J U LY 2 0 11
The Surgeons of the New Jersey Center for Prostate Cancer & Urology Pioneers Who Have Become Masters of Robot-Assisted Laparoscopic Urologic Surgery Also in this Issue
• CMS Issues First Round of EHR Incentive Checks • Sen Lautenberg, Rep Maloney Introduce Bill to Ensure Women are not Denied Access to Contraceptives • President Signs Debt Compromise-Medicare Reimbursements May be Reduced • How Effective is Legislation to Screen New Mothers for Depression?
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Publisher’s Letter Dear Readers, This month we are pleased to update you on the latest developments at the New Jersey Center for Prostate Cancer and Urology (NJCPCU), which continues to perform the largest number of robotic prostatectomies in the state. NJCPCU has also brought the robot into many other urologic surgeries with impressive outcomes. Nitin Patel, MD is the newest member of NJCPCU’s surgical team and brings his expertise in robotics to all of the urologic procedures performed. Also in this issue, how the debt compromise recently signed by President Obama might impact on Medicare providers, who could be subject to reductions of up to 2 percent in addition to projected cuts from the sustainable growth (SGR) formula. Statehouse describes the reasoning behind a bill introduced by Senator Lautenberg (D-NJ) and Representative Carolyn Maloney (D-NY) to ensure that women are not denied access to birth control. This comes on the heels of a recent Institute of Medicine (IOM) report recommending that birth control be made available without copays because of the critical role it plays in preventative
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Contents
The Surgeons of the New Jersey Center for Prostate Cancer & Urology
Pioneers Who Have Become Masters of Robot-Assisted Laparoscopic Urologic Surgery Drs. Vincent Lanteri, Michael Esposito, Mutahar Ahmed, Gregory Lovallo and Nitin Patel of the New Jersey Center for Prostate Cancer & Urology are the true pioneers of robotic prostatectomy, perfoming the largest number of robot assisted laparoscopic prostetectomies in the State of New Jersey and at Hackensack University Medical Center. They continue bringing cutting edge robotic techniques into their practice, using their expertise to perform many other robot assisted urologic surgical procedures.
CONTENTS
3
Special Alert
President signs debt compromise – challenges ahead
11 14
Statehouse
Postpartum Depression
How effective is legislation to screen new mothers for depression?
16 18
Health Law Update
Finance
The EMR Marathon Running or stumbling through it, is your choice.
20
Food for Thought
P.F. Seafood Market and Restaurant
COVER STORY 2
New Jersey Physician
West Caldwell, New Jersey
Category Special Alert
President Signs Debt Compromise, Challenge Ahead for New Congressional Committee The president signed legislation passed by
exempt from automatic cuts, Medicare
debt package. It is critical for Congress to use
Congress representing a compromise deal
would not. Beneficiaries would be held
this opportunity to prevent the 29.5 percent
to raise the debt ceiling and cut federal
harmless, but providers would be subject
Medicare cut from taking effect on Jan. 1 2012
spending.
immediately
to reductions of up to 2 percent in order to
as well as to address the long-term failure of
enacts 10-year discretionary spending caps
achieve required savings. For physicians,
the SGR once and for all.
generating approximately $1 trillion in deficit
these cuts, which would begin in 2013,
reduction; balanced between defense and
would be in addition to projected cuts from
Look for future Washington Connexions for
non-defense spending. These initial cuts are
the sustainable growth rate (SGR) formula.
updates and opportunities to get involved
The
legislation
in MGMA’s grassroots efforts to repeal the
limited to discretionary spending and do not impact Medicare or Medicaid.
MGMA will urge the Select Committee to fully
broken SGR system.
address the SGR as part of a comprehensive As part of the second phase of the deal, a bipartisan Select Committee will be tasked with identifying an additional $1.5 trillion in deficit reductions over 10 years. These may include entitlement and tax reforms. The committee is required to report legislation by Nov. 23, 2011, and Congress is required to vote, without amendment, on the committee’s recommendations by Dec. 23, 2011. Included in the deal is a mechanism intended to force parties to agree to these additional spending reductions as part of the Select Committee process. If the Select Committee fails to report legislation that achieves at least $1.2 trillion in savings, or if Congress fails to enact recommendations that produce at least that amount, acrossthe-board spending cuts for fiscal years 20132021 will automatically occur to achieve the $1.2 trillion amount. Although a number of programs such as Social Security and Medicaid would be July 2011
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Cover Story
The Surgeons of the New Jersey Center for Prostate Cancer & Urology Pioneers Who Have Become Masters of Robot-Assisted Laparoscopic Urologic Surgery By Iris Goldberg
Drs. Vincent Lanteri, Michael Esposito, Mutahar Ahmed, Gregory Lovallo and Nitin Patel of the New Jersey Center for Prostate Cancer & Urology (NJCPCU), true pioneers of robotic prostatectomy, perform the largest number of robot-assisted laparoscopic prostatectomies in the state of New Jersey and at Hackensack University Medical Center (HUMC). Their dedication to HUMC recently culminated in that facility receiving the prestigious 2010 HealthGrades Award for Excellence in Prostatectomy. The surgeons of NJCPCU continue to bring cutting edge robotic techniques to HUMC and have expanded this expertise to perform many other robot-assisted urologic surgical procedures. It is most interesting to profile this unique practice and discover how the surgeons of New Jersey Center for Prostate Cancer & Urology have become recognized leaders within their specialty.
in the last months of a minimally invasive urologic fellowship at the Royal Infirmary in Edinburgh, Scotland. The other was a recipient of a urologic oncology fellowship at the Roswell Park Cancer Institute affiliated with the University of Buffalo, State University of New York.
The Journey Begins Back in 2001 if a man with prostate cancer required a prostatectomy, his only option was an invasive open surgical procedure. This entailed a large incision with significant blood loss. Recovery was a slow and painful process with subsequent incontinence and erectile dysfunction almost certain for some time after surgery and in some instances, permanently. At that very time, two urologic surgeons from New Jersey travelled to Paris on a mission to learn a better way. One was
After training to learn how to perform laparoscopically with Dr. Vallancien in Paris, Dr. Lanteri and Dr. Esposito returned to HUMC to perform their first laparoscopic prostatectomy. The initial procedures took seven hours each, enabling the team to perform only one prostatectomy a day. Even so, they forged on, honing their skills more and more with each surgery. Then, with the FDA approval of the da Vinci™ Surgical System in June, 2001, Drs. Lanteri and Esposito were able to take the laparoscopic
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Dr. Guy Vallancien, Chief of Urology at Institut Mutualiste Montsouris had recently performed the first series of laparoscopic prostatectomies. With this minimally invasive approach, patients are not subjected to the trauma of an open procedure. There is significantly less blood loss with a substantially lower risk of complications and recovery time is greatly reduced. Dr. Lanteri and Dr. Esposito of the New Jersey Center for Prostate Cancer & Urology were committed to bringing this technology back here to their patients with prostate cancer.
prostatectomy to an entirely new and exciting place. HUMC acquired this technology and the surgeons immediately incorporated the robot into the minimally invasive procedure. The da Vinci system translates the large hand movements of the surgeon into precise minute movements inside the patient. It provides magnified 3-D images, along with minimal blood loss which allow for maximized, clear vision of the surgical field. Tiny, exact sutures are created which are the key to preserving normal urinary function. Additionally, the da Vinci technology significantly increases precision while cutting in hard-to-maneuver areas, obviating the need for the use of thermal energy to control bleeders. This is vital to the sparing of neurovascular bundles that preserve sexual function. Dr. Lanteri and Dr. Esposito began the challenging process of learning how to skillfully utilize the robot to assist them in performing prostatectomies. When some skeptical colleagues questioned why they would undertake such an endeavor, the answer could easily be given in one word – outcomes. “The patients were doing very well, post-operatively,” Dr. Esposito relates. Although they were still novices with the robot, Dr. Lanteri and Dr. Esposito, with their complete understanding of the local anatomy, were able to achieve superior outcomes with the minimally-invasive robot-
testing all of the robotic instruments that are currently used in the performance of the robot-assisted prostatectomy. Dr. Lanteri and Dr. Esposito continued to perfect their skills and now require about an hour and a half per procedure. With the arrival of Dr. Mutahar Ahmed to the practice in 2003 and Dr. Gregory Lovallo in 2007, both expertly skilled in the techniques pioneered by Dr. Lanteri and Dr. Esposito, the New Jersey Center for Prostate Cancer & Urology was able to perform 10-12 robot-assisted laparoscopic prostatectomies each week.
p Drs. Lanteri and Espositio at the onset of a Robotic Prostectectomy
assisted approach, without the need for blood transfusions. Patients experienced less trauma, retained more function and recoveries were shorter and much easier. Eventually, the times dropped from seven hours to five hours, to four hours until they were able to do two procedures a day. As time went by, even as other surgeons remained unconvinced, Drs. Lanteri and Esposito persisted and the time dropped from four hours to two hours, allowing them to perform three procedures in a day. The reportable outcomes were continuously improving and exceeding their original expectations as compared to the open procedure. Finally, other surgeons were beginning to take note and expressing an interest in learning how to incorporate the robot to perform minimallyinvasive prostatectomies. From Pioneers to Proctors During the first few years (2002, 2003, 2004), Drs. Esposito and Lanteri began work on a textbook to teach other surgeons and also reported their experiences and research at various national and international urologic symposiums. As early as 2002, when the technology was still in its infancy and there were very few teams performing robotassisted procedures, Dr. Lanteri and Dr. Esposito were called upon by Intuitive Surgical Systems (creators of the da Vinci
robot) to teach others what they had learned thus far. “By pioneering the techniques that are currently being used we started to proctor and teach this operation,� Dr. Esposito shares. Working very closely with the Intuitive surgical engineers, they tested and performed the first ten robotic prostatectomies in the world with the four-arm da Vinci system. One of those surgeries was shown via live broadcast at the meeting of the Urologic Association in 2004. They also assisted in designing and
Most recently, Dr. Nitin Nick Patel has joined the practice. By training directly under Drs. Lanteri, Esposito, Ahmed and Lovallo in robotics/ laparoscopy, Dr. Patel did not experience the trial and error growing pains that most surgeons did when first learning to master those skills. As such, he was able to climb quickly up the learning curve and is highly proficient in performing robotic procedures. In addition to his involvement with laparoscopic robotic surgery, Dr. Patel specializes in male sexual dysfunction and incontinence as well as female urology.
p Drs. Ahmed & Lovallo. With the addition of the newer doctors, the practice has become more diversified, doing more complex procedures. July 2011
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brought NJCPCU into the mix in order to bring the robotics program there to the next level. With the addition of Dr. LaSalle and other colleagues, NJCPCU has now successfully completed the first 125 laparoscopic robotic-assisted da Vinci procedures at Saint Barnabas Medical Center. These include: radical prostatectomies, nephrectomies, partial nephrectomies, adrenalectomies, as well as the first robotic-assisted cystectomy with urinary diversion for bladder cancer. Experience is Key to Success Surprisingly, there are still critics who question whether the outcomes using the robot-assisted laparoscopic approach are in fact superior to those obtained with the open prostatectomy. Dr. Lanteri wants to clarify beyond any doubt why these discrepancies continue to surface and why they are invalid. He explains that the outcomes for surgeons who have limited experience with the robotic approach cannot and should not be compared with the outcomes achieved at NJCPCU.
p Dr.Lanteri utilizes the Viking 3Dimensional Vision Helmet allowing the assistant surgeon to view the same 3D image as the surgeon in high definition.
Besides robotic laparoscopic prostatectomies, there are a myriad of other minimallyinvasive urologic procedures on NJCPCU’s weekly surgical schedule. “With the newer doctors, we have become more diversified, doing more complex procedures more often,” Dr. Lanteri notes.
Medical Center in Long Branch. Plans have now been finalized to also bring the skills of Drs. Lanteri, Esposito, Ahmed, Lovallo and Patel to Englewood Hospital and Medical Center, where minimally-invasive, bloodless surgical techniques are its standard of surgical treatment.
Fortunately for patients in the central and southern parts of New Jersey, it was not long before the surgeons of the New Jersey Center for Prostate Cancer & Urology brought their expertise with the robot to develop complete robotic programs at Saint Barnabas Medical Center in Livingston and Monmouth
At Saint Barnabas Medical Center, Dr. Michael D. LaSalle, who maintains his own urology practice in Florham Park, has spearheaded a program focusing on Men’s Health Initiatives. He has
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Since that first robotic procedure performed by Dr. Lanteri and Dr. Esposito back in 2001, ten years later, NJCPCU has performed more than 3200 robot-assisted prostatectomies. Referring to this huge number, which is dramatically higher than most other practices can claim, Dr. Lovallo emphasizes Dr. Lanteri’s point. “The outcomes for an experienced surgeon at this level of proficiency go well above and beyond those that can be expected from someone who has done considerably fewer procedures,” he reiterates. “There’s a tremendous level of detail involved that a surgeon acquires having done the number of cases that we’ve done,” Dr. Esposito states. “Ten years of cumulative experience in nerve-sparing has arrived at a technique that is dynamic. During each operation, I incorporate all of the techniques I have learned in those ten years,” he goes on to share. This allows the surgeons to make subtle adjustments in technique for each patient depending upon his particular anatomy. “The anatomy of each prostate is
prostate exceeding 500 grams, one of the largest on record. An open procedure would be out of the question for this gentleman since his religious beliefs prohibit him from receiving a transfusion in the event of excessive blood loss. The surgeons at NJCPCU assured him that with the robotassisted laparoscopic prostatectomy, blood loss would be negligible. “We sat him down and explained everything we were going to do and what he could expect would happen. He’s had his surgery and he’s doing fine,” Dr. Lanteri is delighted to report. The patient in question experienced minimal blood loss, required no transfusion and is almost fully continent less than two months postoperatively. p Urethropexy suspension helps to improve incontinence post prostetectomy
different,” explains Dr. Ahmed. “And it is because of this huge number of procedures that we have done and the experience we have that we can do this,” he says. Dr. Lovallo nods in agreement. “There are algorithms that change. There are dynamics that go with each individual patient and what can be described as a ten-step operation has thousands of intricacies,” he offers. Advances in sparing of pelvic vascular supply in addition to nerves as well as bladder neck preservation are examples of nuances in surgical technique that the surgeons at the New Jersey Center for Prostate Cancer & Urology have gathered over the years, which can make a tremendous difference in a patient’s outcome in terms of successfully removing the cancer while preserving functionality and quality of life. Along with the ability to accommodate for individual anatomical differences, their unparalleled experience with the robotassisted laparoscopic prostatectomy allows Dr. Lanteri, Dr. Esposito, Dr. Ahmed, Dr. Lovallo and Dr. Patel to treat many patients who would not be considered as candidates for this procedure by some surgeons with fewer cases under their belts. For example, the surgeons at NJCPCU routinely operate on the most difficult re-operative anatomies such as patients who have had prior hernia repairs
with mesh insertions, colon resections, even those with multiple prior surgeries resulting in extensive scar tissue and adhesions. Also, men with prior transurethral prostate surgery, including Green Light laser prostatectomies and TUMT transurethral microwave thermotherapy patients routinely undergo robotic procedures at NJCPCU. Besides prior surgeries, prostate size, for the treatment of a patient with or without prostate cancer, might be an issue that would cause some less experienced surgeons to shy away from a robotic procedure. Dr. Lanteri offers the example of a Jehovah’s Witness with a
In fact, the surgeons at the New Jersey Center for Prostate Cancer & Urology routinely operate on men with benign large prostates who have developed blockage symptoms. Typically these prostates are larger than 150 grams, making the patient ineligible for traditional endoscopic treatment. At NJCPCU, the surgeons do simple benign laparoscopic prostatectomies with the robot, removing the central part of the prostate and leaving the shell. At NJCPCU, the surgeons also treat men with large volume prostate cancer, incorporating all treatment modalities, including hormonal ablation and post op (adjuvant) radiotherapy
p Atermally spared right and left neurovascular bundles spared without cauterization. The long urethral stump is ready for anastamosis. July 2011
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when indicated. Additionally, the surgeons provide salvage prostatectomy to those men with post-radiation recurrence of prostate cancer. Uncontrolled local disease is a significant risk factor for metastatic progression, cancer specific mortality and presents considerable morbidity to patients who have failed radiation. Local salvage therapy represents the only approach with curative potential in this clinical situation. Unfortunately, very few practices offer this treatment because of its historically high complication rates. With the added advantages robotic surgery offers, the surgeons at NJCPCU have seen a dramatic reduction in the number of complications associated with this procedure. All of the surgeons at NJCPCU are extraordinarily proud of the fact that the expertise they have amassed in performing more than 3200 laparoscopic prostatectomies with the assistance of the da Vinci robot, has allowed them to successfully treat many patients who might otherwise have been left with less than optimal outcomes. This is true not only for those with prostate cancer but happily, patients with other urologic disorders have been benefitting as well. Taking the da Vinci Technology Beyond the Prostate It was a natural progression for the team at the New Jersey Center for Prostate Cancer & Urology to incorporate the da Vinci system to perform all urologic surgeries that would benefit from a minimally-invasive approach. This includes a wide range of complex surgeries that were previously done with an open approach that the surgeons have been able to convert to robot-assisted laparoscopic procedures. “As an experienced team of surgeons who have successfully performed high volumes with the robot, we have moved beyond the point where we feel comfortable taking on the more difficult and complicated cases,” Dr. Esposito explains. “The da Vinci system is particularly suited for performing delicate reconstructive operations,” he continues.
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New Jersey Physician
p Drs. Ahmed and Esposito begin to perform a pediatric pyeloplasty.
Boari Flap Dr. Esposito and Dr. Lovallo share the case of a young woman who had a scarred ureter, preventing drainage of the kidney because of a gynecologic procedure that had been performed. Using the robot the surgeons were able to perform a laparoscopic procedure to create a Boari flap. This involves taking a flap of natural bladder to reconstruct the lower end of the ureter and establish continuity. “Now she is no longer obstructed, no longer in pain and her kidney has regained function,” Dr. Lovallo is pleased to share. Dr. Esposito explains that using a straight laparoscopic approach, without the benefit of robot assistance, would have been extremely difficult because of the tremendous amount of sewing and dissection required. An open procedure to correct this problem would be extremely risky with significant blood loss and other likely complications, making removal of the blocked kidney a preferable alternative. Uterolysis Ureterolysis is the surgical treatment for retroperitoneal fibrosis (RPF), which is a rare disorder characterized by chronic
inflammation of the retroperitoneal structures, most notably, the ureters. Here again, the surgeons at the New Jersey Center for Prostate Cancer & Urology have been able to bring their expertise with the da Vinci system to perform a laparoscopic procedure. In order to free the ureters from the inflammation, with the help of the robot, the surgeons are able to remove the ureters from their encasement in scar tissue and then move them and fix them away from the inflamed area. “Our initial experience and follow-up of these patients has been extremely favorable and we recommend this operation, when indicated, be performed robotically,” Dr. Esposito reports. Pyeloplasty Pyeloplasty, which is indicated for uteropelvic junction (UPJ) obstruction, is another example of a delicate reconstructive procedure. The UPJ is the portion of the collection system that connects the renal pelvis to the ureter. If the transition from the renal pelvis is narrow, the urine will not drain properly, leading to progressive dilation of the renal collecting system and can result in deterioration of kidney function. To treat this condition, the segment of obstructed tube requires removal and careful reconstruction.
At NJCPCU the surgeons use the robot to perform pyeloplasty, replacing other minimally invasive techniques which produced outcomes that were only in the 60% range as compared to 95% when the robot is incorporated. In fact, they are sometimes called upon to perform robotassisted pyeloplasty to correct the failures of some of these other minimally invasive treatments. Cystectomy For people with invasive bladder cancer, Dr. Ahmed and the surgeons at the New Jersey Center for Prostate Cancer & Urology have been able to incorporate the robot to perform robotic cystectomy with reconstruction and currently do a high volume of these procedures, having become the recipients of many patients referred by other urologists. They skillfully operate the robot to remove the bladder through a two inch incision, as opposed to a ten inch incision with the open procedure and only a 50 to 100 ml. blood loss as opposed to one to two liters of blood loss. Typically, in men, the prostate
is also removed and in women, the uterus and ovaries. The magnification offered by the robotic system permits increased precision, sparing vital delicate nerves and muscle tissue. This first part of the procedure generally takes about an hour to an hour and a half. Then, through that two inch incision, they are able to either construct a urine diversion into a urostomy bag or actually create a spherical neo-bladder pouch out of a segment of intestine and place it where the bladder would naturally be. The surgeons at NJCPCU then re-establish connection with the urethra, allowing the patient to urinate as he or she normally would, without any external appliance or bag. This second stage takes another hour and a half to two hours for a total of three to four and a half hours for the entire procedure. As with other robot-assisted laparoscopic surgeries, this is all accomplished with less time under anesthesia, a minimum of trauma and blood loss and results in an extremely careful, meticulous oncologic surgery and precise
reconstruction. Additional benefits are a short hospital stay and a faster recovery and return to normal life. At the New Jersey Center for Prostate Cancer & Urology, the da Vinci technology embraced by the surgeons has also been a blessing for the many women with uterine and vaginal vault prolapse who are not candidates for trans-vaginal repair and therefore require surgery. This falling of any pelvic floor organs (vagina, uterus, bladder or rectum) occurs when the connective tissues or muscles in the body cavity are weak and cannot hold the pelvis in its natural position. Sacrocolpopexy Dr. Ahmed discusses robotic sacrocolpopexy as the treatment of choice. He explains that the traditional open sacrocolpopexy which involved a ten inch incision and then required a lengthy and bloody procedure to sew the uterus to the sacrum is now rarely done. A straight laparoscopic procedure without robot assistance is quite tedious and takes at least four hours to accomplish.
p čŒ€The radical Cystoprostatectomy specimen has been removed athermally, note the complete lack of charring on the specimen. July 2011
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procedure,” Dr. Lovallo is pleased to report. “We do high volumes of these procedures. Tumors that we would have previously not approached laparoscopically, we are now doing robotically,” he adds.
p A 6 cm periumbilical incision is used for the robotic cyctoprostatectomy to access the colon
With the robotic sacrocolpopexy, keyhole incisions are used to grasp the uterus or remnant cervix with a y-shaped piece of mesh and fix it to the inside of the tail bone to keep it in place. “With the robot this takes only an hour and a half,” Dr. Ahmed points out, emphasizing the obvious advantage of utilizing the precision provided by the robot to quickly and successfully make the required repair.
performance of robotic partial nephrectomy for the treatment of kidney tumors. Although at first this kidney-sparing procedure was only utilized for the removal of small tumors, the surgeons at NJCPCU have developed the expertise to take the technology even further. “We’ve moved towards larger tumors in more difficult locations with a very low complication rate or necessity for further surgery, as well as oncologically superior results, equivalent to those with an open
It has been a decade since that enlightening trip to Paris prepared Dr. Lanteri and Dr. Esposito to take urologic surgery in a new direction. They, along with Dr. Ahmed, Dr. Lovallo and Dr. Patel, by becoming masters of robot-assisted laparoscopic surgical techniques, have been able to successfully treat countless patients with minimally invasive, blood-sparing procedures that allow for optimal outcomes, little risk of complication and an easier recovery and return to normal life. As the surgeons of the New Jersey Center for Prostate Cancer & Urology continue to push themselves towards even more challenging goals, it will be their fortunate patients who will reap the rewards. For more information about NJCPCU or to schedule an appointment, please call (201) 487-8866 or visit www.roboticurology.com To make an appointment with Dr. Michael LaSalle, who is located at 205 Ridgedale Avenue in Florham Park, New Jersey, please call (973) 443-9200
“The robot is particularly suited to work in the pelvis,” Dr. Esposito adds. “It was built to work in tight areas and hard to reach spots deep in the body. It is well-suited for extirpative operations and precision in reconstructive procedures,” he continues. In order to access those areas with open surgery, lengthy procedures with large incisions and the associated trauma and blood loss would have to be undertaken. For the surgeons at NJCPCU the decision to incorporate the robot into these pelvic procedures could not have been any clearer. Partial Nephrectomy The precision and dexterity afforded by the da Vinci system, and their vast experience with the robot, has also enabled the surgeons at the New Jersey Center for Prostate Cancer & Urology to enhance the
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p The neo-bladder is created by forming a pouch using a section of the colon
Statehouse
New Jersey Statehouse Medical Board Adopts Rule Amendments
Medicaid Proposes Rule Changes for Claims
Nearly one year after proposing significant rule amendments, the NJ State Board of Medical Examiners (Board) has adopted the proposal without further amendment. Among the changes:
New Jersey Medicaid is proposing rule amendments to require that claims be submitted to the program electronically except when an attachment to the claim is required and that, except for one-time providers, providers will be paid by direct deposit. The proposal also requires that, within 60 days of receiving an overpayment or underpayment from the program, a provider must utilize the webbased claims resolution process or another approved method of automated data exchange to correctly adjust the claim, unless an attachment to the claim is required. The proposal can be accessed at: http://www.state.nj.us/humanservices/providers/ruleprop/.
1) Records from other physicians or providers that are part of a patient’s record must be provided to a patient who requests a copy of his or her record 2) When a licensee ceases practice, the required public notice setting forth how a patient can retrieve his or her records must include the location at which the records will be permanently maintained and the notice must be submitted to the Board 3) A physician may delegate to medical assistants the administration of intradermal, as well as intramuscular and subcutaneous injections, but not allergy shots 4) Amendments to the Board’s controlled substances dispensing rule for prescribing multiple prescriptions for Schedule II CDS 5) Licensees, when required by certain rules to send a certified letter (such as when terminating the physician-patient relationship) may use another method of delivery that indicates proof of delivery 6) Extending from 14 days to 30 days the time period prior to inoffice surgery in which a history or physical examination must be performed While failing to address the 2009 statutory amendments to the Codey self-referral rules, the Board does delete the 10% cap on profits from the sale of medical goods and devices to patients. This reflects the stay on the cap which has been in place for years, and codifies the Board’s position that the sale of medical goods and devices to patients be at fair market value, an as yet undefined term. The 10% above cost cap would still apply to the sale of drugs, over-the-counter preparations, vitamins and food supplements. However, the Board amended its dispensing rule to clarify that, when a physician dispenses medications under one of the statutory exceptions (such as where the drug dispensed is a “salve, ointment or drops”), the charge is not limited to 10% over actual acquisition cost. The rule adoption can be accessed at: http:// www.njconsumeraffairs.gov/adoption/bmeado_060611.htm.
HHS Proposes Changes to HIPAA Accounting Rule The U.S. Department of Health & Human Services has proposed changes to the HIPAA rule regarding the accounting of disclosures of a patient’s protected health information (PHI). Although the proposal shortens the time period covered by the regulation to the 3-year period (previously 6 years) prior to the request, for all disclosures of PHI, both paper and electronic, it removes the exception for disclosures related to treatment, payment and healthcare operations. The proposal also creates a new right for patients to request an “access report” which would include, at a minimum, the date and time of access, as well as the identity of the person or entity that disclosed or accessed the PHI. Although subject to comment, the final rule will undoubtedly affect the requirements of a practice’s health information technology system. For a copy of the proposed rule, go to: http://www.gpo.gov/ fdsys/pkg/FR-2011-05-31/pdf/2011-13297.pdf
Investigation of Physician Owned Distributorships Adding to the already heightened scrutiny of physician relationships with medical device companies, the U.S. Senate Finance Committee has asked the Department of Health & Human Services to investigate the proliferation of physician-owned distributorships (PODs) within the medical supply chain. The Committee cites a recent increase in PODs “which allow physician investors to purchase ownership shares July 2011
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Statehouse in an entity that, in turn, purchases or serves as a medical device distributor for the products the physician utilizes in surgery” and questions the influence such financial interests have on the physician’s utilization patterns.
and the recent Institute of Medicine recommendations highlight its importance to women’s preventive care. By guaranteeing access to birth control, we can ensure that women are never denied the right to make responsible decisions about their reproductive health.”
Sen. Lautenberg, Rep. Maloney Introduce Bill to Ensure Women are Not Denied Access to Contraceptives
“Almost 100% of women in the US will use contraception at some point in their lives-- yet there are widespread, alarming reports that some pharmacists refuse to fill legitimate birth control prescriptions. This bill would place the decisionmaking squarely where it belongs: between a woman and her doctor,” Rep. Maloney said. “That the Institute of Medicine has declared that health coverage should include FDAapproved birth control with zero co-pays under the Affordable Care Act brings new urgency to this issue. Including contraception under health care coverage is moot if a single pharmacist can thwart such coverage.”
New Study Recommends Birth Control Become Available Without Copays
Following the release of an Institute of Medicine (IOM) report recommending that birth control be made available without copays because of its importance for women’s preventive health care, U.S. Senator Frank R. Lautenberg (D-NJ) and Representative Carolyn Maloney (D-NY) introduced legislation to protect a woman’s fundamental right of access to legal contraception. Lautenberg’s and Maloney’s bill, the Access to Birth Control (ABC) Act, would prevent pharmacies from denying the sale of contraceptives because of a pharmacy employee’s religious beliefs. “This legislation would prevent a pharmacy from interfering in the personal medical decisions made by a patient and her doctor,” Sen. Lautenberg said. “Birth control is basic health care for women,
“Americans are fortunate to have strong leaders like Rep. Maloney and Sen. Lautenberg who believe in guaranteeing women’s access to contraception. We are proud to work with them to advance this bill and other policies that make a positive difference in the lives of women and their families,” said Nancy Keenan, president of NARAL Pro-Choice America. “This legislation comes as medical experts are recommending that contraception be covered by insurance plans in the new health-care system so that women can obtain birth control without a copay. The ABC Act would ensure that pharmacies fill women’s prescriptions without delay or harassment.” “Birth control is basic health care for women. Women should be able
Let Brach Eichler’s Health Law Practice Group Help You Chart a Strategic Course For Your Health Care Business Health care providers have long come to rely on the attorneys of Brach Eichler to navigate the regulatory environment at both the state and federal levels. Now that health care reform is being implemented, Brach Eichler is ready to help you make sense of the significant changes, the statutory framework and the ramifications for health care providers in New Jersey. Health Law Practice Group Todd C. Brower Lani M. Dornfeld
John D. Fanburg Joseph M. Gorrell
Richard B. Robins Jenny Carroll Chad D. Ehrenkranz
Carol Grelecki Debra C. Lienhardt Kevin M. Lastorino Mark Manigan
Lauren Fuhrman Eric W. Gross Rita M. Jennings
Leonard Lipsky Isai Senthil Edward J. Yun
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New Jersey Physician
to walk into any pharmacy, anywhere in the country, and get birth control, including emergency contraception, without discrimination or delay,” said Cecile Richards, President of Planned Parenthood Federation of America. “We applaud Senator Lautenberg and Representative Maloney for introducing this common sense bill to help ensure women have access to birth control.” Last week, the IOM released its recommendations for preventive services that women should get for free, with no copays, as part of the Patient Protection and Affordable Care Act of 2010. Birth control was among the services recommended by the IOM as essential for women’s preventive health care. The IOM report was commissioned by the U.S. Department of Health and Human Services as it determines what should be covered under the new health care reform law being implemented. According to a study by the Guttmacher Institute, 99 percent of women in the United States use contraception at some point in their lives, and 82 percent of women use prescription methods. Despite this, women in at least 24 states across the country have reported incidents in recent years where they have been denied access to birth control and emergency contraception. The Access to Birth Control (ABC) Act strikes a balance between the rights of individual pharmacists who might have personal objections to contraception and the rights of women to receive their medication. The bill protects the right of individual pharmacists to refuse to fill a prescription, but also ensures that pharmacies will fill all prescriptions, even if a different pharmacist has to do it. In addition, if the requested product is not in stock, but the pharmacy stocks other forms of contraception, the bill mandates that the pharmacy help the woman obtain the medication without delay by the method of her preference: order, referral, or a transferred prescription. The bill is supported by the American Association of University Women (AAUW), Jewish Women International, National Organization for Women, NARAL Pro-Choice America, National Asian Pacific American Women’s Forum, National Family Planning & Reproductive Health Association, National Latina Institute for Reproductive Health, National Women’s Law Center, National Council of Jewish Women (NCJW), Physicians for Reproductive Choice and Health (PRCH), Planned Parenthood Federation of America, Population Connection, Religious Coalition for Reproductive Choice, Reproductive Health Technologies Project, Sexuality Information and Education Council of the U.S. (SIECUS), and Unitarian Universalist Association of Congregations (UUA).
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July 2011
13
Depression
Postpartum Depression
By Jane B. Sofair, MD LLC
How effective is legislation to screen new mothers for depression? The New Jersey postpartum screening law, BillS213, mandatesthat doctors and midwives screen new mothers for depression (1). It has been in effect since 2007, and while not a newsflash, marks the Garden Stateas being at the forefront ofintegrating psychiatric with obstetrical care. Since 1989,there have been related initiatives in and around the country, California among the first state to pass Resolution #23, raising awareness among corrections officers about postpartum psychosis. Subsequently, there was the Melanie Stokes bill, introduced by the Illinois Congressman, Bobby L. Rush, in 2001 to provide fundingfor improved health care researchfor depressed new mothers. (2,3). The legalcomponent of screening,however, has even furtheredthe mission of identifying new moms at risk, and some have argued why not make it a requirement, if patients ultimately benefit. To back trackslightly, the law was vigorously pushed through in 2004 by former Governor Richard Codey, and his wife, former First Lady Mary Jo, herself afflicted with postpartum depression (4). It was intended to address the potentially unmet needs of women in New Jersey with severe perinatal depression. S213 stipulates that a“birthing facility� must assess the mother for depression prior to her discharge, and providethe familywith postpartum depression education. The law also states that the mother will be re-assessed for depressionearly in postpartum. (1) The law does not stipulate exactly how the depression will be assessed, but many health
14
New Jersey Physician
care facilities haveadapted the Edinburgh Postnatal Depression Scale (EPDS), a 10-item standardized, self-administered questionnaire, to meet the requirements. To augment the screening effort, the Department of Health and Senior Servicesutilizedfunds to establish a24-hour hotline for providers and families and additionallylaunch an intensive perinatal depression educational program. At Atlantic Health, we organized a multidisciplinary research team to better understand the legislation’soverall effectiveness. Realizing we were chartingrelatively new research terrain, our chief concern was to identify whether the law was really picking up what it was supposed to pick up- perinatal depression. If screenings were primarily occurring at the birth and within the first 6 weeks, werepregnant, depressed women orthose with delayed postpartum depressionup to two years after the delivery being missed?A secondary interest was to assess just how compliant wereproviders with the legislation, and in doing so, to assess potential screening barriers. To be eligible for this IRB-approved study, female participants were required to be at least eighteen years old, to be receiving
regular obstetrical care within the hospital system, and to have laboratory confirmation of a viable pregnancy. Patients with a high risk pregnancy or other complications were excluded from the study. The EPDS was available in both English and Spanish. Informed consent was not deemed necessary as this was an anonymous chart review. The representativepatient, both preand post-law was 29 years of age, married, employed, and insured, with a high school educationor above. Demographically, Hispanic women comprised 53% of the postlaw group compared to 21% in the pre-law (p = 0.004), and twice as many post-law patients had three or more pregnancies (p = 0.011). After comparing 84 pre-law obstetrical charts prior with 81 post-law, we found onlymodest gains in the detection of perinatal depression.Specifically, only 8 % of patients pre- versus 14 % post-law met criteria for clinical depression- a 6% increase (ns). We then looked into background stressors being reported by the women during pregnancy, and found high percentages of self-reported stressors.Forty percent of those in the pre-law group and 77% of those in the post-law group showed evidence of life stress, the major cited stressors being financial, medical and languageissues.
Table: Post-Law Adherence with New Jersey Law
All Sites (N = 81)
Number of charts with EPDS documented at delivery
EPDS score >10 at delivery
Number of charts with EPDS documented -at 6 weeks postpartum
EPDS score >10 at 6 weeks postpartum
75 (93%)
1 (1%)
50 (62%)
5 (6%)
A positive EPDS score, indicative of depression, was a score of 11 or above out of a total possible score of 30, and/ or a “yes” response to the question, “The thought of harming myself has occurred to me.”(5). Keeping in mind that only post-law group, as per the legislation, would have had documentedEPDS scores, what did we find? There were 6 positive EPDS scores, one at delivery, and five at the 6-week postpartumcheckup.( see table) Providersdoctors, nurses, midwives werecompliant with administering the EPDS with up to 100% at delivery and up to 62% at the 6-week visit. Commentary: It is apparentthat theEPDS fell short of detecting thenumber of truly stressed new moms at delivery.There a number of ways to explain this. For the mom, at delivery the hospital may have provided a brief respite from outside psychosocial stressors, plus maybe there was increased family support at the birth. Another consideration are the potential
effect on EPDS self-rating of themother’s immediate postpartum physiologic and emotional fluctuations, whatever they happened to be along with the mental status effects of delivery-administered medication. Lastly there is the distinct possibility that delivery was and is not the optimal time to predictwho will go onto to have a postpartum depression. And then there is the ongoing debate about the EPDS itself – whether it is a culturally sensitive instrument, whether it gets lost in translation, and whether it is possibly intimidating to a mother worried about stigma and/or losing the baby to DYFSshould she be too candid on paper (5,6).As for the drop in compliance from 93 to 62 % at 6-weeks, a recent study of new mothers showed that only 27% among the over 50% who agreed to mental health services attended more than two visits, citing lack of time, cost, and other barriers (7). In retrospect, it would have been useful in our study to assess the number of
broken 6-week postpartum appointments to better interpret the EPDS compliance at that juncture. To our knowledge, this is one of the first studies to examine the effectiveness of mandated perinatal depression screening in New Jersey. Meaningful collaboration among obstetricians, psychiatrists, biostatisticians, and social workers comprising the research team resulted in a rich perspective, but despite high provider compliance, the law’s utility was not conclusively demonstrated. Future studies should replicate or counter these results in various health care facilities. Helping hospitals fine tunetheir protocols regarding the optimal time to screen and how best to screen for perinatal depression is a worthy endeavor. Additionally, a prospective study comparing New Jersey to a state without legislation might provide a comprehensive overview of the public health impact of this law.
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July 2011
15
Health Law Update
Health Law
Update
Provided by Brach Eichler LLC, Counselors at Law
MedPAC Recommends Pre-Notification and Pre-Authorization for Advanced Diagnostic Imaging Services
In its June 15, 2011 Report to Congress, the
der which providers were rewarded for limit-
ing of advanced diagnostic imaging tests. Out-
Medicare Payment Advisory Committee (Med-
ing diagnostic testing volume while improving
lier providers who order MRI, CT, and nuclear
PAC) recommended certain changes to limit
the quality of care. In the short-term, however,
medicine tests above these established guide-
the overutilization of in-office ancillary ser-
MedPAC recommended, among other things,
lines would be required to provide CMS with
vices, including diagnostic imaging services.
that the Center for Medicare & Medicaid Ser-
clinical justification for ordering these tests,
Noting that physicians have increased invest-
vices (CMS) establish pre-notification and pre-
from which CMS would provide confidential
ment in diagnostic imaging equipment in or-
authorization requirements for those provid-
feedback as to whether the diagnostic test
der to treat patients with greater speed and
ers who order substantially more than their
was actually necessary. If an outlier physi-
precision, MedPAC acknowledged that physi-
share of advanced diagnostic imaging ser-
cian continued to order these diagnostic tests
cians who own such equipment order more
vices, such as MRI, CT, and nuclear medicine.
excessively despite such feedback from CMS,
diagnostic tests.
the provider then would be required to obtain MedPAC recommended that CMS develop ev-
MedPAC concluded that the long-term solu-
idence-based clinical guidelines and educate
tion would be to develop payment systems un-
providers as to the appropriate use and order-
a pre-authorization before ordering the tests.
CMS Issues First Round of EHR Incentive Checks
Centers for Medicare & Medicaid Services
For the first year in which an EP applies
The first-year EHR bonus for EPs entering
(CMS) recently announced that the Medicare
for and receives an incentive payment, the
the Program in 2011 or 2012 is worth up to
electronic health record (EHR) Incentive
EHR reporting period is 90 days for any
$18,000 per EP. A qualifying EP will receive
Program (Program) issued the first round
continuous period within the year. For every
an incentive payment for 75% of the Medicare
of payments, totaling $75 million, to eligible
year thereafter, the EHR reporting period is
allowable charges for covered professional
professionals (EPs) and hospitals, for the
for the entire year. Incentive payments under
services furnished by the EP up to a maximum
meaningful use of EHRs. CMS announced that
the Program end in 2016. Under the Medicaid
allowable payment. Therefore, for 2011 and
more than 300 EPs and hospitals qualified for
program, EPs can receive as much as $63,750
2012, an EP must earn at least $24,000 in
the first stage of the Program by attesting to
over six years. EPs may not participate in both
Medicare-allowed charges before the payment
meeting the meaningful use requirements of
programs; however, they may switch from one
will be made by CMS. If the EP enters the
stage one of the Program.
program to the other one time. The purpose of
program in 2013, the first year maximum
allowing this is to allow an EP whose patient
payment will be $15,000. Thereafter, the
Payments were made via electronic funds or
volume no longer makes him or her eligible
maximum payment for year two will be
via paper check. If an EP receives Medicare
for the Medicaid program to nevertheless
$12,000, for year three it will be $8,000, for
payments electronically, the payment will
continue to receive incentive payments that
year four it will be $4,000, and for year five it
appear as “EHR Incentive Payment” on the
would encourage the meaningful use of
will be $2,000. Because the program ends in
EP’s bank statement.
certified EHR technology.
2016, EPs who enter the program in 2013 will
16
New Jersey Physician
Health Law Update be eligible for a maximum of $39,000 and in
clinical quality measures through certified
improvement at the point of care and the
2014 for a maximum of $24,000.
EHR technology. The core set of objectives
exchange of information in the most structured
for EPs includes using computerized provider
format possible, such as the electronic
Meaningful use criteria are being phased in
order entry for medication orders, generating
transmission of orders and test results. In stage
over three stages. In stage one, the focus is on
and transmitting permissible prescriptions
three, the goals will be to focus on promoting
electronically capturing health information in
electronically, and recording vital signs and
improvements in quality, safety and efficiency,
a coded format, using the information to track
chart changes. The menu set of objectives for
focusing on decision support for national
key clinical conditions, communicating that
EPs includes implementing drug formulary
high priority conditions, patient access to self
information for care coordination purposes
checks, sending reminders to patients for
management tools, access to comprehensive
and initiating the reporting of clinical quality
preventive and follow-up care, and submitting
patient data and improving population health
measures and public health information. In
electronic syndromic surveillance data to
outcomes.
stage one, there are 25 objectives for EPs,
public health agencies.
divided between fifteen objectives in the core
For additional information, contact Joseph
set and ten objectives in the menu set. EPs
Stage two and three criteria will be developed
M. Gorrell at 973-403-3112 or email at
must meet all of the requirements in the core
and modified over time. Currently, it is
jgorrell@bracheichler.com or contact Kevin
set and five of the objectives in the menu set.
envisioned that in stage two, the meaningful
M. Lastorino at 973-403-3129 or email at
In 2011, EPs may demonstrate their meaningful
use criteria would expand on the stage
klastorino@bracheichler.com
use by attestation. In 2012 and thereafter,
one criteria to encourage the use of health
EPs will be required to electronically submit
information technology for continuous quality
Board of Medical Examiners Rules Re-Adopted On May 3, 2011, the New Jersey State Board
A new provision was added under N.J.A.C.
an office setting. One commenter urged that
of Medical Examiners (BME) re-adopted,
13:35-7.6, relating to the 30-day supply limit
the use of the term “CRNA” was no longer
with certain amendments, its rules governing
for Class II controlled substances, which now
appropriate because the Board of Nursing
the practice of medicine in the State of New
authorizes a practitioner to issue multiple
has amended its regulations to allow nurse
Jersey. The readopted rules contained several
prescriptions for a total of up to a 90-day
anesthetists to obtain certification as advance
technical amendments, but for the most part
supply, provided that (1) each separate
practice nurses (APNs) and practice as APNs.
are largely unchanged from the prior version
prescription is issued for a legitimate medical
The BME responded that because not all nurse
of the rules, with the exceptions noted below.
purpose; (2) the practitioner provides written
anesthetists have obtained APN certification,
instructions on each prescription, other
it is retaining the designation of CRNA for the
A provision was added to N.J.A.C. 13:35-1.5(k)
than the first prescription if it is to be filled
time being. Also relating to nurse anesthetists,
which authorizes the BME to order a resident
immediately, indicating the earliest date on
a commenter stated that the provision requiring
to submit to medical or diagnostic testing and
which a pharmacy may fill each prescription;
supervision of nurse anesthetists contravenes
to monitoring or psychological evaluation or
(3) the practitioner determines that providing
the certification of nurse anesthetists as APNs.
assessment of skills to determine if a resident
the patient with multiple prescriptions does
The BME responded that recognition of a nurse
can continue to practice with reasonable skill
not create an undue risk of diversion or abuse;
anesthetist as an APN by the Board of Nursing
and safety, in the event the BME determines
and (4) the practitioner complies with all
does not overrule regulations imposed by other
the resident’s continued practice would not
other state and federal laws and regulations.
regulatory bodies, and therefore, a physician
constitute clear and imminent danger, but the
“Practitioner” is defined under this section
who uses the services of an APN specializing
resident’s continued practice could pose a risk
of the BME rules to include physicians,
in anesthesia will be required to supervise
to the public health, safety and welfare.
podiatrists, and to the extent permitted by law
the APN and adhere to all of the regulatory
and rule, registered residents, resident permit
mandates imposed by other governmental
An occupational therapist was added as an
holders, physician assistants and certified
entities. The BME also stated that it would
individual included under the definition of
midwives.
not reconsider its position until or unless the
“licensed health care provider” in N.J.A.C.
New Jersey Department of Health and Senior
13:35-6.14, which addresses the delegation of
Comments to the rules included several
Services addressed the practice of APNs in
physical modalities to a licensed health care
relating to certain provisions of Subchapter 4A,
ambulatory surgical centers.
provider or an unlicensed physician aide.
which governs the performance of surgery in July 2011
17
Finance
The EMR Marathon
Running or Stumbling Through It, Is Your Choice Some Tips, Reminders & Cautions Along Each EMR Track to Help Yield Positive Practice Results By Leslie A. Thomas, CPA
From my non-clinical, tax accounting world and havingdone researchthrough our EMR Exploration Seriesto gain perspective on what affect electronic medical records (EMR) have on practice bottom lines, I now view the entire EMR process as a marathon encompassing threetracks-Selection, Implementation and Attestation. While legging the trio of tracks seeking the $44,000 Medicare financial incentive over a five year termfor the “meaningful use” (MU) of certified EHR technology, physicians and administrators tasked to be the “EMR champions” for their practice need to scale hurdles of increased staffing, training, support and equipment costs, as well as a period of reduced productivity when bottom lines are diminished as it is. The tips, reminders and cautions outlined below for each track are designed to keep EMR champions focused and efficient so the EMR marathon can be finished with positive practice results, rather than stumbled through with corresponding aches and pains.
1) Selection Track The EMR Selection Track starts unsuspecting physicians and administrators off with an overwhelming number (over 300) of EMR vendors and no full-proof method of screening since not all review sources are impartial. Marathoners on this first track should heed the following: • Google search – “EMR Exploration SeriesNisivoccia” for impartial resources, tools,
18
New Jersey Physician
contract negotiation tips in the article “Successful EMR Implementation”. You can also print out “20+ Questions You Need Ask – EMR Selection Guide”for good informed questions to ask of EMR vendors; or email healthcare @nisivoccia. com-write “20+ Questions-EMR Guide” in subject line. •W hen financing the EMR system, be sure to do so via a “Capital Lease” (with a 10% or $1 buyout),or bank financing in order to reap the maximum tax savings potential through a Sec179 depreciation deduction on thefull costof the EMR hardware/software in the year it is placed in service. Tax savings through the Sec 179 depreciation can often cover the loan/ lease payments on the system for the first 2-3 years. Financing via an Operating Lease cuts the tax savings for the first year down to 20% of the EMR system cost rather than 100%. •A lso ask the EMR vendors about patient portal integration, and whether the EMR system exports a CCR/CCD (continuity of care record or document); does it populate the CCR/CCD fully, and if not, then what is not populated? (i.e. are lab/test results populated?) Asking for a reference of other practices in your specialty and how their patient portal is being utilized may help give some perspective on what will be involved in achieving Meaningful Use (MU) measures relating to patient
health records. This can be a sticky area for practices to coordinate. Realizing this sooner than later and seeing other practice approaches can help lend perspective.
2) Implementation Track (Before & During the 90 Day Measurement Period) Once the Selection Track finish line is crossed and an EMR system has been acquired, then the pace speeds up on the two part Implementation Track. Part I is the Implementation – Before the 90 Day MU Measurement Period. Part II is the Implementation – During the 90 Day MU Measurement Period. Some tips and reminders along each track are as follows: Implementation - Before the 90 Day Measurement Period • Register for the ‘EHR’ incentive program. Go towww.cms.gov/EHRIncentiveprograms and select Registration and Attestation. Besides the NPPES (NPI) number, the EMR system’s certification number will be needed. Registering early doesn’t mean a practice has to perform attestation immediately. Confirming accurate practice registration makes sense at this time, rather than finding out there is an issue with a physician’s NPI number delayingincentive receipt down the road. • Practices should be sure to enroll for E-prescribingand access Medicare EHR Incentive, PQRS, E-prescribing
Comparison” guide https://www. cms.gov/MLNProducts/downloads/ EHRIncentivePayments-ICN903691.pdf, or go to “Getting Started” at http://www.cms. gov/erxincentive • Coordination of the 1% E-prescribing incentive in 2011, and MU attestation for the $18,000 maximum EMR incentive in 2012 really depends on the volume of Medicare patients in a practice. Higher Medicare volume practices may find it more worthwhile to take the 1% E-prescribing incentive in 2011 and hold off onattesting for the initial EMR incentive in 2012. • Practices need to be mindful of the required 10 E-prescribes by June 30, 2011 plus15 more byDecember 31, 2011 equaling 25 total E-prescribes in 2011 to avoid the 1% and 1.5% reduced Medicare fees in 2012-2013. Even if the first deadline of June 30, 2011 was not met, prudent practices should make sure to do 25 total E-prescribes by December 31, 2011 to avoid the 1.5% reduction in 2013. • Check that patient demographics are complete in the billing system.Since most patient records are uploaded from a billing system, many times there are missing items such as language, ethnicity and race. Proactive practices should start entering that data into the billing system, sooner than later, as more than 50% of patients seen during the 90-day MU measurement period need to have all demographic information besides date of birth and gender entered. • Consider the logistics and advantages of utilizing apatient portalsooner rather than later (this is a whole article unto itself). Without getting into all the Core and Menu measuresof MUinvolving patient access to their health information at this point, suffice it to say that a practice who decides not to have a patient portal put in place early in the implementation process will incur excessive costs for staffing, paper, USB or DVD’s, printing, and mailing to cover the two Core measures (12 and
13) of MUfor providing electronic copies of patient health records and a clinical summary of patients’ office visits within 3 business days. Even if you do not plan on demonstrating Menu measures of Timely Access to patient health information, a practice still needs to purchase technology that is “certified” in order to qualify for Meaningful Use (MU). CMS dictates this athttp://questions.cms.hhs. gov/app/answers/detail/a_id/10162. For many practices that say a patient portal will come later, they need to change that approach tosooner than later. Implementation - During the 90 Day Measurement Period • To meet the Meaningful Use (MU) criteria involving E-prescribing, 40% of all prescriptions (not including controlled substances) needs to be done via E-prescribing, and 30% of all patients with medications indicated in their charts need to have at least one prescription generated (CPOE) during the 90-day measurement period. Some EMR vendors offer E- prescribing for free, but practices should still be careful in determining if the overall EMR system associated with the free E-prescribing software is the right fit for their practice and productivity requirements. • Survey and perform a Privacy and Security Audit (It has to be done-no exceptions). Every practice must survey their system and make sure that Protected Health Information remains private and secure according to HIPAA regulations. A word of caution when attesting to Core Measure 15- Protecting Health Information. With OCR enforcement plans ramping upat the end of 2011, and the significant legal risk to practices for a HIPAA security breach,security has to move up on a practice’s priority list. Just checking the box YES to attest to Core Measure 15, and utilizing a list that the EMR vendor has comprised is not an adequate HIPAA security approach. An EMR vendor’s security checklistmay only focus on technical issues (i.e. firewalls), and not
give the proper attention to the policies, training and documentation needed to adequately address federal and state privacy rules. While there is more of an upfront cost to hiring a respected third party security audit firm to assess a practice’s risk of an information breach due to the EMR system with HIPAA,the comprehensive approach of a third-party will bode much better than merely producing an EMR vendor generated checklist to an OCR enforcement agent.(Let the tax savings of the Sec 179 depreciation help pay for the third party security audit firm.)
3) Attestation Track Marathonersreaching this point should be proud.With just over 500 eligible providers having received their EMR payouts up through June 2011,and there being over 55,000 registered Medicare providers in all, there is still some elbow room for marathoners on this third track. • Google search – “Coordinating E-prescribing & Medicare – Nisivoccia” for an article listing all applicable Meaningful Use Attestation Resources or send an email to healthcare@nisivoccia.com and put “MU Attestation Resources” in the subject line. EMR champion providers and administrators who remain focused and proactive in scaling some of the largerimplementation hurdles along the waywill be able to keep their legs throughout theEMR marathon, and see positiveEHR results for their practice that will last beyond the finish line. Leslie A. Thomas, CPA is a Supervisor offering 20+ years of tax and healthcare advisory experience in the Healthcare Business Services segment at Nisivoccia LLP, a multidimensional CPA firm with offices in Mt. Arlington and Newton, NJ. The firm offers traditional tax, accounting and audit services, and maintains practice specialties in sectors including health care, technology, municipal government, education, nonprofit and financial services. Contact her at lthomas@ nisivoccia.com or (973)-328-1825 July 2011
19
Food For Thought
P.F. Seafood Market and Restaurant West Caldwell, New Jersey In our neck of the woods, which is at least an hour away from even the most northern towns on the Jersey shore, restaurants that dedicate themselves entirely to seafood are few and far between. Try as we might, finding a place that stocks freshly caught fish year round and knows how to properly prepare it, has been a challenge, to say the least. So when Michael announced the recent opening of a seafood restaurant in West Caldwell, I was more than mildly skeptical. Located on Bloomfield Avenue, across from Samm Sound (which might be familiar to some), P.F. Seafood Market and Restaurant is not much to look at from the outside. Do not let appearances deceive you. Inside, awaits an enticing variety of freshly caught seasonal fish, lobsters, clams, oysters, mussels, etc. This BYO is quite casual in its décor, with wooden chairs and tables as well as a definite seashore motif. For me, the perfect atmosphere in which to enjoy a fish dinner. Once seated, there are two menus to investigate. One contains the special offerings of the day, while the other has P.F. Market’s standard dishes which are always available, including entrees such as a shellfish medley in light tomato broth, sole Milanese, jumbo sauteed sea scallops, stuffed shrimp, stuffed flounder filet, grilled salmon and live lobster from their tank which can be steamed, baked or broiled. Also served daily is a raw bar of little neck clams on the half shell, East Coast oysters, West Coast oysters, king crab leg, colossal crab meat and shrimp cocktail. Appetizers include baked stuffed clams, crab cakes, PEI mussels, zuppa de clams and fried cala-
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New Jersey Physician
mari. There are daily fresh salads as well. Michael and I were intrigued by some of the specials of the day and we both actually ended up ordering from that menu. I started with the lobster bisque. This has always been a favorite of mine but I can say with total conviction that I have never enjoyed it more. The bisque itself was rich, creamy and perfectly seasoned and in it were chunks of fresh succulent lobster. I would not even consider adding the oyster crackers for fear of somehow spoiling the experience. For his first course Michael had grilled octopus on a bed of arugula. I can always tell by the look on his face when Michael is really enjoying his food. He had the look. I took a bite of the fish with a couple of the greens and had to agree. The octopus was cooked perfectly and incredibly tender. The arugula added just the right touch. I was torn between the soft shell crabs and the monk fish osso bucco for my main course. I went with the monk fish and was
glad I did. Served in a thick and flavorful stew composed of tomatoes, mushrooms, onions, sausage meat and even lobster, the delectable monk fish was in great company. On the side was half a baked potato with a crust as crisp as could be and a generous stalk of broccoli. Michael ordered a whole Bronzini, which was grilled with olive oil and herbs. Whole fish is not my thing. I really hate the bones. Michael on the other hand, really got into picking out the bones and placing them in the dish provided for that purpose. He gave me a piece to try - assuring that there would NOT be a bone. The fish was delicious! His side dish was the same as mine and he commented on the unusually crisp potato skin, enjoying it as much as I did. The service was great. The prices are reasonable. The fish is fresh and wonderfully prepared. I plan to be a regular patron. I hope that by sharing this terrific find with our readers, I don’t end up waiting in line to get in.
Surgery Center Liability Specialists 30 Technology Drive, Warren, NJ 07059
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Argent Professional is New Jersey’s leading medical professional liability insurance agency, specializing in Ambulatory Surgery Centers, and other healthcare facilities. Our knowledge, expertise and access to all of the major NJ markets helps to ensure our clients find the best possible coverage at the lowest available rates.
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