoing medical care.
for residency training, the Resident Physician Shortage Act of 2015 (S. 1148/H.R. 2124), is given 0% chance of passage by the public interest website govtrack.us. Second, we should focus on improving the ability of primary care physicians to provide high-quality mental health care. Actions that would help achieve this goal include: • support research to develop evidence-based standards of care, clinical guidelines, and quality measures
•1develop a systematic approach to ensure that evidencebased practices are being delivered to patients •1reform payment systems to recognize the role primary care physicians play in mental health care and reimburse appropriately
•1integrate mental health care with primary care, creating closer collaboration between psychiatrists and other mental health specialists and primary care providers. Various models to accomplish this goal hold promise for reduced wait-times for patients to receive mental health care, greater effectiveness of treatment, reduced use of EDs for psychiatric care, and reducing the burden on primary care providers.
continued on next page >
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An additional barrier is the stigma that goes along with mental illness. Unfortunately, negative beliefs and attitudes are still rather prevalent toward those with a mental health condition. With stigma comes discrimination. Discrimination can be intentional and direct, or it can be unintentional and very subtle. Several ways to deal with the stigma that comes along with mental illnesses include: seeking treatment, joining a support group, and speaking out against stigma in an attempt to educate those around us. The judgment of others almost always stems from a lack of understanding rather than factual-based information. Learning to accept the condition and recognize what you must do in order to treat it is most important.
Maybe the most important thing we can do is focus on ways to improve general access to mental healthcare. One key action would be to increase the number of actively practicing psychiatrists. The federal government is the predominant source of funding for residency programs, and in 1997 the Balanced Budget Act Congress capped the number of positions to be supported at the number reported at the end of 1996. Despite projections of a worsening physician shortage from the Association of American Medical Colleges beginning back in 2006, and subsequent expansion of medical school slots in the U.S., Congress has taken no action to increase support for post-graduate medical education and seems unlikely to do so. The legislation most recently introduced to increase funding
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Charles Barbera, M.D., Chair of the Department of Emergency Medicine, RHS, responded to the following questions: Q: Approximately what proportion of people seeking care at the Reading Health System Emergency Department have a psychiatric diagnosis as their primary reason for presenting? A: Seven to 10% of our visits are mental health—600 plus a month. Q: Has this proportion been trending up or down over the past 5 years or so? A: The proportion is steadily increasing, at a rate of 5 – 10% annually.
Q: Approximately what proportion of this population is not receiving any community-based care for their mental illness at the time they present to the ED? A: I do not have this answer.
Q: What proportion of this population has a primary diagnosis of alcohol or other substance abuse vs. other mental illness? A: Fifty percent are dual diagnosis.
Q: When admission to an in-patient psychiatric bed is indicated, how does the wait-time to place such patients compare to wait-times for medical/surgical patients, and how often must psychiatric patients be transported to in-patient facilities outside Berks County? A: The average length of stay is five hours, but can be as short as an hour and has gone into days. When that occurs, the patient is admitted to a med/surg unit. We transport approximately 1/3 of our mental health admissions out of county because the inpatient capacities at the acute care facilities within Berks County are full. Of note, the Reading Health System is building a crisis center, as part of the ED annex to be completed in October 2016. We will then triple our capacity to handle acute mental health patients, while we will also have a mental health observation unit. We have been working closely with Dr. Michalik and Dr. Kolin Good to identify these needs of our community and build a facility that meets those needs.
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Access to Mental Health Care in Berks County continued from page 11
•1Increase the use of Advanced Care Practitioners such as Psychiatric Nurse Practitioners and non-physician mental health care professionals.
Accessing behavioral health services for patients of primary care providers at the Berks Community Health Center has become easier under the auspices of a grant program created by the Affordable Care Act. Since being awarded this Behavioral Health Integration grant, providers at the center who encounter a patient with behavioral needs can have that patient evaluated by an on-site psychiatric social worker, Helen Wooten, L.C.S.W., before leaving the building.
According to Dr. Kelleher, Chief Medical Officer for the health center, arranging for prompt counseling services with outside non-physician providers is relatively easy. However, referrals to psychiatrists for patients with major psychiatric illness often involve delays stretching to months. One possible outcome of such delays is progression of the illness to a crisis requiring intervention in a hospital Emergency Department.
One of the most common mental disorders, depression, “has almost become a primary care disease,” according to Dr. Kelleher—referring to how frequently people with depression seek care from their PCP and to how untreated depression complicates care for diabetes, obesity, hypertension, and other medical conditions. “You cannot disconnect your head from your body,” she tells her patients. Providers at the Center assess every patient for depression at every visit, and are generally comfortable treating all but severe cases of depression in adults. Treatment by a psychiatrist, however, is crucial for acute or severe mental illness and for children with mental illness. Access to psychiatric treatment, she points out, depends not just on the presence of psychiatrists in a community and their participation in insurance plans but also on the waittime for an appointment, which is often the problem.
How Many PSYCHIATRISTS Does It Take? 1 or purposes of determining eligibility for F certain government programs and grants, the federal Health Resources and Services Administration uses the designation ‘Health Professional Shortage Area’ or HPSA, based on ratios of population to providers. (A HPSA may be a population group, a facility, or a geographic area. The Berks Community Health Center is a facility designated as a Mental Health HPSA.)
Additional increase of 10% is forecast to occur between 2013 and 2025 A 46% increase in the population 65 and older is forecast by 20253
• Expanded insurance coverage for behavioral health services
A geographic area with 30,000 or more people for each psychiatrist, or a ‘high needs’ area with a ratio of 20,000/1, meets the current definition of a Mental Health HPSA. Currently there are approximately 4,000 Mental Health HPSAs.
To use the word “shortage” implies measurement of the current supply of psychiatrists against a generally agreedupon standard of what would constitute an adequate supply, but no such universal standard exists. An approach used in one in-depth study1 involved using location-specific prevalence data for mental disorders, and actual utilization figures, to estimate the hours of care required to meet the total need, compared to estimates of hours of care available from the current workforce. Using this method, 95% of U.S. counties had some degree of unmet need for psychiatric care, and 77% had a severe shortage (less than half the current need being met).
United States Psychiatric Workforce is Declining2 Between 2008 and 2013:
• Number of active adult psychiatrists decreased by 4%
• Number of first-year residents/fellows in ACGME accredited psychiatric training programs increased only 1.2%
59% of actively practicing psychiatrists were 55 y.o. or older in 2013.
The Demand for Psychiatric Care is Increasing • Population growth
Total U.S. population increased 5% between 2008 and 2013
Mental Health Parity and Addiction Equity Act of 2008
Medicaid expansion under the Affordable Care Act (ACA)
Expansion of private insurance coverage under the ACA Inclusion of mental health and substance abuse services as essential benefits under the ACA
• Government-led and private initiatives to integrate behavioral health services with primary care are expanding in recognition of the impacts mental illness and substance abuse have on overall population health.
Berks County Compared to the U.S.
11 • Population-to-psychiatrist ratio: 14,769/1 (approximately4)
• Population-to-psychiatrist ratio for entire U.S.: 8,476/1 (2013 data).
References 1 Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. Countylevel Estimates of Mental Health Professional Shortage in the United States. Psychiatr Serv. 2009; 60 (10) 1323-8. 2 AAMC 2014 Physician Specialty Data Book, Center for Workforce Studies. Nov. 2014 3 U.S. Census estimates 4 Based on Google search and physician directories for Penn State Health St. Joseph and Reading Health System. Does not count psychiatric care available at Wernersville State Hospital or the Caron Treatment Center.
Employee Handbook Spring Cleaning Now that benefits open enrollment is finished, you may want to consider dusting off your employee handbooks for an annual review. Regularly reviewing employment policies and procedures is becoming increasingly important as workplace legislation and regulations continue to change.
flexibility in interpreting and applying policies. Wherever possible, use general language (such as “may,” “typically,” etc.) in place of more limiting language. Make sure that the handbook includes a clear statement that the employment relationship is not a contract but “at will” and may be terminated at any time with or without cause. Determine if there are any local or statespecific policies that must be added or updated, such as paid sick leave. Consider updating the format and tone of the handbook to be consistent with desired company culture.
Final Rule—FMLA Protections for Same-sex Spouses
On Feb. 25, 2015, the Department of Labor (DOL) issued a final rule that expands protections under the federal Family and Medical Leave Act (FMLA) for same-sex spouses. This final rule, effective March 27, 2015, revises the definition of “spouse” under the FMLA to:
DOL Clarifies Worker Classification Test
Here are some things to consider when reviewing your employee handbook: •
Make sure that internal company policies and procedures are in line with actual practice. A policy that is not consistently enforced as it is written can become problematic if your organization is ever faced with litigation. Ensure that policies on harassment, discrimination, leave, drugs and alcohol, sexual harassment and background checks are updated to reflect the most current federal and state laws. Review the language in the handbook to ensure that your organization maintains
The above are suggested starting points and not an all-inclusive list of things that you should consider. It is important for the handbook review to be a collaborative process that includes not only your human resources department, but also the managers and supervisors who are enforcing and interpreting the policies on a daily basis.
Adopt a “place of celebration” rule, which is based on where the marriage was entered into, in place of the “state of residence” rule that applied under prior DOL guidance; and Expressly include same-sex marriages in addition to common-law marriages and encompasses samesex marriages entered into abroad that could have been entered into in at least one U.S. state.
Lastly, it is highly recommended that you Under the final rule, eligible employees in have legal counsel review your legal same-sex marriages will be able to organization’s employee handbook. The take FMLA leave to care for their spouses, National Labor Relations Board (NLRB) has regardless of where they live. recently claimed that many employer policies relating to employee conduct and social Employers should review and update their media are unlawful, which can result in FMLA policies and procedures as terminated employees being reinstated and necessary, and they should train given back pay. Having an employment employees who are involved in the leave n July 15, 2015, the U.S. Department of Labor (DOL) lawyer review the handbook can help your management process on to theclarify expanded issued an administrative interpretation how organization avoid costly litigation. rules for same-sex spouses under the to determine whether a worker is an employee or an FMLA.
Employers should use the six factors of the economic realities test as a guide in their efforts to determine whether a worker is an employee or an independent contractor.
Employee misclassification is a growing concern for the DOL. An increasing number of U.S. workplaces are restructuring their business organizations, creating a higher risk of misclassifying employees as independent contractors. Employer misclassification has a direct impact on employee eligibility for benefits, legal protections (such as minimum wage and overtime rights) and taxation.
WORKER CLASSIFICATION TESTS
QUICK FACTS •1On July 15, 2015, the DOL issued guidance on determining whether a worker is an employee or an independent contractor. •1Workers who are employees are entitled to legal protections under federal law. •1The DOL uses the “economic realities test” to classify workers. •1The DOL’s guidance provides clarification on the six factors of the economic realities test.
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Several tests exist to determine whether a worker is an employee or an independent contractor. The most common tests include the common law or agency test, the economic realities test, the hybrid test and the IRS test.
Traditionally, the DOL has favored using the six-factor economic realities test because this test seeks to determine whether a worker is economically dependent on his or her employer or whether the worker is in business for him- or herself. The DOL’s rationale is that if the worker is economically dependent on the employer, the worker should be classified as an employee and protected by employment laws, including the Fair Labor Standards Act (FLSA) and the Family and Medical Leave Act (FMLA).
THE ECONOMIC REALITIES TEST The six factors for the economic realities test are:
1.1Whether the worker’s job is an integral part of the employer’s business;
definition of employment was “specifically designed to ensure as broad of a scope of statutory coverage as possible.” This “suffer or permit” standard prevents employers from using agents to evade labor and employment responsibilities. According to the DOL, under the economic realities test, most workers will be considered employees subject to the FLSA.
2.1Whether the worker’s managerial skill affects his or her opportunity for profit or loss;
AN INTEGRAL PART OF THE EMPLOYER’S BUSINESS
4.1Whether the work performed requires special skills and initiative;
A worker that performs activities that are an integral part of the employer’s business is more likely to be dependent on the employer, and, therefore, should be classified as an employee.
3.1Whether the worker’s and the employer’s investments are comparable; 5.1Whether the relationship between the worker and the employer is permanent or indefinite; and
6.1An analysis of the nature and degree of the employer’s control over the worker.
In the administrative interpretation, the DOL emphasized repeatedly that no one factor is determinative and that the factors should not be applied in a mechanical fashion. Rather, the DOL encourages employers to use the six factors as a guide in their efforts to classify workers correctly. The DOL further explains that the six factors should be interpreted within the context of the FLSA’s definition of employment. The FLSA defines “to employ” as to suffer or permit someone to work. The DOL explains that this broad
The administrative interpretation states that the courts have found the “integral” factor to be compelling even when the activity in question is just one component of the business or is performed by hundreds or thousands of other workers. For example, the DOL states, “a worker answering calls at a call center along with hundreds of others is performing work that is integral to the call center’s business, even if that work is the same as, and interchangeable with, many others’ work.” The DOL also mentioned that work can be integral to an employer’s business even if it is performed away from the employer’s premises, at the worker’s home or even on the premises of the employer’s customers.
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MANAGERIAL SKILL The focus of this factor is whether the worker’s managerial skill can affect his or her opportunity for profit or loss. To determine profit or loss opportunities, employers should look beyond the job at hand and determine whether the worker’s skills can lead to additional business from other parties or reduce the opportunities for future work. When evaluating this factor, employers should consider a worker’s decision to hire others, purchase materials and equipment, advertise, rent space and manage timetables.
The DOL specifically mentions that a worker’s ability to work more hours and the amount of work available from the employer have “nothing to do with the worker’s managerial skills and do little to separate employees from independent contractors.” This is because both are likely to earn more if they work more and if there is more work available.
To determine whether the employer and worker investments are comparable, employers should look at the nature and the extent of the investments.
An independent contractor should make some investment and undertake at least some risk of loss if he or she is in business for him- or herself. The investment should support a business beyond any particular job. These types of investments include furthering the business’ capacity to expand, reducing business cost structure and extending the reach of the independent contractor’s market. However, a worker’s investments should not be considered in isolation. They should be compared to the employer’s investment. If the worker’s investment is relatively minor, the employer and the worker may not be on the same footing and the worker may be economically dependent on the employer. Finally, investing in tools and equipment is not an automatic indication of significant investment or that the worker is an independent contractor. This type of investment must be compared to the worker’s investment in his or her overall business and to the employer’s investment in the project and perhaps in its overall activities.
SPECIAL SKILLS AND INITIATIVE
A worker’s skills and initiative can be an indicator of economic independence. However, when considering a worker’s skill, employers should consider the worker’s business skills, judgement and initiative, rather than his or her technical skills, which are often required to perform the work. Special skills and initiative are indicators of economic independence when the worker can use them in an independent way, such as demonstrating business-like initiative.
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The DOL provides the following illustrative examples:
EXAMPLE 1 A highly skilled carpenter provides carpentry services for a construction firm; however, such skills are not exercised in an independent manner. For example, the carpenter does not make any independent judgments at the job site beyond the work that he is doing for that job; he does not determine the sequence of work, order additional materials, or think about bidding the next job, but rather is told what work to perform where. In this scenario, the carpenter, although highly-skilled technically, is not demonstrating the skill and initiative of an independent contractor (such as managerial and business skills). He is simply providing his skilled labor.
EXAMPLE 2 In contrast, a highly skilled carpenter who provides a specialized service for a variety of area construction companies, for example, custom, handcrafted cabinets that are made-to-order, may be demonstrating the skill and initiative of an independent contractor if the carpenter markets his services, determines when to order materials and the quantity of materials to order, and determines which orders to fill.
PERMANENT OR INDEFINITE EMPLOYMENT Employment that is permanent or indefinite in character suggests that the worker is an employee. Most independent contractors will avoid permanent or indefinite work relationships and are usually hired to work until a job or a project is complete (even if this takes several months or years). Moreover, once a job or project is complete, the independent contractor does not necessarily continue to provide his or her services to the employer.
Employers should consider a worker’s reasons for intermittent, seasonal, permanent or indefinite employment. Neither working for others nor having multiple sources of income transforms a worker into an independent contractor. The key is to determine “whether the lack of permanence or indefiniteness is due to operational characteristics intrinsic to the industry (such as employers that hire part-time workers or use staffing agencies) or the worker’s own business initiative.” For seasonal employment, the proper test to determine permanency is whether the employees worked for the entire operative period of a particular season, not whether the worker returns from season to season.
NATURE AND DEGREE OF EMPLOYER CONTROL An independent contractor controls meaningful aspects of the work he or she performs. This type of control should lead objective observers to conclude that the worker is conducting his or her own business. Control over meaningful aspects of the work may extend beyond controlling working hours and could include work schedules, dress code and task prioritization.
The DOL asserts that this control cannot be theoretical and explains that what counts is not what the worker could have done, but what the worker actually does.
Finally, the DOL warns that the control factor should not “play an oversized role” and dwarf other factors in the economic realities test when determining whether a worker is an employee or an independent contractor.
Please contact Power Kunkle Benefits Consulting for additional information on appropriate worker classification. This article is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. © 2015 Zywave, Inc. All rights reserved.
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Don’t Forget Some Important Details! By: Daniel B. Kimball, M.D., F.A.C.P.
arlier this year while I was answering telephone calls at our medical society office, I was reminded of some important details related to retiring or closing one’s practice that are important to our patients and to us. I received calls from two different individuals and family members trying to gain access to medical records from practices related to a recently retired physician and a physician who had closed his practice. No physician would want to be accused of abandoning his or her patients, but that can happen to physicians who do not assure proper handling of their patients’ medical records when they retire or close a practice. This issue is clearly most challenging for the solo practitioner, but even physicians who are in group practices or are employed need to assure proper notification of their patients and other entities, and proper provision for storage of and access to their patients’ medical records. One cannot just decide to retire and walk out of the office and close the door.
While your practice “owns” the patients’ medical records, all patients have the right of access to information in their medical records and assurance of their privacy rights. A letter should be sent to each patient of the physician who is retiring or closing his/her practice, indicating the retirement date. Often, practices will enclose an authorization for release of medical information which patients may sign to release their records to a newly chosen physician. If arrangements are made to sell the practice, including the patients’ medical records, or if the records are left with the group practice or a hospital, the patient should be informed of the location and means of access to those records. Ideally, notification should be at least 90 days in advance of retirement or closure, so that patients can choose a new physician and arrange for medical records transfer. Many practices also publish a notice of an impending retirement in a local newspaper, and include access information for medical records. In Pennsylvania, medical board regulations require retention of medical records for 7 years after the last medical service for adult 18 | www.berkscms.org
patients, and at least 7 years for “minors” plus 1-2 years after the patient reaches the “age of majority,” which is 18 years of age. (Our allopathic board requires retention 1 year beyond the age of majority while the osteopathic board requires retention for 2 years beyond.) There are commercial businesses that a practitioner can contract with for storage and appropriate retrieval of patient information by former patients. While informing patients and arranging for proper disposition of medical records are very important issues for the retiring physician, there are other important issues as well. There are enough issues that a checklist, as advocated by several of our specialty professional societies, is worth considering.
Who needs to be notified of your plans to retire? Requirements will differ from one state to another, but here are some important notifications physicians will generally need to remember. Your state board of medicine needs to be notified, and in some states they ask for your plans for disposition/storage of your patients’ records. In Pennsylvania, you will need to decide whether you want to keep your active license, switch to an “active-retired” license (with the ability to treat “immediate family members”), or have your license placed on an inactive status. There are different requirements for each license for continuing education and medical liability coverage. You will need to notify your insurance carrier for your medical liability coverage and assure appropriate “tail” coverage. Your carrier may also want to know about the disposition and storage of medical records, in case a subsequent claim is made by one of your patients. Other important notifications include any health insurance company with which you have a contractual relationship and your employees, particularly if you are in a solo practice. Do not forget the Federal DEA (and some states have an equivalent agency), hospital medical staff offices, medical societies where you hold memberships, and third party insurance carriers (such
as Medicare and Medical Assistance). The post office should be provided with your forwarding address. Many of your medical or specialty societies may have reduced-dues rate membership categories for retired or semi-retired physicians.
Whether you own or lease your practice facility will dictate notifications for its maintenance or disposition. And in addition to arrangements for patients’ medical records, you need to assure appropriate storage and retention of other practice related records, such as records related to OSHA training (at least 3 years) and financial records (for at least 6 years). There may be additional personal matters that require your attention as well, such as continued health insurance coverage for you and your family, retirement accounts, and review of your will, estate plans, advance directives and healthcare power of attorney.
If you are employed or part of a group practice, your employer or practice may well assume the professional responsibilities noted above, but you are responsible for seeing that they are in fact accomplished.
After all these requirements are met, sit back and enjoy the next chapter of your life, whether that entails some altered style of practice, pursuit of a new career path or relaxation and spoiling of grandchildren. Enjoy it!
References 1. Boateng A. “Is Retirement Calling You? A Few Things to Consider….” 3 July 2015. http://www.pamedsoc.org/ MainMenuCategories/Laws-Politics/Weekly-Capitol-Update-Blog/ Weekly-Capitol-Update/13192.html (accessed 30 Aug 2015). 2. Boateng A. “What Should Happen to Medical Records When Physicians Leave Practice?” 18 August 2014. http://www. pamedsoc.org/MainMenuCategories/Laws-Politics/WeeklyCapitol-Update-Blog/Weekly-Capitol-Update/11569.html. (Accessed 30 Aug 2015). 3. Gallagher JW. Practice Transitions: Starting, Stopping and In Between. Chapter 8. “Legal, Ethical and Practical Aspects of Closing Your Practice.” PAMED publication, Jan 2007. 4. Council on Ethical and Judicial Affairs of the American Medical Association. Opinion 7.03 “Records of Physician Upon Retirement or Departure from a Group.” Feb 2002. http://www.ama-assn. org/ama/pub/physician-resources/medical-ethics/code-medicalethics/opinion703.page? (Accessed 30 August 2015). 5. Babitsky S. and Mangraviti JJ., Eds. The Biggest Legal Mistakes Physicians Make and How to Avoid Them. “The 10 Biggest Legal Mistakes Older Physicians Make in Retirement Arrangements,” Executive Summary excerpt. http://www.seak.com/blog/ uncategorized/10-biggest-legal-mistakes-older-physicians-makeretirement-arrangements/ (accessed 12 Aug 2015). 6. O’Halloran M. “Preretirement Checklist.” May 2013. American Academy of Pediatrics Publication. https://www.aap.org/en-us/ professional-resources/practice-support/Closing-a-Practice/ pages/Preretirement-Checklist.aspx. (accessed 12 Aug 2015). 7. Wall JD. Family Practice Management. “A Must-Do List for the Departing Physician.” American Academy of Family Physicians. Fam Pract Manag. 12:54-56, Oct 2005. http://www.aafp.org/ fpm/2005/1000/p54.html. (accessed 12 Aug 2015), FALL 2015
As fellow clinicians—
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Consolidation Here, There, and Everywhere
How Will This Affect Physicians and Patients? By: Heath Mackley, MD, FACRO
atients and physicians in the fifth district have seen a steady stream of headlines over the last few years, with different hospitals and physician groups joining larger health systems. Although this is certainly not an exhaustive list, announcements include Holy Spirit Hospital in Camp Hill joining Geisinger Health System, Good Samaritan Hospital in Lebanon joining Wellspan Health, Lancaster General Hospital joining Penn Medicine, St. Joseph’s Regional Health Network of Reading joining Penn State Health, and Pinnacle Health of Harrisburg seeking to join Penn State Health. Most observers expect additional mergers to happen in central Pennsylvania and beyond.
This is not meant to be a sound of alarm. It would be presumptuous to say this is either “good” or “bad.” But this trend is clear, and it has a clear antecedent. With the passing, and subsequent affirmation by the Supreme Court, of the Affordable Care Act, the federal government has set a clear mandate. Through the creation of accountable care organizations and expanding the insured population by incentivizing younger, healthier adults to purchase health coverage, managing the health of populations is going to be the means by which health care costs are contained. Conventional wisdom states that larger integrated health networks will need to form in order to make this possible, but this remains to be seen.
This consolidation is not limited to health care providers. In the month of July, two takeovers were announced involving the five biggest insurance providers in the United States. Anthem announced the intention to buy Cigna for $48 billion, and Aetna wishes to purchase Humana for $37 billion. In a large, lowermargin industry, insurers have felt an impetus to consolidate, leading antitrust regulators to debate whether three or four insurers are enough competition to protect the interest of consumers.
And of course, there is nothing to prevent insurers from buying health care networks, like Highmark merging with West Penn Allegheny Health System, or health care networks from offering health insurance products, like UPMC and Geisinger. Other Pennsylvania health networks are likely to follow suit.
All of this begs the question: At what point do we as physicians become concerned? Is it when a patient “only” has three choices of health plans? Is it when a patient “only” has two choices of hospital systems? While no one would advocate a patient have only one choice of a health care provider, or a physician of any particular county have only one choice of employer, the matter is more complex than that.
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Insurance mergers have been associated with premium hikes, not the cost-savings that are often promised because of increases in efficiency. Additionally, less competition can make it easier for health insurers and health provider networks to prioritize corporate policy over good clinical decisions. PAMED and the AMA did not make a clear policy position, for or against, health care provider mergers, such as what occurred in the 1990s, in the same way that they have with health plans. Larger health provider networks can lead to clear advantages for patients and physicians, such as the creation of integrated electronic medical records. However, PAMED has also acknowledged the importance of regulators minding the potential downside of decreased competition. In its statement, “The Eight Essential Principles of Health System Reform,” PAMED states, “Health care delivery markets should be constructed to be competitive, thus increasing efficiency, innovation and quality as well as reinforcing a physician’s ability to compete.” All eight principles can be found at the PAMED websiteI. Similarly, the AMA has recently expressed concerns about hospital monopolies, stating in an amicus brief to the U.S. Supreme Court, “When physicians lack practice options due to a hospital monopoly created by a hospital merger, they cannot bargain effectively for a competitive income sufficient to stay in the market or for equipment, staffing, laboratory and other
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services—dimensions along which hospitals typically compete for physician relationships, to the benefit of patients.”
This is a natural extension of the work the AMA has done as a watchdog when it comes to insurance mergers. This includes publishing annual reports. The latest report can be found at the AMA websiteII. It reveals that a single health insurer has over fifty percent of the market share in seventeen states and forty percent of the metropolitan areas of the U.S. In central PA, HarrisburgCarlisle, Lancaster, Lebanon, Reading, and York-Hanover were all classified as “highly concentrated” using the HerfindahlHirschman Index, a measure of market concentration. For more information on the AMA’s concerns, please refer to their July press release, “Insurance Mergers Will Reduce Competition and Choice.”III
Thankfully, the AMA has not limited its actions to dusty reports. The AMA successfully opposed the merger of Highmark and Independence BlueCross in Pennsylvania in part by providing expert testimony to the U.S. Senate Judiciary Committee Subcommittee on Antitrust. In other cases, the AMA didn’t prevent a merger, but gained important conditions that preserved reimbursement for physicians and choice for patients. The AMA has worked with the Antitrust Division of the Department of Justice and the Federal Trade Commission, testified in the U.S. House of Representatives’ Small Business Committee, and
provided expertise for the FTC competition workshop. The AMA provides comments on DOJ/FTC merger guidelines and model legislation for state governments. This is a “battle” with many fronts. The insurance companies are organized, and we need to be as well!
Pediatric and Adult Patients Treating Ear, Nose, Throat Problems Thyroid Nodules, Neck Masses & Sinusitis
Physicians: James P. Restrepo, M.D., F.A.C.S. Charles K. Lutz, M.D., F.A.C.S. Jeffrey S. Driben, M.D., F.A.C.S.
PAMED has always had a “large tent.” Our physician members are employed physicians working for large corporations, independent practitioners running small businesses that compete and/or collaborate with large networks, executives for health insurance companies and health systems, and regulators in the state and federal governments. We stand with all of these physician members as one body, representing the physicians of Pennsylvania, cognizant of the inevitable issues that arise from legitimate competition or differences of opinion. PAMED also stands for the patients of Pennsylvania. With the gradual increase in public access to outcomes data, whether or not these systemic changes are good for the health of Pennsylvanians will become clear. As long as our patients are doing well, and physicians are being treated fairly, this can be a win-win situation. But we, the physicians of PAMED, must remain vigilant, because we will always be the best advocates for the interests of our members and our patients. So, please, keep your eyes and ears open, and let us know what you’re seeing in your practice. We need each other, now more than ever!
Dr. Mackley is a radiation oncologist in the Penn State Hershey Cancer Institute and serves as the 5th District Trustee on the PAMED Board, representing physicians of this county. References I http://www.pamedsoc.org/DocumentVault/ VaultPDFs/GovernmentPDFs/ NewsfromHarrisburgPDFs/ PrescriptionforPennsylvaniaPDFs/Principles. aspx. II https://commerce.ama-assn.org/store/ catalog/productDetail.jsp?product_ id=prod2560005&navAction=push III http://www.ama-assn.org/ama/pub/news/ news/2015/2015-07-24-insurance-mergersreduce-competition-choice.page
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For additional news and information, visit www.berkscms.org. FALL 2015
BCMS Members Mentor Students’ Summer Research By: Lucy J. Cairns, MD
Berks County physicians encourage bright young people from our community to pursue careers in the health care field in a variety of ways, including participating in career days at schools, allowing students to observe clinical practice, and offering clinical and research training to college students and medical students. The research abstracts presented here summarize projects completed by students during a 6-week internship program offered by the Reading Health System. This valuable experience will stand these students in good stead as they pursue their ultimate career goals. We hope that at least some of these future health professionals will return to the community that nurtured them and return the favor. — Lucy J. Cairns, MD
The Clinical Significance of AGC of Endometrial Origin
AUTHORS: Emily Amendola, BS, Xuezhi Jiang, MD, Peter F. Schnatz, DO, Obstetrics and Gynecology
OBJECTIVES: To identify, in 2 age groups (age younger
than 51 vs 51 years or older), patients with atypical glandular cells of endometrial origin (AGC-EM) and assess their risk of endometrial cancer (EC).
METHODS: A retrospective case series identified cases of AGC from an electronic medical record and pathology database between January 2005 and July 2009. Cervical cytology results, final diagnoses (including clinically significant diseases and cancers), and demographic information was recorded from the initial AGC diagnosis until June 2015. Data was analyzed using the χ2 test to compare rates of disease between AGC subclasses by age groups.
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RESULTS: Among the 444 patients with AGC, 41% (183/444) had AGC-EM. Women aged ≥ 51 who have AGC are more likely to have AGC-EM than women aged < 51 (52.7% [78/148] vs. 35.5% [105/296], p=0.0005, odds ratio [OR] 1.49, 95% confidence interval [1.20-1.85]). Of the 266 who had an endometrial biopsy, women aged ≥ 51 who have AGC are more likely to have EC than women aged < 51. (20% [20/100] vs. 4.8% [8/166], p<0.0001, OR 4.15, 95% CI [1.909.07]). In women younger than 51 years who underwent endometrial biopsy, the rate of EC had a stepwise increase across 3 subclasses of AGC (from AGC of endocervical origin [AGC-EC] to AGC not otherwise specified to AGC-EM). CONCLUSIONS: AGC-EM and endometrial cancer is more common in women with AGC that are aged 51 years or older than women younger than 51 years. However, AGC-EM is the subclass most associated with endometrial cancer in women younger than 51 years when compared to AGC not otherwise specified and AGC-EC. These findings support the current guidelines that recommend endometrial sampling
in women with atypical endometrial cells regardless of patient’s age.
Diagnostic Accuracy of FRAX in predicting 10-year risk of Osteoporotic Fractures: A systematic review and meta-analysis
Emily Amendola is a second-year medical student at The Commonwealth Medical College, Scranton, PA.
AUTHORS: Xuezhi Jiang, MD, PhD. 1,3, Morgan
KEY WORDS: atypical glandular cells, atypical endometrial cells, endometrial cancer, dysplasia, cervical cytology
Use of Scribes in Family Medicine Practice AUTHORS: Katie Smith and Jana Franey,
William J. Lovett, MD (Advisor), Family Medicine
OBJECTIVE: The use of scribes in various medical
specialties, such as emergency medicine, has been shown to greatly improve physician satisfaction and productivity; however, little to no research has been done to look at the use of scribes in a family medicine practice.
METHODS: A time, prospective study was performed, comparing patient encounter times with and without the use of a scribe. An average of 122.5 visits to the family health care center were documented in both the control and the intervention phases. 7 faculty physicians and 8 third year residents served as the providers for these visits. During each visit, the patient’s face to face interaction with the front desk staff, nursing staff, physician and scribe was recorded by a research assistant. Physician documentation times and total visit times were examined along with physician satisfaction.
Gruner, BS 1, Florence Trémollieres, MD, PhD 5, Wojciech Pluskiewicz, MD6, Elisabeth Sornay-Rendu, MD7, Piotr Adamczyk, MD6, Peter F. Schnatz, D.O.1-4
INSTITUTIONS: The Reading Hospital; Reading, PA,
Department of ObGyn1 and Internal Medicine.2 Jefferson Medical College of Thomas Jefferson University, Departments of ObGyn3 and Internal Medicine,4 Philadelphia, PA. Centre de Ménopause, Hôpital Paule de Viguier, TSA, France5 Department and Clinic of Internal Diseases, Diabetology and Nephrology-Metabolic Bone Diseases Unit, Medical University of Silesia, Katowice, Poland6 INSERM Research Unit 831 and Université de Lyon, Lyon, France7
CONFLICT OF INTEREST: The authors have no
conflicts of interest.
OBJECTIVES: The aim of this study was to conduct a
systematic review and meta-analysis on the performance of
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RESULTS: Physicians overall saved 2.15 minutes on documentation time outside of office hours with the use of a scribe. This p-value was under the standard significance level of 0.05 with a p-value of 0.012, proving its statistical significance. Physician satisfaction surveys utilized a Likert Scale, the results of which showed mean values of between 4 and 5 to all questions on the surveys. This indicated that all physicians either agreed or strongly agreed with questions relating to their efficiency with the scribe, their charting time with the scribe and their opinion on future use of scribes. DISCUSSION: Using scribes in a family healthcare clinic decreases physician documentation time and increases physician satisfaction.
Katie Smith is a second-year medical student at Lake Erie College of Osteopathic Medicine, Erie, PA. Jana Franey is in her junior year as a Biology major with a biomedical concentration at Messiah College, Mechanicsburg, PA. She plans to pursue a career as a Physician Assistant.
the WHO’s Fracture Risk Assessment (FRAX) instrument for predicting 10-year risk of Major Osteoporotic Fractures (MOF) and Hip Fractures (HF) in populations other than their derivation cohorts.
DESIGN: PubMed, Google Scholar, Embase, Cochrane
Library, and MEDLINE were searched for the Englishlanguage literature from 2008 to 2015. Limiting our search to articles that analyzed only MOF and / or HF as an outcome, 7 longitudinal cohorts from 5 countries (USA, Poland, France, Canada, New Zealand) were identified and included in the meta-analysis. SAS NLMIXED procedure (SAS v 9.3) was applied to fit the hierarchical summary Receiver operating characteristics (HSROC) model for meta-analysis, HSROC plot was generated by Review Manager (RevMan v 5.3).
RESULTS: Seven studies (n=57,027) were analyzed to assess diagnostic accuracy of FRAX in predicting MOF using 20% of 10-year fracture risk as a threshold, the mean sensitivity, specificity, and diagnostic odds ratio (DOR) along with their 95% confidence intervals (CI) are 10.25% (3.76% - 25.06%), 97.02% (91.17% - 99.03%) and 3.71 (2.73 – 5.05), respectively. For HF prediction using 3% of 10-year fracture risk as a threshold, six studies (n=50,944) were analyzed, the mean sensitivity, specificity, and DOR along with their 95% confidence intervals (CI) are 45.70% (24.88% 68.13%), 84.70% (76.41% - 90.44%) and 4.66 (2.39 – 9.08), respectively. CONCLUSIONS: Overall, FRAX performs better in
identifying patients who will not have MOF and HF within 10 years, however, substantial number of patients who developed fractures especially MOF within 10 years of follow up period were missed at the baseline by FRAX using intervention thresholds of 10-year risk of 20% for MOF and 3% for HF.
KEY WORDS: FRAX, Fractures Prediction, Meta-Analysis
Morgan Gruner is a second-year medical student at Oakland University William Beaumont School of Medicine in Rochester, Michigan. Morgan is currently interested in the field of Obstetrics and Gynecology.
Effectiveness of Clinical Decision Support for Hypercoagulable Evaluations in One Facility AUTHOR: Patrick Schukraft Advisor: Andy Donato, M.D., Hospitalist Services
BACKGROUND: Venous Thromboembolism (VTE) is a
potentially life-threatening disorder that may be provoked by venous stasis, endothelial injury or hypercoagulable states. Workups for hypercoagulable states are frequently undertaken, but tests are often uninterpretable (if treating or active thrombi) or not indicated (if provoked). Clinical decision support at point of order entry has the potential to prevent this unnecessary testing.
METHODS: As part of a larger QI project to improve
care of VTE patients, we studied the impact of clinical decision support embedded in order sets, measuring the rates of appropriate hypercoagulable evaluations as a primary outcome. Hypercoagulable workups were defined as appropriate when ordered in patients who are < 45 with unprovoked thrombi, and for functional tests, patients without active thrombi or anticoagulants. Study was undertaken from February 2013-May 2015.
RESULTS: 698 patients were admitted with VTE over
the period of the study. Hypercoagulable workups were performed on 164/ 633 (25.9%) of the patients before the intervention, and 14/65 (21.5%) after the intervention (p=NS). In the period following the intervention, the order set was used by 53.8% of the admitting physicians. Workups were performed in 11/35 of patients using the order set (31.4%). When hypercoagulable workups were undertaken, fewer tests were ordered after the new order set than before (mean 7.0 vs. 4.6, p=.01).
CONCLUSION: Addition of clinical decision support did not statistically reduce the number of patients receiving hypercoagulable evaluations, but reduced number of tests ordered. More study is needed to see if use of order set will result in reduction of unnecessary testing. Patrick Schukraft is a senior in the Biology Department at Kutztown University, Kutztown, PA. Additional areas of study include biochemistry, bioethics, and philosophy. He plans to attend medical school.
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Evaluation of Continuing Vancomycin after 72 Hours of Therapy AUTHORS: Rebecca Cofsky, Pharm.D., Robert Jones, DO, MS FIDSA, and Rebecca Keenan, Infectious Disease
BACKGROUND: Intravenous (IV) vancomycin is a
glycopeptide antibiotic used for the treatment of Grampositive bacterial infections, especially methicillin-resistant Staphylococcus aureus (MRSA). An antimicrobial “timeout” is recommended 24-48 hours after therapy starts to facilitate reevaluating the need for and appropriateness of antibiotics and the potential to de-escalate antibiotic therapy. An internal review was conducted at Reading Hospital and Reading Health Rehabilitation Hospital of patients receiving IV vancomycin to identify the potential to improve de-escalation of antibiotic therapy.
METHODS: An electronic retrospective chart review of all patients older than 18 years who received IV vancomycin for 72 hours or longer during their hospitalization from January 1, 2015 to June 30, 2015 was conducted. A report generated via Safety Surveillor identified the above cohort. Data collected included demographics, β-lactam allergy, presence of an Infectious Diseases (ID) consult and date, average time from vancomycin order to ID consult, length of therapy, indication stated on the vancomycin order, history of MRSA colonization and/or infection, and microbiological data. The appropriateness of continuing vancomycin for more than 72 hours was assessed by evaluating whether
patients had an allergy to B-lactam antibiotics, history of MRSA colonization or infection, and whether a Gram-positive organism was isolated from culture.
RESULTS: Six-hundred-twenty-five patients received IV vancomycin for 72 hours or longer during the study period. Patient age ranged from 19 to 102 years old, with an average age of 64 years. The majority of patients had no listed allergy to β-lactam antibiotics (73%). Average duration of vancomycin therapy during hospitalization was 5.8 days. Sixty percent of patients were examined by an ID physician (n = 372). Thirty percent of patients had a history of MRSA. A Gram-positive organism was isolated in 46% of patients’ cultures. Approximately one third of patients (32.5%) did not have an allergy to β-lactam antibiotics, history of MRSA colonization or infection and Gram-positive organism isolated. In this sub-group, patients were likely continued on vancomycin beyond 72 hours of therapy inappropriately. The average length of therapy in this sub-group was 5 days. Three patients did not have a history of MRSA colonization or infection and vancomycin resistant Enterococci was the only Gram-positive organism isolated.
CONCLUSIONS: Approximately one third of patients remained on vancomycin after 72 hours of therapy when it was potentially inappropriate. We conclude that the continued need for vancomycin should be reevaluated at 72 hours to reduce patient adverse effects, potential development of antibiotic resistance, and healthcare costs. Rebecca Keenan will graduate in May 2016 from Ursinus College with a B.S. in Biology and a minor in French. She plans to attend medical school.
Figure 1. Forest plot – Sensitivity and Specificity of FRAX for prediction of Major Osteoporotic Fractures and Hip Fractures
Figure 2. HSROC plot of FRAX to predict Major Osteoporotic Fractures within 10 years using 20% as an intervention threshold
Figure 3. HSROC plot of FRAX to predict Hip fractures within 10 years using 3% as an intervention threshold
PHP Evolves To Address Modern Physician Burnout By: Jon Shapiro, MD, Medical Director
Physicians’ Health Programs (PHP), a program of The Foundation of the Pennsylvania Medical Society, provides support and advocacy to physicians struggling with addiction or physical or mental challenges. The program also offers information and support to families of impaired physicians and encourages their involvement in the physician recovery process. The PHP, embarking on its 30th anniversary, is funded by grants and contributions from physicians, hospitals, and others interested in physician health issues. PHP assists all physicians (MDs and DOs), physician assistants, medical students, dentists, dental hygienists, and expanded function dental assistants. As we are approaching our 30th anniversary at the Pennsylvania PHP, it is natural for us to undergo reflection and self examination. Our main mission has and will continue to be the “care and feeding” of the recovering doctor. We are expanding our focus as we view the condition of the modern physician. As medical director, I have been called upon to examine and lecture about some areas that affect the practice of medicine in the Commonwealth of Pennsylvania in the 21st century. Once I get over the initial terror of stage fright, lecturing can be an educational experience. I only hope my audiences learn as much from me as I do from them. For the last year or so I have spoken at several hospitals about physician burnout and stress. The increased attention to physician burnout reflects the multiplicity of stressors faced by modern health care professionals.
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Burnout is defined by the presence of overwhelming physical and emotional exhaustion, feelings of cynicism and detachment from the job and a sense of ineffectiveness and lack of accomplishment. Burnout seems to have increased in prevalence. For a complete discussion of physician burnout I refer you to some excellent sources that are listed below, including a blog and CME presentation produced by the Pennsylvania Medical Society. See www.pamedsoc.org/ lifeofmedicine.
I would like to share what some Pennsylvania doctors are saying. In Erie, doctors told me they feel in conflict with a large health system. Large health care systems provide economies of scale and bargaining power, but small hospital staffs are characterized by a warmth and camaraderie that may be lost in larger organizations. Local medical staff influence easily becomes diluted and ineffectual.
One hospital in Philadelphia endured more than the usual pain of breaking in an electronic health record. When they found that they had purchased an inferior product they had to suffer the frustrations and lost productivity of learning a second EHR within a single year. Other common complaints include that EHRs don’t communicate with one another and that clinicians spend more time viewing screens than faces.
A practitioner in central Pennsylvania sold his practice to his local hospital. When he began to work as an employed clinician, he found that his values and those of the health care were not in accord. His priorities had always involved the health of his patients and long-term relationships. The hospital system seemed to prize aggressive coding and billing. My ex-partner in a primary care practice wants to know why pharmacies and urgent care centers are allowed to skim off the
easy cases when they aren’t responsible for continuity of care. Anyone can treat a sore throat, but only the family doctor will be there when hand holding is needed as much as pills.
Physicians are drowning in the alphabet of regulation. It is hard to swallow so many abbreviations-PQRS, M.U., EMR, PCMH, OMG. Okay, the last one isn’t real but the point is clear. Every minute we spend on charting, reporting and regulations is a minute less that we spend with our patients. The subjective experience of being sued in a malpractice case is an earth-shattering event. It penetrates to the core, eroding confidence and inducing depression. It contributes to the waste of medical resources through the defensive practice of medicine. Our response to stress and burnout may be simple if not easy. Live the life you suggest for your patients. Eat right. Exercise regularly. Sleep a wholesome full night. Try generally to balance your profession with time spent with family and hobbies and community. Concentrate on the wonderful core of medicine: the doctorpatient relationship that called you to this illustrious career. We are privileged to be able to serve our patients in a therapeutic trusting relationship and study the fascinating sciences of life.
For more information, visit www.foundationpamedsoc.org.
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Physicians and pharmacists that engage in collaborative drug therapy management must have a collaborative agreement that: • Documents the identity of the physician responsible for authorizing and the pharmacist authorized to perform the management of drug therapy.
• Makes clear that the physicians initiate the regimens for drug therapy management for patients referred to a pharmacist. • Identifies the types of decisions the pharmacist is authorized to make, regarding drug therapy management, within the physician’s scope of practice and the types of management of drug therapy authorized.
What Pennsylvania Physicians Should Know About the New Collaborative Drug Therapy Management By: Angela Boateng, Regulatory Counsel
ollaborative drug therapy management is not a new concept; this strategy has been around at least since the late 1970s. And, now, we have it in the Commonwealth.
(Okay. So, it’s actually not really new to Pennsylvania. The Pharmacy Act was amended in 2002 to permit pharmacists practicing in an institution setting to manage drug therapy by means of a written protocol. The Act was amended again in 2010 to allow for collaborative drug therapy management via a written collaborative agreement between a physician and a pharmacist in a setting other than an institutional setting.)
On July 9, the Independent Regulatory Review Commission (IRRC) approved the State Board of Pharmacy’s regulation, implementing the 2010 amendment to the Pharmacy Act, for the Collaborative Management of Drug Therapy. What does this mean for Pennsylvania physicians? Good question. The passage of the regulation is one more opportunity for physicians to engage in patient-centered, team-based care. As a result of collaborative drug therapy management, researchers have also noted improved patient outcomes for chronic diseases, resulting in an overall cost savings due to the appropriate management of these diseases. What’s not to like about that?
Despite its prevalence and (…some would argue) popularity across the nation, Pennsylvania physicians are not required to participate in collaborative drug therapy management with pharmacists; it’s totally voluntary. Should they choose to do so, however, there are a couple of rules that must be followed. (This wouldn’t be a regulatory blog if I didn’t talk about the rules, right? Right.) 30 | www.berkscms.org
• Specifies when the pharmacist is allowed to adjust the drug regimen, the drug strength, and the frequency of administration; adjust the route of administration; administer drugs; order laboratory tests and perform other diagnostic tests necessary in the management of drug therapy without prior written or oral consent by the collaborating physician. • Lists the functions and tasks the pharmacists must follow, including the method of documenting decisions made and a plan for communication or feedback to the authorizing physician concerning specific decisions made. The pharmacist is required to document each intervention as soon as practicable, but no later than 72 hours after the intervention, and must be recorded in the pharmacist’s record.
• Requires that the pharmacist notify the authorizing physician of changes in dose, duration or frequency of medication prescribed as soon as practicable, but no later than 72 hours after the change. • Explains how the collaborative agreement will be implemented when the physician or pharmacist who is party to the collaborative agreement is temporarily unavailable to participate in its implementation. • Describes how the physician will notify affected patients of the role of the pharmacist in the management of their drug therapy. And, the opportunity for the patients to refuse drug therapy management by a pharmacist. In this partnership, collaborating physicians will have access to the patient’s pharmacy records and pharmacists will also have access to patient records.
The collaborative agreement must be effective for no more than two (2) years from the date of execution and must reviewed at least every two years to determine renewal, modification, or termination. The agreement must be filed with the Department of State’s Bureau of Professional and Occupational Affairs and maintained on the pharmacy premises.
And, recognizing the increased exposure to risk, the regulation requires that pharmacists maintain professional liability insurance in the minimum amount of $1 million per occurrence or claims made. So, there you have it—a quick summary of Pennsylvania’s new(ish) tool in our continuing effort to promote team-based, patient care. See more at: http://www.pamedsoc.org/MainMenuCategories/ Laws-Politics/Weekly-Capitol-Update-Blog/Weekly-CapitolUpdate/13420.html#sthash.LYwsH26L.dpuf
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On Sept 19, My Gut Instinct, Inc., a nonprofit organization in Berks County hosted its second annual Guts and Glory Digestive & Wellness Expo at the First Energy Stadium in Reading. This public educational health fair was created to emphasize the importance of good digestion and healthy nutrition, educate community members about symptoms that warrant medical attention, encourage a proactive and preventative approach to wellness, celebrate health, and empower individuals to take action to live healthier lives. The 2nd annual Guts and Glory brought hundreds of visitors, including State Senator Judy Schwank, who kicked off Opening Ceremonies with a few words and well wishes. There were expert lectures on nutrition, fitness and healthy living, live yoga and fitness presentations, massage therapy, a circuit training course for all ages, informational booths, cooking demonstrations with free food tastings, salsa dance lessions, a wellness tent with holistic experts, farmer’s market, and even a rock climbing wall. Free health screenings were offered by the event’s title sponsor, Penn State Health St. Joseph, as well as biometric testing through Adventist Health Wellness Delivered. Attendees memorialized their visit and made a commitment to improving their own health by signing the Pledge Wall and snapping a picture with Gutsy Girl On the Go, the event’s mascot. The whole day delivered a full senses experience, showcasing the sights, smells, tastes, sounds, and feel of health---a true health celebration and exciting journey of wellness education, nutritional awareness and health consciousness for all community members! The goal of My Gut Instinct, Inc. is to promote community awareness of health and wellness through preventative health care and holistic wellbeing. The organization aims to increase public understanding of preventable diseases impacting community health by preventing avoidable diseases, motivating the community to make healthy choices, promoting cancer screenings and raising awareness of health concerns. The organization was founded by Dr Aparna Mele, a local gastroenterologist, who stated: “We aim to provide people with health knowledge and empower them to take action to live healthier lives and become beautiful from the inside out, because we believe beauty starts on the inside,” says Mele. “We want to show the community that eating and living healthy is not only easy to do, but it can also be fun and delicious, too.” Count on Guts and Glory being an annual early fall festival to celebrate health and come out and join the fun next year!
Alliance Update Fall brings a new year of programming planned for the Berks County Medical Society Alliance, with many exciting events and philanthropic efforts already underway. The annual community health project
will be held in April 2016 on the issue
of adolescent mental health. The 20152016 Board will also be presenting
programming this year on the benefits of
backyard beekeeping, medical marriages, and socially conscious consumerism in Berks County, and participated in the second annual Guts & Glory 2015. Finally, the Alliance is proud to
announce that it has been granted
the AMA ALLIANCE SOCIAL MEDIA EXCELLENCE AWARD given to
LOCAL & STATE ALLIANCES at the 2015 AMAA ANNUAL MEETING.
For more information about BCMSA, please check out: http://berkscmsa.org or â€œLikeâ€? us on Facebook! FALL 2015
UPDATES AND TOOLS
to Help PA Physicians Understand Proposed 2016 Medicare Fee Schedule and Ease the Transition to ICD-10 on Oct. 1
By: : Jennifer Swinnich, Associate Director of Practice Support, Pennsylvania Medical Society
he Centers for Medicare and Medicaid Services (CMS) has been busy with the release of the 2016 Medicare Physician Fee Schedule (MPFS) Proposed Rule and clarification on the joint statement with the American Medical Association (AMA) on ICD-10 implementation. Here are a few highlights. The MPFS Proposed Rule aims to enhance support for primary care practices through several different initiatives. This includes allowing payment for Advance Care Planning Services for Medicare beneficiaries. CMS defines advance care planning as a face-to-face meeting with the patient, family members, and/ or surrogate for “the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health professional.” CPT code 99497 is used for the first 30 minutes, and then add-on CPT code 99498 for 30 minute increments thereafter.
Although advance care planning was available in the past, it was only covered when included with the Initial Preventive Physical Exam (IPPE), also known as the “Welcome to Medicare” visit. Most beneficiaries were not likely to discuss advance care planning at the time of that visit. This enhancement will allow for greater flexibility for scheduling advance care planning services for both beneficiaries and providers. In recent years, CMS has recognized the need for care management. As a result, CMS developed payment for Transitional Care Management (TCM) for patients recently 34 | www.berkscms.org
discharged from inpatient hospitals, and Chronic Care Management (CCM) for patients with multiple chronic conditions. Although these codes were approved in rules from prior years, in the 2016 proposed rule CMS is looking for feedback to relieve some of the administrative burden when billing for care management services. The Pennsylvania Medical Society (PAMED) also offers resources to help providers understand TCM reimbursement at www.pamedsoc.org/TCM and CCM reimbursement at www.pamedsoc.org/CCM.
In an effort to clarify “incident to” requirements, CMS reiterates the supervising physician is the physician who bills for “incident to” services. In a recent conversation with CMS’ subject matter expert, PAMED was told, “The proposal is intended to clarify that the ordering physician or other practitioner and the supervising physician or other practitioner DO NOT need to be one in the same. Rather, the proposal is intended to clarify that the physician or other practitioner who bills for the “incident to” services must always be the supervising physician or other practitioner.”
Lastly, CMS and AMA released a joint statement on the implementation of ICD-10 scheduled for Oct. 1, 2015 and later issued clarifications to their statement. The initial statement reiterated that there will be no delay for implementing ICD-10. Medicare will not accept any ICD-9 codes with a date of service on or after Oct. 1, 2015, and all claims must have a valid ICD-10 code. The statement also claimed that Medicare can be “flexible” with ICD-10 implementation.
Let our family The clarification defines flexibility with ICD-10 codes to include the “family of codes.” A family of codes is the first three characters of the code within a category that are clinically related. One must report a valid code within the code family and not simply a category. In most instances, the code will have more than three characters – most valid codes will have a fourth, fifth, sixth, or seventh digit for greatest specificity.
CMS will not deny claims based on the specificity of the ICD10 diagnosis code alone. However, claims will be held to the same coverage standards under ICD-10 as they were under ICD-9. Therefore, national coverage determinations (NCDs) and local coverage determinations (LCDs) that required specific ICD-9 codes will continue to require specific diagnosis codes under ICD-10. PAMED has more information and resources on ICD-10 at www.pamedsoc.org/ICD10, including specialty-specific crosswalks, online documentation training for physicians, education, and coding scenarios. PAMED members who have questions can contact our Practice Support Team at (717) DOC-HELP, that’s (717) 362-4357.
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Read by more than 30,000 Berks County Residents... Physicians, Dentists, Practice Managers and Other Engaged Readers! Publishing Group
Advertise in Medical Record, the Official Magazine of the Berks County Medical Society For Advertising Opportunities Contact Alicia Lee 610.685.0914 x210 | Alicia@HoffPubs.com FALL 2015
Fall Golf Outing! It was a beautiful sunny day at Golden Oaks Golf Club on September 16, 2015 for the Berks County Medical Society’s annual Fall Golf Outing. Proceeds from this event help fund our weekly talk radio program on WEEU entitled HEALTH TALK. We would like to sincerely thank the following sponsors for making this happen: Pro Package Sponsors BMW of Reading-Chad Wallace Weik Investment Services Hole Sponsorships Alan Ross and Company Medical Protective National Penn Bank Baker Tilly Penn State Health St. Joseph Tompkins VIST Bank West Reading Radiology Associates
And the Winners of the day were: 1First Overall- Kristen Sandel 1 Greg Owsik 1 Mark Dougherty 1 Tom Stauffer Second Overall- Eugene Shaffer 1 Michael Abboud 1 Tim Stringer 1 Bob Brigham 1st Second Flight- Lori Shyda 1 Jim Restrepo, Jr. 1 Corey Porrino 1 Steve Horvat 2nd Second Flight- Bhaskar Deb 1 William Pierce 1 Brian Obst Longest Drive Women #2- Kristen Sandel Longest Drive Men #11- Bill Pierce Closest to the Pin Women #13- Kristen Sandel-16’8” Closest to the Pin Men #9- Ron Herb-5’4”
A great time was had by all!
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Calendar of Events & Notes
FALL Department of Family 2015 Medicine Lecture Series October 16 – 6385 October 23 – 6386 October 30 –
Hot Topics in Infectious Disease/ What’s New With Flu 2015? Debra Powell, MD Chief, Section of Infectious Disease Reading Health System
The Premature Infant: Focus on the First Year of Life Nicholas Obiri, MD Department of Neonatology Reading Health Physician Network
No Conference (Residency In-training Exam)
November 6 – Friday’s Child Lecture Series — 5537 The Foundation for Healthcare Transformation: The Patient Centered Medical Home of the Future Paul Grundy, MD Global Director of Healthcare Transformation BM Corporation SPECIAL LOCATION: THUN/JANSSEN AUDITORIUM November 13 – Forty Years of Creating Rural Family 6387 Physicians: What We Know and What We Don’t Fred Markham,Jr., MD Professor of Family and Community Medicine Thomas Jefferson University
November 20 – The Reigning Framework in Clinical 6388 Ethics Decision-Making & Why We Should Rethink It Autumn Fiester, PhD Director of Education; Director of Penn Clinical Ethics Mediation Program Perelman School of Medicine at the University of Pennsylvania SPECIAL LOCATION: THUN/JANSSEN AUDITORIUM SPECIAL TIME: 7:30 – 8:30 a.m. November 27 – No Conference December 4 – 5538
Friday’s Child Lecture Series — Glomerulonephritis in Children Steven Wassner, MD Penn State Hershey Medical Center
December 11 – Lupus: An Update for Primary Care 6389 Gregory Emkey, MD Arthritis and Osteoporosis Center
December 18 – Narrative Medicine: Placing the 6390 Patient’s Story at the Heart of Patient Care Roxana Delbene, PhD The College of New Jersey
CME and AAFP credits have been applied for. Approval is pending. Presentations may meet PSRM criteria as outlined by ACT 13 for Patient Safety Credit for CME as approved by the Pennsylvania Medical Society. All PSRM credit is recorded and self-reported by the physician. All conferences take place in the 5th Avenue Conference Center Rooms 1 and 2 from 8:00 – 9:00 a.m. unless otherwise noted.
38 | www.berkscms.org
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Published on Oct 19, 2015
Published on Oct 19, 2015
The official publication of the Berks County Medical Society. www.berkscms.org. Medical Record is published by Hoffmann Publishing Group, In...