May/June Newsletter

Editors: Ellen W. McKnight, M.D. | Erica Huffman, Executive Director

www.escambiacms.org

Bulletin MAY/JUNE 2015 VOLUME 45, NO. 3

PRESIDENT’S MESSAGE It is hard to believe we are almost half way through the year already. It seems that each new year flies by faster and faster as we get busier and busier. But we have accomplished quite a bit along the way.

The ECMS calendar started off with a great inaugural ball in January with our special guest, FMA president Dr. Alan Pillersdorf. It was fun to do the photo-booth and celebrate the kick-off to a great year with so many of my colleagues and friends.

Our legislative meeting was a big success. It was an opportunity for us as physicians to ask questions and give our feedback on issues that face physicians and our patients. I appreciate Representatives Clay Ingram and Doug Broxson taking an interest in our concerns and taking the time to understand our perspective on issue in healthcare legislation.

The vendor fair drew a large crowd. The speed networking is a helpful activity that allows us to meet with other physicians in the area who we haven’t had the opportunity to meet before. I like to get to know the new physicians, residents and medical students as well. In addition to our traditional vendor fair and networking, we had a BIG check presentation for the Florida State University College of Medicine – both literally and in the dollar amount. Later in this issue you will see some photos of our event and can read more about the gift. But I can’t stress enough how proud I am of our members and our board for creating this endowed scholarship to give back to the FSU medical students from our area and our community as a whole.

The first Doctors’ Day event got rained out, but rescheduling it worked out well. We had perfect weather for a baseball game. I enjoyed getting to see many of you there with your families. Doctors’ Day is one of my favorite events of the year because we get to relax and get to interact on an informal level.

CONTENTS It seems we have packed a lot in the first half of the year. But there is even more ahead.

July brings the annual FMA meeting where our delegates will go to Orlando and put forth resolutions that will help physicians practice medicine. We have had many successes at the FMA, and our medical society has been well represented in the past four years that I have been going.

In August we have our Young Physicians Section meeting, which has always had a great turnout (even from the not so young physicians). This year we will have Pat Clark coming, and she will provide us tools we can use when communicating with our representatives in politics or with the media.

As you may have noticed from our last issue, communication is a topic I really enjoy because it is an essential part of being a physician.

I am also looking forward to having Dr. Kevin Pho join us for our October meeting.

He is the creator of the kevinmd blog, which is one of the top medical blogs in the world. He is going to share with us his experience online and in social media. This will be an interesting and timely topic.

Our November CME event is also an excellent opportunity for physicians to catch up on required CME. If you need to get caught up, this event is for you. It is nice to have it all in one sitting – much more efficient than traveling across the country to pick up hours here and there.

The second half of the year will be a lot of fun and very informative. I know it will fly by quickly, but I’m going to enjoy every minute of it. I look forward to having you be a part of our events as well. We appreciate your feedback, so let us know if there is anything we can do as your ECMS officers to make the second half of the year a great one!

Page 3 - Announcements Page 4 - Membership Page 6 - Medical/Legal Page 8 - Practice Mgmt.

Page 12 - Foundation Page 15 - In the Community

SAVE THE DATE Tuesday, August 11, 2015 5:30 pm V.Paul’s Italian Ristorante Young Physicians Section Meeting Speaker: Patricia Clark Social Sponsor: Rick Lambert, CFP®, Financial Advisor Edward Jones & FD Insurance Sunday, September 27, 2015 11:30 am - 1:30 pm Hemingway’s Bimini Beach Bar Women in Medicine Brunch Sponsors: Danna Gracey Insurance, Rick Lambert, CFP®, Financial Advisor - Edward Jones, Fisher Brown Insurance, Safe Harbor Tax Advisory, LLC., Physicians Indemnity, and Plateful of Yum

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8880 University Pkwy., Suite B Pensacola, FL 32514 Ph: 850-478-0706 x2 Fx: 850-474-9783 Email: info@escambiacms.org www.escambiacms.org

E.C.M.S. Bulletin

The Bulletin is a publication for and by the members of the Escambia County Medical Society. The Bulletin publishes six times a year: Jan/Feb, Mar/Apr, May/Jun, Jul/Aug, Sept/Oct, Nov/Dec. We will consider for publication articles relating to medical science, photos, book reviews, memorials, medical/legal articles, and practice management.

•

•

Vision for the Bulletin:

Appeal to the family of medicine in Escambia and Santa Rosa County and to the world beyond.

A powerful instrument to attract and induct members to organized medicine.

Mission:

The mission of the Escambia County Medical Society is to promote the art and science of medicine in order to improve the health of our community. | Tradition – Honoring the history of medical care in Escambia and Santa Rosa counties. | Service – Serving the needs of our community through the service of our members in the practice of medicine. | Leadership – Meeting the challenges of the future and safeguarding our community’s health through organized collaboration on the local, state, and national level.

Ad placement Contact Erica Huffman at 478-0706 x2 Ad rates 1/2 page: $350 · 1/4 page: $200 · 1/8 page: $150

View and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the board of directors, staff or advertisers. The editorial staff reserves the right to edit or reject any submission.

Announcements 2015 Calendar of Events Monday, May 18, 2015 | 6:30 p.m. | Pensacola Wahoos Game Doctors Day Celebration (Rescheduled) Sponsors: Beck Properties, Edward Jones, & Mag Mutual Insurance, Physicians Indemnity, Underwood Anderson Insurance, Inc. Tuesday, August 11, 2015 | 5:30 p.m. | | V. Paul’s Italian Ristorante Young Physicians Section Meeting | Speaker: Patricia Clark 1 AMA PRA Category 1 Credit™ Social Sponsor: Edward Jones & FD Insurance Sunday, September 27, 2015 | 11:30 a.m. - 1:30 p.m. | Hemingway’s Bimini Beach Bar Women in Medicine Brunch Sponsors: Danna Gracey Insurance, Edward Jones, Fisher Brown Insurance, Safe Harbor Tax Advisory, LLC., Physicians Indemnity, Plateful of Yum Tusday, October 20, 2015 | Pensacola Little Theater General Membership Meeting | Kevin Pho, M.D. 1 AMA PRA Category 1 Credit™ Social Sponsors: Dyken Wealth Strategies, Edward Jones Dinner Sponsor: Regions Bank Saturday, November 14, 2015 | Hilton Garden Inn on Airport Blvd.

General Membership Meeting | FALL CME Conference Sponsors: Catalyst CRE, Edward Jones, Mag Mutual Insurance, Physicians Indemnity, Safe Harbor Tax Advisory, LLC. New Members Jamal Joudeh, M.D. Oncology/ Hematology Woodlands Medical Specialists 4724 North Davis Highway Pensacola, FL 32503 (P) 850-696-4000 Rebecca Martin, M.D. Internal Medicine Baptist Medical Group- Main Office 1000 W. Moreno Street Pensacola, FL 32501 (P) 850-469-7406 Eric Shoemaker, D.O. Physical Medicine & Rehabilitation Baptist Medical Group 9400 University Parkway, Suite 407 Pensacola, FL 32514 (P) 850-208-6481 Erica Whittingham, M.D. Pediatrics Sacred Heart Hospital 5153 N. 9th Avenue Pensacola, FL 32504 (P) 850-416-7713

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Reinstated Members Alka Wells, M.D. Diagnostic Radiology Pensacola Radiology Consultants, PA P.O. Box 9210 Pensacola, FL 32513-9120 (850) 476-8602 Retiring Doctors Glen Burleson, M.D. Deceased On April 9th Douglas Tappan, M.D. passed away. Dr. Tappan was the Vice President of the Escambia County Medical Society Foundation. He will be greatly missed.

If you are interested in making a donation to the ECMS Foundation in honor of Dr. Tappan please send a check made payable to the ECMS Foundation.

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Membership On Monday, May 18th ECMS hosted the annual Doctors Day Celebration at the Pensacola Blue Wahoos baseball game. We had the highest attendance of any ECMS event with nearly 130 doctors and their guest. ECMS President Dr. Christopher Burton started the game by throwing out the first pitch and the Blue Wahoos ended the game with a 4-3 win over the Mississippi Braves. The event was a huge success!

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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Membership

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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Medical/Legal ELECTRONIC MEDICAL RECORDS MAY CAST PHYSICIANS IN UNFAVORABLE LIGHT DURING LAWSUITS

by Keith L. Klein, MD, FACP, FASN

While the electronic medical record (EMR) has advantages, it also has introduced liability risks. EMRs can lead to lawsuits or result in a weak defense by casting the physician in an unfavorable light.

For example, examine these exchanges in a recent malpractice trial: • Plaintiff Attorney: Doctor, if the emergency renal consult was called in at 11:30, why did you wait until 6 PM to see the patient, during which time his kidneys became severely damaged?

• Doctor: I did see the patient within 30 minutes.

• Plaintiff Attorney: Where does it show that in the chart?

• Doctor: Uh…it doesn’t, I guess. I saw the patient but wrote the note later.

• Plaintiff Attorney: So you claim you saw this critically ill patient in 30 minutes, spent one hour evaluating him, but did not document your findings for another six hours?

And later in the trial: • Defense Attorney: But the lab record shows that the kidney function was declining…

• Judge: [interrupting] The physician notes state each day that kidney function was normal. How do you explain that in the face of deteriorating kidney function? Why would a physician write that, unless he hadn’t looked at the lab testing or the patient?

EMRs can increase malpractice risk in documentation of clinical findings—copying and pasting previously entered information can perpetuate any mistakes that may have been made earlier.1 Incorrect information is the most common user-related contributing factor in malpractice cases involving EMRs, according to a study by The Doctors Company of EMR-related closed claims from 2007 to 2013.

In the study, 15 percent of cases involved pre-populating/copy-and-paste as a contributing factor. Copy-and-paste is a necessary evil to save time during documentation of daily notes, but whatever is pasted must also be edited to reflect the current situation. Too often the note makes reference to something that happened “yesterday.” For example, the sentence “Patient presented to ED with chest pain yesterday…” is pasted over the next two weeks in the daily progress note. An even more telling example is a sentence like “Patient’s admitting lab is normal…” being perpetuated while the actual creatinine levels rise every day.

In one case, the judge commented about copy-and-paste issues: “I cannot trust any of the physician notes in which this occurred and the only conclusion I can reach is that there was no examination of the patient…it means to me that no true thought was given to the content that was going into ‘the note.’”

Checkboxes, particularly those that pre-populate, can be a physician’s nemesis. It’s easy to click on checkboxes, and often they are pre-checked in templates. EMRs have been presented in court that show, through checkboxes, daily breast exams on comatose patients in the ICU, detailed daily neurological exams done by cardiologists, and a complete review of systems done by multiple treating physicians on comatose patients. Questioning in court as to how long it takes to do a review of systems and a physical examination, the patient load of the physician for that day, and how many hours the physician was at work cast doubt on the truthfulness of the testifying physician. A time analysis showed that there was no way the physician could have accomplished all that was charted that day.

In one case that typifies how to impeach a doctor, it was clear that the doctor spent eight hours at work and, accounting for lunch, spent a little over seven hours seeing patients. But the total time it was documented that he spent on each patient would have required his time at work to be 15 hours.

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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Medical/Legal As one judge stated in court: “This medical record is simply not believable. I don’t know whether to fault the hospital, the company that wrote the software, or the physician, but the only one on trial here is the physician. In medical malpractice, the record must speak for itself, but this record is worse than silent. It is egregious.”

Notes can also be problematic. One issue that frequently comes up is the actual time the patient was seen. It is the accepted practice, especially on teaching rounds, to see all patients and then write notes at the end of the day. The EMR will automatically date and time-stamp the physician’s note as the time the note was created. This gives a misleading impression of when the patient was actually seen, and in a rapidly changing clinical situation, the note may not accurately reflect the patient’s clinical condition at the time the physician actually saw him. Therefore, it’s important to state in the note the specific date and time that the patient was seen and examined.

Reading an EMR is like taking a drink out of a fire hydrant—it is bloated with repetitive data, and critical findings can easily be missed. Copying information such as entire x-ray reports and lab data into notes only adds to this problem. Because the details of the chest x-ray can easily be looked up, the x-ray should only be summarized in the note, such as, “chest x-ray normal except for right upper lobe infiltrate consistent with a viral pneumonia.”

The fundamental mantra when writing a note in an EMR is to show that you put thought into the record. Discrete data, though strongly favored by IT professionals and insurance companies, does not accomplish this. Free-text entry of three or four sentences can convey far more information than several pages of template-driven notes and will reflect that you saw the patient and put thought into the note.

All these common EMR issues—incorrect information, copy-and-paste, and poor note-taking—cast doubt on the integrity of the doctor and the medical record. While the doctor may not have committed a clear-cut act of malpractice, these types of issues in the medical record cast the doctor in an unfavorable light in front of a judge or jury.

Reference 1 Mangalmurti S, Murtagh L, Mello M. Medical malpractice liability in the age of electronic health records. N Engl J Med. 2010: 363:2060-2067. http://www.nejm.org/doi/full/10.1056/NEJMhle1005210?viewType=Print&. Accessed December 8, 2014.

Keith L. Klein, MD, FACP, FASN, is Clinical Professor of Medicine, David Geffen School of Medicine at UCLA. Contributed by The Doctors Company

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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Practice Management HOW TO DISCHARGE A PATIENT

by Virginia (Ginger) Kelley, MHA, ARM, CMPE, CPHRM, FASHRM, LHRM, Senior Vice President of Risk Management

One of the most frequent calls I receive from our clients is regarding the discharge of a particular patient from their practice.

While every case is different, some principles apply to all situations. Florida law requires providers to provide the patient with at least 30 days of “emergency” care from the time of notification. Patients may be notified in person and a letter is not required by law, however, a letter is certainly recommended for documentation purposes.

Before discharging a patient, make the effort to determine whether the problem can be resolved short of discharge. For instance, in the case of non-payment, has anyone attempted to call the patient rather than just sending several invoices? Did you send them a letter informing them that non-payment will result in discharge? Have you offered them a payment plan?

If the patient has a history of rudeness or staff abuse, has anyone taken the individual aside and informed him that the behavior is unacceptable? Are there underlying issues that are causing this behavior? Is this behavior only being reported or witnessed by one employee and could the problem rest with the interaction between them?

For non-compliant patients, is there a financial burden preventing them from following the plan? Has the provider discussed the reasons for non-compliance with the patient? Is the treatment plan unmanageable to the patient for some reason? Can the plan be adapted to better suit the patient’s needs? Has the provider engaged in an informed consent/informed refusal process so the patient is making a conscious decision to decline part of the treatment plan? A documented informed refusal should NOT be considered non-compliance. Patients do have a right to choose as long as they have been informed of the alternatives and potential risks of each option.

I suggest the following elements for the patient termination process: 1.

Have the responsible physician review the file to confirm that discharging the patient will not endanger their medical condition and that discharging the patient is the appropriate action.

2. Prepare a discharge letter that includes in brief terms, the reason for the termination, such as:

a. non-compliance with the treatment plan

b. behavior during your visit on ...

c. treatment of our staff

d. refusal to meet your financial obligations (i.e. pay your bill), etc.

3. Note the effective date of the termination (no less than 30 days from the date on the letter) and that you will provide emergency care during this 30 day period.

4. Provide 3 alternatives for obtaining another qualified provider. I recommend providing the name and phone numbers of your local medical society, the local hospital referral service, and the patient’s insurance company or a local free clinic if they are uninsured.

5. Send the letter certified mail, return receipt requested but at the same time, send the letter regular mail. In the event the patient refuses to sign for the certified letter and the regular mail letter is not returned as non-deliverable, it implies that the letter was received. Place any returned mail in the patient’s chart, as well as the delivery receipts.

6. If the patient is on any maintenance or long-term prescriptions from your office, I would suggest including a prescription for a 30-day supply in their letter, with the possible exception of pain medications, which may require more customized handling.

7. Lastly, include a medical records release form so they won’t have to contact your office for it when they find a new provider.

This is not required under HIPAA, but many practices prefer to use it as a means of record keeping. Most practices will send a copy of the chart to a new provider at no charge to the patient. However, if the patient doesn’t already owe you money and they request a copy to take themselves, I recommend giving it to them at no charge as well. If the patient does owe you money, I would let them know they may have a copy at no charge when they have paid their balance due, but still offer to send it directly to another provider at no charge as a courtesy. You may not hold their records as ransom for unpaid balances, but you are certainly justified in charging the patient for a copy of their records in these cases.

Sample termination letters are available on our web site at www.fdinsurancecompany.com/formsanddocuments. If you have any questions or would like additional information, please feel free to contact me.

Ginger Kelley Sr. VP of Risk Management FD Insurance 904-296-2887, extension 230 gkelley@fdinsurancecompany.com Disclaimer: The risk management advice presented in this document is intended as general information of interest to physicians and other healthcare professionals. It is not intended to constitute legal or medical advice. For advice in those areas, please consult an appropriate professional. The recommendations and advice published in this document do not reflect or establish a standard of care and do not establish rules for the practice of medicine. This guideline is not intended to establish a policy or procedure or create a mandated course of action for any physician or medical practice.

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Foundation ESCAMBIA COUNTY MEDICAL SOCIETY FOUNDATION AND FLORIDA STATE ANNOUNCE GIFT SUPPORTING MEDICAL EDUCATION IN PENSACOLA

On Wednesday, May 6th the Escambia/Santa Rosa County Medical Society and the Escambia County Medical Society Foundation presented the first $50,000 check to the Florida State University College of Medicine Pensacola Regional Campus at the Hilton Garden Inn Airport Boulevard. For the past three years, ECMS has been awarding the Michael Redmond Scholarship Fund to a 4th year medical student here at the Pensacola campus who is interested in returning to this area to practicing medicine. The ECMS Foundation is honored to continue this scholarship through the creation of this endowment; this helps to create a legacy for future doctors in Escambia and Santa Rosa County for years to come.

“As president of the ECMS foundation I am excited and pleased that we were able to participate in helping the recipient medical students with their senior year expenses. The benefit to them is also a benefit to our local medical community as these students are planning to return to the area to practice.” – Paula Montgomery, M.D., ECMS Foundation President The President of ECMS, Dr. Christopher Burton states: “I am proud to see the influence that our current Escambia County Medical Society members are having on future generations of doctors. It was my privilege as the Escambia County Medical Society president on May 6 to present Dean Fogarty and the Florida State University College of Medicine with the first contribution of the $100,000 dollars scholarship endowment that you are members voted to set up for the medical students from our area who want to serve our community after they graduate. I am also proud of our Escambia County Medical Society board and staff for the time and commitment they have put into researching, preparing, and finalizing the endowment. We have a great group of leaders in our healthcare community, and the impact of the work they have done will influence future physicians and their patients for generations to come. It is a pleasure to serve as president of an organization that recognizes the importance of giving back and desires to leave a legacy that will have a positive impact on our medical community by encouraging the best and brightest medical students to practice here.”

Pensacola was one of the first regional campuses for Florida State University and many of our members serve as faculty teaching the medical students as they progress through their various rotations. Under the direction of Dr. Paul McLeod the partnership between our communities, physicians, and Florida State University College of Medicine continues to grow. Florida State University’s commitment to training excellent young doctors fits well with the mission of the Escambia County Medical Society and our Foundation. I would also like to thank Cindy Tyler and others on the FSU staff for their assistance as we put together our endowment. But most of all thank you to our members who support the medical students of our community – and perhaps our own doctors in the future.

John Maxwell says, “Leadership is influence, nothing more and nothing less.”

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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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In the Community SACRED HEART NEWS Neonatal and Pediatric Symposium The Children’s Hospital at Sacred Heart will host the 2015 Gulf Coast Neonatal and Pediatric Symposium Friday, June 12, through Saturday, June 13 at the Hilton Pensacola Beach Gulf Front on Pensacola Beach.

Designed for physicians and clinical staff, this two-day symposium will address the latest developments and trends in diagnosing, treating and managing the health of neonatal, pediatric, adolescent and young adult patients.

To register, visit www.GulfCoastNPS.org or call 850416-6204.

Pediatric After-Hours Clinic Relocates The Pediatric After-Hours Clinic of The Children’s Hospital at Sacred Heart has relocated to 4435 Hwy 90 in Pace. The clinic hours remain Monday through Friday from 5 to 11 p.m. and Saturday and Sunday from noon to 10 p.m. A local pediatrician from the Pace and Pensacola community is on-site at all times, and the clinic’s pediatric-trained staff are available to care for most nonlife-threatening medical issues in children of all ages, For more information, call (850) 416-5205 or visit www.sacred-heart.org/pediatricafterhours.

Bariatric Surgery Center of Excellence The Sacred Heart Surgical Weight Loss Center has been named a Center of Excellence through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Sacred Heart has held this distinction, which must be renewed every three years, since 2008.

To learn more, call 850-416-7546 or visit www. sacredheartsurgicalweightloss.com.

High-Volume Center for Pancreas Surgery In 2014, surgical oncologist Dr. Leo Villegas and general surgeon Dr. Kurt Stockamp performed enough Whipple procedures and distal pancreatectomies to make Sacred Heart Hospital Pensacola a High-Volume Center for Pancreas Surgery. Multiple studies have shown that with an increase in a hospital’s volume of pancreatic surgeries comes improved long-term survival and a decrease in mortality rates, postoperative complications, length of stay and overall cost.

For more information about pancreatic or liver cancer surgery at the Sacred Heart Cancer Center, call (850) 4162770 or click here.

BAPTIST HEALTHCARE NEWS Baptist Health Care on Becker’s ‘150 Great Places to Work’ List Baptist Health Care (BHC) earned a spot on the 2015 Becker’s Healthcare “150 Great Places to Work in Healthcare” list for the second consecutive year. BHC is the only health care provider in the area to earn a spot on the list.

The list was developed through nominations and editorial research. BHC was chosen for its benefits, wellness initiatives, commitment to diversity and inclusion, professional development opportunities and work environments that promote employee satisfaction and work-life balance.

Becker’s cited additional benefits of BHC as being the availability of a 403(b) or 401(k) plan, tuition reimbursement for full- and part-time employees and discounts from local and national retailers. BHC also hosts mentoring programs within the system and in the community for middle school, high school and college students.

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Baptist Medical Group Announces New Neuro Hospitalist Program; Welcomes Krystin Baker M.D., and Keena Risola, D.O. Baptist Medical Group, the growing physician network of Baptist Health Care in Pensacola, Fla., is pleased to announce the new neuro hospitalist program. Along with the new program, Baptist Medical Group welcomes two experienced, board certified neurologist physicians, Krystin Baker, M.D., and Keena Risola, D.O., who offer quality, convenient treatment and diagnosis of a wide scope of neurologic conditions to patients in Baptist and Gulf Breeze hospitals.

Dr. Baker is an experienced neurologist who has been practicing in the Pensacola area since 2012. She completed her residency at Baylor College of Medicine, Neurology Department, in Houston, Texas, and earned her medical degree from St. George’s University in Grenada, West Indies.

Dr. Risola is an experienced neurologist who has been practicing in the Pensacola area since 2008. She completed her residency at St. John Macomb-Oakland Hospital in Madison Heights, Mich., and earned her medical degree from Kirksville College of Osteopathic Medicine in Kirksville, Mo. 15 | ECMS

www.edwardjones.com

Meeting on your schedule, not ours.

Face-to-face meetings. One-on-one relationships.

How did Edward Jones become one of the biggest financial services companies in the country? By not acting like one.

With more than 10,000 offices. Including the office of Rick Lambert, CFP® in Pensacola.

Rick Lambert, CFP® Financial Advisor .

1800 W Garden Street Pensacola, FL 32502 850-429-8403

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MKT-8275-A-AD © 2013 EDWARD JONES. ALL RIGHTS RESERVED.

ECMS | 16

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY