The Journal of the Medical Association of Georgia by PubMan, Inc.

Vol. 106, Issue 3, 2017

Physicians in Georgia weigh in on EHR (and it’s not great news)

HIPAA-compliant texting How the Medicare QPP could change in 2018 Little-known GCMB rules The academic practice model One physician’s views on our health care system

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TABLE OF CONTENTS VOLUME 106, ISSUE 3

IN EVERY ISSUE

32 Specialty Feature

3 President’s Message

34 County, Member & Specialty News

4 Editor’s Message

38 Opinion

6 Executive Director’s Message 14 MAG’s Department of Education 16 Georgia Composite Medical Board 18 Legal: A regulatory minefield 22 Practice Models

43 Prescription for Life

FEATURES 8 A lot of physicians see EHR as a glass that’s less than full 28 HealtheParadigm

37 MAG Medical Reserve Corps 24 Legal: CMS expected to change the Medicare QPP/MIPS 41 Georgia Board for Physician Workforce programs in substantial ways 42 Perspective: The fundamental 30 Patient Safety humanity of medicine

PRESIDENT’S MESSAGE

Thelma and Louise Steven M. Walsh, M.D.

Steve.Walsh@PeriopPartners.com

recently heard a politician compare our health care system to the last scene of the movie ‘Thelma and Louise’ – the one where the car is speeding toward the canyon rim. It was a moment that created a great sense of urgency, but it’s also one that provided little insight. Meanwhile, an article that I read in the Journal of the American Medical Association – ‘Stories Doctors Tell’ – offered some intriguing perspectives. It was based on the stories of more than 150 physicians who were featured in articles that appeared in an array of media outlets, including JAMA, the New England Journal of Medicine, and the Annals of Internal Medicine. There were two dominant themes. The first is a belief that “humanity matters.” The second is a widespread recognition that the model for our health care system is dated and flawed. And some survey results that I came across a while back indicated that… • 75 percent of the physicians knew they wanted to be a physician when they were young (i.e., by the time they are in their teens) • More than 50 percent of physicians view medicine as a calling versus a job • 75 percent of physicians are motivated first and foremost by making a difference in their patients’ lives Historians attribute at least some of this predisposition to Sir William Osler, M.D., who is widely recognized as “the father of modern medicine.” Dr. Osler believed that, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” This goes to the heart of the relationship between physicians and patients and between the application of science and the human condition. Dr. Osler’s name is also synonymous with the “two pillars of medical education,” which include two years of medical science study and two years of clinical science (which is then followed by an internship and residency). These pillars have served our society well for more than a century. It has produced myriad “miracles of medicine,” and it has increased our life expectancy by more than 50 percent. The curriculum may have changed over time, but the basic formula for medical education has remained largely intact.

Unfortunately, physicians have become entangled in the bureaucracy of today’s health care system. This has undermined the patient-physician relationship, and it has led to widespread physician burnout. If the goals are excellent care and sustainable solutions, I believe that we need to fortify – and not dilute – the traditions of our medical education and curriculum. There simply isn’t an acceptable shortcut. We also need to eliminate the silos of care that have become so prevalent in today’s health care system. As leaders, physicians need to foster a culture of teamwork – especially when you consider the shortage of physicians. We consequently need to continue to support programs like the MAG Foundation’s Georgia Physicians Leadership Academy, which now has nearly 120 graduates – including 11 of the 13 members of MAG’s Executive Committee. I, for one, view the development of leadership skills as a necessity for today’s physician. Physicians also need to remain up-to-date on the latest technology. This includes data analytics, like the HealtheParadigm solution that MAG has endorsed, which enable physicians to use their patients’ unique socio-ecological profile to ensure that they receive the best, most efficient individual care – while also helping our practices fulfill the new payer metrics. Efforts are underway to get us from here to there. For example, the American Medical Association (AMA) has formed a ‘Medical Education Consortium’ of 32 member schools that has proposed the addition of “health system science” curriculum, which has been described as the “third pillar” of medical education. What’s more, the AMA has or will provide grants to more than 30 medical schools to develop health system science teaching strategies to better prepare medical students for the complexities of the modern health care system. And I realize that the bar is high, but we must also be effective advocates for our patients and our profession in the legislative and regulatory arenas – not to mention being literate in the areas of health care policy and economics. Like Dr. Osler, I believe that physicians in Georgia are passionate about science, they are passionate about their profession, and they are passionate about their patients. But unlike Thelma and Louise, I don’t believe that physicians in Georgia will ever allow our health care system to reach that canyon rim.

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EDITOR’S MESSAGE

The Medical Association of Georgia 1849 The Exchange, Suite 200 Atlanta, Georgia 30339 800.282.0224 www.mag.org MAG’s Mission To enhance patient care and the health of the public by advancing the art and science of medicine and by representing physicians and patients in the policy-making process. Editor Stanley W. Sherman, M.D. Executive Director Donald J. Palmisano Jr. Publisher PubMan, Inc. Richard Goldman, rgoldman@pubman.net 404.255.5603, ext. 1 Editorial Board Jay S. Coffsky, M.D., Decatur Mark C. Hanly, M.D., Brunswick Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee Steven M. Walsh, M.D., President E. Frank McDonald Jr., M.D., President-elect John S. Harvey, M.D., Immediate Past President Steven M. Huffman, M.D., First Vice President Lisa C. Perry-Gilkes, M.D., Second Vice President Rutledge Forney, M.D., Chair, Board of Directors Frederick C. Flandry, M.D., Vice Chair, Board of Directors Edmund R. Donoghue Jr., M.D., Speaker James W. Barber, M.D., Vice Speaker Andrew B. Reisman, M.D., Secretary Thomas E. Emerson, M.D., Treasurer S. William Clark III, M.D., Chair, AMA Delegation W. Scott Bohlke, M.D., Chair, Council on Legislation Advertising PubMan, Inc. 404.255.5603 or 800.875.0778 Fax 404.255.0212 Brian Botkin, bbotkin@pubman.net Subscriptions Members $40 per year or non-members $60 per year. Foreign $120 per year (U.S. currency only). The Journal of the Medical Association of Georgia (ISSN 0025-7028) is the quarterly journal of the Medical Association of Georgia, 1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Periodicals postage paid at Atlanta, Georgia, and additional mailing offices. The articles published in the Journal of the Medical Association of Georgia represent the opinions of the authors and do not necessarily reflect the official policy of the Medical Association of Georgia (MAG). Publication of an advertisement is not to be considered an endorsement or approval by MAG of the product or service involved. Postmaster Send address changes to the Journal of the Medical Association of Georgia,1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Established in 1911, the Journal of the Medical Association of Georgia is owned and published by the Medical Association of Georgia. © 2017.

4 MAG Journal

Meeting with our legislators Stanley W. Sherman, M.D.

he Medical Association of Georgia’s (MAG) 2017 Summer Legislative Education Seminar was held on June 24 at Brasstown Valley Resort in Young Harris. The attendance was so good that we filled the property and some of us had to stay at a nearby property.

Our morning session began with MAG Council on Legislation Chair Dr. Scott Bohlke making introductions. Dr. Jay Smith led the first session with a panel of seven representatives and senators. This session dealt with inadequate and narrow networks and the 2017 bills that were proposed to deal with them. MAG opposed, and legislators did not pass, H.B. 71 – which would have required physicians to participate in every health care plan offered by any hospital where they have privileges. MAG also opposed another bill, that did not pass, that was introduced by Sen. Renee Unterman to address “surprise billing.” This would have required set payments for doctors providing out-of-network emergency services. Instead, MAG supported a “surprise health insurance coverage gap” bill under which the balance of our emergency care billing would be paid at the 80th percentile of the FAIR Health data base. Although this did not pass, comparable proposals are likely in next year’s legislative session. In the meeting’s second session, Rep. Sharon Cooper discussed the opioid epidemic and the Georgia Prescription Drug Monitoring Program (PDMP). Please see her article in the last edition of the Journal for a review of these issues, as well as legislation that allows optometrists to administer injections in or near a patient’s eye. Rep. Deborah Silcox discussed rural health care and the resources to provide this care. Rep. Betty Price, M.D., discussed a bill she introduced, H.B. 165, which fortunately passed and will prevent the state’s Medical Practice Act from requiring maintenance of certification (MOC) for licensure, insurance panels, or malpractice insurance. MAG also supported Rep. Price’s distracted driving bill – but this did not pass. She also informed us about a U.S. Department of Health and Human Services (HHS) website that she says is a good resource for physicians to help their patients deal with addiction. Rep. Beth Baskin and Sen. Blake Tillery also discussed “surprise billing” and PDMP issues. Rep. Katie Dempsey spoke on patient safety issues, including obesity, better children’s mental health care for suicide prevention, and the lack of funding for Alzheimer’s patients, as well as the need for a greater emphasis on earlier intervention in a number of health care arenas. Session three involved insurance issues, with a report from a representative from the Georgia Insurance Commissioner’s office, who noted concern about the lack of the insurers disclosing their payment information. Rep. David Knight introduced a bill that MAG supported that passed, which will allow the Commissioner of the Georgia Department of Community Health to pass rules for the oversight of pharmacy benefit managers. Because of this, the insurers may be investigated for violations which are deemed financially motivated.

With time at lunch and dinner to get to know our legislators better and personally discuss the issues that matter to us as physicians, this is definitely a ‘Do Not Miss’ event. Many thanks to our MAG legislative team, our representatives and senators who have supported our patients and our profession, and our GAMPAC Board and members who are responsible for the success we have had. Given the number of proposals we had to oppose this year, and the attempt to impose criminal offenses against us this year (related to the PDMP), this event was also the perfect time for Dr. John Harvey to give the attendees the American College of Surgeons’ ‘Stop the Bleed’ presentation and demonstration. In this issue of the Journal, MAG CEO Donald J. Palmisano Jr., discusses MAG’s efforts to address opioid abuse and the PDMP. Our feature article discusses electronic health records, both the pros and cons. It gives some suggestions to help us get the most out of our existing systems, with some hope for a better future if EHR systems can become more user-friendly and clinically relevant. Please see page 12 for the results of our physician survey on EHR. Dan Huff ’s legal article addresses the HIPAA regulations that are related to our technology for storing and communicating a patient’s personal health information. We have an update from the Georgia Composite Medical Board by Dr. John Antalis on important rules that you must know. Dr. Mark Hanly and LaSharn Hughes gives us an update on the Georgia Board for Physicians Workforce and its efforts to improve rural health care in Georgia. Our MagMutual article discusses how telemedicine helps bring needed health care services to rural Georgia. This issue also

includes a report on MAG’s Department of Education, keeping in mind that Chair Dr. Darrell Dean is actively recruiting members to serve on the CME Committee. Our series on practice models with Dr. Barry Silverman continues, as this edition concentrates on Dr. Dimitri Cassimatis’ academic cardiology practice at Emory. Meanwhile, Dr. John Cantwell continues his historical series on doctors who have contributed to the cardiac physical exam. Regarding national health care issues, our Polsinelli legal article reviews CMS proposals in the Medicare Quality Payment Program (QPP) and its merit-based incentive program (MIPS) for 2018. MAG’s president, Dr. Steven Walsh, reminds us to remain passionate in our patient advocacy both within the legislative and regulatory arenas of health care policy. Keeping in mind that we have different perspectives as individuals, and often by specialty, Dr. Minor Vernon begins a two-part series on his take on the problems of our present health care system; in the second part, which will appear in the next edition of the Journal, he will offer his solutions. We hope that his personal views stimulate discussion from our members to write letters to the editor of their own – in agreement and/or disagreement with his views. If we can one day have a consensus, then perhaps we could present this to our legislators rather than have them continue to present us with poor alternatives. Finally, we have very personal contributions by Dr. Jay Coffsky and Dr. Mark Murphy. If you ever need a reminder of what’s really important in life, keep these powerful articles to read again.

MAG’s House of Delegates to take place in Savannah on October 21-22 The Medical Association of Georgia (MAG) will hold its 2017 House of Delegates (HOD) meeting at the Hyatt Regency Savannah on Saturday, October 21 and Sunday, October 22. The HOD is MAG’s primary legislative and policy-making body. The HOD consists of delegates who represent county medical societies, specialty societies that meet minimum membership requirements, and a number of sections – including International Medical Graduates, Medical Students, Organized Medical Staff, Resident Physicians, and Young Physicians. MAG members who are interested in running for MAG office for 20172018 should contact Donna Glass at dglass@mag.org or 678.303.9251. HOD meeting attendees who need assistance with HOD lodging should contact Anita Amin at anita@associationstrategygroup.us or 404.299.7700. HOD attendees are encouraged to attend a welcome reception that will take place at the Hyatt at 6 p.m. on Friday, October 20. MAG’s Board of Directors is scheduled to meet at the Hyatt from 1 p.m. to 4 p.m. on October 20, while GAMPAC’s Board of Directors will meet at the Hyatt from 4 p.m. to 5:30 p.m. on October 20.

HOD delegates can download MAG’s HOD meeting app by searching for ‘MAG HOD 2017’ in the Apple or Google Play app stores. It features information on the HOD meeting schedule, reports and resolutions, sponsors and exhibitors, lodging and parking, and staff and physician leader contacts. Contact Mandi Milligan at mmilligan@mag.org with questions related to the HOD meeting app. MAG will host a medical student abstract competition for MAG member students that will place in the lobby of the Hyatt from 12 p.m. to 4 p.m. on Saturday, October 21. The competition will have four categories, including basic science/bench work, clinical research, public health, and case studies. The winning abstracts will be published in the Journal of the Medical Association of Georgia. Participants will also be given the opportunity to participate in a ‘Best Pitch Competition,’ where they will have 45 seconds to “pitch” a panel of physician judges. The winner of that competition will be featured on MAG’s website. Finally, a new HOD delegates’ orientation webinar will take place at 7 p.m. on Wednesday, October 4. Contact Renai Lilly at rlilly@mag.org for details. Also contact Lilly with any other questions related to the HOD meeting. Go to www.mag.org for additional information on the HOD meeting.

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EXECUTIVE DIRECTOR’S MESSAGE

There is a better way Donald J. Palmisano Jr. dpalmisano@mag.org

ome people have suggested that physicians are responsible for the prescription drug abuse epidemic. Over- or irresponsible prescribing, they say. While misguided and untrue, this mindset has resulted in some very real change that has subjected physicians to new and often onerous rules and regulations. For example, physicians in Georgia will be required to check the state’s prescription drug monitoring program (PDMP) before they prescribe certain Schedule II drugs or benzodiazepines beginning in July of next year. Meanwhile, the Georgia Composite Medical Board (GCMB) recently approved a rule that will require physicians to take a three-hour CME course on opioid prescribing. And with a clear disregard for physician autonomy, Blue Cross Blue Shield of Georgia has limited the number of days it will okay for new opioid prescriptions. With this in mind, do we really need to ask why so many physicians are frustrated, demoralized, and burnt out? If there is a silver lining, it is that things could be far worse if not for the efforts of the Medical Association of Georgia (MAG). MAG worked with Rep. Kevin Tanner (R-Dawsonville) to reduce the administrative burden that is associated with the aforementioned PDMP requirement (H.B. 249). MAG lobbied to…

• Increase the number of exceptions • Reduce the number of drugs that are covered by the mandate • Remove the limits on the number of days for firsttime prescriptions • Delay the implementation timeline to give the state additional time to fix a number of technical glitches MAG also deserves much of the credit for convincing lawmakers to eliminate a provision that would have subjected physicians who fail to use the PDMP to criminal penalties. Based on the policy that was established by our House of Delegates, MAG has called for allowing individual physicians to decide what CME they should take based on what is best for their patients. MAG has emphasized that there is no compelling reason to require physicians who prescribe opioids on a regular basis to take any particular CME course 6 MAG Journal

if they believe they could spend their time in better ways to enhance and expand their skill sets (based on their judgment, as well as their education and experience and training). I genuinely believe that GCMB – which faced enormous pressure from a lot of groups to take action – took MAG’s perspective into account and made a good faith effort to develop a balanced and generally workable “self-regulatory” solution. It’s not ideal, but GCMB’s mandatory CME solution was more palatable than having lawmakers address the issue with a statute. If we really want to curb prescription drug abuse, I believe that we should look at solutions that ensure physicians have easy access to the complete and real time patient data they need to make the best possible decisions – keeping in mind that the biggest problem with the PDMP and most of today’s electronic health record systems is a lack of interoperability. This is why MAG has endorsed HealtheParadigm, a physicianled health information network. HealtheParadigm helps physicians make the transition to the new value-based payment programs (e.g., the Medicare QPP) by providing them with easy access to the patient data that is available in the state’s health information exchange (HIE). It has several unique features, including an “analytics dashboard” and “business intelligence” that enable physicians to detect patterns within atrisk populations, to engage patients sooner, and to reduce costs. With HealtheParadigm, physicians have real time access to 100 percent of a patient’s information at the time of the encounter – and the information that the attending physician enters into the system becomes available to their colleagues on a 24/7/365 basis. So when a physician prescribes an opioid, any other physician can find out about the prescription on an instantaneous basis – rather that contend with a 24-hour turnaround, which is the case with the PDMP today. And before the naysayers point any more fingers at physicians, they should consider that MAG (i.e., physicians) has been a leader in promoting good prescribing practices and fighting prescription abuse in the state since the MAG Foundation established its ‘Think About It’ campaign in 2010. Editor’s note: Visit www.healtheparadigm.com for details on HealtheParadigm and contact Bethany Sherrer at bsherrer@ mag.org for information on Georgia’s PDMP requirements.

NCI Designated Comprehensive Cancer Center

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A lot of physicians see EHR as a glass that’s less than full By Tanya Albert Henry

hen it comes to how physicians in Georgia feel about electronic health records (EHR), it’s clear that many see the glass as less than full. In fact, nearly 60 percent of the 180 physicians in the state who completed a survey that the Medical Association of Georgia (MAG) conducted in July have a “generally unfavorable view of EHR.” Perhaps more troubling is that a comparable number “are not optimistic that EHR will continue to enhance patient care with time.” The clear takeaway is that a significant number of physicians in the state have grown increasingly disenchanted with EHR – as more than half say their view of EHR is “less favorable” today than it was five years ago. So what’s the problem? MAG President Steven M. Walsh, M.D., believes that much of the angst surrounding EHR can be attributed to government intervention. He asserts that, “A lot of physicians believe that the federal government has turned EHR into a time burdensome, cost-control exercise that takes precious time away from patients – which explains why more than 70 percent of the physicians who completed the MAG survey do not believe that the Medicare and Medicaid EHR ‘incentives’ programs enhance patient care.” While Dr. Walsh was encouraged when U.S. Health and Human Services Sec. Tom Price, M.D., recently acknowledged 8 MAG Journal

that, “We’ve turned physicians and other providers into data entry clerks,” the Roswell anesthesiologist is convinced that, “We would be in a much better place, and we would be having a much different conversation, if the effort to develop the EHR systems and metrics had been physician-led.” Douglas orthopedic surgeon James Barber, M.D., agrees in full. He recalls that, “There was a time when I was excited about EHR’s potential to become a valuable tool for physicians to enhance patient care, but I have grown more despondent with each passing year.” Dr. Barber adds that, “EHR has been terribly inefficient and costly, and physicians and practice staff spend way too much time inputting metrics – which obviously undermines patient care.” He is not alone, as four of every five doctors who took the MAG survey said that the amount of time that spend on EHR is “not reasonable” – while seven of every 10 said it has “hurt their relationship and interaction with patients.” One physician reported that, “I spend more time on EHR than I do with my patients. [It is] a real pain to edit and customize. It does not benefit the patient, and it certainly does not benefit the provider.” Another remarked that, “The diagnosis database that my EHR vendor uses adds incredible complexity and makes it too easy to choose the wrong diagnoses codes, which could result in third party payer reviews and claw backs as well as denials of services.”

A third said that, “I have to spend too much time on documentation because of the poorly designed, multi-click choices.” And Jake Choi, M.D., who is completing a one-year internship in Gwinnett Medical Center’s transitional program – which exposes him to a wide range of specialties – says that he “does not like the fact that today’s EHR systems are neither interoperable or user-friendly for physicians or practice staff.” EHR vendor (dis)satisfaction Beyond the software and systems, more than 60 percent of the physicians who completed MAG’s survey said they are also “not satisfied” with their EHR vendor – and Christopher Kunney, a managing partner and technology strategist with InfiniteOptions’ Technology and Business Strategists in Atlanta, isn’t surprised. “I get it,” he says. “I genuinely understand why so many physicians are frustrated.” That said, Kunney appeals to physicians to be patient, stressing that, “EHR is evolving, and it’s really still in its infancy.” He explains that, “Someone can use an application like Facebook or Twitter almost immediately, without training. Unfortunately, today’s EHR systems generally aren’t very intuitive or easy for clinicians to use in that kind of instantaneous way at the point of care.” Kunney does, however, believe the HIT industry is listening and that the ship will be righted – though only time will tell whether the change will be precipitated by a carrot or a stick. “When I use my Amazon Echo device, I talk and the technology (i.e., “Alexa”) interprets what I’m saying,” Kunney explains. “History and logic suggest that’s where EHR technology must inevitably go.” He adds that, “It might not always seem like it’s the case, but the IT industry is keenly aware of the need for physicians to be able to get back to a point where they can spend more time face-toface time with their patients versus looking at a computer screen and typing.” He is also confident that, “The companies that develop innovative, physician-friendly ‘AI’ solutions in the most expeditious way are the ones that will ultimately prevail in the marketplace.”

And while he does not believe it’s an acceptable excuse, Kunney does point out that EHR vendors have been focused on developing products and solutions to help physicians fulfill the post-SGR payer requirements (e.g., the Medicare Quality Payment Program).

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“Better, more user-friendly technologies do exist. They just need to be adapted for the medical profession, something that I believe will occur in the next five or so years.”  Tic toc One the most common complaints that physicians have about EHR is the amount of time it takes away from their patients when they are in the exam room. The results of an ‘Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties’ study that were featured in the December 2016 edition of the Annals of Internal Medicine bears this out – as it found that for “every hour a physician provides direct clinical face time to patients, he or she spends nearly two additional hours on EHR and desk work within the clinic day.” This American Medical Association (AMA)-funded study also found that “physicians spend another one to two hours of personal time each night doing additional computer and other clerical work, mostly devoted to EHR tasks.” Dr. Walsh says, “This is obviously unacceptable and unsustainable. We must find a way to flip this trend on its head. We need to get to a point where physicians embrace EHR as a valuable resource, one that enables them to deliver better and more efficient patient care.” Some good news

Kunney also stresses that, “Better, more user-friendly technologies do exist. They just need to be adapted for the medical profession, something that I believe will occur in the next five or so years.”

While the great majority of today’s physicians are less-thanenthralled with EHR, it is important to acknowledge that 30 percent of the physicians who completed the MAG survey do have a “generally favorable” view EHR.

Recognizing that just less than 10 percent of the physicians who took the MAG survey said they like their EHR system’s interoperability with other systems, Kunney believes the banking industry has proven that interoperability is possible.

In terms of the positives, Dr. Barber says, “I like the fact I don’t have to chase down paper charts, and I like knowing that more than one physician can access a patient’s record at the same time.”

He says, “The banking industry shares data all the time, so I think the real key is breaking down some historical barriers and getting to a point where physicians and health care systems are willing and able to share their patient data.”

Dr. Choi adds that with EHR, a patient’s information is “legible and easily accessible, both inside and outside the hospital. Plus, physicians generally have easier access to a patient’s lab results, as well as their historical records – so we can spot trends.” (continued on page 10)

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(continued from page 9)

He is among the growing number of physicians who see the value associated with EHR systems that have enhanced capabilities – like HealtheParadigm, which is a health information network that has been endorsed by MAG that enable physicians to generate “a longitudinal patient record in addition to business intelligence and data analytics.” Dr. Choi says, “I am really excited to see how we can leverage our EHR systems and innovative solutions like HealtheParadigm to become more efficient and improve patient outcomes, not to mention fulfill the new payer metrics.” It is also worth noting that one of his fellow physicians who completed the MAG survey pointed out that, “Physicians also like e-prescribing and being able to use their EHR to automate some repetitive tasks,” while another viewed being able to “read other physicians’ notes as the biggest advantage [with EHR].”

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“I like the fact I don’t have to chase down paper charts, and I like knowing that more than one physician can access a patient’s record at the same time.”  MAG’s efforts MAG continues to push for change in the EHR arena. In addition to forming a task force that deals with ad hoc EHR issues, MAG has supported the AMA’s advocacy efforts to address the problems surrounding EHR at the federal level. This includes endorsing an AMA position paper that outlines eight priorities that should be taken into account to improve EHR that was written by a group of physicians that included Decatur rheumatologist Gary Botstein, M.D. It calls for the development of EHR systems that will…

• Enhance physician-patient communication and engagement • Support team-based care • Enhance care coordination across the continuum of care • Offer product modularity and configurability to meet individual practice requirements • Support medical decision making with concise, context sensitive and real-time data • Facilitate connected health care across care settings and enable both exporting data and properly incorporating data from other systems 10 MAG Journal

• Work with patient mobile technology to support patient engagement • Accommodate end-user input and facilitate postproduct implementation feedback For now… What, then, are frustrated physicians supposed to do until we get from here to there. Kunney has some suggestions that he believes can help physicians get the most out of their existing EHR, while also minimizing their costs. He says to…

• Talk to your vendor. According to Kunney, “A physician should view their EHR vendor as a partner and a member of the practice team. A close working relationship with your vendor will help ensure that your EHR system works well for your unique practice setting.” • Emphasize training. Kunney says, “Determine what is the best approach for you and your practice, whether that’s online training, classroom training, or having an expert come to your practice to shadow practice staff and teach them the best approach for your practice setting. At least one person in the office should have in-depth knowledge of your EHR so they can be the point person to answer questions and help optimize the system. Just like a physician needs to learn how to deliver patient care, practice staff needs to learn how to use any given EHR technology.” • Optimize your system. Kunney suggests that, “After the first 30 days, 90 days or six months of implementing a new EHR system, do a postmortem to determine what’s working and what isn’t. And on an ongoing basis, identify gaps and issues and work with your vendor and your IT department to make sure that you are getting the most out of what your EHR system has to offer – and it is essential to understand your EHR system’s features and capabilities.” • Rent equipment. Kunney explains that, “Your IT infrastructure needs to be available and working properly at all times, including your privacy and security safeguards, printers, and laptops. You can buy a service that stores the data and takes care of privacy and security. You can also lease your hardware so you don’t have to replace it every two to three years. It’s like leasing a car, where you pay a set amount each month and get new equipment at the end of the life cycle. And in some cases, system maintenance is included in the contract.”

• Invest in consultants, but only as-needed. Kunney notes that, “A good consultant can deliver great value and help you improve and streamline your EHR processes in a cost-effective way. For practices that don’t have a chief information officer, these consultants can effectively serve as a virtual CIO.”

And he promises that, “The Medical Association of Georgia will continue to work with the American Medical Association and lawmakers and other key stakeholders until it is satisfied that EHR is a seen as a user-friendly tool that physicians can use to enhance patient care.”¨

• Include your patients in the process. Kunney suggests that physicians, “Turn the computer screen or iPad to face the patient so they can discuss the patient’s medical history or lab results together. This will help the patient feel like they are empowered and part of the process, and it will strengthen the physicianpatient relationship.”

‘How to Select EHR Technology’ www.americanehr.com Features reviews that are submitted by EHR users (“verified physicians, physician assistants, nurse practitioners and practice managers”)

Hope for the future “Despite the challenges we now face, I am optimistic that EHR will eventually achieve its full potential,” says Dr. Choi. “I believe EHR will become more user-friendly and clinically-relevant.” He adds that, “I also believe that we owe it to our patients to do the best we can in the short term, while we continue to press for better solutions in the longer term.” Dr. Walsh remarks that, “I understand why so many physicians are frustrated and disappointed with how EHR has evolved in the American health care system. But turning our back isn’t going to solve the problem, no matter how fatigued we might feel. We have to insist that we have a seat at the table, we need to begin speaking with a more powerful and unified voice, and we need to be relentless in our efforts.”

Resources

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www.mag.org 11

Physicians in Georgia weigh in on EHR The Medical Association of Georgia (MAG) recently conducted a survey of physicians in the state to see how they feel about electronic health records (EHR). Nearly 180 physicians completed the survey. The following is a summary of the survey results. How do you view EHR? 31% > generally favorably 58% > generally unfavorably 10% > indifferent How have your views on EHR changed in the last five years? 20% > more favorable 54% > less favorable 25% > about the same Are you satisfied with your EHR system? 28% > yes 64% > no What do you like about your EHR system (MAG asked for all that applied)? 31% > patient data/analytics 22% > ease of use 11% > security features 10% > Medicare/Medicaid incentives 10% > cost 9% > interoperability with other systems 6% > vendor support Comments… • E-prescribing. • Access to diagnostic tests/images for comparison purposes and the ability to scan paper and reduce storage space. • Better accessibility to some historical data compared to paper charts. • Ability to read other physicians’ notes is the biggest advantage. I also like being able to see every encounter in the system, as well as test results. • I like being able to find records at other facilities that use the same system. • I can use my EHR for charting and looking at billing and collections. • Being able to automate some repetitive tasks. What do you dislike about your EHR system (MAG asked for all that applied)? 67% > interoperability with other systems 55% > ease of use 50% > cost 43% > vendor support 25% > Medicare/Medicaid incentives 25% > patient data/analytics 25% > security features Comments… • I have to spend too much time on documentation because of the poorly-designed, multi-click choices. • I spend more time on EHR than I do with my patients. [My EHR is] a real pain to edit and customize. It does not benefit the patient, and it certainly does not benefit the provider. • [EHR] Adds hours to my day [compared to my old] paperbased system. • EHR is not paperless by any means. • The diagnosis database that my EHR vendor uses adds incredible complexity and makes it too easy to choose

12 MAG Journal

the wrong diagnoses codes, which could result in third party payer reviews and claw backs as well as denials of services. • My EHR screens are often overwhelming, with too much information presented…and my patients think that I have reviewed every note prior to seeing them. Do the Medicare/Medicaid EHR programs enhance patient care? 6% > yes 72% > no 9% > undecided What is the single most important change you would like to see occur in the Medicare/Medicaid EHR program? • Make every computer interconnect. • Eliminate the penalties for failing to use features of a lagging industry that is overpriced and unprepared to handle true patient care. • Proof that EHR helps patients and reduces costs. • Employ a single system that is simple to use and interoperable and can be used on mobile devices. • Get away from measures that aren’t important but easily measurable and work on measuring things that are important – even if it’s more difficult. • Limit the number of goals, and make it more specialtyspecific. • Use systems that are designed by practicing physicians. • Make EHR optional, or at least back off and phase it in over the next 15 to 20 years – allowing the technology to mature. Are you optimistic that EHR will continue to enhance patient care with time? 20% > yes 62% > no 18% > undecided Is the amount of time you and your practice staff spend on EHR reasonable? 13% > yes 81% > no Is the amount of money you and your practice spend on EHR reasonable? 12% > yes 74% > no How has EHR affected your relationship/interaction with your patients? 5% > helped 68% > hurt 22% > no change Are you excited about any new EHR or health IT products or developments? • Being able to quantify risk for individualized medicine. • Apps that help patients get healthy and stay healthy, that remind them to take the medication and remember their appointments, and that monitors their conditions. • Patient data analytics. Are you familiar with HealtheParadigm (www. healtheparadigm.com), which enables physicians in Georgia to generate patient data reports that they can use to improve patient outcomes and fulfill today’s qualitybased payer metrics? 20% > yes 80% > no

OC CU U SS O ON NH H EE LL PP II N NG G FF O OT H H EE RR S. S. OT “It was the first note I ever got in crayon. “It was the first note I ever got in crayon. ‘Thank you for making my daddy feel better.’ ‘Thank you for making my daddy feel better.’ I keep it on my desk, where I pore over patient I keep it on my desk, where I pore over patient records and cash flow statements. records and cash flow statements. Because even if the medical field seems to Because even if the medical field seems to be changing by the day, the reasons be changing by the day, the reasons I practice never do.” I practice never do.”

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CME PROVIDERS

MAG Department of Education

he Medical Association of Georgia’s (MAG) Department of Education manages the accreditation process for organizations that offer Category 1 credit toward the AMA Physician’s Recognition Award. MAG receives its authority to accredit intrastate providers from the Accreditation Council for Continuing Medical Education (ACCME). MAG accredits 38 organizations (hospitals, voluntary health organizations and specialty societies) that are authorized to offer physicians AMA PRA Category 1 Credit(s)TM that meet Georgia and Tennessee license renewal requirements. MAG’s Department of Education abides by all ACCME accreditation requirements and polices. Go to www.mag.org/accreditation for more information on MAG’s Department of Education.

that desire to provide accredited CME activities to Georgia physicians. [It] reviews and approves applications for accreditation and reaccreditation, establishes accreditation policies, provides supervision and guidance to surveyors and holds periodic training sessions for staff of accredited organizations. [It] keeps all accredited organizations updated concerning MAG, Accreditation Council for Continuing Medical Education (ACCME) and American Medical Association (AMA) requirements and policies related to CME.” The committee’s chair, Darrell Dean, D.O., says that, “This is an easy and rewarding way to make a contribution to the medical profession in Georgia. The primary role of this group is to ensure that the CME providers that MAG accredits offer interesting and relevant CME programs.” He also stresses that, “Of course, this is ultimately a great way to enhance patient care.”

MAG recruiting members to serve on CME Committee

Dr. Dean says that the time commitment is nominal – as the committee generally only meets by conference call four times a year.

MAG’s Committee on CME is a “[special committee that is] charged with the responsibility of accrediting organizations

MAG members who are interested in serving on MAG’s CME Committee should contact Andrew Baumann at abaumann@mag.org.

MAG Accredited CME Provider Organizations Hamilton Medical Center 706.272.6056

South Georgia Medical Center 229.259.4131

Houston Healthcare 478.542.7963

Southeast Georgia Health System 912.466.7140

Covenant Health 931.459.7037

John D. Archbold Memorial Hospital 229.228.2768

Southern Alliance for Physician Specialties CME 770.613.0932

William Silver, M.D.

DeKalb Regional Health System 404.501.1628

MagMutual 404.842.5681

Southern Regional Health System 770.991.8353

Online CME

Emory Regional Perinatal Center 404.616.4219

Medical Center of Central Georgia 478.633.1144

St. Francis Hospital 706.660.6058

Floyd Medical Center 706.509.5789

Memorial Health Care System 423.495.4759

St. Joseph’s/Candler Health System 912.819.7646

Georgia Academy of Family Physicians 404.321.7445

Memorial Health University Medical Center 912.350.8168

St. Mary’s Health Care System, Inc. 706.389.2655

MAG’s CME Committee Darrell Dean, D.O. (Chair) Fred Flandry, M.D. Wayne Mathews Jr., M.D. William Miller Jr., M.D. James Rawson, M.D.

The following websites offer free online CME activities: freeCME.com www.freecme.com Medscape www.medscape.org MedPageToday www.medpagetoday.com/cme MyCME www.mycme.com

American Academy of Pediatrics – Georgia Chapter 404.881.5067 Children’s Healthcare of Atlanta 404.785.7624

Georgia Chapter of the American College of Cardiology 770.271.0453 Georgia Hospital Association Research and Education Foundation 770.249.4517

Northeast Georgia Medical Center & Health System, Inc. 770.219.7715

Georgia Psychiatric Physicians Association 404.298.7100

Northside Hospital 404.236.8418

Georgia Society of Ophthalmology 404.299.6588 Gwinnett Hospital System 678.312.4341

14 MAG Journal

Memorial Satilla Health 912.287.2597

Phoebe Putney Memorial Hospital 229.312.1426 Piedmont Athens Regional 706.475.7525 Piedmont Healthcare 404.605.2750

Tanner Health System 770.812.5973 The Medical Center 706.571.1179 The Southeast Permanente Medical Group, Inc. 404.504.5591 Tift Regional Medical Center 229.353.6805 University Healthcare System 706.774.5786 WellStar Health System 470.956.6431

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www.mag.org 15

GCMB UPDATE

Little-known Georgia Composite Medical Board rules By John Antalis, M.D., Georgia Composite Medical Board

t has been an honor and a privilege to serve as the chair of the Georgia Composite Medical Board (GCMB). As I move into the past-chair’s position, I am very proud of GCMB’s progress in addressing opioid abuse and unprofessional conduct. Also note that we are working with our staff to improve their response time to physician inquiries and streamlining the process for acquiring a medical license. I thought that this would be a great opportunity to update you on several little-known regulatory and administrative rules that should be of interest. Physicians in the state are required to complete 40 hours of CME biennially. A physician does not need to demonstrate that they have fulfilled this CME requirement unless they are randomly audited. If you are audited, failing to prove that you completed the required CME may lead to punitive action by the GCMB. Physicians who are retired, who have an active license, or who provide uncompensated health care services need only 10 hours of Board-approved continuing education every two years. CME must be Category 1 credit from the AMA, AOA, AAFP, ACOG, or ACEP. Medical boards in 45 states require a criminal background check as a condition of initial licensure, 43 states check the FBI database before they license a physician, and 39 states require physicians to be fingerprinted as a condition of licensure. But in Georgia, the only physicians who undergo criminal background checks are the ones who operate pain clinics – and that only takes place during the initial licensure process. When it comes to expert witnesses, Georgia only requires a physician to “have an appropriate level of knowledge” to testify – keeping in mind that they must “have practiced or taught for at least three out of the last five years to establish the requisite level of knowledge” and they must be an M.D. or D.O. Non-physician medical professionals are not allowed to be expert witnesses in the state. Expert witnesses in a medical malpractice case may be subject to the ‘Daubert Rule’, which allows a judge to decide whether scientific expert testimony is based on requisite scientific knowledge. It is also important to remember that telemedicine physicians who prescribe controlled substances for “a patient, their guardian, or their agent” based solely on a consultation via 16 MAG Journal

John Antalis, M.D.

electronic means are subject to GCMB disciplinary action. I should also stress that physicians who are on-call or covering for another physician or in an emergency are allowed to write a 72-hour prescription. And it is worth noting that telemedicine physicians must perform an H&P, they must present a differential diagnosis, and they must identify underlying conditions – as well as any identifying contraindications to the recommended treatment. Georgia is one of 48 states that require telemedicine physicians to be licensed in the state where they are located. It is also one of 28 states that require both private insurance and Medicaid to cover telemedicine services to the same degree they do a face-to-face encounter. If it is passed into law in the state in 2018, the Interstate Medical Compact would streamline Georgia’s process for multistate licensure. In 2015, Georgia passed a law that allows patients to use up to 20 ounces of “low THC” oil to treat eight illnesses, including cancer, seizures, and Parkinson’s disease. The law was expanded during this year’s legislative session to include AIDS, Alzheimer’s, autism, epidermolysis bullosa, peripheral neuropathy, Tourette’s syndrome, and patients who are in hospice care. GCMB has established criteria for physicians to “certify” the patients to qualify for Georgia’s ‘Low THC Oil Registry’ – but note that those physicians are subject to disciplinary action if they violate their agreement of certification with DCH, fail to sign the waiver form that cannabinoids benefits are unknown and could cause harm, or fail to send the quarterly reports that are required by the Georgia Department of Community Health. The process for residents to obtain a training license in Georgia requires a yearly “positive” report from the resident’s program director. For post-graduate training (PGT) physicians, the requirement for licensure is one year – while the requirement for foreign medical graduates is one to three years. There is no examination requirement to obtain a PGT license in Georgia. Board regulations affect how you practice within the law. I hope that my articles provide you with the information you need to make the best possible decisions. Dr. Antalis served as GCMB’s chair from July, 2016 to July, 2017. He was MAG’s president in 2004-2005.

GCMB amends opioid prescribing CME requirement The Georgia Composite Medical Board (GCMB) has amended a ruling that it issued that is related to the opioid prescribing CME that will be required for physicians who prescribe controlled substances in the state to renew their medical license beginning in 2018 as a result of H.B. 249. The GCMB ruling now says that, “(4) Effective January 1, 2018, every physician not subject to Rule 360-15-.01(3) who maintains an active DEA certificate and prescribes controlled substances, except those holding a residency training permit, shall complete at least one time three or more hours of AMA/AOA PRA Category 1 CME that is designed specifically to address controlled substance prescribing practices. The controlled substance prescribing CME shall include instruction on controlled substance prescribing guidelines, recognizing signs of the abuse or misuse of controlled substances, and controlled substance prescribing for chronic pain management. Any controlled substances prescribing guidelines coursework taken within two years of [the physician’s] last renewal will count toward this requirement. Completion of this requirement may count as three hours toward the CME requirement for license renewal.”

Protecting your patients, your profession & your future GAMPAC is your peace of mind. Joining MAG’s non-partisan political action committee is the best and easiest way to elect pro-physician candidates in Georgia. Go to mag.org/affiliates/gampac to join GAMPAC today.

In a related development, the Georgia Chapter of the American College of Physicians is offering a free online ‘Safe RX Opioid’ course for physicians (including non-members) that offers “3.5 CME credits and 3.5 MOC points.” Go to www.gaacp.org or call 770.965.7606 with questions. Go to http://bit.ly/2xkjjdG for the ACP ‘Safe RX Opioid’ course. Go to http://bit.ly/2xigJra for MAG’s H.B. 249 fact sheet. Paid for by GAMPAC

www.mag.org 17

LEGAL

A regulatory minefield By Daniel J. Huff, Esq., partner, and Christian P. Dennis, Esq., associate, Huff, Powell & Bailey, LLC

ost physicians are familiar with the regulatory requirements concerning protecting patient information. Technological advances, regulatory complexities, and misinformation results in frequent noncompliance. As communications technologies advance, it can be difficult to identify the appropriate regulations that govern the technology – let alone remaining compliant with the patient privacy requirements. Physicians use a range of communications devices – including watches, PDAs, tablets, and mobile devices – that enable them to communicate via “text messaging” (e.g., SMS messaging, iMessage, instant message, etc.). These devices make communicating more efficient, effective, and instantaneous, which leads physicians to use them with greater frequency, particularly when it is at the bequest of their patients, a consulting physician, or a physician resident.1 Application of HIPAA Without discounting the Health Insurance Portability and Accountability Act’s (HIPAA) Privacy Rule2, it is essential for physicians to become familiar with HIPAA’s Security Rule.3 The Privacy Rule generally concerns the access, use, or disclosure of Protected Health Information (PHI),4 while the Security Rule applies to electronic PHI and its presence, storage, and disclosure in electronic form. The Security Rule requires physicians to “[i]mplement technical security measures to guard against unauthorized access to [e-PHI] that is being transmitted over an electronic communications network.”5 The two rules work in unison, often overlap, and do not override or preempt each other, absent express language. It is possible to violate one of these two rules but not the other. For instance, the Privacy Rule requires physicians to communicate with their patients in the patient’s requested medium, including email and/or text.6 However, a physician who improperly discloses a patient’s information under the Privacy Rule may inadvertently violate the Security Rule. HIPAA governs technology that is capable of storing or transmitting PHI. The Security Rule applies to “electronic media storage” and “electronic media” – which are both broadly defined under HIPAA.7 Electronic media includes “[e]lectronic storage material on which data is or may be recorded electronically, including, for example, devices in computers (hard drives) and any removable/transportable digital memory medium…”8 Electronic media also includes “[t]ransmission media used to exchange information already in electronic storage media.”9

18 MAG Journal

The U.S. Department of Health and Human Services’ (HHS) Office of the National Coordinator for Health Information Technology (ONC) has provided that: In general, individuals and organizations that meet the definition of a covered entity…who transmit health information in electronic form in connection with certain transactions must comply with the Rules’ requirements to protect the privacy and security of health information, even when using mobile devices. Their business associates are also contractually required to follow these requirements.10 HIPAA says that PHI is any “identifiable health information… transmitted or maintained in any other form or medium.” Importantly, the “Security Rule does not apply to the patient. A patient may send health information to you using email or texting that is not secure.11 That health information becomes protected by the HIPAA Rules when you receive it.” 12 Texting orders The Joint Commission, in collaboration with the Centers for Medicare & Medicaid Services (CMS), prohibits physicians from texting orders. The Joint Commission initially issued a decree that provided direction for orders by text. But in 2011, it concluded that it would no longer be acceptable for physicians to text orders.13 Then in May of 2016, the Joint Commission changed its position and said that physicians may use text messaging for orders as long as their systems met specific requirements.14 Finally, it reversed its position yet again last year when it prohibited text messaging (including secure texts) to communicate orders.15 Texting allowed, but safeguards necessary The Joint Commission and CMS have also recommended that health care organizations adopt policies prohibiting the use of unsecured text messaging from personal mobile devices to communicate PHI.16 While the Joint Commission and CMS stances on texting are generally seen as recommendations, noncompliance is an issue HHS is pursuing. Risks of texting PHI include the chance of theft or misplacement, PHI remaining on the device after being it is traded-in or discarded, and service providers storing PHI in messages. Texting PHI from a mobile device may also create challenges and vulnerabilities in litigation (e.g., the information may be requested years after the communication), keeping in mind the information in a text message to and/or from a patient can be helpful for either party. The Security Rule does not expressly prohibit the electronic transmission of PHI or text messaging,17 and the Privacy Rule allows covered health care providers to share PHI electronically (or in any other form) for treatment in a networked environment (continued on page 20)

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www.mag.org 19

(continued from page 18)

– as long as one applies reasonable safeguards.18 The Security Rule does, however, require compliance with standards that are related to access control, integrity, and transmission security of the information and polices that ensure the safeguards.19 HHS recently fined Children’s Medical Center of Dallas $3.2 million for violating the Security Rule as a result of 1) an unencrypted, non-password protected BlackBerry that was lost in 2009 and 2) the theft of an unencrypted laptop in 2013 and 3) failing to implement risk management plans and 4) knowingly failing to encrypt or protect electronic devices.20 This may be an outlier, but fines for individual infractions can range from $100 per record/violation for unknowing violations to $1.5 million for willful neglect per record/violation. 21 HIPAA-compliant texting There are two ways providers can remain compliant with HIPAA when they are using their mobile devices. The first, as a minimum, calls for 1) using a password or other user authentication and 2) installing and activating remote wiping and/or remote disabling and 3) disabling and do not install/use file sharing applications and 4) installing and enabling a firewall and 5) maintaining physical control of the device and 6) installing and enabling encryption.22 The second method involves using an application or platform that allows all authorized parties to access PHI and collaborate through a secure platform, which must comply with regulatory security measures. And each party should have their own access information to authenticate their identity to access the platform. Medical providers may be tempted to seek more practical HIPAAcompliant alternatives when they are communicating with their colleagues, such as sending sterilized or de-identified messages (i.e., those that do not include PHI). But these also present vulnerabilities. First, the requesting physician may have to document the message in the patient records – remembering that patients are entitled to access their records under HIPAA. And while the requesting physician may document the communication in the patient’s record, the consulting physician may not possess enough identifying information (e.g., PHI) to document or recall the consult should litigation or an event requiring recollection arise. Conclusion While HIPAA allows medical providers to communicate PHI via electronic mediums in certain instances, there are significant risks. Providers should refrain from texting or emailing PHI to any party using a device that does not contain the safety mechanisms prescribed by HIPAA. Providers should ensure any technology that accesses, stores, or transmits PHI complies with HIPAA and other HHS rules. Providers should also train employees to use the least amount of PHI necessary when communicating, especially when they are using automated appointment reminders, leaving messages, etc. to reduce the chance of inadvertent disclosures. However, with the proper safeguards in place, physicians can use technology to improve their practice and the well-being of their patients.¨

20 MAG Journal

Huff and Dennis are with the Atlanta law firm of Huff, Powell & Bailey, LLC. They defend civil lawsuits on behalf of hospitals, physicians, product manufacturers, businesses, corporations and other professionals. Huff and the firm tries several jury trials each year. Contact Huff at dhuff@huffpowellbailey.com. Paid editorial submission.

References See Ventola, C. Lee. Mobile Devices and Apps for Health Care Professionals: Uses and Benefits. Pharmacy and Therapeutics 39.5 (2014): 356–364. 45 C.F.R. §§ 160, 164.500. 3. 45 C.F.R. §§ 160, 164.302. 4. 45 C.F.R. § 160.103. 5. 45 C.F.R. § 164.312(e)(1). 6. 45 C.F.R. § 164.522(b). 7. 45 C.F.R. § 160.103 (2011). 8. Id. 9. Id. 10. Office of the National Coordinator (ONC) for Health Information Technology, U.S. Department of Health and Human Services (HHS), www.healthit.gov/providersprofessionals/frequently-asked-questions/516#id193. 11. ONC/HHS, Privacy and Security Guide: Chapter 4 Understanding Electronic Health Records, the HIPAA Security Rule and Cybersecurity, www.healthit.gov/sites/default/files/ pdf/privacy/privacy-and-security-guide-chapter-4.pdf. 12. Id. 13. The Joint Commission, “Clarification: Use of Secure Text Messaging for Patient Care Orders is Not Acceptable,” The Joint Commission Perspectives (December, 2016), www. jointcommission.org/assets/1/6/Clarification_Use_of_Secure_Text_Messaging.pdf. 14. Id. 15. The Joint Commission, “Clarification: Use of Secure Text Messaging for Patient Care Orders is Not Acceptable,” The Joint Commission Perspectives (December 2016), www. jointcommission.org/assets/1/6/Clarification_Use_of_Secure_Text_Messaging.pdf. 16. Id. 17. Office for Civil Rights, HHS, “Guidance on Risk Analysis” (July 14, 2010). www.hhs.gov/ ocr/privacy/hipaa/administrative/securityrule/rafinalguidancepdf.pdf. 18. See Office for Civil Rights, HHS, “The HIPAA Privacy Rule and Electronic Health information Exchange in a Networked Environment,” (August 1, 2017), www.hhs.gov/sites/ default/files/ocr/privacy/hipaa/understanding/special/healthit/safeguards.pdf; see also 45 C.F.R. § 164.530(c). 19. 45 C.F.R. § 164.312. 20. Press Release, HHS, Lack of timely action risks security and costs money (February 1, 2017), www.hhs.gov/about/news/2017/02/01/lack-timely-action-risks-security-and-costs-money.html. 21. 45 C.F.R. §160.404(b)(2). 22. ONC, HHS, “Mobile Device Privacy and Security,” www.healthit.gov/providers-professionals/ how-can-you-protect-and-secure-health-information-when-using-mobile-device. 1. 2.

MAG’s CEO to run 100 miles to raise funds for distracted driving campaign The Medical Association of Georgia (MAG) is encouraging its members to support MAG Executive Director Donald J. Palmisano Jr. with a tax-deductible donation when he participates in the 100-mile ‘Javelina Jundred’ trail run in Arizona on October 28-29 to raise funds for a campaign that the MAG Foundation is developing to reduce distracted driving in the state. According to the AAA Foundation for Traffic Safety, distracted driving is responsible for about 16 percent of all fatal motor vehicle crashes in the U.S. – which is about 5,000 deaths per year. It also notes that, “Nearly half of all people who say they feel less safe than they did five years ago say distracted driving by other drivers fuels their concerns.” Palmisano hopes to raise at least $15,000 for the campaign, which is aligned with a patient safety policy that MAG’s House of Delegates passed in 2016. Donors will be recognized on MAG’s website, MAG’s Facebook and Twitter accounts, and in the fourth quarter edition of the Journal of the Medical Association of Georgia. Campaign sponsors include the MAG Alliance and the Medical Association of Atlanta. Contact Lori Cassity Murphy at lmurphy@mag.org or 678.303.9282 or go to www.mag.org to make a donation.

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PRACTICE MODELS

Academic medical practice: What’s it all about? By Barry Silverman, M.D.

n the past decade, there has been tremendous growth in the variety of practice models that physicians employ. This has been driven by the economics of medicine, insurance companies and managed care, EMR requirements and other government regulations, student debt, and generational changes – including the Greatest Generation, Baby Boomers, Generation X, and Millennials.

• Do you handle all or most of the patient management? Do you have your own nurse or are you supported by a group of nurses? Does your nurse(s) handle phone calls, patient concerns, prescriptions, etc.?

The Editorial Board of the Journal of the Medical Association of Georgia determined that it would be worthwhile to ask some physicians in the state who use different practice models to write about their experiences to help MAG members make informed decisions about the practice model they employ. We asked these physicians to consider the following questions…

• Do you believe that you are earning an income that is commensurate with your skill set and experience?

• When you went into medicine, what were your interests, how did you visualize your future, and have you achieved your goals? • Did you choose your practice model based on financial considerations (e.g., school debt, income potential, lifestyle, and meeting your family’s needs)? • Do you feel like you are in control of your schedule? Is the amount of time you are on call a major problem? Is the number of patients you see reasonable (i.e., can you still deliver good patient care)? • Do you feel like you are truly responsible for your patients’ care – or is management and/or other physicians actively involved? To what extent do PAs direct patient care at your practice, and how do you feel about that? • How much time do you spend managing your practice? Does your perspective matter when it comes to practice management decisions? Does practice staff answer to you or management? How good is the patient scheduling process at your practice, and does your practice contact your patients in person or does it employ “robo” calls for scheduling, test results, etc. • Are you able to generate enough income to meet your overhead expenses, including up-to-date office space (and your EMR system) in a good location? 22 MAG Journal

• How much vacation and other time off do you have? How many hours do you work every week? Do you work a lot of hours because you love working or does the practice control your schedule?

• Have you experienced any burnout, and how enthusiastic are you about medicine compared to when you graduated from medicine school? The following is the second in a series of individual perspectives that will appear in the Journal. It was written by Dimitri Cassimatis, M.D., FACC, an associate professor of medicine at the Emory University School of Medicine in Atlanta. Academic Medical Practice

From the outside, you might think an academic medical practice is easy to characterize – but each faculty’s practice is unique. An academic physician’s clinical workload can range from under 20 percent to over 90 percent of their time, with a mix of teaching, research, and administration making up the balance. Clinical work typically involves a mix of outpatient and inpatient care in a variety of locations, including tertiary care hospitals both on and off university campuses, urban and suburban community clinics, Veterans Affairs Hospitals, and inner-city safety net institutions like Grady Memorial Hospital. My decision to join Emory and practice cardiology in an academic setting stems from my feeling energized by interactions with students and trainees. I spend about 60 percent of my time seeing patients – evenly divided between inpatient, outpatient, and imaging (mostly echocardiography). Another 10 percent of my time is spent on administration, while the rest is spent teaching medical students in the classroom. The beauty of this schedule is that much of my clinical practice is linked to clinical teaching

of residents and fellows, so I have teaching encounters on a daily basis. I also spend the equivalent of approximately one full day peer week in a private clinic setting – without any trainees, but with a superb group of clinical nurses who assist with follow-up and patient communication.

maximize income but still choose to have an academic career might seek to spend more time directly seeing patients, and they might opt to be based at locations with less active graduate medical training, both of which generally, but not in all cases, increase compensation.

I spend a little more than one weekend a month on call (12 to 14 weekends per year), and I average one weeknight on call per week. Although this is on the high side for an academic general cardiology practice, I am always on call with a cardiology fellow – which both softens the burden on me and increases the “fun” factor, as each case represents an opportunity to teach and learn together. Although I might have a number of phone calls in the course of a night, it is rare that I actually need to drive to the hospital in the middle of the night.

At Emory, I have significant but not complete control over my career path. Like most of us in the medical profession, I am highly committed to a demanding schedule in the short run. I recognize that tailoring my career takes time and requires patience, and I can accept that large organizations such as Emory move slowly – something I learned well during my 11 years on active duty in the U.S. Army.

Although private practice in general compensates at a higher rate, my academic general cardiology practice pays me enough to live comfortably in Atlanta, to support my family, and to indulge in occasional luxuries-like a Disney cruise. The difference in income between private practice and academic practice varies greatly based on specialty and specific clinical setting. The Emory physicians who wish to

I feel genuinely lucky to be on Emory’s faculty, and I am grateful every day that I get to care for patients in many settings and I get to teach medical trainees of all levels at the bedside and in classrooms – all of which keeps each day unique, challenging, and satisfying.¨ In addition to MAG, Drs. Cassimatis and Silverman are members of the Medical Association of Atlanta. MAG members who would like to share their practice model experience in the Journal should contact Dr. Silverman at mssbds@gmail.com.

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www.mag.org 23

LEGAL

CMS expected to change the Medicare QPP/MIPS programs in substantial ways By Stephen M. Angelette, William E. Henderson, Rebecca Frigy Romine, Cybil G. Roehrenbeck, Neal D. Shah, and Sidney S. Welch, Polsinelli PC

n June 30, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule on the Medicare Quality Payment Program (QPP) for the 2018 calendar year in the Federal Register.1 Designed to decrease the burden on physicians and others, these changes received mixed reviews. As such, CMS likely will make some substantial changes in the final rule, which will be released this fall. This article addresses the portions of the proposed rule that are related to QPP’s MeritBased Incentive Program (MIPS). MIPS proposals

Under MIPS, eligible clinicians are given a score for their performance in four categories, including Quality, Cost, Advancing Care Information (ACI), and Improvement Activities (IA). Those scores are then used to determine a positive or negative adjustment for the clinician’s Medicare Part B payments two years later. The proposed rule includes CMS’ proposed changes to the overall scoring methodology for the program’s second year (i.e., 2018 reporting will impact payments in 2020). Key changes include keeping the 2018 weights for the Cost factor at zero percent and the Quality component at 60 percent. The proposed rule effectively ends the ‘Pick Your Pace’ minimal participation track and makes it slightly more difficult to earn a positive score under the partial participation track. CMS expects the vast majority of clinicians to receive a neutral or positive adjustment in 2020 payment year (based on 2018 performance) due to the flexibilities under the Proposed Rule, including a number of exemptions and new bonus opportunities. Quality measure

Methods of quality reporting. Eligible clinicians may report data using several means, including claims (for individuals only), qualified registries, Qualified Clinical Data Registries (QCDR), electronic health records (EHR), or the CMS Web Interface (for larger groups only). For 2018, CMS has proposed allowing clinicians to submit data using multiple sources, even in the same category, to calculate an overall score for each component. If a clinician reports data on the same measure using different sources, CMS will use the highest score. However, practices using EHR and QCDR would no longer be able achieve a high score on the quality component without submitting all six measures. 24 MAG Journal

Performance improvement bonus. CMS is proposing a new performance improvement bonus for MIPS-eligible clinicians who report at least six measures in 2018 (and who otherwise fully perform under the Quality category). A clinician or a group could earn a Performance Improvement Bonus of up to 10 points on their Quality component score. This would be determined by dividing the difference between the 2018 and 2017 Quality score and the 2018 Quality score and multiplying it by 10. CMS is soliciting comments on alternative ways to measure improvement, including the use of a series of “bands” that reflect ranges of improvement and the Accountable Care Organizations improvement bonus. ICD-10 exceptions. CMS has proposed creating a set of exceptions for scoring against measures in which 10 percent or more of the diagnosis codes would be changed in the middle of a year. CMS would publish the list of these measures in advance. For measures using these codes, CMS would only look at data from January to September in its scoring – reflecting the agency’s understanding of the timing of ICD-10 changes. Cost

By keeping the weight for the Cost component of the final score at zero percent for 2018, as proposed, CMS would have another year to work with stakeholders to iron out some of the concerns that have been expressed with the episode-based Cost measures. Advancing Care Information

CMS has proposed retaining the existing ACI base score methodology, but the proposed rule would create several new avenues for reporting flexibility – as well as new options to address the practical barriers associated with participating in this category. For example, clinicians could continue to use either 2014 or 2015 Edition Certified Electronic Health Record Technology (CEHRT) in 2018, but clinicians who use the 2015 Edition CEHRT would be eligible for a bonus. Measure specifications. Under the proposed rule, MIPSeligible clinicians would be required to allow a patient to view (online), download, and transmit their health information within four business days of the information being available to the MIPS-eligible clinician to meet the Patient Electronic Access Measure. CMS has also proposed a number of technical changes to ACI measures.

(continued on page 26)

• • • •

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(continued from page 24)

New exceptions. CMS is also proposing new exceptions for reporting obligations under the ACI category. Clinicians who write fewer than 100 prescriptions in a performance period would not be required to report on the e-prescribing objective and measures. Also, any MIPS-eligible clinician who transfers a patient to another setting or who refers a patient fewer than 100 times during the performance period would be excluded from Health Information Exchange measures. The proposed rule also would establish a new hardship exception for eligible clinicians in small practices – 15 or less professionals – if they submit an application by December 31 of the performance period or a later date that would be determined by CMS, which demonstrates that there are “overwhelming barriers” that prevent the clinician from complying with the requirements of the ACI performance category. Ambulatory surgical center (ASC)-based MIPS-eligible clinicians who provide more than 75 percent of their professional services in an ASC/POS (place of service) 24 also may have their ACI performance category reweighted to zero percent of their MIPS final score. MIPS-eligible clinicians may also apply for an exemption (and a reweight of the ACI performance category to zero) if their CEHRT is decertified either during the performance period or the calendar year preceding the performance period. But, as proposed, the MIPS-eligible clinician would have to demonstrate that he or she made a good faith effort to adopt and implement another CEHRT in advance of the performance period and file an exemption application by December 31, 2018 of the performance year and on an annual basis thereafter – and this exemption could only be granted for up to five years. Improvement Activities

Under the proposed rule, Improvement Activities would continue to represent 15 percent of the MIPS total score. CMS has proposed new improvement activities and limited modifications, including... • Greater overlap between the ACI and IA categories – with new opportunities to earn points in both categories by reporting on the same set of measures. • Proposed IA measures that would give practices credit for complying with Appropriate Use Criteria for diagnostic imaging. • The inclusion of the CPC+ model in the definition of a “patient centered medical home” (PCMH), giving participants who use this model an automatic high score in this category. • A modification to the PCMH rules that provides that one would only receive favorable treatment under the IA rules if at least 50 percent of a Taxpayer Identification 26 MAG Journal

Number (TIN)’s practice sites are a PCMH. MIPS scoring methodology

CMS has proposed changes to the MIPS scoring methodology. Under the current rules, a clinician can earn a bonus of up to five percent of the prior year’s Medicare Part B reimbursement. The actual amount of any bonus or penalty is determined using a MIPS final score that ranges from zero to 100 points. Modifications to the performance threshold. CMS determines the reimbursement implications of a MIPS final score by comparing a physician’s score to a “threshold” amount that the agency has established. Scores that are below the threshold result in a penalty, while scores that are equal to the threshold may result in no adjustment, and scores that are above the threshold may result in a bonus. For 2017, the threshold is three points – which means that a clinician could avoid a penalty by submitting minimal data on a single Quality measure or data on one other component. The proposed rule would raise this threshold to 15 points. This increase would make it more difficult to achieve a positive score, but CMS has pointed out that a clinician could meet this threshold by reporting on just one component if their substantive performance on that component is strong. Even with this change, CMS estimates that over 90 percent of clinicians will receive a positive or neutral adjustment for the 2018 performance year – which, again, will serve as the basis for the 2020 payment year. Small practice bonus. Under the proposed rule, a small practice (i.e., 15 or fewer clinicians) is automatically eligible for a five-point scoring bonus that would be added directly to the final score. It is not yet clear whether clinicians who report individually will be treated as a “small practice.” Patient Complexity bonus. For clinicians who submit at least one measure in any component, and not just Quality, CMS is proposing a ‘Patient Complexity’ bonus.2 Hierarchical Condition Categories (HCC) would be used to calculate this bonus, reflecting the clinical complexity of the patients the clinician sees. CMS would analyze the clinician’s average HCC scores from September 1, 2017 to August 31, 2018, and the clinician could receive a bonus of up to three points. ‘Low Volume’ exclusion. The MIPS ‘Low-Volume’ exclusion shields practices that have limited Medicare volume. The proposed rule would expand the exemption from MIPSeligible clinicians who see 100 or fewer patients or received $30,000 or less in Medicare Part B reimbursement in a performance year to 200 or fewer patients or $90,000 or less in Medicare Part B reimbursement in a performance year. This proposal would exempt nearly half of the 1.2 million otherwise MIPS-eligible clinicians.

Methods of reporting

The proposed rule includes new reporting options – including partial group reporting, virtual groups, and facility-based measurement – and it would finalize a new, distinct set of rules for clinicians who primarily practice in hospitals. Partial group reporting. CMS is proposing partial group reporting, whereby portions of a TIN participate in an Advanced Alternative Payment Model (APM) (e.g., a single location of a multi-location group). Under this proposal, the non-APM clinicians would be able to report as a group – even though the TIN would be split between two reporting methods. Virtual group reporting. CMS has proposed a virtual group reporting option for 2019. Virtual groups would be able to choose their participants, but they would be required to include at least two entities (or an entity and an individual). A group would only be able to join a virtual group if it contains 10 or fewer clinicians. The virtual group would have to submit a list of participants to CMS no later than December 1 of the year before the performance year (i.e., by December 2, 2017 for the 2017 performance year). Participants in a virtual group would not be able to change this election to participate in a virtual group during the performance year. Virtual groups would also have the same options as group practices to report data (e.g., they would not be able to utilize claims reporting). A virtual group would not be limited to any number of total clinicians or defined geographic area or set of specialties. However, its members would only be able to participate in a single virtual group, and they would not be eligible to participate in a virtual group if they were excluded from MIPS (e.g., the group falls below the low-volume exclusion). CMS has not proposed any changes to the application of Stark Law for participants in a virtual group, so physicians and practices should proceed carefully in structuring such arrangements. CMS would identify virtual groups using a two-step process. In stage one, CMS would provide the prospective virtual group with an optional determination of its eligibility early in the year. In stage two, the virtual group would have to submit a list of its members to CMS and enter into a participation agreement. CMS has stated that it would provide a ‘Model Agreement.’ Physicians and practices that consider the virtual group option should note that failure to participate in stage one could lead to a rejection in stage two without sufficient time to amend and resubmit prior to the election deadline.

Facility-based measurement. Finally, CMS has proposed a scoring option for clinicians who are primarily hospitalbased. Under this proposed “Facility-Based Measurement” (FBM) standard, a clinician who provides at least 75 percent of their Medicare-covered professional services in a hospital inpatient or emergency department setting (POS 21 or 23) would be able to elect to be scored using FBM. The total performance score from the hospital where the clinician treats the highest number of Medicare beneficiaries during the period would be converted into a MIPS quality performance category and cost performance category score. FBM would use the benchmarks that are established for the applicable facility under the hospital VBP (Value Based Purchasing) program for the applicable year to calculate a MIPS quality score for the clinicians. The benchmark would be converted into a MIPS score by relating the VBP performance percentile to an equivalent percentile rank for the MIPS quality score (as compared to non-FBM clinicians). However, clinicians using FBM would not be ranked lower than the 30th percentile. Conclusion

CMS estimates that under the proposed rule, the vast majority of clinicians would receive either a neutral payment or bonus – and more than 70 percent would receive an “exceptional performer” bonus. Given the budget-neutral nature of the program, this likely means that the impact of any MIPS penalties would be concentrated among a small group of providers (i.e., those who receive a large penalty), while bonuses would be spread across a large pool of providers. A lot of physicians would consequently be expected to receive a bonus, but the amount of the bonuses would be relatively small. As such, 2018 is expected to be viewed as another “transition year” – one that enables physicians and other eligible clinicians to continue to evaluate their performance in preparation for a wider shift to value-based payment.¨ Welch is the chair of Health of Health Care Innovation at Polsinelli. She counsels physicians, physician practices, and health care technology clients in transactional, regulatory, and administrative law and litigation matters on a national basis. Go to www.polsinelli.com/professionals/swelch for additional information. Contact Welch at 404.253.6047 or swelch@ polsinelli.com. Paid editorial submission. References 1. 2.

82 FR 30010. Accessible at https://www.federalregister.gov/documents/2017/06/30/201713010/medicare-program-cy- 2018-updates-to-the-quality-payment-program. Used in other CMS programs, HCCs have been useful in measuring relative complexity of patient health needs; however, HCCs have also been criticized for potentially incentivizing upcoding

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HealtheParadigm and the Medical Association of Georgia— a partnership focused on health care transformation The escalating importance and availability of health care analytics deliver providers a means to successfully transition to the new Quality Payment Program (QPP) models. Providers are expected to manage diverse data sets, to face increased competition, to answer growing regulatory complexity, and to deliver value-based care to their patients. How can providers harness this new opportunity? Robust data and analytics. Meaningful analytics hold the power to transform patient care, reveal new sources of value, and differentiate competitors. Can You Meet the New Reporting Requirements? HealtheParadigm analytics dashboards can ease the transition to QPP reporting by providing physicians with access to patients’ aggregated data from the HIE presented through meaningful analysis. Dashboards available include: Quality Metrics, High Risk Patient, Readmissions, Disease Registries, and Population Health. Coming soon: Utilization and Behavioral Health. See examples:

Quality Metrics

High Risk Patients

Physicians and hospitals are undergoing a major transformation in how they are paid and how they are expected to deliver care. As payment models evolve, margins shrink, and budgets tighten, health care data analytics open a door. Financial, operational, clinical, and other data impact the goals of improving care, providing access, and controlling cost. James Walton, D.O., MBA, FACP and the president and CEO of Genesis Physicians Group in Dallas, reminds physicians that health care organizations need to utilize resources and produce value quickly. In a recent webinar focused on MACRA, he said, “Number one, doctors and practice managers need to get ready to use data and move into the data-driven atmosphere. We can expect this trend around data collection and utilization to increase. And Number two, the pressure is on health care and is going to continue to increase—patients are expecting more service while living longer with more chronic conditions, just as payers and regulators are increasing expectations on documenting quality and efficiency across the care continuum.” Business intelligence and analytics such as those generated by HealtheParadigm detect information patterns and present unseen alternatives. Analytics-driven acumen helps providers identify and treat at-risk populations, proactively engage patients sooner, understand the performance of health interventions on health outcomes, and reduce costs.

Disease Registries

Meaningful analytics include using data for quality reporting, population health management, risk management, and clinical effectiveness, which allows physicians to analyze a more complete accounting of their patients’ healthcare. Georgia physicians can access powerful performance data through HealtheParadigm, a new MAG-endorsed, physician-led health information network. Analytics tools of the past often failed to provide effective integration of all a patient’s data. Today, organizations with a data analytics strategy built upon participation in a successful HIE will be well positioned to meet the new MACRA and QPP requirements. Web-based dashboard visualization tools offer more than just an increase in data comprehension; dashboards reveal data trends and patterns, making the information more accessible and actionable. For more information, visit www.HealtheParadigm.com.

28 MAG Journal

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www.mag.org 29

PATIENT SAFETY

Telemedicine in Georgia By William Kanich, M.D., J.D., chief medical officer, MagMutual

y any measure, telemedicine services across the country are in a growth mode. From an estimated 350,000 patient users in 2013, telemedicine services are expected to reach seven million patient users in 20181 – a 2,000 percent increase. The global telemedicine market value is set to hit $36.2 billion by 2020, up from $14.3 billion in 2014.2 The market forces driving this growth are numerous. Less costly interactions with physicians, more frequent and efficient monitoring of chronic health problems, and increased access to specialty care that would otherwise be unavailable or logistically difficult all play a part. The national telemedicine trends are also evident in Georgia. Telemedicine continues to grow, and its use has been addressed by both the Georgia State Legislature and the Georgia Composite Medical Board. It is expected that telemedicine use will continue to grow in Georgia – in the number of interactions between health care providers, the number of patients utilizing the technology, and in the breadth of conditions that are evaluated and treated with telemedicine. The impetus behind the growth of telemedicine in Georgia is similar to the growth on the national level, but from a patient safety perspective the increased ability of rural Georgians to access specialty care is one of its greatest benefits. Of Georgia’s 159 counties, 109 are classified as rural, according to the Georgia State Office of Rural Health.3 Residents of these counties tend to be older, have less health insurance, and have higher rates of chronic health conditions such as diabetes, heart failure, and obesity. According to a report by the Georgia Board for Physician Workforce, these counties lack access to medical care that residents of urban areas in Georgia enjoy.4 Telemedicine is a tool that has helped bring needed health care services to rural Georgians. While there are many important telemedicine initiatives in our state, what follows is a brief discussion of three telemedicine projects in Georgia and how they have impacted rural Georgians. Each year, thousands of children in Georgia require specialized evaluation and care in cases of sexual or physical abuse and neglect. While these children may reside anywhere in the state, resources needed to evaluate these children are concentrated in urban areas, making access to these resources logistically difficult for patients and their families. To address the disparity in access the Children’s 30 MAG Journal

Healthcare of Atlanta Center for Safe and Healthy Children (CSHC) turned to telemedicine. In 2009, the CSHC partnered with the Georgia Partnership for Telehealth and several child advocacy centers around Georgia to provide children in rural areas access to practitioners who specialize in child abuse and neglect. Child advocacy centers provide education, intervention, and treatment to victims of child abuse or neglect. In cases of suspected abuse, legal authorities will contact a local child advocacy center associated with the telemedicine network and schedule a consultation. At the appointed time, the child and parent come to the child advocacy center where they are met by a social worker and a medical professional, typically a nurse. The nurse explains the procedure to the family and introduces the family to the specialist. The specialist in Atlanta greets the family using a high-resolution video and audio interface that allows for two-way conversation. Together, the nurse and doctor elicit the history and the nurse performs a physical examination of the child with the guidance of the specialist. Beyond reaching children with medical resources that might otherwise be unavailable, the benefits of using telemedicine in suspected abuse cases include decreased parental anxiety and a prompt evaluation. There is also the benefit of families and law enforcement officials not having to travel for evaluation, saving time and travel expenses. According to Jordan Greenbaum, M.D., a staff physician for CSHC, the interactions are a way to mentor sexual assault nurse examiners, or “SANE” nurses, in remote areas. Physicians at the center in Atlanta can provide pointers and coaching during evaluations to build the confidence and expertise of the SANE nurses, who can then provide more care independently. In its 2016 Premature Birth Report Card, the March of Dimes gave Georgia a grade of “D” based upon the state’s preterm birth rate of 10.8 percent. Georgia ranked 32nd out of the 50 states, according to the March of Dimes. While preterm births are a problem in both urban and rural settings, the difficulty of accessing appropriate medical care, particularly for high-risk pregnancies, is more acute in rural areas of the state. To address this lack of access, the Southwest Health District’s Centering Pregnancy®5 program teamed with Women’s Telehealth in Atlanta to deliver access to advanced pre-natal care through telemedicine to minority populations in two counties in Georgia. The program initially focused on low-

income African-American women in Dougherty County. It then expanded to low-income (and often undocumented) Hispanic women in Colquitt County. The women periodically meet in groups for educational programs during their pregnancies. They are joined, via television monitor and audio connection, to a remote maternal fetal specialist who participates in the educational session. If the women experience no problems during their pregnancies, they have no additional interaction with the specialist. If, however, they were to develop a complication, they are already familiar with both the specialist and the telemedicine format. This familiarity can ease any apprehension the woman may have about an obstetric evaluation using telemedicine. Initial results of this program show promise in reducing rates of preterm deliveries. The rate of preterm births among African-American women in the Southwest Health District from 2004 to 2008 was 18.2 percent. The Dougherty location, where the telemedicine intervention was implemented, had a preterm birthrate of 8.6 percent. Similarly, positive results were seen among Hispanic women in Colquitt County. Compared to the rate of preterm births of 12.1 percent for all Hispanic women in the District, those in the Centering program had a preterm birth rate of 6.7 percent. Nearly 800,000 people suffer a stroke in the U.S. every year. It is the leading cause of long-term disability and one of the top causes of death in the U.S. The numbers are similar in Georgia, where stroke was the fifth leading cause of death in 2014, according to the Centers for Disease Control. In 1996, the Food and Drug Administration (FDA) approved tissue plasminogen activator (tPA) for the treatment of acute stroke. While tPA could be found in most hospital pharmacies, its use was rare for many years after it was approved by the FDA. The reason for this was that the medication is most efficacious when it is used quickly after symptom onset. Most small hospitals, however, did not have neurology specialists who were comfortable administering the mediation. As a result, stroke victims were transferred to tertiary care facilities where they could see a specialist in stroke care, but they were outside of the temporal window for treatment of the stroke. The situation at Augusta University, a leading stroke treatment center, was similar. It was admitting half of its stroke patients from outside hospitals and it was using tPA approximately once per month to treat acute strokes. In the early 2000s, a group of doctors at Augusta University decided that telemedicine could help get quick specialist evaluation of distant patients with stroke symptoms. Their initial tools involved one-way video capacity coupled with audio provided by a phone line. The service was provided

to eight small, rural Georgia hospitals. While the service and reach of the project was limited, the doctors began to see clinical improvements in their stroke patients. The neurologists, centrally located in Augusta, had enough clinical information to make educated decisions about the best course of treatment. Physicians in the distant emergency departments and hospitals felt reassured that their clinical decision making was being aided and supported by an expert in stroke evaluation and management. The program has flourished and now serves 30 health care facilities in Georgia and South Carolina. The technology now allows for two-way video and audio that is integrated with clinical workflow and patient data. A PACS viewer is included, and clinical documentation can be completed contemporaneously. The technology is designed for rapid, easy deployment by appropriately trained personnel. Administration rates for tPA have increased at all facilities served and clinical outcomes have also seen improvement. Augusta’s telestroke system continues to grow, and it has been implemented in other health care networks around the country. The three examples above show how telemedicine has begun to take root in Georgia. The ability to reach areas of our state with sophisticated medical care through an economical medium will benefit not only the residents of rural counties, but it will also improve the overall health of Georgians. What does the future hold? As telemedicine technology improves and becomes more affordable, the possibilities are immense. The diabetic who can transmit their blood sugars daily to their home health nurse, the patient with CHF who sends his weight each day to their internist, or the patient in the emergency department at a small, critical access hospital who can have a minor fracture evaluated by an orthopedic surgeon in Atlanta; all of these patients can benefit from telehealth.¨ Dr. Kanich is a MAG member. The information that is presented in this article is intended to serve as general information of interest for physicians and other health care professionals. The recommendations and advice that is published herein do not reflect or establish a standard of care and do not establish rules for the practice of medicine. The publication of this information is not intended to serve as an offer to insure such conditions or exposures or to indicate that MagMutual, LLC will underwrite such risks for the reader. MagMutual’s liability is limited to the specific written terms and conditions of the actual insurance policies issued. References 1. 2. 3. 4. 5.

IHS Technology report, January 17, 2014. Nathaniel Lacktman, ‘Five Telemedicine Trends Transforming Healthcare in 2016,” November 16, 2015, Foley & Lardner LLP website. Georgia’s State Office of Public Health Presentation to Georgia Southern University College of Public Health, February 11, 2009. ‘Doctor shortage Remains Acute in Rural Areas,’ Georgia Health News, January 2, 2014. CenteringPregnancy® is evidence-based model of scheduled health assessments and educational opportunities for pregnant women (i.e., gestational age-matched groups going through similar physical, mental and social changes secondary to pregnancies).

www.mag.org 31

SPECIALTY NEWS

The doctors who have contributed to the cardiac physical exam (Part II) By John Davis Cantwell, M.D., MACP, FACC

John Davis Cantwell, M.D.

The following is the second of a three-part series that will appear in the Journal.

left lung problems suggests consolidation of the lung. If dullness is found, it favors a pleural effusion.

1800s

Philadelphian Jacob DaCosta (1833-1900) studied under Trousseau, the celebrated French physician. DaCosta was among the first to emphasize bedside teaching – rather than having students just memorize material from textbooks. The syndrome that bears his name is a functional disorder or “irritable heart” or “soldier’s heart,” which he reported concerning 300 Civil War cases in 1871. Some of these cases, in retrospect, may have had mitral valve prolapse. DaCosta correctly believed that recurrent muscular activity could produce cardiac hypertrophy, which has been called the “athlete’s heart.”

Rene Laennec (1781-1826) was a multi-talented Parisian who also wrote poems under the pseudonym “Cenneal,” which is Laennec spelled backwards. Beginning his five-year study of medicine at the age of 14, Laennec once observed children playing with a wooden baton, through which sound could be transmitted. He applied this principle to auscultation of the chest and heart (which previously had required putting the ear to the chest), after first using a rolled-up paper cylinder. A woodworker by hobby, Laennec then used a hollowedout wooden tube, the forerunner to today’s stethoscope. Through studying his new apparatus, Laennec made important observations concerning tuberculosis and coined terms such as rales, bronchophony, and pectoriloquy (known to all medical students today who study physical diagnosis). He also identified diseases like emphysema, bronchitis, pulmonary edema, and even cirrhosis (which bear his name). Adolph Kussmaul (1822-1902) was born in Germany, studied under Virchow, was a “country doctor” for many years, then became a professor of medicine at Heidelberg, Freiberg, and Strasbourg. He was the first to describe the deep, slow breathing pattern in diabetic ketoacidosis, he discovered periarteritis nodosum, inspiratory increase in neck veins, and the paradoxical pulse in constrictive pericarditis, and he was the first to attempt esophagogastroscopy. Ludwig Traube (1818-1876) studied in Germany. Among his many contributions was the introduction of the thermometer to his clinic in 1850. In 1872, Traube described pulsus alternans, a finding associated with left ventricular disease and the pistol shot sounds over the femoral arteries in aortic regurgitation. Another finding is now known as “Traube’s space” in the left lower lung field. Traube observed that preservation of the tympanitic percussion sound over the gastric area in a patient with 32 MAG Journal

Austin Flint (1812-1886) was born in Massachusetts and educated at Harvard Medical School. He founded the Buffalo Medical College. One of the first to use a binaural stethoscope, Flint spent several winters examining patients’ hearts at Charity Hospital in New Orleans. While there, he saw a patient who had a murmur of aortic regurgitation and a diastolic rumble (as in mitral stenosis). Flint felt that the rumble was functional, resulting from impingement of the regurgitant stream on the anterior mitral leaflet. Modern studies combining echocardiography and phonocardiography pretty much support his contention, although suggesting that the regurgitant jet abuts the left ventricular endocardium. Braunwald’s text states that the rumble results from antegrade flow “across an orifice (mitral) of diminished or diminishing size.” Graham Steell (1851-1942) was a champion boxer in his early years in Edinburgh, and he then became an early advocate of exercise for his patients. In Barry Silverman, M.D.’s fine profile1, he describes Steell as one who was “dedicated, industrious, loved to teach at the bedside, and contributed numerous papers and a textbook of cardiology.” Although the leading cardiologist in Northern England, he was a boring and unenthusiastic lecturer (“he read verbatim from crumpled pieces of paper, in stilted, discursive style”). He described the murmur of functional pulmonic regurgitation secondary to rheumatic mitral stenosis.

Although the eponym is still used, Steell probably was not the first to observe this. His name is often linked with Austin Flint’s, as both described dual diastolic regurgitant murmurs and diastolic rumbles, although due to different mechanisms. Several outstanding physicians practiced in Dublin in the 1800s… • Robert Graves (1796-1853) taught William Stokes at the Meath Hospital, and they worked together for 30 years. They were “colleagues, but not rivals, united in their zeal for the discovery of the new.” Of Graves, Stokes wrote, “he was once my teacher, later my colleague, always my friend.” • William Stokes (1804-1878) noted several patients with syncope and a slow pulse and including a case seen by Adams, a surgeon. The condition is known today as the Stokes-Adams (or Morgagni-StokesAdams) syndrome of complete heart block, often associated with aortic stenosis. Stokes also described an unusual pattern of breathing in certain patients and referred to a case published by John Cheyne. Cheyne-Stokes respiration today is usually seen in severe heart failure. Stokes had a multitude of interests beyond medicine, including archaeology, music, art, and literature. In 1861, he was elected physician to the Queen in Ireland. His obituary stated that, “Stokes did not obtain any title. He never coveted any; he never sought any. He was a prince from birth of the aristocracy of intellect. His name is crowned with a triple coronet of the gratitude of the poor, for whom he tenderly and piously cared; the confidence of the public, whose approbation he universally secured; and the love and esteem of his profession, whose honor and interest he unflinching upheld.”2 Sir Dominic John Corrigan (1802-1880) was the son of a Dublin farmer and one of the few practicing Catholic physicians in the area. A surgeon, he noted physical findings in patients with aortic regurgitation, referred to later as the “maladie de Corrigan.” Although the collapsing pulse

of the disorder (compared to a water-hammer toy) is often ascribed to Corrigan, Thomas Watson was probably the first to note this. Corrigan’s practice was slow at first, but he soon became “one of Europe’s most famous physicians.” Outspoken, he railed at authorities about the potato famine and was “black-balled” when he applied for election into the Kings and Queens College of Physicians. Eight years later he was finally elected a Fellow. He was one of the rare physicians in Irish history to be made a baronet. Maurice Raynaud (1834-1881) was born in France a few years after the death of Laennec. The son of a prominent university professor, he obtained his medical degree in Paris in 1862, the year that his famous article on the disease/ phenomenon that bears his name was published. He believed that the disorder reflected an increased sensitivity of the sympathetic nervous system, and that it occasionally could lead to gangrene. The signs include initial pallor of the digit(s), followed by bluish discoloration as the blood getting through is deoxygenated. Upon re-warming, the digits are reddish, due to reactive hyperemia. Some refer to this as the “French tricolors,” reflecting the three colors in their flag. Raynaud’s “disease” accounts for over 60 percent of the disorder, with the onset taking place between the ages of 20 and 40 and a heavy preponderance of women. The “phenomenon” may be associated with disorders like primary pulmonary hypertension, scleroderma, and coronary vasospasm. It may also be triggered by repetitive minor trauma to the digits, as in typists, pianists, and baseball pitchers and catchers.¨ Dr. Cantwell is a cardiologist with the Piedmont Heart Institute in Atlanta, and he is a member of MAG and the Medical Association of Atlanta. References 1. Silverman B. Graham Steell in Profiles in Cardiology, by editors Hurst, Conti and Fye, The Foundation for Advances in Medicine and Science, Inc. Mahwah NJ, 2003. 2. Cantwell JD. William Stokes (1804-1878). Clin Cardiol 1988; 11: 856-858.

MAG updates website to be more secure, mobile-friendly The Medical Association of Georgia (MAG) recently updated its awardwinning mag.org website. “MAG’s website is consequently more secure, more mobile-friendly, and easier to navigate,” says MAG Director of Communications Tom Kornegay. “And the update cost less than $2,000 and will deliver more than $2,500 a year in savings.” Kornegay also stresses that, “The website is an important, highly-visible part of our efforts to build MAG’s brand and reputation – keeping in mind that mag.org was visited nearly 80,000 times in just the first eight months of 2017.”

He applauds MAG Communications Manager/Webmaster Mandi Milligan for her efforts, pointing out that, “She took the initiative to identify a cost-effective solution, and she managed the process from beginning to end.” Kornegay concludes that, “The updated website is a great resource, and it’s going to create a lot of value for MAG and its member physicians.” MAG has won nine awards for its website since 2012. MAG members can contact Milligan at mmilligan@mag.org with any suggestions to enhance MAG’s website.

www.mag.org 33

COUNTY, MEMBER & SPECIALTY NEWS

COUNTY MEDICAL SOCIETY NEWS Bibb County Medical Society

Go to www.bibbphysicians. org or contact Dale Mathews at bibbphysicians@gmail. com for information on the Bibb County Medical Society. Coffee County Medical Society

Go to www. coffeemedicalsociety. com or contact Charles Miller, M.D., at wcmiller@ windstream.net for information about the Coffee County Medical Society (CCMS) or contact Dawn Williams at 678.303.9261 or dwilliams@ mag.org to join CCMS. DeKalb Medical Society

by Hank Holderfield, Executive Director The DeKalb Medical Society (DMS) hosted its ‘Annual Legislative Open House Reception’ at the Druid Hills Golf Club in Atlanta in September. Working with MAG’s Government Relations team, DMS invited DeKalb County legislators to attend the event to discuss health care issues. DMS is encouraging its members to make plans to attend its annual meeting and 25th Physicians’ Care Clinic (PCC) anniversary celebration at the Druid Hills Golf Club on February 10, 2018. DMS will also present its Judy and Bob McMahan Citizenship Award during the event. DMS founded the non-profit PCC in 1992. The PCC provides primary health care to low income and uninsured county residents who do not have 34 MAG Journal

access to medical treatment except through hospital emergency room visits. Go to www.dekmedsoc.org or contact Melissa Connor at mconnor@pami.org for information on DMS. Dougherty County Medical Society

Go to www.dc-ms.org or contact Susan Workman at 229.436.8191 or dcms. director@gmail.com for information on the Dougherty County Medical Society. Georgia Medical Society

by Ca Rita Connor, Executive Director Retired and ‘Life’ members of the Georgia Medical Society (GMS) met for quarterly luncheons in February and July. They enjoyed sharing their experiences in medicine. In May, GMS sponsored its annual high school preceptorship/ internship program, which is a collaborative effort with the Savannah Chatham County Public School System. High school seniors who have expressed an interest in studying medicine are selected to participate in this program each year. They shadow one or more physicians for a day. The program begins with an orientation breakfast and ends with a banquet, during which each student shares their experiences of the day. Twenty-three GMS members participated in this year’s program. In other news, GMS President Joshua McKenzie, M.D., attended a dinner in July for new Medical College of Georgia at Augusta University students

who are based in Savannah. He discussed the history of the society and the value of GMS membership – which is free for students. Dr. McKenzie also addressed a group of students at the Mercer University School of Medicine’s Savannah Campus in August. Contact Ca Rita Connor at gamedsoc@bellsouth.net with questions related to GMS. Hall County Medical Society

by Hank Holderfield, Executive Director The Hall County Medical Society (HCMS) will hold its fall meeting at the Chattahoochee Country Club in Gainesville on Wednesday, October 11. The ‘ACOs, CINs, HP2: How do these letters impact your practice?’ program will feature several prominent speakers, including Amelia “Mimi” Collins, the CEO of The Longstreet Clinic, PC, Lewis G. Smith Jr., the president of Northeast Georgia Medical Center, Steve McNeilly, vice president of managed care and integration strategies with the Northeast Georgia Medical Center, and Bill Beyer, the CEO of the Northeast Georgia Diagnostic Clinic. Meeting sponsors include MagMutual and Open MRI and Imaging of NE Georgia. The dinner program will begin with a reception at 6 p.m. Contact Melissa Connor at mconnor@pami. org with questions. Muscogee County Medical Society

by Dan Walton, Executive Director The Muscogee County

Medical Society’s (MCMS) May meeting featured a CME program that was sponsored by MagMutual. MagMutual Board of Directors member and MCMS member Ben Cheek, M.D., gave an overview of closed claims that highlighted ways for physicians to avoid medical malpractice lawsuits. MCMS will hold its annual ‘Fall Beer Tasting’ at the RiverMill Event Centre in Columbus on Thursday, September 28. Go to www.muscogeemedical. org or call 706.322.1254 for additional information or to join MCMS.

Dr. Ben Cheek addressing fellow MCMS members in May.

Ogeechee River Medical Society

Contact Michelle Zeanah, M.D., at doctor@zeanah. com with questions related to the Ogeechee River Medical Society. Richmond County Medical Society

by Dan Walton, Executive Secretary MagMutual Patient Safety Institute Chief Medical Officer Bill Kanich, M.D., JD, gave a talk on ‘The Opioid Crisis: Practical Strategies’ at the Richmond County Medical Society (RCMS) meeting in May. MagMutual sponsored the meeting. RCMS and its Drug Abuse and Addiction Task Force have funded a

secure prescription drug disposal box for the Richmond County Health Department in Augusta. The dignitaries who attended a dedication ceremony in July included Task Force Chair Adair Blackwood, M.D., former RCMS President and task force member Craig Kerins, M.D., RCMS President Donnie Dunagan, M.D., East Central Health District Director Stephen Goggans, M.D., Medical College of Georgia (MCG) at Augusta University student and task force and RCMS Board member Ben Wilson, Captain Scott Gay with the Richmond County Sheriff’s Office, RCMS Executive Director Dan Walton, and Michael Cohen, M.D., who represents RCMS on MAG’s Board of Directors. The event was covered by several local media outlets. The RCMS task force has also developed ‘Generation Rx’ resources that address the dangers associated with prescription drug abuse for use in middle schools and high schools in Richmond County. Following a presentation by MCG student Jose Puentes, PharmD, the Richmond County School Board of Trustees unanimously approved the use of the resources in schools in the county beginning this year. Puentes also gave a presentation on the program to RCMS members on July 25. Go to www.rcmsga.

The dedication ceremony for the prescription drug disposal box that the RCMS funded for the Richmond County Health Department.

org or call 706.733.1561 for additional information or to join RCMS. Rome Area County Medical Society

Physicians who like information about the new Rome Area Medical Society should contact Dayna Jackson 678.303.9281 or djackson@ mag.org or John A. Cowan, M.D., at jacowanjr@gmail. com. Contact Dawn Williams at dwilliams@mag.org or 678.303.9261 to join the society. Troup County Medical Society

Physicians who have questions about the Troup County Medical Society should contact Dayna Jackson 678.303.9281 or djackson@mag.org. Walker-CatoosaDade County Medical Society

Physicians who have questions related to the Walker-CatoosaDade County Medical Society should contact Michael E. Wilson, M.D., at tenwilsons@ gmail.com.

MEMBER NEWS Albany orthopedic surgeon Charles Gillespie, M.D., was recently honored with the 2017 Emory School of Medicine Alumni Award during a ceremony that took place in Atlanta in May. The award “honors distinguished alumni from the Emory School of Medicine who display extraordinary leadership and accomplishment in the field of medicine at the national or international level.” Dr. Gillespie is credited with developing Georgia’s

Dr. Charles Gillespie receiving the Emory School of Medicine Alumni Award from Arthur Yancey, M.D.

Emergency Medical Services system in the 1970s. It is also worth noting that he is the recipient of both MAG’s Hardman Cup and MAG’s Physician’s Award for Community Service.

SPECIALTY SOCIETY NEWS Georgia Academy of Family Physicians

by Tenesha Wallace, Manager of Communications and Public Health Each year, the Georgia Academy of Family Physicians (GAFP) honors members who “exemplify excellence in the practice of family medicine and for their national, state chapter and communitybased leadership roles and contributions to clinical research and health care.” Samuel “Le” Church, M.D., of Hiawassee is the winner of GAFP’s 2017 Family Physician of the Year Award. Dr. Church has worked in a rural setting for the majority of his 17-year career. He also serves on numerous community boards, as a volunteer physician for public school sports teams, and as the medical director of a child advocacy and domestic violence prevention program. John Bucholtz, D.O., of Columbus won GAFP’s Family Medicine Educator of the Year Award, which honors a member who is “dedicated

to teaching, mentoring and educating to help advance the specialty of family medicine.” Dr. Bucholtz has been with the Columbus Family Medicine Residency Program for over 25 years, and he currently serves as its director of medical education. According to one of his faculty counterparts and a former resident, Dr. Bucholtz is “one of the best teachers with whom they have had the pleasure of working.” Another said that, “From handling difficult interpersonal or familial situations, to transitioning from residency into practice, to engaging personal growth, Dr. Bucholtz is a friend, a confidant, a wise sage, and a pillar of support through the best and worst of times.” Go to www.gafp.org for information on the Georgia Academy. Georgia Association of Pathologists

Contact Stacie McGahee at 706.738.3119 or smcgahee@ medicalbureau.net or go to www.gapathology.org for information on the Georgia Association of Pathologists (GAP) or to join GAP or renew your GAP membership. Georgia Chapter of the American College of Cardiology

by Hank Holderfield, Executive Director More than 200 cardiologists are expected to attend the Georgia Chapter of the American College of Cardiology’s (GAACC) ‘Scientific Meeting’ at The Ritz-Carlton at Lake Oconee in Greensboro, Georgia on November 17-19. The meeting – one of the best educational offerings for cardiology in www.mag.org 35

the southeast – will feature a number of prominent speakers, including James Min, M.D., from The Dalio Institute for Cardiovascular Imaging at New YorkPresbyterian Hospital and Weill Cornell Medicine in New York, Joann Lindenfield, M.D., from the University of Colorado, Michael Reardon, M.D., from Houston Methodist Hospital, and Richard Kovacs, M.D., from the Krannert Institute of Cardiology at the Indiana University School of Medicine. This year’s meeting will focus on four key areas, including ‘Controversial Topics in the Management of Coronary Artery Disease,’ ‘The New Age of Heart Failure,’ ‘Novel Valvular Concepts,’ and ‘The Athlete’s Heart.’ Jerre F. Lutz, M.D., FACC, will also be honored with GAACC’s Lifetime Achievement Award during the meeting. Contact Melissa Connor at mconnor@ pami.org or go to www.accga. org for additional information. Georgia Chapter of the American Academy of Pediatrics

by Kasha Askew, Director of Membership & Education More than 200 physicians from 26 states attended the Georgia Chapter of the American Academy of Pediatrics’ ‘Pediatrics by the Sea’ CME Meeting in June. The meeting chair was Susan Mazo, M.D. Next year’s event will take place on Amelia Island on June 13-16. The Chapter’s fall CME meeting – ‘Pediatrics on the Parkway’ – will be at the Cobb Galleria in Atlanta on November 2-4. Rebecca Reamy, M.D., will serve as 36 MAG Journal

program chair. The meeting will feature pre-conference seminars on mental health, coding and practice management, hospital medicine, and MOC/injury prevention. The Chapter will also present its annual awards during a lunch program. It is worth noting that the Chapter’s philanthropic arm, the Pediatric Foundation of Georgia, will celebrate its 20th anniversary with a dinner celebration on Friday, November 3 (details to come). Finally, the Chapter has plans to unveil webinars on mental health, PCMH, and nutrition in the near future. Go to www.gaaap.org or call 404.881.5091 for additional information on the Chapter’s events and webinars. Georgia Gastroenterologic and Endoscopic Society

by Dan Walton, Executive Director The Georgia Gastroenterologic and Endoscopic Society (GGES) hosted its annual meeting at the Atlanta Marriott Buckhead Hotel and Conference Center in September. Contact Stacie McGahee at 706.738.3119 or smcgahee@medicalbureau. net for additional information or to join GGES. Georgia Chapter of the American College of Physicians

by Mary Daniels, Executive Director The Georgia Chapter of the American College of Physicians (ACP) hosted a meeting at the Hyatt Regency Savannah at the end of September that featured CME, SEP MOC, and internal medicine academic program competitions. Go to www.

gaacp.org or contact Mary Daniels at mdaniels@gaacp. org with questions or for information about joining ACP. Georgia Obstetrical and Gynecological Society

The Georgia Obstetrical and Gynecological Society has hired Daniel Thompson to be its executive director. Thompson replaces Pat Cota, who served in the role for 15 years. Cota will lead the society’s foundation. Go to www.gaobgyn.org or call 770.904.0719 for additional information. Georgia Society of Dermatology and Dermatologic Surgery

by Maryann McGrail, Executive Director The Georgia Society of Dermatology and Dermatologic Surgery (GSDDS) held its 62nd annual meeting at The Cloister

at Sea Island in June. The 41st annual Southeastern Consortium for Dermatology will take place at the Augusta Convention Center on November 3-5. Go to www. gaderm.org for information on these meetings and for other information on GSDDS. Please submit your Georgia county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag.org. Also contact Kornegay with any corrections, which will run in the next edition of the Journal. The Journal reserves the right to edit submissions for length and clarity. Bolding recognizes the physicians who are active MAG members at the time the Journal was prepared. Go to www.mag.org/membership to join MAG.

MAG mourns loss of past president, Milton Johnson, M.D. The Medical Association of Georgia is mourning the loss of Milton I. Johnson, M.D., who served its president in 1977-1978. Dr. Johnson passed away in July. Born in Macon in 1927, Dr. Johnson cared for his patients at his family practice in Macon from 1961 to 1986. He then worked at the VA Hospital in Dublin until he retired in 1991. Dr. Johnson received his medical degree from the Medical College of Georgia in Augusta. He conducted his internship at Macon Hospital. It is also worth noting that he served in the U.S. Navy during World War II. In addition to his MAG leadership roles, Dr. Johnson was the president of the Bibb County Medical Society. Dr. Johnson is survived by his wife of 68 years, Joyce McCowen Johnson, as well as a number of other family members.

MAG MEDICAL RESERVE CORPS

MAG MRC promoting the ‘Stop the Bleed’ campaign

embers of the Medical Association of Georgia (MAG) Medical Reserve Corps (MRC) promoted the ‘Stop the Bleed’ campaign during MAG’s ‘Summer Legislative Education Seminar’ in Young Harris on June 23-24. The MAG MRC and the American College of Surgeons have been credited with helping secure a grant to fund bleeding control kits in every public school and other public places in Georgia – as well as training school nurses and administrators in the proper hemorrhage control techniques. The MAG MRC presenters and instructors included Shoheb Ali, M.D., Hannie Batal, M.D., Jim Barber, M.D., Tom Haltom, M.D., John S. Harvey, M.D., Benjamin Hayes, M.D., Stephen Jarrard, M.D., Sen. Kay Kirkpatrick, M.D., Ian McCullough, M.D., Haoran Peng, M.D., and Hayes Wilson, M.D. More than 50 physicians and 22 legislators were on hand for

the event – and many were trained and certified in the proper use of a tourniquet. Special guests included Georgia Trauma Care Network Commission Executive Director Dena Abston and Georgia Trauma Care Network Commission Executive Secretary/Treasurer Victor Drawdy. Go to www.dhs.gov/ stopthebleed for details on the ‘Stop the Bleed’ campaign. Visit www.mag.org/mrc for information on the MAG MRC. www.mag.org 37

OPINION

The Emperor’s Clothes By Minor C. Vernon, M.D.

Minor C. Vernon, M.D.

he story is told of the Emperor who ordered the finest clothes in the land. The Royal Tailor was summoned to fit, produce, and dress the Emperor. The Tailor assured him that he was dressed in the finest clothes that money could buy. The next week during the Royal Parade, the Emperor walked proudly, until a young man pointed out that the Emperor was dressed only in his underwear. The Emperor had spent a lot of money, only to be duped by the Tailor. Alas, the Emperor represents all of us in the United States and his clothes represent our health care. As will be explored in this paper, do we have the best health care system in the world, is it fairly priced, or are we being duped like the Emperor? When exploring health care, it all begins with cost. It is reported that the Starbucks Corporation spends more on health care for its employees than it spends on coffee beans! General Motors spends more on health care costs than it spends on steel! According to Consumer Reports, the cost of health care in the United States would make that health care budget the fifth largest economy in the world.1 How does the U.S. system compare to the rest of the world? The U.S. currently spends approximately 18 percent of our Gross National Product on health care and is projected to spend 20 percent by 2020, or one fifth of our GNP. In comparison, France, Germany, Japan, and Australia all spend about 11 percent of their GNP. This is a tremendous economic difference and puts us at a horrible economic disadvantage. Of note, 50 percent of our costs pay for 5 percent of the population. This is mostly spent at the beginning of life (Newborn Intensive Care Units/ NICU) and the end of life (the last three months of life.) As Michele Munz pointed out in December 2015 in the St. Louis Post, there has been a 46 percent increase in NICU beds since 2000 despite a flat to falling birth rate. These expensive beds must be filled with patients and some minimally ill babies. Hospitals are doing just that. Twenty percent of health care spending is on waste, overtreatment, failure in care coordination, fraud, and abuse according to some experts.2 Why are health care costs in the U.S. so high? First, hospital administrative costs are at least 25 percent higher 38 MAG Journal

here than in other countries. An example: Duke University Hospital has 900 beds with 1,300 billing clerks. Canada has a handful of billing clerks for the entire country! Also of note, the CEO of United Healthcare made more than $100 million in salary and benefits for the year of 2012. Salaries of CEO’s of the top 10 insurance companies exceeded $200 million for that year. At the risk of disparaging our capitalist system, these are obscene salaries. Athletes and entertainers make high salaries, but nothing in this range. Also, these salary costs are passed along to employers and subsequently to the employee.3 The second driver of high cost is simple overuse. Ontario, Canada has a population more than 13 million people and has 11 hospitals that can perform heart surgery. The state of Pennsylvania, with a comparative population, has 60 hospitals that can perform open heart surgery. There are a multitude of examples comparing the high number of CT and MRI machines in the U.S. compared to other countries. The number of suppliers and equipment manufacturers also help drive up costs. Physician salaries, compared to other countries, must also be implicated. Orthopedic Surgeons in the U.S. make, on average, well over $400,000 per year compared to $154,000 per year in Germany.4 The common thread to all of this: If you have it, you will use it and consequently, high costs must be paid. There are many drivers of cost but third, and possibly the biggest, may be the cost of pharmaceuticals. Our drug costs are 54 percent higher than the rest of the world.5 One example is Enbrel® (a drug with many uses, especially for arthritis). A one-month supply in Great Britain would cost approximately $1,200 per month compared to $3,000 per month in the U.S. Cymbalta, for depression, would cost about $54 per month in the U.K. compared to $240 per month in the U.S. Nexium would cost $30 per month in the U.K. compared to $300 per month in the U.S. Finally, COPAXONE®, for multiple sclerosis, would be $1,100 per month in the U.K. versus $3,900 in the U.S.6 One can look at Norway, one of the world’s richest economies and an expensive place to live. Norway pays roughly 93 percent less than the U.S. on the top 40 branded medicines. All

drugs are bought, provided and paid for by the government. The reasons U.S. patients pay more for medicines are: 1. Philosophical and practical differences in the way our health system provides benefits 2. Drug industry’s political clout 3. Many Americans’ aversion to limiting care of any kind to anyone (i.e., rationing) The drug companies tout research and development as the reasons for high costs in the U.S. In reality, many of these costs, possibly as high as 85 percent, are paid by government grants. Higher U.S. drug prices also help companies afford hefty marketing allowances, which are not allowed in Europe. Also, it can only be imagined how much is spent on lobbying by the drug companies. Lobbying and direct consumer marketing should be banned. Pharmaceutical companies earn an average profit of 16 percent compared to seven percent profit for all other companies in the Standard and Poor’s 500.7 According to James Love, the U.S. taxpayer pays three times for drugs: 1. Government grants increasing taxpayer burdens 2. Tax credits to drug companies 3. Much higher costs at the drug store It is clear that the U.S. is heavily supplementing drug costs for all other countries in the world. Why do drug companies charge so much? Because they can. Insurance companies and the government allow it.8 As noted, health care costs in the U.S. are clearly higher than the rest of the world. But the U.S. system is the best in the world so we should pay more, correct? According to the World Health Organization ranking of health care systems, France is ranked 1st, The U.K is 18th and the U.S. is ranked 37th. This ranking is based on a number of metrics including access to care, life expectancy, infant mortality, cost, outcome, and fairness. Life expectancy is one year shorter in the U.S. than in most advanced countries. The Commonwealth Fund ranked the U.S. compared to Australia, Canada, Netherlands, UK, and New Zealand. The U.S. was ranked last in quality, efficiency, access, cost, and healthy lives. In one other study based on similar metrics, the U.S. was ranked 73rd. Other outcomes, according to the Huffington Post, showed the U.S. next to worst in asthma mortality in the 5 to 39-year-old. This study also showed the U.S. next to worst for lower extremity amputations in people with diabetes.9 A study in the New Yorker showed how long it took several major discoveries – such as the finding that the use of beta blockers after a heart attack improves survival – to reach even half of Americans.

The average was 15 years. To be fair, the U.S. has been shown to do better than most countries in breast and colorectal cancer survivals.10 There are many metrics and many interpretations of these metrics. One could argue back and forth, but any way the numbers are interpreted, results are not great for the U.S., especially considering what we all pay for care. Gallup surveyed Canadians and Brits as to whether they have confidence in their health care systems. People in both countries noted a 73 percent positive ranking of their health care systems. In the U.S., despite spending more per person on health care, the affirmative figure was only 56 percent.11 Do we pay higher prices than other countries for comparable care? We have examined and shown higher drug costs. In terms of procedures, we pay on average $1,080 for a MRI in the U.S. versus $599 in Germany. A CT scan of the head is $510 on average in the U.S versus $272 on average in Germany. Procedural costs as well as drug costs are much higher in the U.S.12 So how does the Affordable Care Act (ACA) factor into all of this? The majority of people felt that health care reform was needed, as can be seen in the above factors of cost and quality, not to mention coverage for the uninsured. The ACA has some good features including… • Coverage of children to age 26 on parents’ insurance • No gap on benefits, thus helping people avoid bankruptcy due to high medical bills • Preexisting conditions cannot block someone from having insurance coverage • The number of uninsured Americans was cut in half Negatives of the ACA include… • Higher taxes • A decrease in full time employment for workers as employers attempt to decrease health care costs • Increase in premiums being paid by people in the middle class • High deductibles that many consumers are unaware exist and will not be able to pay • At least half of uninsured Americans are still uninsured One further problem is our tort system. Tort reform enacted thus far has lowered malpractice insurance rates, but had little effect on the rising costs of health care. The measurable costs on our system (i.e., the costs of lawsuit judgements and their defense) are not that great, according to available research. The real costs of malpractice are those of defensive medicine. The costs are tremendous, but impossible to quantitate. We must continue to strive for significant tort reform. www.mag.org 39

Again, many people felt that health care reform was needed, but not THIS reform. The good news about the ACA is that it did get discussion regarding health care reform started. Hopefully, we can move forward from here. We are in critical need of a true, cost effective, reformed health care system that will cover all Americans.¨ Editor’s note: Dr. Vernon will address how he believes America’s health care system should be reformed in the next edition of the Journal. Dr. Vernon’s views do not necessarily reflect MAG’s views or policies. MAG did not edit or verify this article’s facts or assumptions. MAG members who would like to respond to this article are encouraged to submit a letter to the editor or an article to Tom Kornegay at tkornegay@mag.org. All submissions are subject to editorial review.

Dr. Vernon is a pediatrician who has been in private practice for nearly 40 years. He served as the president of the Bibb County Medical Society in 1991. Dr. Vernon has served as a delegate at MAG’s annual House of Delegates meeting for more than 20 years. He is the treasurer of the Georgia Academy of Pediatrics. It is also worth noting that he has two children who are in the medical profession. References “Why is health care So Expensive?” Consumer Reports, November 2014. St. Louis Post, Michele Munz, December 2015 “health care Costs: A Primer”, Kaiser Family Primer, 2012 4. PBS newsletter, by David Cutler, November 19, 2013. 5. “Why Drugs Cost More in the U.S.”, New York Times, May 1991. 6. “US Drug Prices Are Literally Insane.” uncut.com/ News/ US 7. “Why the U.S Pays More than Other Countries for Drugs”, The Wall Street Journal, December 1, 2015. 8. “Consumer Project on Technology”, by James Love, April 20, 2011 9. “Why U.S. health care is Obscenely Expensive” Huffington Poast.com, October 3, 2013. 10. “Big Med”, The New Yorker, Atul Gawande, August 2012 11. “Why we must ration health care”, The New York Times, July 19, 2009. 12. “US versus European health care costs: The Data” Epianalysis.wordpress.com, July 18, 2012. 1. 2. 3.

HHS Sec. Price among dignitaries to address 10th GPLA class

U.S. Department of Health and Human Services Sec. Tom Price, M.D., addressed the 10th class of the MAG Foundation’s Georgia Physician Leadership Academy (GPLA) during it’s session on St. Simons Island in August. The GPLA is a year-long program that is designed to enhance the participating physicians’ skill sets in the areas of advocacy, communications, and conflict resolution. The GPLA now has nearly 120 graduates. Pictured from the left is GPLA class member Zachary Lopater, M.D., GPLA Steering Committee member William Clark, M.D., GPLA members Anna Skold, M.D., and Joash Lazarus, M.D.,

40 MAG Journal

MAG President and GPLA graduate Steven Walsh, M.D., MAG President-elect and GPLA graduate Frank McDonald, M.D., GPLA members Masoumeh Ghaffari, M.D., Keisha Callins, M.D., Sudha Tata, M.D., Brett Cannon, M.D., Margaret Wong, M.D., Syamala Erramilli, M.D., Nicki Hughes, M.D., and Brandy Cross, M.D., Georgia Sen. Ben Watson, M.D., GPLA Steering Committee Chair John Sy, D.O., Sec. Price, GPLA member Sultan Simms, M.D., Georgia Sen. Dean Burke, M.D., Georgia Rep. Mark Newton, M.D., GPLA members John Johnson, M.D., Anurag Sahu, M.D., Ahmed Ali, M.D., and Kelly Homlar, M.D., and Georgia Rep. Betty Price, M.D. Go to www.mag.org/GPLA for information on the GPLA.

GEORGIA BOARD FOR PHYSICIAN WORKFORCE

Making an impact on rural health care By Mark Hanly, M.D., chair, and LaSharn Hughes, executive director, Georgia Board for Physician Workforce Mark Hanly, M.D.

ew state agencies impact the health of Georgians quite like the Georgia Board for Physician Workforce (GBPW). GBPW is a state agency that identifies the professional workforce needs of physicians and allied health care professionals across the state, and it meets those needs by supporting and developing medical education programs. GBPW’s vision is to “improve access to care and enhancing the health and well-being of all Georgia citizens.” During the 2017 legislative session, GBPW was honored by the General Assembly with S.R. 117 and H.R. 133 for its contributions to the health of the citizens of Georgia with its ‘Country Doctor Scholarship Program,’ which is also known as the ‘Medical Student Scholarship Program.’ This program covers the tuition of physicians who agree to practice primary care in rural areas (i.e., counties with a population of 35,000 or less, based on the most recent U.S. census). GBPW is proud to announce that more than 200 doctors who participated in this program continue to practice in rural Georgia. This program is being phased out, so GBPW is shifting its focus to loan repayment programs. GBPW administers several service-cancellable loan repayment programs for physicians, physician assistants, advanced practice registered nurses, and dentists in the state. These programs support practitioners who practice (or agree to practice) in an underserved/rural county in Georgia on a full-time basis pay by paying the debt they incurred during the completion of their degrees. Physicians and dentists are eligible for awards of $25,000 per year for up to four years, while PAs and APRNs can get awards of up to $10,000 per year for up to four years. The recipients must renew their commitment on an annual (12-month) basis, and they are required to practice in the underserved/rural area at least 40 hours per week. Early this year, GBPW gave out repayment awards to 25 physicians, 20 APRNs/PAs, and eight dentists – supporting more than 40 rural counties in the state with additional, much-needed access to care. It is also worth noting that nearly 65 percent of the 355 physicians who completed GBPW’s ‘2016 Graduate Medical Education Exit Survey’ said that they are now more than

LaSharn Hughes

$200,000 in debt – and more than 50 graduates said their debt exceeded $350,000. Since their average salary is expected to be less than $250,000 per year, GBPW’s loan repayment program is making a real difference. Also worth noting is that GBPW works with medical schools, legislators, the Georgia Hospital Association, and the Medical Association of Georgia (MAG) to encourage them to inspire high school students in the state to consider careers in health care earlier in life – keeping in mind that just a quarter of the physicians who completed the aforementioned GBPW survey attended high school in Georgia. GBPW hopes, and believes, that these efforts will ultimately result in more physicians in the state. One red flag in the survey is that just 30 percent of the respondents said that they plan to practice in Georgia, so it is clear that we collectively still have a lot of work to do to convince more of the physicians who are trained in this state to practice medicine in this state. Finally, GBPW recently activated an interactive, webbased resource – which can be found at gbpw.georgia.gov/ physician-workforce-database – that provides information on physicians in the state by county, gender, age, race, retirement plans, and Medicaid/Medicare acceptance. This new resource will replace the fact sheet reports that GBPW has produced in the past. GBPW is grateful for the ongoing support that it receives from Georgia’s General Assembly, Gov. Nathan Deal, and MAG and its members. There is no doubt that these kinds of partnerships will improve Georgia’s health care system. GBPW is composed of 15 volunteer members who are appointed by the governor. Go to www.gbpw.georgia.gov for additional information on GBPW and to obtain the ‘2016 Graduate Medical Education Exit Survey’ results. Dr. Hanly is a pathologist in Brunswick. In addition to MAG, he is a member of the Glynn County Medical Society. It is also worth noting that he is a long-time member of the Journal’s editorial board. Ms. Hughes has been GBPW’s executive director since 2016. www.mag.org 41

PERSPECTIVE

The fundamental humanity of medicine By Mark Murphy, M.D.

he woman was only 28 years old – a young wife and a mother to two preschool children. Stunningly attractive, she was the sort of woman that men could not help but stare at, the sort of woman that made other women jealous. And she was dying. I stared, unbelieving, at her chest x-ray. A massive cancer had wrapped itself around her vena cava, surrounding her heart and crushing her trachea. The patient was standing right behind me. “What is it?” she asked. “I…I don’t know,” I lied. I seated her in the radiology lobby and called my friend Andy Greganti, M.D., the young woman’s internist, to help me break the news to her. I needed Andy’s wisdom and compassion, of course – but most of all, I wanted Andy there because I did not want to be alone, looking into those beautiful brown eyes, when I told my wife she was going to die. That one moment, 25 years ago, now, crystallized for me what medicine is all about. We all learned pathophysiology in medical school. Checking the electrolytes of a patient in diabetic ketoacidosis or rattling off the differential diagnosis of right upper quadrant abdominal pain became as easy as tying our shoes. Ultimately, I realized that life is a colossal miracle. It is astonishing to think that billions of years of evolution have somehow come up with an intelligent, self-perpetuating, self-healing creature that can live a hundred years or more. No magician on Earth can perform a better feat. But that’s not all there is. Understanding pathophysiology is only one small part of being a doctor. There’s this other part – the humanistic part – that is equally important. And I would contend that it is the humanity, not the science, that ennobles the practice of medicine. That morning, I could not tell my wife that she had cancer. But I did. We drove home that day holding hands, not saying much. The silence was excruciating. “It’s…it’s going to be okay,” I finally stammered. “No, it’s not,” she replied. “I’m not going to see the kids 42 MAG Journal

Mark Murphy, M.D. grow up. They won’t know me.” I squeezed her hand, not knowing what else to say. When I looked at my wife’s chest x-ray that day, I knew the data, but the data did not give me the whole picture. Data helps us to make decisions, but it was faith that got me through my wife’s illness. I’m not merely talking about faith in God. That helped too, of course. But I also had faith in the inherent compassion of the team of health care providers headed by John Parker, M.D., my wife’s oncologist. We consistently believed they were doing the right things for us. That meant everything. My wife’s illness, which turned out to be lymphoma, taught me a lot about being a doctor. During my medical career, I have seen a multitude of things both wonderful and miraculous. I have seen babies draw their first ragged breath, surgery on the human brain, children cured of cancer, victims of horrible injuries restored, the dead brought back to life – all of it, every bit of it, the product of both divine providence and hard work, the work of dedicated doctors, nurses and ancillary personnel working together, in concert, to benefit another human being. We spend a great deal of time learning the scientific basis of medicine. But at the end of the day, science merely provides us with the tools we need to do our job. Instead, the medical profession is about people. We have been charged with maintaining the fundamentals of life for everyone else. It is an incredible honor to be afforded that privilege. I recently spoke to a group of first-year medical students about what to expect from their impending medical careers. Here’s what I said to them... “There will be no paper you can publish, no accolade, honor and certainly no paycheck which would give you the satisfaction that you have chosen the right field of endeavor. Instead, you will see it in the eyes of those you have helped. For there is no other profession in the world where you can get up every single day and say, truthfully, ‘Today, I’m going to make a fellow human being better.’ No profession, that is, except this one.” My wife survived, by the way. And our two sons, both grown men now, know her very, very well. Dr. Murphy, a Savannah gastroenterologist and longtime MAG member, is the former President of the Georgia Medical Society.

PRESCRIPTION FOR LIFE

The elephant in the room

Jay Coffsky, M.D.

’d like to acknowledge the elephant in the room.

I recently opened my 1961 yearbook from the Medical College of Georgia. But I regretted doing so almost immediately once I began to cross-check that with a directory that I recently received from the school’s alumni office. I was shocked and deeply saddened to see that more than half of the 86 members of my graduating class are now deceased. Reading every name was like getting stabbed – one after the other, 44 in all. These were my classmates, my colleagues, and my friends. I remember their vigor and enthusiasm like it was yesterday – every one of them grinning from earto-ear as they walked across the stage to receive their diplomas. I have been in the medical profession for 60 years, which includes eight years of medical school and radiology training, taking scores of CME courses, and serving my country in the military for two years during the Vietnam War. It also makes me proud knowing that I have practiced at the same hospital complex and radiology group – Radiology Associates of DeKalb, P.C. – for more than 50 years. Having evaluated more than one million chest x-rays, tens of thousands of CT scans, thousands of nuclear scans, and hundreds of MRI scans, and having conducted 50,000 barium enemas and 250,000 mammograms, I know that we all have a bullet with our name on it (i.e., the aforementioned pachyderm) – we just don’t know when it’s coming or what form it will take. I have been in love with my beautiful wife, Sandy, since the 10th grade. So, in all of my years of medicine, the most difficult report I ever had to give was when she brought her CT scan home from the doctor and I had to tell her that she had advanced lung cancer. If you or a loved one has ever battled cancer, you know that this insidious disease affects the entire family. Sandy is a candidate for immune therapy, and she is undergoing treatment. But a week never seems to go by without a cancer treatment or complication therapy, blood work, or some sort of doctor’s appointment. It feels like a full-time job.

I tell you this story because several months after she was diagnosed, I experienced some severe neck discomfort while I was working out. Keeping in mind that one of my associates recently died suddenly while playing golf, I got nervous and decided I should go to the ER. That ER visit led to a cardiac catherization. During the procedure, I noticed that there was a long lapse between one QRS complex and the next. I overheard a nurse say, “His pulse is 29,” followed by, “Give him Atropine.” The cardiologist told me I had a long, 99-percent stenosis of the right coronary artery – and for any non-physicians, that’s bad. The cardiologist put in three stents and I was placed in the care of a large university medical complex. The quality of the medical care I received was top notch. Those caring and talented people saved my life. I dodged a bullet that day. As I reflected on those events – and as I thought about life and death – I thought about my MCG classmates. I know it’s not possible or practical to maintain a day-to-day relationship with everyone who has been in your life, but I do regret not telling more of them that I was thinking about them over the years. If you are reading these words, the good news is that it’s not too late for you. Sandy and I are two of the “richest” people in the world. We have been together since we were teenagers, and we have three happilymarried children, eight grandchildren, and one greatgrandchild. We see them just about every week. I play a round of golf or enjoy a good book from time-to-time. I even work several days a week. That’s a long way of saying I don’t have any complaints. Still, he’s sitting there, staring at me. I’ve received all kinds of advice about ways to come to grips with that darned elephant, but none of them seem to work all that well. Who knows, maybe I’ll just buy a pet mouse. Dr. Coffsky and his wife, Sandy, have been married for 58 years and have three children, eight grandchildren, and a greatgrandchild. He is in his 50th year at DeKalb Medical. You can email Dr. Coffsky at m3wejr@bellsouth.net.

www.mag.org 43

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