BCMS Medical Record Fall 2014 issuu

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FALL 2014

Ready or Not:

“Meaningful Use” of Health IT

Berks County Medical Society Members Participate in Medical Mission Work

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EDITORIAL BOARD D. Michael Baxter, MD John Moser, MD Betsy Ostermiller



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RetractionOur Sincere Apology to Dr. Hector Seda for misspelling his name in the retraction published in the Summer Issue of the Medical Record. The corrected retraction states

Spring 2014 Issue The Berks County Medical Society would like to sincerely apologize to Dr. Nicola Bitetto for mislabeling a photograph taken at the Installation Brunch. Pictured was Dr. Nicola Bitetto, not Dr. Hector Seda receiving his 50 Year Award from Dr. Michael Baxter. Dr. Seda also received his 50 Year Award but was not present for a photograph.

Kristen Sandel, MD, President Lucy J. Cairns, MD, President-Elect D. Michael Baxter, MD, Chair, Executive Council Michael Haas, MD, Treasurer Andrew Waxler, MD, Secretary Pamela Q. Taffera, DO, Immediate Past President Berks County Medical Society 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610 Phone: 610.375.6555 | Fax: 610.375.6535 Email: info@berkscms.org

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Berks County Medical Society.

Manuscripts offered for publication and other correspondence should be sent to 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. The editorial board reserves the right to reject and/or alter submitted material before publication. The Berks County Medical Record (ISSN #0736-7333) is published four times a year by the Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices. POSTMASTER: Please send address changes to the Berks County Medical Record, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610.


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Table of Contents FALL 2014 FEATURES

Berks County Medical Society BECOME A MEMBER TODAY! Go to our website at www.berkscms.org and click on “Join Now”

Cover Feature

Ready or Not: “Meaningful Use” of Health IT


Berks County Medical Society Members Participate in Medical Mission Work 12 Members of the Berks County Medical Society contribute to the health of our community 20 Physician Revalidation Requirements 27 Elements of a Good Social Media Policy 28

DEPARTMENTS Editor’s Comments

President’s Message Foundation Update Alliance Update

Legislative Updates Events Calendar

6 8 9

26 30 34

Cover Photo: Aalok V. Malankar, D.O. and Margaret G. Flores-Posadas, M.D. at Berks Genesis Family Practice. Photographer: Dave Zerbe

Editor’s Comments

Migration Season Autumn is migration season, so on this bright and cool September morning I enjoyed the annual spectacle from the North Lookout at Hawk Mountain. It was the right kind of day, with a bit of wind out of the north following passage of a cold front, and the crowd that gathered on the rocks was not disappointed. Over the valley a series of broad-winged hawk kettles materialized as if by magic, each with dozens of these beauties effortlessly circling on outstretched wings in an upward vortex before gliding swiftly southward out of sight. To escape the cold and scarcity of prey in the winter months, broad-winged hawks head for Central America, and some don’t stop until they reach Brazil or beyond. It’s how they survive. Lucy J. Cairns, MD, Editor

In particular, the push to adopt an Electronic Health Record (EHR) has created challenges that some physicians and some hospitals/health systems have been unable or unwilling to accept—at least up till now. Adoption of an EHR is a huge and continuing expense and requires significant changes in patient care work flow and a re-wiring of the pathways followed by the physician’s brain during the patient encounter—and that is only the beginning! Much more data is recorded during each patient encounter with an EHR than with most paper chart systems, and many physicians find that the need to ‘feed the computer’ tends to distract and detract from the time available to listen to and examine their patients. Patient satisfaction declines as well when the doctor spends more time attending to the screen than to the person. In a time-tracking study of first-year medical residents at the Johns Hopkins Hospital and the University of Maryland Medical Center in January 2012, it was found that the residents spent more than 40% of their time at a computer and just 12% examining and talking with patients.

In the field of medical practice, challenges to survival have been mounting in the forms of increasing government regulation and the failure of reimbursements to keep pace with the rising costs of staying in business. In Berks County, more than a few physicians have side-stepped these challenges by ‘migrating’ to the haven of early (or earlier-than-planned) retirement. The patients and the colleagues of these physicians miss them sorely, but I believe most sympathize with their decision to glide to a more welcoming climate.

For all its drawbacks—and I have only scratched the surface— the EHR is here to stay.

6 | www.berkscms.org

Information technology is a tool with tremendous potential for improving the effectiveness and safety of medical care while simultaneously reducing costs. But, as with any tool, the outcome depends on the skill of the users, how well the tool is designed, and the exact way in which it is used. Which brings us to Medicare’s ‘Meaningful Use’ initiative, the program designed to prod providers into using EHRs in very specific ways to achieve the objectives mentioned above. Modest financial rewards go to providers who are successful, while those who are not successful or opt out entirely face cuts in their Medicare reimbursements which increase over time. The effect on the bottom line of any practice with a large percentage of Medicare patients (such as ophthalmology) is potentially substantial.

Although 2014 is the fourth year that providers have been able to earn incentives by achieving ‘Meaningful Use,’ a significant number of physicians and hospitals/health systems are still missing out on the incentive payments and in danger of being penalized. In this edition’s feature article, Michael T. Brown Jr. examines the history of the Meaningful Use roll-out and identifies the types of providers facing the greatest challenges to successful participation. Michael served as the BCMS’s first college student intern this summer and has now matriculated at the Johns Hopkins University to earn an MS in Health Care Management. As I read his article, his appreciation for the positive potential of Health Information Technology is obvious, and I realize that the issue is probably a ‘no-brainer’ for any educated person of his generation. BCMS member Dr. Aalok Malankar (who appears on our cover) is an example of a computer-savvy young physician who has embraced the use of Health IT to the benefit of his practice and its patients. I am inspired by Michael’s optimism and by Dr. Malankar’s success, but speaking strictly for myself (as one of the older generation), I must confess that this morning I found myself envying the hawks as they disappeared to the south. n





President’s Message

You don’t just accidentally show up in the World Series. – Derek Jeter

s 2014 comes to a close, it seems like the perfect time to review some of the major endeavors of the Berks County Medical Society during the past year. We started the year saying goodbye to our longtime Executive Director, Mr. Bruce Weidman. We thanked him for his years of service and culminated his tenure with a retirement dinner in June. Since that time, some of our members have been very engaged in the search for a new Executive Director for Berks County. In September, the search committee recommended to the Executive Council that we partner with the Pennsylvania Medical Society for the recruitment, as well as the employment of our new executive. As we look to the future of the society, we recognize the importance of the Executive Director’s role to reach out to physicians, practices, and health systems in order to understand the issues facing physicians in various specialties and employment environments. Declining membership has been and continues to be an issue with medical societies throughout the nation. This issue is not exclusive to medical societies, but also to a variety of membership organizations in general. Each society is trying to discover ways to prove relevance and value to their members. Membership dues are the cornerstone of our county income and are the reason that we can provide various programs for patients, physicians, and practices in Berks County. These initiatives include but are not limited to Residents Day, Health Talk on WEEU, advocacy for physicians and patients, practice seminars, physician training courses, and the Legislative Breakfast in May. Some physicians may ask, what does the Berks County Medical Society or the Pennsylvania Medical Society do for me? Why do I need the society? I am already a member of my specialty society, so the others don’t really matter, right? As Derek Jeter stated, “you don’t just show up in the World Series.” It takes a great deal of effort and foresight to make a team, or in our case, a society, successful. In this fast-paced new world of medicine, we need a united physician voice in medicine. BCMS and PaMed are two of the only societies who are able to speak for every physician in Berks County and the Commonwealth regardless 8 | www.berkscms.org

of specialty, employment status, or stage in career. When the governor, a congressman, or a news organization has a question concerning emerging medical issues, legislative issues dealing with medicine, or medical practice, they contact BCMS or PaMed. We are the preeminent voice of the physician and of medicine in Berks County and Pennsylvania. Don’t allow that voice to grow soft or silent especially during this critical time in medicine. I would like to thank our officers and our executive council members for the fantastic job that they did all year in order to maintain the Berks County Medical Society as one of the preeminent county societies in the commonwealth. Individuals cannot run a society, instead it needs an outstanding team of physicians to shape and guide it. I know that I am leaving the society in excellent and capable hands, as Dr. Lucy Cairns becomes the 141th President in January. I have confidence that we will thrive in the upcoming years with the excellent leaders who are emerging in Berks. Thank you for allowing me to serve as your president. I was honored and grateful to have been entrusted with this role. n

People ask me what I do in winter when there is no baseball. I’ll tell you what I do. I stare out the window and wait for spring. – Rogers Hornsby


Kristen Sandel, MD

Foundation Update

Foundation’s LifeGuard® Program Offers Help to Physicians A

llentown-based Surgeon George W. Hartzell Jr., MD, FACS, enjoyed the combination of teaching, learning, training, and patient care for 33 years, but at age 65, he found that his feet were hurting at the end of the day, and getting up at 3 a.m. was losing its charm. “I was still working a full schedule, but I noticed that it took me five minutes longer to perform a routine hernia repair. This change was noticed only by me and by my favorite scrub nurse, but it would only be a matter of time before others would take an interest in my performance. It was time to let my partners know that I would retire the following year,” he said in 2011 in Medical Economics.

But retirement didn’t take for Dr. Hartzell. He had already voluntarily gave up his license and turned to LifeGuard® to help get it back so that he could continue to practice medicine in a different capacity.

The Foundation of the Pennsylvania Medical Society’s Lifeguard program assists physicians who need a seamless pathway for reentry into the workforce. The program provides remediation for those who may have fallen behind in clinical skills or continuing education, or about whom quality concerns have arisen through a peer review process. Other reasons for using the program are varied such as taking time off to raise a family or, like in Dr. Hartzell’s case, the desire to return to medicine in a different capacity. LifeGuard offers physicians guidance as to how to re-enter the practice of medicine. The program offers the availability of a multi-component evaluation and assessment process to hospital medical staffs, medical executives, the State Board of Medicine, and other potential sources of referral. Physicians are also encouraged to refer themselves when appropriate. LifeGuard utilizes the medical model as its basis and a case management approach to provide components of the program as needed. No single pathway is appropriate for all referrals; rather, individualized evaluation, clinical skill assessment, and remediation/refresher plans are considered, depending upon the needs of the individual physician.

After participation in LifeGuard, Dr. Hartzell now enjoys being back to work as a Primary Care Physician. “The physician-patient

relationship feels the same, and taking care of complex problems is challenging,” said Dr. Hartzell. “I still have a lot to learn, and, many times, I find myself relying on reference sources. My smartphone always is at the ready with the appropriate applications. When I refer to the device in the presence of a patient, I explain that, as a surgeon, I was familiar with about 14 drugs, and now, as a PCP, I am supposed to be familiar with 1,400. Patients actually seem to appreciate that I am looking up information, and I do not believe that I am losing face by relying on an external source of wisdom. “Am I glad that I went through the arduous process that was necessary to become a practicing physician again? The answer is an enthusiastic yes. The studying made me feel like a medical student again and awakened many neurons that had been in a resting state for eight years. I am now 76 years old, but I feel much younger, and I hope that I will be able to work for another five or 10 years,” he said. Reading-based Neurosurgeon Dr. Raymond Truex Jr. serves as chair of the Board of Trustees of The Foundation of the Pennsylvania Medical Society. He chose to undertake this leadership role to support the foundation as it offers programs that speak to improving the human conditions of wellness, knowledge and competency for every physician regardless of the political and economic influences that impact the practice of medicine. “Ensuring high standards of professional conduct is the greatest responsibility of a professional and one that the public has a right to expect. It is the responsibility of the physician community to ensure that quality and safety of our colleagues’ performance. It is paramount to provide healthcare that is safe and certain for all Pennsylvania residents,” said Dr. Truex.

Vice President for Medical Affairs at Philadelphia’s Riddle Hospital Helen Kuroki, MD, said that LifeGuard is an asset to hospital organizations as well as for individual physicians. “At times, we as continued on next page > FALL




physician leaders need to identify whether or not our colleague physicians can continue to provide the best care. Knowing that an external organization like the LifeGuard program can provide services such as independent medical exams and neurocognitive assessment is important,” she said.

“Physicians love the work they do and they want to continue to serve their patients in their community for a lifetime. Occasionally they run up against problems that may limit that ability to practice and we need to be respectful of their years of service and find a way to enhance their practice. Physicians may find it difficult to sit in judgment of other physicians,” according to Kuroki.

The LifeGuard® Program has three essential core characteristics: • Objectiveness: Evaluations are based on data such as evidence of compliance with performance standards. • Fairness: The evaluation process is open, unbiased, and it complies with labor regulations. • Responsiveness: Physicians enter into case management promptly and they are moved through the assessment and remediation phase in a timely manner to enable them to continue or return to the practice of medicine, when possible. The pathways to address licensure and asses clinical competency include:


LifeGuard provides licensing boards with a convenient process to help reinstate physicians who wish to re-enter the practice of medicine after an extended leave. A unique and common component of the re-entry case management process involves time in active practice settings through a customized preceptorship or shadowing arrangement. The duration of this component is based on each individual physician’s length of time away from active practice.

LifeGuard develops individualized remediation plans based on the documented deficits by the physician and/or the licensing body, if applicable, as well as those identified through the assessment process. A variety of resources can be used to create such individualized plans, including services from specialized referral sources. The remediation experience affords the physician the opportunity to refresh knowledge and skills as well as use a realtime ongoing evaluation process conducted by a board-certified, fully credentialed preceptor. LifeGuard provides a comprehensive report to the referring licensing board outlining the physician’s performance related to all assessment tools utilized within the individualized program, as well as evaluation of the physician’s practical phase of the program.

External Peer Review Assessment

This service is designed to assess actively practicing physicians when medical knowledge and/or clinical abilities in relation to medical responsibility are called into question. When a problem or deficit is identified and ongoing privileging is called into question, the LifeGuard program can assess variations identified through the external peer review process. LifeGuard utilizes an 10 | www.berkscms.org

extensive panel of physician reviewers who are fully credentialed, board certified within their specialty, and are actively practicing in their field to provide external peer review assessments.

Aging Physician Assessment

For entities and organizations that need “ability to perform” assessments for senior physicians, the aging physician assessment measures abilities, competencies and health status. A core component of the assessment includes an objective measurement of cognitive and physical abilities. Additional assessment options, including the National Board of Medical Examiners (NBME) practice based exams and proctoring for technical skill evaluation, are available based on the need identified by the requesting entity.

Competency Testing

Competency testing, a key component in the LifeGuard® program, is designed to assess a physician’s medical knowledge and decision-making skills. It is also used by physicians who want to assess their respective clinical and medical knowledge on a selfreferral basis. Competency testing available through the LifeGuard program is offered in collaboration with the NBME and Federation of State Medical Boards (FSMB).

Objectives: The objectives of the LifeGuard® Program:

• To protect the public welfare and ensure patient safety. • To increase the number of physicians in the Commonwealth of Pennsylvania, thereby increasing the workforce capacity to meet the health care needs of patients. • To provide a customized, unbiased process to address physician performance concerns. • To provide objective clinical assessment to identify and address concerns. • To provide physicians with appropriate educational remediation to meet their learning goals/objectives. • To help medical organizations, the State Board of Medicine, physicians, and the general public through a collaborative effort to improve the consistency of care, enhance patient safety, and assure access to needed medical care. According to new Association of American Medical Colleges work force projections, nationwide physician shortages are expected to balloon to 62,900 doctors in five years and 91,500 by 2020. In a 2011 research study sponsored by the 2011 American College of Surgeons, Richard Cooper, MD, senior study author and professor at the Perleman School of Medicine at the University of Pennsylvania, predicted a national physician shortage increase of seven to eight percent annually. Kim Dianich, CMSR PHR, Senior Physician Recruiter, PeaceHealth Medical Group, Vancouver, said, “In the many CVs that come across your desk each week, you may have noticed an increase in the number of candidates who have completed a re-entry or mini fellowship program in hopes of returning to practice. As the physician candidate pool continues to tighten, especially in primary care, you may wish to keep an open mind when considering these candidates. Educating your organization’s leaders about these candidates and the programs they complete

may help you tap into a hidden source of candidates.”

The LifeGuard Program helps to solve the Pennsylvania physician shortage by putting physicians back to work in a manner that responsibly assesses their needs, provides a program of remediation, and tests to insure that knowledge or skill has been increased and competency criteria has been achieved. Upon completion of the program, a report is issued to satisfy credentialing/licensure expectations of the state and/or health system. This report provides critical information that helps to ensure that the physician has reached a level of competency that assures a high level of patient safety. The program graduates return to the workforce as safe and certain physicians. “Re-entry programs provide these physicians with a pathway that allows them to resume a clinical practice,” said Dianich. “Unfortunately, there is a stigma associated with re-entry programs which often causes recruiters and organizations to pass over these candidates. Fortunately, there are a handful of reputable, accredited re-entry programs in the United States, including LifeGuard,” she said. Dianich uses an example of a recruit that could have been lost due to the large gap in her CV: Pamela Yanoviak, MD—an Internist with Evangelical Community Hospital in Lewisburg, Pa. Dr. Yanoviak had been away from medicine for 12 years raising children and caring for her elderly parents. In her time off, she explored other careers in education and obtained a master’s degree in school psychology, all while maintaining her required CMEs for medical licensure. Her new career in psychology allowed her a stronger work/life balance, but did not satisfy her calling to medicine.

enter medicine and serve patients in her community. The Foundation’s Board of Trustees provides program oversight and LifeGuard’s staff has worked closely with Bureau of Professional and Occupational Affair’s administrative staff to structure appropriate assessment and/or remediation services that are customized to meet the unique circumstances of each case. “It is so important for us as physicians to continue to serve our patients throughout our lifetime. However, we are just human beings with the frailties that come with that and we are subject to various illnesses or accidents that limit our ability to practice,” said Dr. Kuroki. “Sometimes we can come to that conclusion on our own and leave our practices or ask for help in proctoring to improve our skill set but sometimes we need the help or advice of others to get there. LifeGuard provides that very unique and specific service to evaluate our physicians and make sure they can provide the highest level of care to our patients,” she said. n

Sources: Medical Economics, June 25, 2011 ASPR, Mini fellowships: Physicians re-enter medical practice, Spring 2014 For more information: The Foundation of the Pennsylvania Medical Society 777 East Park Drive, PO Box 8820 Harrisburg, PA 17105-8820 www.foundationpamedsoc.org Contact LifeGuard® at (717) 909-2590 or www.lifeguardprogram.com

After years out of practice, Dr. Yanoviak began to have dreams about practicing medicine again … in Philadelphia. When she discovered the Drexel Refresher/Re-Entry course while conducting an online search, the dream became reality. Her mentor, Dr. Nielufar Varjavand, became instrumental as a structured plan was formulated specifically for Dr. Yanoviak—that included academic medicine, research, lectures, grand rounds, and clinical rotations. She valued the personal contact with Dr. Varjavand who provided constant encouragement. Meanwhile, Dr. Yanoviak contacted the Pennsylvania Medical Society who recommended that she enter the LifeGuard program. LifeGuard assigned a physician-led assessment to guarantee that Dr. Yanoviak met current standards of medical care. They oversaw online clinical simulation and case review tests, and completed a neurocognitive evaluation of her. LifeGuard recommended and coordinated a two-month preceptorship for Dr. Yanoviak alongside a currently practicing Internist with Evangelical Community Hospital’s medical group.

The LifeGuard team assisted her in obtaining a stipulated medical license to do the preceptorship. The entire process was confidential, allowing Dr. Yanoviak to work alongside her peers without them having knowledge of her situation. Components of both the Drexel Refresher/Re-Entry Course and LifeGuard programs created a solid foundation for Dr. Yanoviak to return to medicine. She successfully passed through the re-entry program in 2011 and obtained an unrestricted medical license to practice. Dr. Yanoviak is very grateful for the opportunity to re-





Berks County Medical Society Members Participate in Medical Mission Work Many physicians feel the call to volunteer their time and talents providing medical and surgical care to underserved populations inside and outside the United States. In response to an offer to increase awareness of such activities, and specifically to publicize opportunities for more physicians to become involved, BCMS members responded with information about the initiatives they support in hopes of inspiring others to join these efforts.

“It is basic equipment (right now),” said Rogers, who has made multiple trips to Guatemala this year. “We don’t even have an anesthesia machine. We do everything under either local or spinal. We can do more extensive surgeries with a more permanent setup.” With a service area covering 42 villages, the project is pursuing an 8,400-square-foot permanent health center with two buildings and an operating room. About $15,000 of the needed $270,000 has been raised.

Beavercreek’s Dr. Rogers organizes yearly surgical trip to Guatemala By Mark Gokavi, Staff Writer, DailyNews.com

BCMS Member Dr. Bamberger is a General Surgeon with Surgery Consultants of Berks County. Payment for surgeries performed at the Sangre de Cristo Health Care Project in Guatemala is appreciated, but not something doctors put in the bank.

Aided by Sister Dani Brought and Sister Margo Young, a physician whom Rogers said worked at Precious Blood and attended Wright State University, the project has grown. This last trip April 17-25 included a team who performed 93 surgeries, including hernias, carpel tunnel repairs, and scar revisions to improve mobility. The Hand Center of Southwest Ohio donated syringes, drapes, gloves and other disposable supplies. “I had my carpal tunnel fixed in Guatemala,” said Rogers, who works at Orthopedic Associates of Southwest Ohio in Centerville. “There’s no co-pay.”

“We don’t make any money off doing what we’re doing down there,” said Beavercreek anesthesiologist Dr. Jeffrey Rogers, who organizes the trip each year. “Some of them pay a couple rolls of toilet paper for their surgery. Some of them pay with a dozen eggs.” A group of area physicians from mostly Grandview and Southview A Guatemalan girl is all smiles hospitals have gone to La Labor about a dozen times to perform after her surgery. surgeries in the impoverished village north of Guatemala City. Now, their goal is to house their annual surgery campaign in permanent quarters instead of in the parish hall of a church. 12 | www.berkscms.org

Beavercreek’s Dr. Jeffrey Rogers comforts Angelita after her surgery at the Sangre de Cristo Health Care Project in Guatemala.

Participating along with Rogers in this latest mission trip to La Labor were David Mann, D.O., anesthesia resident; Andy Kulkarni, D.O., anesthesiologist; Skip Wolfe, CRNA, nurse anesthetist; Brent Bamberger, D.O., hand surgeon; Kurt Bamberger, M.D., general surgeon; Deba Sarma, M.D., general surgery fellow; Gretchen Baker, R.N.; Carla Robinson, physicians assistant; Debbie Basinger, CRNP; Robin Deehaan, surgical scrub; Jill Bamberger, team support specialist; and Young, M.D., internal medicine. For more information on the project with a goal to be completed by 2016, go to health-care-project-guatemala.org/home. htm. To make a donation e-mail Brought at danibrought@yahoo.com. Contact this reporter at (937) 225-6951 or mgokavi@Dayton. The mission in Guatemala is ongoing, the website is the following http:// www.pssc-guatemala.org/home.php Reprinted from DailyNews.com, author Mark Gokavi.

I went to Haiti through Faith care Mission trip. Naba Raj Mainali, MD. BCMS Member Dr. Mainali is Chief Medical Resident and Junior Faculty Member in the Department of Medicine of the Reading Health System Medical/Surgical specialists needed: Both, we had a mixture of Ob-GYN, Pediatrics, Medicine & Ortho

Nature of services provided: General Medical Examination and management, Hysterectomy, minor surgeries like lipoma, ganglion cyst, HIV test

Geographic area(s) and population(s) served: A village in Haiti (Caribbean) and general population including pediatrics

Name and contact information of sponsoring organization(s): Peter Schnatz, DO (peter.schnatz@readinghealth.org) Frequency and length of trips: 8 - 10 days, annually

Dates of next trip: TBD (likely 2nd week of February, 2015)

Brief description of the last trip you participated in: It was my first medical mission trip through Faith Care and we as a team saw around 1700 people in five business days including about 60 surgical procedures. I very much enjoyed seeing more than 50 patients a day, treating and counseling them and had an inner satisfaction to serve the people in real need as many of them have never seen a doctor before. This opportunity also implanted an appreciation on me for what I have and a burning desire to serve people who do not have an adequate access to healthcare resources.

continued on next page >

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She went to Kenya Lucy J. Cairns, MD. Soshella Jalaluddin, O.D. practices Optometry in Berks County and I support her work caring for people with eye disease in Kenya Sponsoring organization: World Hope, Inc. is a nonprofit started by Dr. Jalaluddin to bring eye care to the children of the Pokot people of northeastern Kenya. More information at www.worldhopeinc.com or email Dr. Jalaluddin at president@worldhopeinc. com.

Specialists needed: Optometrists, Ophthalmologists, nurses, and interested health care providers of any specialty.

Since her first trip to Kenya in 2004, Dr. Jalaluddin has participated in and helped organize many projects to improve the lives of the Plains Pokot, a people who live in a remote and arid region by herding cows and goats. Although her first impulse was to use her skills as an eye care provider, she quickly realized that obtaining a secure source of water was a prerequisite to providing any type of medical care. A well powered by solar panels and a permanent building in which to conduct medical clinics are now a reality. Since 2006, three eye camps have been conducted and have provided eye care for over 3,000 people. World Hope, Inc. partners with local nonprofits and health care providers.

Date of next trip: A two-week trip is planned for November 2014.

14 | www.berkscms.org

I would like to tell you a little about my mission trips to Ethiopia. Winifred Kao, MD. BCMS member Dr. Kao is an Otolaryngologist and Head and Neck Surgeon with Berks E.N.T. Surgical Associates I have participated in medical mission trips to Ethiopia yearly with a group of physicians, nurses and other healthcare professionals. This group was initiated by Dr. Glenn Isaacson and Dr. Elizabeth Drum, both affiliated with Temple University Hospital and Medical School. The sponsoring organization is Healing The Children through its Greater Philadelphia Chapter. The group typically would include 3-4 otolaryngologists, 3-4 Anesthesiologists and CRNAs, OR nurses, audiologists and sometimes pediatricians and neuromonitoring specialist. The group goes to Addis Ababa twice a year, one week in the spring and one in the fall. The base of our operation is Cure Hospital, where we do most of our work including clinic and surgery. We are able to address many childhood ENT problems including hearing restoration and we also provide care to some adult patients. We are heavily involved in the ENT residency training program of Addis Ababa University, thus give lectures and sometime do surgical cases at Black Lion Hospital. For the last couple of trips, some graduated residents would return for additional training when we were there. It is rewarding to see that we are able to not only provide the care needed but also advance the level of the care that Ethiopian physicians could provide.

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Ready or Not:

“Meaningful Use” of Health IT By: Michael T. Brown, Jr.

Back in 2009, Congress passed the “Health Information Technology for Economic and Clinical Health” or HITECH Act. This legislation provided nearly $30 billion to facilitate the adoption of an Electronic Health Record (EHR) nationwide. The authors of the bill painted a Utopian picture of how this initiative would transform our health system by improving the quality of care, reducing errors and inefficiencies, controlling costs, improving public health, and promoting industry competition and consumer choice. These are ever so popular taglines, but seemingly elusive objectives of every health tech company in the market. In this article I will examine how the healthcare industry has responded to the incentives and penalties created by the HITECH Act and why it has been slow to adopt IT practices whose importance is painfully obvious. 16 | www.berkscms.org


y now you have heard plenty of doctors groaning as they struggle to make the change to a paperless system, with the ‘epic’ headache that ensues. The EHR Incentive Program is an initiative under Medicare which rewards providers who use the capabilities of their EHR systems to achieve ‘Meaningful Use’ objectives designed to improve patient care. It will impose financial penalties on providers who do not participate. Even so, some physicians are opting out of the “Meaningful Use” initiative entirely.

Meaningful Use is defined by a set of objectives that must be achieved by eligible hospitals (EH) and eligible providers (EP) in their use of EHRs. Only providers using EHR systems certified for the Incentive Program are able to meet Meaningful Use requirements. By 2013, 78% of office-based physicians reported having adopted an EHR. However, only 48% of these physicians said that their systems met the requirements for a ‘basic health record’. 1 (A ‘basic health record’ is defined as one having all the following functionalities: patient history and demographics, patient problem lists, physician clinical notes, comprehensive list

of patients’ medications and allergies, computerized orders for prescriptions, and ability to view laboratory and imaging results electronically.) What is it about Meaningful Use that has so many hospitals and professionals missing out on the incentive payments and at risk of financial penalties?

To fully explore Meaningful Use woes and hardships one would have to write a doctoral thesis. Rather, I will provide a broad timeline and synopsis of the roll out thus far, which has taken place in stages of increasing complexity. Stage 1 was rolled out in 2011. By 2013, Meaningful Use Stage 1 required eligible providers (EPs) to meet 13 core objectives of Meaningful Use and to achieve 5 of 10 ‘menu’ objectives. Eligible hospitals (EHs) were required to meet 12 core objectives and choose 5 of 10 ‘menu’ objectives to achieve. The objectives for EPs included the requirements that EHRs be used to capture patients’ medications, allergies, smoking status, demographic information and patient problem lists, among other data, and support E-Prescribing and other functions. The objectives for EHs were of course different in some regards from those for EPs, but entering all the necessary data and utilizing the additional functionalities to achieve Meaningful Use resulted in extra time and extra work for providers regardless of whether they were based in a hospital or an office.

After this deadline, CMS reported that only 972 out of 2823 eligible professionals have attested to Stage 2 and out of 128 eligible hospitals currently on Stage 1, a dismal 10 have attested to Stage 2. 4 Keep in mind that only professionals and hospitals that have qualified for Stage 1 of meaningful use for a year before the July 1, 2014 deadline must be ready to demonstrate Stage 2 by October to maintain incentives. If they cannot successfully do this, they risk losing incentives and can receive a 1% penalty on Medicare and Medicaid reimbursement. This penalty can increase to 2% and 3% in 2015 and 2016. The CMS has recognized that many healthcare providers are facing hardships achieving acceptable EHR standards. In response, they are offering a one-year hardship extension program that will spare physicians the 1% penalty expected to start next year. Hardships can include anything from lack of sufficient Internet access to a natural disaster to problems with product vendors. The CMS website contains a search engine that lists vendors offering products to utilize for achieving meaningful use. It includes over 1,000 different EHR software systems and software updates that could allow EPs and EHs to qualify for these incentives. An article in FierceEMR shows that eligible

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Success in demonstrating Meaningful Use under the Stage 1 requirements qualifies EPs and EHs to advance to Stage 2. Under Stage 2, most of the Stage 1 core and menu objectives are now core objectives. New objectives have been introduced, primarily as menu objectives, but a new core objective for EPs is to use secure electronic messaging to communicate with patients on relevant health information. For EHs, a new core objective is to automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record. Providing patients the ability to view online, download, and transmit their health information is a core objective under Stage 2 for both EPs and EHs. Electronic information exchange is a priority in Stage 2, including between patients and providers, provider-to-provider, and provider-to-public health agencies and health registries.

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Under Stage 2, both the number of objectives that must be met and the performance thresholds have been increased compared to Stage 1. 2 Numbers from 2012 show that while 42.2% of hospitals were able to meet Stage 1 requirements, only 5.1% of hospitals had the capability to fulfill the broader Stage 2 requirements, which were then due to be instituted on July 1, 2014.3

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professionals used eight different vendors to quality for Stage 2. The top two were Athenahealth, used by 61% of EPs, and Epic, used by 20%. Eligible Hospitals had five different major vendors. The top three were Cerner, CPSI, and MEDITECH, at 33%, 22%, and 22% respectfully. 5 The article also cited that EPs used 37 different vendors to qualify for Stage 1 and EHs used 13. The overcrowded Health IT market has created a dilemma in the form of lack of interoperability between EHR systems. This must be eliminated, and data sharing needs to be one of the top priorities of all EHRs if a homogenous national platform is to exist.

He stated, “RHS places a high priority on protecting personal health information (PHI). Access to its clinical networks is restricted to authorized users only, and RHS uses a role-based strategy to restrict the access to PHI.” On the matter of crosspractice exchange of patient information, he further explains that data exchange between two providers only takes place upon agreement, and requires a verified, secure email address. This is much more secure than the current practice of faxing information, which carries the risk of entering the wrong fax number or having extraneous personnel view the information on the receiving side.

Another area of concern in need of increased attention when implementing Stage 2 is that of giving patients access to their personal records over the Internet. This feature makes it easier for patients to view lab and test results or prescriptions, but adds extra challenges in cyber security by displaying health information over the Internet. Dr. Jorge Scheirer, VP and Chief Medical Information Officer at Reading Health System, commented that personal health information is backed by a high degree of security. RHS requires a patient to enroll with their “My Chart” portal using a unique, time-limited access code. No personal health information is ever sent directly to the patient.

The article points out that, unlike other industries, the scale and complexity of healthcare is proving to be a challenge to manage.

One of many problems in widespread EHR adoption is that these software companies could not upgrade their 2011 systems in time to be certified and rolled out for the 2014 Stage 2 deadline. Only the biggest urban hospital systems and academic institutions could employ the proper resources and workforce needed to achieve success. Many rural and smaller hospitals have fallen behind in the implementation of electronic health records. To ensure the highest rate of EHR adoption possible, the Health Policy Committee must roll out a “No hospital left behind” program for smaller practices and for rural and small hospitals, to avoid a technical divide among providers.

18 | www.berkscms.org

The medical industry is no stranger to technology, and has been quick to incorporate robotics and gene therapies to promote a higher quality of care. However, this apparent fondness for technology is paradoxical given the relatively slow rate of adoption of Health IT as compared with other industries. Nicolas Terry, author of Information Technology’s Failure to Disrupt Health Care (published in Nevada Law Journal), points out “HIT still appears to be a large rock that only a few dedicated converts are pushing up a steep and expensive hill.” 6 This quote hits the nail on the head. To truly have an industry-wide adoption of EHR in a meaningful way, everyone must be on board. Entrepreneurs and IT gurus recognize the need and possibility to disrupt the healthcare industry with technology, but the task is much more complex than that of other industries. Healthcare is waiting for the disruptive technology that created search engines and online banking. The Institute of Medicine recently said, “Just as the information revolution has transformed many other fields, growing stores of data and computational abilities hold the same promise for improving clinical research, clinical practice, and clinical decision making.” 7

Each patient is different, with many treatment and therapy combinations producing a spectrum of desired outcomes, and this poses a daunting task for collecting standardized data. Currently the process of computerized provider order entry (CPOE) is a tedious and painful transition, but widespread usage and adoption of standard EHR practice will benefit the industry on numerous platforms. To truly make meaningful use of Health IT, systems must go beyond simply storing, receiving, and sending health data to actively incorporating discoveries in collected data. Not coincidentally, the July 2014 issue of Health Affairs centers on using Big Data to transform care. One article discusses how CMS is spurring the health system transformation. It states that, historically, the CMS has faced technological challenges in storing, analyzing, and disseminating its own massive amounts of data points. For many years its data was spread across multiple systems, and retrieving data for analytics was time-consuming and expensive. Now rapid progress of the big-data revolution has given CMS the tools and capabilities to use data in innovative ways, such as detecting fraud and abuse, and increased provision of data to providers, researchers, beneficiaries, and stakeholders.8

There is a silver lining to the cloud that has hung over the struggles of providers to transition to electronic health records and utilize their capabilities. Where these efforts have been successful, they have shown good returns for the patient. Significant growth has occurred in capabilities to engage patients and their families in their care, improve care coordination, and improve population and public health, says Health Affairs. 85% of health centers had the ability to provide clinical summaries for patients after each visit in 2012, up from 63% in 2010.9 EHR functions that have the highest adoption rate are the ones that reduce health disparities and improve quality and safety. Furthermore, if a monetary incentive is not enough to spur implementation, Health Affairs says health centers that had met Stage 1 Meaningful Use objectives have 2.4 times greater odds of receiving third-party quality recognition, relative to centers that lack even a basic EHR system. 10

After five years and $30 billion worth of incentives and aid for healthcare providers to adopt an electronic health record system, the industry has seen a significant increase in adoption of EHRs on some level. Many of the objectives of Meaningful Use have been incorporated into computer systems, promoting better patient experiences, improving quality, and reducing dangerous drug interactions. Stage 2 Meaningful Use has proved to be challenging to achieve by the July 1st date, with only 10 hospitals attesting in the first two quarters of 2014. Health policymakers need to concentrate their efforts on aiding rural and small health systems with adoption of EHRs to minimize a “digital divide.” The healthcare industry is no stranger to incorporating quality medical technology to improve care

outcomes, but now it is time for our “GDP-devouring health system” to focus on utilizing Health IT in a productive and truly meaningful way. n

Resources: 1 Hsiao C-J, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: 
United States, 2001–2013. NCHS data brief, no 143. Hyattsville, MD: National Center for Health Statistics. 2014. 2 ,3 Catherine M. DesRoches, Dustin Charles, Michael F. Furukawa, Maulik S. Joshi, Peter Kralovec, Farzad Mostashari, Chantal Worzala and Ashish K. Jha. Adoption Of Electronic Health Records Grows Rapidly, But Fewer Than Half Of US Hospitals Had At Least A Basic System In 2012. Health Affairs, 32, no.8 (2013). 4 Elisabeth Myers. Medicare & Medicaid EHR Incentive Program. HIT Policy Committee Presentation, 07/08/2014. 5 Maria Durben Hirsh. Hospitals continue to struggle with Meaningful Use stage 2 attestation. FierceEMR.com. July 8, 2014. 6,7 Nicolas P. Terry. Information Technology’s Failure to Disrupt Health Care. Nevada Law Journal. Vol. 13:722. 06/12/13. 8 Niall Brennan, Allison Oelschlaeger, Christine Cox and Marilyn Tavenner. Leveraging The Big-Data Revolution: CMS Is Expanding Capabilities To Spur Health System Transformation. Health Affairs, 33, no.7 (2014):1195-1202. 9,10 Emily B. Jones and Michael F. Furukawa Adoption And Use Of Electronic Health Records Among Federally Qualified Health Centers Grew Substantially During 2010−12 Health Affairs, 33, no.7 (2014):1254-1261. Whether you need high-tech treatment or a helping hand, choose Berks VNA for compassionate, skilled care from the best nurses, therapists and home health aides around. Rest easy. Choose Berks VNA. Nursing | Therapy Home Health Aides Hospice

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Members of the Berks County Medical Society contribute to the health of our community by providing care to patients on a daily basis, of course, but many choose to contribute in other ways as well. By: Lucy J. Cairns, MD

Encouraging bright young people from Berks and nearby counties to pursue a medical career is crucial to ensuring a sufficient supply of physicians to care for our community in the future. Local physicians do this by participating in career days at local high schools, volunteering to allow students to observe their work in the office and operating room, and offering clinical and research training to pre-med and medical students. The research abstracts presented here are a sampling of projects undertaken this summer by students who completed 6-week internships at the Reading Hospital. Their quality speaks well for the mentoring each young person received from our fellow physicians, which will stand these students in good stead as they pursue their ultimate goals. With luck, at least some of them will return to the community that nurtured them to return the favor.

Analysis of Continuity of Care at Reading Hospital Family Health Care Center Joshua Luginbuhl and William Lovett, MD

BACKGROUND: Continuity of care is the process by which the patient and physician are cooperatively involved in ongoing health care management toward the goal of high quality, cost-effective medical care (AAFP, 2014). It is a hallmark and primary objective in family medicine and has been shown to lead to lower costs, better health outcomes, and higher patient satisfaction. Previously at Reading Hospital Family Health Care Center, almost all of a graduating resident’s patients, sometimes over 300, were given to the incoming resident. Despite this large patient panel, first year residents are only in the office about ½ day per week, and at the beginning of the year, only see 2 patients per half day, creating a disconnect between their availability and patient load. Because of this system and its possible negative effects on continuity of care, patient panels for first year residents were created and made small (about 35 patients) to match the residents’ availability in hopes of improving continuity of care at Reading Hospital FHCC. METHODS: Patient panels for incoming family medicine residents were “right sized” in July 2013 to match their availability in the clinic. This initial patient pool (about 35 patients) was then

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20 | www.berkscms.org

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allowed to grow during the year. Physician-Patient encounters (n=18,594) were analyzed before (February-June 2013) and after (July 2013-June 2014) the intervention and continuity of care scores were calculated for the pre-intervention and post-intervention periods. These measures included Patient Continuity of Care and Physician Continuity of Care. Patient COC is defined as the percentage of total visits by a specific patient panel that are with their assigned primary care provider (PCP). Physician COC is defined as the percentage of a physician’s total patient encounters that are with his or her assigned patients.

RESULTS: All resident years showed an increase in both patient and physician COC scores after the intervention. Patient COC scores for first year residents went from an average of 0.334 (0.268-0.405) during the pre-intervention period to an average of 0.376 (0.311-0.490) after patient panels were “right sized,� although this difference was statistically insignificant. Likewise, physician COC scores for first year residents increased to 0.448 (0.384-0.526) after averaging 0.417 (0.246-0.519) before the intervention. Despite these general trends of increasing COC scores after the intervention, only third year residents showed a statistically significant increase in both average patient and physician COC score after the intervention (p<0.05). Second year residents showed a significant increase in average physician COC score (p<0.05) as well. 22 | www.berkscms.org

CONCLUSIONS: Continuity of care has been associated with numerous positive effects on medical care, making it important to maximize in a family practice setting. By creating small patient panels for incoming residents, average patient and physician COC scores increased in all resident years, although only 3 differences were significant. In the future, it is necessary to be cognizant of continuity and, because of its positive impact on patient care, seek improvement whenever possible. (Joshua is a graduate of Muhlenberg College, Allentown, and is currently in his second year at the Drexel University College of Medicine. He is considering training as an Internist, possibly specializing in cardiology, but is also interested in Emergency Medicine. His home town is Denver, PA.)

Building a Culture of Academic Inquiry; A 14-Year Analysis Using CQI methods Veronica Andre, Rich Alweis, MD, Anthony Donato, MD, MHPE

BACKGROUND: Without on-site basic research facilities, academic independent medical centers may struggle to meet research expectations as part of their mission of academic medicine. Cited barriers to research productivity in the literature include protected time and availability of experienced mentors. This study evaluated the effect that a series of interventions, including a pay-for-performance incentive, had on the research output of Internal Medicine residents at the Reading Health System. METHODS: This study was a retrospective analysis of multiple interventions analyzed using continuous process improvement methodology. Academic productivity (defined as accepted regional abstracts, national abstracts, and publications coming from the residency or faculty of the residency) was measured by academic year over 14 years. Data were verified by analysis of resident files, PubMed and Web of Science databases. A series of eight interventions were carried out in residency programs with the intent of stimulating increase in research productivity. The interventions included hiring a statistician, adding teaching seminars, pairing residents with faculty to conduct research, and beginning a pay-for-performance intervention to residents (a scaled incentive, worth up to an additional $1000 for top performers). RESULTS: Overall research output during residency increased over the course of the period studied. The most dramatic increase occurred after the addition of the pay-for-performance incentive plan. We noted a gradual transition from regional abstracts to national to publications, with a trend toward more publications and fewer abstracts in recent years. CONCLUSIONS: Research increased significantly over the time period studied. Impacts of any one individual intervention are likely additive, but the largest gains came temporally related to pay-for-performance interventions. Whether residents in this program can transfer what they learned about research to new environments is a direction for future research.

(Veronica will graduate from Susquehanna University in May 2015 with a B.S. in Biology and a Minor in Health Care Studies. She plans to attend medical school after a gap year and is interested in sports medicine/orthopedics. Her home town is Oley, PA.)

Outcomes in Tier 3 Geriatric Trauma Patients

Charles Barbera, MD, MBA, FACEP; Forrest Fernandez, MD, FACS; Adrian Ong, MD; Kristen Sandel, MD; Rachael Trupp, BS

BACKGROUND: As health care advances, the geriatric population is continuously growing and demonstrating an increased presence in emergency departments. Geriatric patients often have more comorbidities and require a greater number of physician subspecialty consults when compared to their counterparts. Specifically, traumatic mechanisms often increase the complexity of the geriatric patient’s visit due to lower physiologic reserves. However, due to conventional triage criteria, this vulnerable population may not meet the threshold criteria to activate the trauma team. In order to properly care for this vulnerable population in a time-dependent manner, the Reading Health System initiated Tier3 (T3) with thresholds including the usage of anticoagulants or antiplatelet agents and history of blunt head or torso trauma. This new addition to the trauma activation system allows geriatric patients to be given expedited care and proper evaluation and treatment. This study will investigate the utilization of T3 as a way of identifying at-risk geriatric patients for time-dependent care. METHODS: We are currently conducting a retrospective study utilizing patient chart review with inclusion criteria that includes all T3 patients 65 years of age and older. Data will be compared between one year prior to and one year after revisions to the Tier 3 system in order to investigate mortality, patient disposition, length of stay upon admission, test utilization, and patient discharge destination. (Rachael earned a B.S. in Biology from Lafayette College in 2014 and is currently enrolled in the Masters of Biological Sciences Program of the Drexel University College of Medicine School of Professional Studies. Her goal is to attend medical school and practice Emergency Medicine. Her home town is Reading, PA.)

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Staphylococcus aureus Bacteremia: An Evaluation of Management within the Reading Health System. Robert Jones, DO, MS, FIDSA, Rebecca Cofsky, Pharm.D. and Sean Wagner

BACKGROUND: Staphylococcus aureus is a serious and prevalent source of nosocomial and community-acquired blood stream infections. A recent study has identified Quality of Care Indicators (QCIs) for the evaluation and management of S. aureus bacteremia (SAB) in order to maximize treatment effectiveness. A review was conducted using these QCIs to evaluate the management and outcomes of patients with SAB within The Reading Health System.

METHODS: Patients with SAB were identified by querying the Cerner laboratory system for S. aureus isolated from the blood from March 2013 through June 2014. A retrospective chart review was conducted on 209 patient encounters (199 unique patients). Patients’ charts were accessed electronically. Data collected included general demographics, presence of echocardiography, adherence to obtaining repeat blood cultures, antibiotics prescribed, duration of antibiotics, presence of Infectious Disease (ID) consult, average time from admission to ID consult, antibiotic de-escalation, length of stay, and mortality. RESULTS: There were 134 patient encounters that identified MSSA bacteremia and 68 encounters where MRSA was isolated (66.3% and 33.7%, respectively). Patient age ranged from 17 to 96 years old, with an average age of 61 years. One hundred sixty

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24 | www.berkscms.org

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seven (88%) of eligible patients were seen by an ID consultant, while 12% did not receive a consult. Within the ID-consulted population, 98% patients had repeat blood cultures ordered, 96% had a transthoracic echocardiogram (TTE), and 43% had a transesophageal echocardiogram (TEE) performed. In the nonID consulted group, there was a decreased rate of repeat blood cultures ordered (50%), TTE (44%) and TEE (0%). The time from admission to ID consult was approximately 2 days. The average length of stay (LOS) for patients seen by ID was longer compared to patients not evaluated by ID (13.7 days vs. 6.2 days, respectively). There were no differences noted between patients with MSSA and MRSA bacteremia with respect to obtaining repeat blood cultures, echocardiography or ID consultation. Twenty patients were not eligible for antibiotic de-escalation. Among the 117 patients who were eligible for de-escalation, 101 cases were de-escalated (86%). The overall mortality was 19.2%.

CONCLUSIONS: Consulting ID leads to increased adherence to quality of care measurements in regards to the management of SAB. The ratio of MSSA to MRSA SAB reflects the community ratio of all-source cultures as noted in The System’s antibiogram. Delayed time to ID consult may have added to the LOS. The overall mortality in this study falls within published rates. (Sean is a graduate of Penn State University, earned a M.S. in Physiology and Biophysics from Georgetown University in May 2013, and will graduate from Georgetown University School of Medicine in 2017. His home town is Wernersville, PA.) n


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Alliance Update The Berks County Medical Society Alliance kicked off its already successful 2014-2015 year with outreach efforts geared toward new members and the community at large, through its Fall New Member Coffee and by setting the topic and date for the annual Health Project.

26 | www.berkscms.org

Via a bi-annual New Member Coffee – held this year in September 2014 in Wyomissing, Pennsylvania - the BCMSA reaches out to potential new members, introducing its educational and philanthropic activities to physician spouses – including newly re-located families – in Berks County. One of the Alliance’s most important county-wide educational activities – the Annual Health Project – has been set for April 9, 2015. The topic “Eating for Well-Being” will focus on food-related symptoms and remedies, exploring the link between food and physical health and between food and anxiety and other mood disorders. Featuring local resources and speakers, including confirmed lead-off speaker, Aparna Mele, M.D., founder of MyGutInstinct.org, the annual Health Project promises to be an informative and practical program directed toward food services representatives, teachers, parents, and the Berks County community at large. n


Avoiding Disruption to Reimbursement

Revalidation, the process by which

the Centers for Medicare and Medicaid Services (CMS) requires physicians to certify the accuracy of their existing

enrollment information, can be a new and confusing process for physicians. With the passage of the Affordable

Care Act (ACA), revalidation requires physicians to be screened under new program integrity rules.

Complying with these requests within the specified time is crucial to avoid

deactivation of billing privileges. Here’s what you need to know about Medicare and Medicaid revalidation to avoid

disruption to your reimbursement.

Medicare Revalidation Medicare requires revalidation every five years, but they may also perform “off-cycle” revalidations under certain circumstances. The revalidation letter will be mailed in a colored envelope to the physician’s practice address and/or their pay to address. Do not submit a revalidation application unless specifically requested by Medicare.

Upon receipt of the request to revalidate, you have 60 days from the postmark date of the letter to submit complete enrollment information using one of the following methods: • Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) – This system, accessible at https://pecos. cms.hhs.gov/pecos/login.do, allows you to review information currently on file, upload supporting documentation, and electronically sign and submit your revalidation application. • Paper application form – To revalidate by paper, download the appropriate and current CMS-855 Medicare Enrollment Application and mail the completed application and all required supporting documentation to Novitas Solutions. The requests are issued by NPI; thus a group practice may have multiple enrollments that must be revalidated.

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Avoiding Disruption to Reimbursement continued from page 27

Elements of a Good Social Media Policy By: Tonya Nevling, PHR, Power Kunkle HR Solutions

The National Relations Labor Board continues to keep social media in the forefront of employee relations labor news. As soon as your organization feels like they have created a sound social media policy, new case law comes into play and you may need to revise it yet again. As you are creating (or recreating) your social media policy, remember these key elements: 1. Identify the social media technologies, e.g., personal blogs, LinkedIn, Twitter, Facebook, MySpace, YouTube. 2. Address use of social media during working time. 3. Provide that there is no expectation of privacy while using the internet and that employer may monitor postings. 4. Remind employees that individuals are personally responsible for their commentary and can be held personally liable to commentary that is defamatory, obscene, proprietary, etc. 5. Remind employees that they are not authorized to speak on behalf of the company (offer disclaimer: “the views expressed are my own and not those of the Company, or of any person or organization affiliated or doing business with the Company”). 6. Forbid employees from using social media to harass or threaten.

Provides for discipline of employees up to and including termination. n 28 | www.berkscms.org

While CMS has instructed their Medicare carriers to work with physicians to ensure compliance (e.g., calling a physician that fails to respond to a revalidation request), physicians should seek out with diligence revalidation requests to prevent deactivation and disruption of reimbursement.

Physicians should review the CMS website at www.cms. gov/Medicare/Provider-Enrollment-and-Certification/ MedicareProviderSupEnroll/Revalidations.html for a list of providers/suppliers by NPI number to see if a revalidation request has been sent. The Provider Enrollment Inquiry Tool, available on CMS’ website at www.novitas-solutions.com/webcenter/content/ conn/UCM_Repository/uuid/dDocName:00004864, provides the status history of all enrollment applications submitted to Medicare. The Pennsylvania Medical Society (PAMED) strongly encourages physicians to utilize this tool for tracking enrollment applications. If there is a discrepancy with the application, requests for additional information from Medicare may be sent to an email address if provided on the application. CMS began the process of revalidating physicians and group practices that were enrolled in Medicare prior to March 25, 2011. Medicare will continue to send revalidation notices on an intermittent and regular basis until all affected physicians revalidate their information with CMS by March 2015.

Medicaid Revalidation The ACA also requires the Department of Public Welfare (DPW) to validate all new physicians and revalidate all currently enrolled physicians by March 16, 2016, and at least every five years thereafter. In order to do this, DPW is requiring that all physicians re-enroll by submitting a fully completed Pennsylvania PROMISe ™ Provider Enrollment Application, along with any required additional documentation for every active and current service location. As of May 2014, only 18 percent of Medicaid physicians revalidated their enrollment, with over 83,884 service locations set to expire in March 2016.

Unlike Medicare which notifies physicians when it’s time to revalidate enrollment, the onus is on the physician to initiate this process. While March 24, 2016, might sound far away, physicians should complete the process as soon as possible for several reasons: 1. March 24, 2016, is not the deadline by which DPW has to receive your application. It’s the deadline by which your application must be processed and in the system. 2. DPW expects longer wait times for approvals. 3. Waiting for a written notice? Don’t. DPW has confirmed that providers will not receive written notices. It’s imperative that physicians submit applications immediately to avoid disruptions in claim payment as all service locations that are not revalidated will expire.

Physicians also are reminded of the ongoing requirement to inform DPW of any changes, including changes of direct or indirect ownership and controlling interest five percent or greater, contact information changes (including email), address changes, closed or invalid service locations, or any other change to the information provided on their enrollment record that would otherwise render the information in their current provider file inaccurate.

All provider letters and portal login screens will indicate your next revalidation due date. Verify this information on the DPW provider portal for each 13-digit logon at each service location. Information about this helpful tool can be found on DPW’s website at www.dpw.state.pa.us/cs/groups/webcontent/ documents/communication/p_034770.pdf. Physicians who have not yet revalidated will be well-served by advance preparation by gathering the information needed to complete the appropriate Medicare and/or Medicaid enrollment applications. Diligence on the front-end can help avoid a costly and disruptive enrollment deactivation. n

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Legislative Update

By: Scot Chadwick, Legislative Counsel, State Legislative Affairs, Pennsylvania Medical Society

They’re Back!


HB 2221 would allow other trained school personnel to administer diabetes medications, and HB 803 would allow trained school personnel to administer epinephrine. These bills contain adequate safeguards, and are important because they provide critical back-up care when the school nurse may be unavailable.

Like everyone else in town, the Pennsylvania Medical Society (PAMED) has a long list of issues we’d like to see our solons address. We won’t get everything we want – no one ever does – but we’re hoping for meaningful progress on as many of the following initiatives as possible.

We would also like to see action on SB 405, which would place controls on the substitution of “biosimilars,” which in lay terms are the generic equivalent of biological medications. Among other safeguards, the bill would require pharmacists to notify prescribing physicians within 72 hours after substituting a biosimilar for a biologic medication.

ennsylvania legislators will take a brief break from door knocking and other activities associated with campaigning for reelection when they return to Harrisburg next week for the first time since early July. The House and Senate have scheduled five session days in September and another five in October, when they will try to take care of as much unfinished business as possible before the two-year term ends on Nov. 30.

Controlled Substances Database

Our top priority remains the enactment of a controlled substance database. We’ve got a House bill (HB 1694) that passed the House 191-7, and a Senate bill (SB 1180) that passed the Senate 47-2. There are some important differences between the bills, but they need to resolve those differences and get this done. Lives are at stake. Naloxone

While I’m on the subject of opioids, we want the House to pass Sen. Pileggi’s naloxone bill, SB 1164. The bill would provide Good Samaritan protection to people who try to get help for someone experiencing a drug overdose, and put life-saving naloxone in the hands of first responders like firemen and police officers, as well as the friends and family members of atrisk individuals.

The bill passed the Senate 50-0 and is set for final consideration in the House. This is another life-saving measure, and we’re hoping for quick action in the House. Aiding Students with Health Challenges

High on PAMED’s fall wish list are two bills that would provide additional assistance to school students who face non-opioid health challenges. Under existing law, students experiencing diabetic distress or anaphylaxis must look to the school nurse for help. 30 | www.berkscms.org


Pharmacists Administering Flu Shots to Minors

PAMED now supports SB 819, which would allow pharmacists to administer flu shots to minors aged 7 and up. We opposed earlier versions of the bill, which would have allowed pharmacists to administer all childhood immunizations, due to issues of patient safety and fragmented care, but we favor the bill in its current form. There’s no reason the House and Senate can’t get this done. Health Care Cost Containment Council

Another important measure is SB 1267, which would extend the life of the Health Care Cost Containment Council (HC4) for another three years. HC4 provides valuable data on morbidity and mortality at health care facilities, and is one of those entities whose existence needs to be renewed periodically by the General Assembly. Truth in Advertising

Also high on our to-do list is HB 2061, a pro-patient measure that would require licensed health care providers to be straightforward with the public when advertising their services. In the case of a physician, that means a “board certified” advertisement must clearly state which board the physician is certified in.

In the case of non-physician providers, many of whom hold doctorates and refer to themselves as doctors, an advertisement

must identify the type of license the provider holds.

Non-Compete Clauses in Physician Employment Contracts Another pro-patient initiative is HB 2342, which would prohibit employers from including non-compete clauses in physician employment contracts. Such clauses prohibit physicians who leave an employer from practicing nearby for several years, forcing patients to seek a new physician and potentially disrupting their treatment. Law firms are ethically prohibited from using non-compete clauses in employment contracts, and physician employers should be too. Liability Protection for Emergency Care Providers

We’d also like to see progress on HB 804, which would strengthen liability protection to health care providers while they are administering emergency care. Emergency care requires quick decision-making by providers who probably don’t have access to a patient’s medical history, are unaware of a patient’s allergies, existing health problems and medications, and in some cases may not even be able to speak with a patient. In such a situation it simply isn’t right to hold emergency care providers to the same liability standards as other providers. As I said at the beginning of this post, we won’t get everything we want in the 10 session days that have been scheduled between now and the end of the legislative two-year term on Nov. 30. However, our goal is to get as many of these measures on the governor’s desk as possible, and make meaningful progress on the others, setting the table for (we hope) quick action when the new term begins in January.

Check back often, and we’ll let you know how it’s going. As always, you can reach me with questions or comments at (717) 558-7814 or schadwick@pamedsoc.org.

The guidelines are available for download on the PAMED website, and I’m delighted to report that they have been viewed more than three thousand times since we posted them on July 11. Admittedly, some of the people who viewed the guidelines were probably not prescribing physicians, and I’m including reporters who were covering the story in that group. However, we also received inquiries from hospital systems asking if they could download the guidelines and distribute them to all of their prescribing physicians, and I got a call from a pharmaceutical company asking if their drug reps could distribute them to the physicians they visit. Hence, some page views likely resulted in distribution to many prescribers.

My point is that if the first six weeks are any indication, the guidelines are going to be a big success. I’m particularly pleased by the reception they have received in the media, and the positive comments from physicians interviewed by their local news outlets. The only question that seems to come up from time to time is why the guidelines are voluntary and not mandatory. Now, I’m not a physician, and I wouldn’t know the difference between Percocet and Pepto Bismol (actually, I could probably figure it out), but I can tell you that the stakeholders who put the guidelines together know a LOT about opioids, and they were unanimous in their view that the guidelines shouldn’t be mandatory. The consensus was that patients present with widely varying circumstances, and that requiring prescribers to follow every element of the protocol in exactly the same way for every patient would be inappropriate. For that reason the guidelines state that they are not intended to replace a physician’s clinical judgment.

And, here’s the best thing about the guidelines. They’re a living document, and the Department of Drug and Alcohol Programs plans to review and update them annually to stay current with scientific advances and changes in best practices.

Have You Downloaded the Opiod Prescribing Guidelines Yet?


ix weeks ago I used this forum to talk about the July 11 unveiling of the state’s new prescribing guidelines for opioids to treat chronic, non-cancer pain. The Pennsylvania Medical Society (PAMED) was actively involved in drafting those guidelines, and we hosted and participated in the media event at which the guidelines were released. FALL




Last week the Department, in conjunction with PAMED and the Pennsylvania College of Emergency Physicians, released a second set of guidelines aimed at opioid prescribing in hospital emergency rooms. Hopefully they will see the same level of success and acceptance as the chronic pain guidelines. Meanwhile, the work goes on. The Corbett task force is currently reviewing opioid prescribing by dentists, and efforts are under way to try to get the urgently needed controlled substance database legislation enacted this fall. PAMED is in the middle of those efforts, and we’ll keep you posted on our progress. As always, you can reach me with comments or questions at (717) 558-7814 or schadwick@pamedsoc.org.

What Should Happen to Medical Records when Physicians Leave Practice?


don’t know about you, but I am totally amazed at how fast this year has gone by! In a blink of an eye, here we are, approaching the last third of the summer.

As we reluctantly are pulled through the summer months, we are forced to recognize a very important annual event: BACK TO SCHOOL! Most parents are feeling elated! Reflecting on my own childhood, I would imagine that most kids, however, do not share in their parent’s joy. Despite the differing opinions about the celebratory nature of the occasion, all are getting prepared.

In preparation for this occasion, some parents and custodians will need to make sure that their child’s immunizations meet state requirements for school attendance and will need access to medical records to do so. As a result, a handful will discover that their child’s physician has passed away, retired, or is no longer practicing in the state.

Throughout the year, we regularly get calls from former patients and distraught parents in search of their medical records. Here’s a brief overview of what we’ve shared with former patients in search of their medical records.

32 | www.berkscms.org

Who has ownership of the medical records? The hospital, solo or group practice has ownership of patient medical records. The rights of a physician departing a practice will depend on the arrangements. Patients do not own their medical records, however, copies of the medical records should be provided upon a patient’s request.

How long are physicians required to keep the medical records?

State Board of Medicine regulations say this is at least seven years from the last date of service for adults, and at least seven years from the last date of service and one year after the patient turns 18, whichever is longer, for minors. Regulations for osteopathic physicians are almost identical, except that the extended period of time for minors is two years after the patient turns 18.

When a physician retires or is no longer with a practice, what happens to her patients’ medical records? • Patients should be notified when a physician is leaving a practice, is retiring, or has passed away. Generally, it is good practice for the physician to send a letter to her patients to notify them of his/her impending departure. If the physician has passed away, his/her estate may also consider placing a notice in the newspaper to inform patients how they can access their medical records. • If the physician was part of a group practice, the group may retain the records. Upon the patient’s request, the group should provide the patient with a copy or transfer a copy to the patient’s new physician. Medical records that are not forwarded to a new physician should be retained by the group practice. • If the physician was a solo practitioner, arrangements may have been made for another practice to take over the care of her patients. Preparations may also have been made for a local hospital to store the medical records. Patients of solo practitioners no longer in practice are often encouraged to inquire with area practices and hospitals when in search of lost medical records. No doubt physicians are already aware of and have answers to most of these questions. If not, no worries, PAMED has lots of resources available on this topic and others related to medical records. As always, you can reach me with comments or questions at (717) 558-7814 or schadwick@pamedsoc.org. n

The Berks County Medical Society in partnership with the Pennsylvania Medical Society

held a “Welcome To Berks” event for the new physicians and young physicians in the county at “Say Cheese” in West Reading on July 31, 2014.

Attendance was great and a good time was had by all!






Calendar of Events

FALL Department of Family 2014 Medicine Lecture Series October 24 – Beyond Advance Directives: Have You Had the Conversation Yet? – 5483 Daniel Kimball, Jr., MD, FACP Physician Advisor, Circle of Life Coalition, Reading October 31 – No Conference (Residency In-training Exam)

November 7 – Friday’s Child Lecture Series – Evaluation and Management of Strabismus – 4975 Ajay Soni, MD Penn State Hershey Children’s Hospital November 14 – Screening for Depression: A Population-based Approach to Improving Mental Health – 5484 Kolin Good, MD, Chair Department of Psychiatry Reading Health System

November 21 – Cardiology for the 21st Century – 5485 Greg Wilson, DO Eric Elgin, MD Cardiology Associates of West Reading November 28 – No Conference

December 5 – Friday’s Child Lecture Series – Children and Lifelong Vascular Health: Who’s Minding the Store? – 4970 Stephen E. Cyran, MD Penn State Hershey Children’s Hospital December 12 – Prescription Drugs and Alternative Medicine: Are They Truly Complementary? – 5486 Joan Mege, PharmD Reading Health System December 19 – Geriatric Transitions: Assisting Older Patients Through the Life Changes of Aging – 5487 Dennis Gingrich, MD Professor of Family and Community Medicine Penn State Hershey College of Medicine

> 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 lectures will be held in the Reading Hospital Conference Center, Rooms 1 and 2 at 8:00 a.m. unless otherwise noted.

Berks County Medical Society

Tuesday, October 14 8-Noon October 18 & 19 Friday, October 31 7AM Thursday, November 6 6PM Friday, November 21 7AM Thursday, December 4 Noon Thursday, December 4 6PM Friday, December 19 7AM Sunday, January 18, 2015 Friday, April 10, 2015 Wednesday, September 16, 2015

34 | www.berkscms.org

CPR Recertification PAMED House of Delegates-Hershey Administrative Committee Executive Council Administrative Committee Retired Physicians Luncheon Executive Council Administrative Committee Installation Brunch Residents’ Day & Memorial Lecture Fall Golf Outing

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