ACMS Bulletin May 2022 by TEAM

Bulletin Allegheny County Medical Society

May 2022

Appropriateness To be, or not to be...

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Allegheny County Medical Society

Bulletin May 2022 / Vol. 112 No. 5

Opinion

Departments

Articles

Editorial ....................................5 Society News .........................18 Materia Medica .......................20 • May Adventures • 2022 David C. Martin Award Recipient • Vericiguat (Verquvo®) Deval (Reshma) Paranjpe, MD, MBA, FACS

Editorial ....................................8 • Appropriateness Richard H. Daffner, M.D., FACR

Perspective ............................11 • To be, or not to be... Maria J. Sunseri, M.D. FAASM

Perspective ............................14 • Neighbors Helping Neighbors: How Communities Drive Change in Bone and Joint Health Jessica Carlson, Hannah Hamlin, and Tony DiGioia, MD

Society News .........................19 • 2023 Nomination Form

Lauren Sittard, PharmD and William Beathard, PharmD, BCPS

Legal Summary .....................22 • Disclosure of Mental Health Records: Traps for Psychiatrists and Other Providers Beth Anne Jackson

Meeting Schedule .................28 • 2022 ACMS Meeting and Activity Schedule by Committee

Specialty Report ....................24 • Q1 Reportable Diseases report

On the cover

Waterfall

Nina Verghis, MD Dr. Verghis specializes in General Surgery

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 2022 Executive Committee and Board of Directors President Peter G. Ellis President-elect Matthew B. Straka Vice President Raymond E. Pontzer Secretary Mark A. Goodman Treasurer Keith T. Kanel Board Chair Patricia L. Bononi DIRECTORS 2022 William F. Coppula Micah A. Jacobs G. Alan Yeasted Alexander Yu 2023 Steven Evans Bruce A. MacLeod Amelia A. Pare Maritsa Scoulous-Hanson Adele L. Towers 2024 Douglas F. Clough Kirsten D. Lin Jan B. Madison Raymond J. Pan

PEER REVIEW BOARD 2022 Niravkumar Barot Kimberly A. Hennon 2023 Lauren C. Rossman Angela M. Stupi 2024 Marilyn Daroski David J. Levenson

PAMED DISTRICT TRUSTEE G. Alan Yeasted COMMITTEES Awards Mark A. Goodman Bylaws Raymond E. Pontzer Finance Keith T. Kanel Membership Matthew B. Straka Nominating Chair Raymond E. Pontzer

Douglas F. Clough (dclough@acms.org) Richard H. Daffner (rdaffner@acms.org) Kristen M. Ehrenberger (kehrenberger@acms.org) Anthony L. Kovatch (mkovatch@comcast.net) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Anna Evans Phillips (evansac3@upmc.edu) Andrea G. Witlin (agwmfm@gmail.com)

ADMINISTRATIVE STAFF

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Executive Director Sara Hussey (shussey@acms.org)

Co-Presidents Patty Barnett Barbara Wible

Governance Administrator Dorothy Hostovich (dhostovich@acms.org) Vice President—Operations and Physician Services Nadine M. Popovich (npopovich@acms.org) Director of Publications Cindy Warren (cwarren@pamedsoc.org)

Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Sandra Da Costa Assistant Treasurers Liz Blume Kate Fitting

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Improving Healthcare through Education, Service, and Physician Well-Being.

EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address. The Bulletin of the Allegheny County Medical Society is presented as a report in accordance with ACMS Bylaws, Articles 6, 8, and 11. The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication. Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA. Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted. The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board. Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted. Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the Allegheny County Medical Society of any company or its products. Annual subscriptions: $60 Advertising rates and information available by calling (412) 321-5030 or online at www.acms.org. COPYRIGHT 2022: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212. ISSN: 0098-3772

Editorial

May Adventures Deval (Reshma) Paranjpe, MD, MBA, FACS

fter what seems like an eternity, sunshine and good weather have returned to our area. You can see the smiles and the energy returning to people’s faces. It’s as though a giant weight has been lifted. Half the patients I’ve seen this week have been dressed for August in the tropics, and so it’s been a glorious state of affairs in my windowless office. Linen, paradise prints, sandals, parrot earrings, sunglasses, and straw hats have all made appearances. My heart is lighter too. Sunshine and warm weather means that I can feel better about seeing friends again since dining outdoors is now an easier option. Gardening season has started suddenly. I’ve put all my plants out on the deck where they will begin to thrive again after a long winter indoors. I can almost hear their sighs of relief as I water them and their leaves unfurl against the sunlight. I can almost see their anemic leaves getting greener. The immense satisfaction of seeing them bring forth bud, flower and fruit is only weeks away. Moods are better, conversation brighter, and people more agreeable under blue skies, cool breezes and spring sunlight. Many of us haven’t been on a vacation in years, and this feels like one without leaving home. Put away the winter coats; bring on the lemonade and light lunches.

ACMS Bulletin / May 2022

I remember the Ray Bradbury story “All Summer in a Day,” and that’s exactly what it feels like. I feel the urge to enjoy these few months of beautiful climes to their maximum, so that the memory may sustain me through another cold winter to come. So, I asked myself: how do we make the most of this? The obvious answer is traveling and getting away from familiar surroundings. If you are (rightfully) worried about getting on a plane at this time and going to somewhere Covid-y, where can you go to enjoy yourself within driving distance? (By the way, that’s apparently become a new term---Covid-y. As in, “I don’t want to get in that crowded line; it’s too Covid-y,” or “An indoor unmasked party for 200 in the middle of this surge? Nah, I’ll pass; it just feels too Covid-y”, or “That guy? He’s a complete social butterfly, and he never wears a mask. I’d rather not sit next to him at dinner—he just seems Covid-y”). Avast, pandemic! Here are some wonderful nearby outdoor places with plenty of social distance, ventilation, and fresh air in which to explore and make hay while the sun shines. Of course, the amenities at Nemacolin Resort and Omni Bedford Springs Resort are also lovely nearby options, but I wanted to take you a bit farther afield for this column.

1) Presque Isle State Park About a two-hour drive from Pittsburgh, Presque Isle has 11 miles of clean sandy beaches and offers boating, fishing, birdwatching, swimming, hiking and general relaxation complete with concert areas, a picturesque lighthouse dating from 1873, lagoons and an environmental center. Camping available nearby. It feels like the seashore, though you’re not on the ocean, and it doesn’t feel crowded. 2) Erie Waterfront Enjoy outdoor waterfront dining at restaurants like the Bayfront Grille (55 W Bay Road, in Sheraton Erie), Rum Runners (133 E Dobbins Landing), and the eccentrically named Sloppy Duck Saloon (726 W Bayfront Parkway), or Smuggler’s Wharf (3 State Street). It’s a quick getaway, only about two hours from Pittsburgh, but well worth the feeling of being by the sea. A great day trip. And check out the Lake Erie Tall Ships Festival, which returns to the Erie Waterfront this August 25-28. Explore beautiful working tall sailing ships of old for a small taste of history and a Pirates of the Caribbean feeling. Continued on Page 6

Editorial From Page 5

3) Fallingwater (1491 Mill Run Rd, Mill Run, PA 15464) If you haven’t been lately, it’s time you went back. Fallingwater is worth a visit in every season. If you’ve never been, you need to go see this Western Pennsylvania treasure. Frank Lloyd Wright’s architectural masterpiece in Fayette County is managed by the Western Pennsylvania conservancy and offers tours led by exceptionally wellversed docents. A day trip could include a complete Wright architectural tour, with visits to nearby Wright-designed houses at Polymath Park and Kentuck Knob. 4) The Lodge at Glendorn (1000 Glendorn Drive, Bradford, PA 16701) Looking for a luxurious getaway to celebrate an anniversary or other special occasion? Consider the Lodge at Glendorn. Named the #1 Resort Hotel in the Continental US by Travel and Leisure magazine in 2016, Glendorn is sure to delight. Nestled in the midst of a forest, the journey is as tranquil and calming as the Lodge itself. A full-service spa as well as cooking classes and farm to table five star dining will inveigle indoors types. A wide range of outdoors activities and lessons including hiking, fly fishing, trap/skeet/clay shooting, swimming and more will delight outdoors enthusiasts. About three hours away. 5) Gateway Lodge Country Inn Resort (14870 Route 36, Cooksburg, PA 16217) The Gateway Lodge, nestled in the heart of Cook Forest, is a more walletfriendly alternative to Glendorn under 3 hours from Pittsburgh. Offering rustic but well-appointed cabins, no cell service, 6

and an acclaimed wine list, it is the perfect place to unplug and relax. Enjoy the beauty of the forest in summer in privacy and peace. 6) Allenberry Resort and Lodging (1559 Boiling Springs Road, Boiling Springs, PA 17007) One of only 3 Orvis-endorsed fly-fishing lodges in Pennsylvania, Allenberry is in the heart of the Cumberland Valley with Yellow Breeches Creek, a nationally known trout stream, running through the property. Offering guides and lessons for novices as well as seasoned flyfishers, this escape also offers a variety of other outdoor activities and great amenities including a spa, farm to table dining and famous sticky buns. Orviscertified guides and equipment available on site—you don’t need to own a rod to join in the fun. Offering 1- and 2-day fly-fishing classes. 7) Niagara Falls, NY Old-school, but well worth doing if you or your children have yet to experience the glory of Niagara Falls. Perfect for an old-fashioned second honeymoon (or a first!), let the romance of the falls sweep you away. (Or at least, let the thunderous noise of the falls prevent you from hearing any griping or sniping whether from spouse or children.) 8) Niagara-on-the-Lake, Ontario, Canada Twenty miles from Horseshoe Falls in Canada lies the charming small town of Niagara-on-the-Lake. Famous for wineries and the George Bernard Shaw festival, this town also offers charming outdoors activities, dining,

special historical outdoor events, trails and paths, a historic fort and sites, and more. Itineraries and full information from bed and breakfasts to the Prince of Wales Hotel are available at www.niagaraonthelake.com 9) The Finger Lakes, NY Wineries, boating, swimming, fishing, and beautiful views abound. Take a leisurely tour of the Seneca Wine Trail, either on your own or with a group. Watkins Glen Racetrack (www. theglen.com) offers world-class racing events and even regular Drive the Glen days where you can drive your own car on the legendary track. Watch everything from Ferraris and supercars to Nascar and historic cars. The Finger Lakes Wine Festival at Watkins Glen Racetrack is July 7-10, so that would be a busy weekend. 10) The Greenbrier (101 Main Street West, White Sulphur Springs, WV 24986) A favorite of presidents (and home to the legendary secret Eisenhower Cold War nuclear fallout bunker that could shelter all 535 Members of Congress as well as the Executive Branch), the Greenbrier has always been a secret getaway. Offering world-class golf, fine farm to table dining, spa services, and a full range of indoor and outdoor activities, the Greenbrier is an elegant escape (note: it’s old school, with dress codes.) Happy Adventuring! The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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Running for the State House in District 30 Arvind Venkat, MD, FACEP

“Why do you want to do this? I have been asked this question by many of the residents in my community. My wife and I have lived in McCandless for 15 years. I had a pretty good idea we would be returning to Pittsburgh after our medical training since my wife grew up here. We all know Pittsburgh folks return home. It has been a great place to practice medicine and raise our three children. As an emergency physician, I have had the privilege of caring for my neighbors in their time of greatest need. But simultaneously, I have seen the challenges in our community – when a woman in her 50s lacking health insurance could not get cancer screening and presented with metastatic breast cancer. When an adolescent with serious mental illness

ACMS Bulletin / May 2022

could not get an inpatient psychiatric bed for days. When a man in his 40’s lost his job and could only receive care in the emergency department. And when a young woman died from an opioid overdose despite multiple attempts by her family and friends to get her help for her substance use disorder. All of us have seen that the pandemic has only exacerbated these healthcare and social pathologies. When COVID hit, I was President of the Pennsylvania College of Emergency Physicians and worked with policymakers to address the immediate needs of the emergency medicine community and our patients in a truly frightening situation of a novel infectious disease. I also began to speak on local media about where we were in the pandemic, answer questions about COVID, and give evidence-based guidance on how my community could stay safe and move forward. But I began to realize that the root cause of the challenges of the last two years was that we simply were unprepared for a crisis foretold and had run the services on which we all rely – health care, schools, police, EMS, and fire – at the ragged edge, with no excess capacity and significant underinvestment. I felt that I could extend my service to my community by running to represent them in the State House and advocate for policies that would ensure that these vital services would have the resources to be there for all of us in our time of need.

If elected, I would be the only physician in the General Assembly. I believe I can be an effective voice and leader not only for residents of the 30th House District but also for the healthcare community by advocating for common-sense policies such as bolstering the importance of physicianled teams in patient care, expanding telehealth access, and ending restrictive covenants. I ask for your support and help. Please visit my website at www.VenkatforPA.com to learn more about my candidacy. I would like to invite all ACMS members to attend my June 5th fundraiser [https://secure.actblue.com/donate/ venkat220605event?refcode=ACMS.] with Lieutenant Governor Nominee and State Representative Austin Davis. Finally, if you are a resident of the 30th District (McCandless, Franklin Park, Ohio Township, Emsworth, Ben Avon, Ben Avon Heights, Kilbuck, and the Western part of Hampton) or have friends or family who live there, I would ask for your active support and, if eligible, vote to allow me to serve my community as their State Representative.

Editorial

Appropriateness Richard H. Daffner, MD, FACR

haron Taylor’s recent perspective piece on prior authorization (PA)1 inspired me to “dust off” my plans to comment on a subject that I was intimately involved with for many years – appropriateness of diagnostic imaging. In the early ‘90’s, Medicare, looking for ways to reduce costs, began requiring providers to obtain approval before ordering a diagnostic procedure or implementing certain treatments. The goal was to eliminate unwarranted or inappropriate care. The private insurance carriers (the “Blues”, Aetna, United, et al) quickly followed suit and began their own systems for PA. The use of imaging in medical practice has exploded over the past eighty years. In the 1940’s imaging impacted the diagnosis in one of twelve patients; in the 1950’s, one in six; in the 1960’s, one in three; and in the 1970’s, one in two. By the 1980’s, virtually all patients had some form of imaging performed. With the development of CT and MRI, the costs skyrocketed. Prior to 1970, a fluoroscopy unit was the most expensive piece of equipment in a radiology department. In the 1970s, a CT scanner cost $200,000 on average. As CT evolved and MRI entered the picture, the costs of those pieces of equipment rose dramatically. Today, MRI or PET CT machines can cost upwards of $3,500,000. 8

In 1993, the American College of Radiology (ACR) recognized the need to develop national guidelines for the appropriate use of imaging technologies. These guidelines became the ACR Appropriateness Criteria® 2 (ACR AC®) as a guide for radiologists and, more importantly, for non-radiologists who ordered imaging studies on their patients. The concept was formally presented to the US House Ways and Means Committee by the former chair of the ACR Board of Chancellors, Dr. K. K. Wallace, who stated that the ACR was ready to create these guidelines to help eliminate the inappropriate utilization of diagnostic imaging. In 1994, the ACR formed a task force to begin developing scientifically based guidelines that would be nationally accepted, to assist referring physicians in making appropriate imaging decisions depending on their patient’s clinical conditions. The charge of the task force was to follow acceptable medical practice guidelines used by the federal Agency for Healthcare Research and Quality that had been designed by the Institute of Medicine. The methodology relied on evidence from the scientific literature. In those instances where the data from the literature was insufficient or were inconclusive, the recommendations were based on expert consensus.

Expert panels were selected for each of the eleven areas in diagnostic radiology (Breast, Chest, Cardiac, Gastrointestinal, Interventional, Musculoskeletal, Neurologic, Pediatric, Urologic, Vascular, and Women’s). Members of each panel are nationally recognized experts and leaders in their subspecialty. In addition to radiologists, each panel has physicians from other medical specialties to provide important clinical perspectives. I was a member of the Expert Panel on Musculoskeletal Diseases (MSK) from 1994 - 2011 and chaired the panel from 2006 - 2011. The MSK panel has an orthopedic surgeon, an emergency medicine physician, and a neurosurgeon as our clinical consultants. The goal, as mentioned above, is to produce evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for a specific clinical condition. An additional goal is to maximize the benefits of performing medical imaging and invasive radiologic procedures as well as to minimize risk to patients. Each member of an expert panel submits a list of topics to the ACR staff for them to conduct a search of the literature in Pub Med. The author then assesses the literature and determines www.acms.org

Editorial which articles to retain and which to reject. After reviewing the literature, the author produces an evidence table of the articles reviewed to determine the validity of the conclusions of each article. The Evidence Table considers four categories of study quality. In Category 1, the study is clearly welldesigned and accounted for common biases. In Category 2, the study is moderately well-designed and accounted for most common biases. In Category 3 there are important study design limitations. Category 4 studies are deemed not useful as primary evidence because of flawed design or conclusions (“bad science”). Once the literature review by the author is completed, the author will create a list of variants for each category. (S)he will then list the procedures to be evaluated. This document is sent to the other members of the expert panel in tabular form for evaluation and voting. The panel is asked to rate each procedure for that variant based on the benefits of performing a specific procedure for a specific clinical scenario balanced against the risks. The ratings given by each panel member are based on the evidence in the literature. On rare occasion, the rating may be based on the reviewer’s own experience. If the evidence is incomplete or unavailable, expert opinion by consensus will determine the rating. Ratings do not consider availability, contradictions, or costs. The rating system ranges from 1 - 9. Ratings of 1, 2, or 3 indicate that the procedure is usually not appropriate. In addition, the imaging procedure or treatment is not only unlikely to be indicated or

the risk-benefit ratio for patients is likely to be unfavorable. Ratings of 4, 5, or 6 indicate that the procedure may be appropriate. Ratings of 7, 8, or 9 indicate that the procedure is usually appropriate. In this category, the imaging procedure or treatment is indicated in the specific clinical scenario at a favorable risk- benefit ratio for patients.

Following the initial voting round, the results are sent back to each panel member for a second vote. This second vote may result in a change of how an individual member initially voted once they can now see how their colleagues have voted. (“Gee, I thought that was appropriate, but I guess I’m wrong.”) A third vote then occurs. After the third vote, there is a conference call for reconciliation. When 80% of the panel agrees, consensus is achieved, and the author writes the final document. If consensus is not reached, comments explaining the reason(s) are made in the narrative portion of the final document. The final document begins with a tabular listing of each variant. A scholarly narrative summary of the

literature review follows, beginning with the title of the clinical condition (e.g. Suspected Spine Trauma) followed by a background discussion on the topic and the conclusions reached by the expert panel in the summary and recommendations for each variant. This is followed by a supporting documents section that gives an Internet link if the reader wants to see the Evidence Table from which the conclusions are based. The document also includes a table defining appropriateness category names and definitions as well as a table defining relative radiation level for each study. The references used in arriving at the conclusions are listed at the end, as is a separate patient-friendly summary (in layman’s terms). Figure 1 shows an excerpt from the current (2018 revision) ACR AC® on Suspected Spine Trauma. I authored the original document in 2008. Each topic is reviewed annually and is updated as necessary. In 2021, there were 216 diagnostic imaging and interventional radiology topics with over 1,030 variants as well as 2,400 clinical scenarios in the diagnostic imaging topics. In June 2016, the Centers for Medicare and Medicaid Services (CMS), named the ACR as a “Qualified Provider” approved to provide appropriate use criteria (AUC) under the Medicare Appropriate Use Criteria program for advanced diagnostic imaging. ACR AC® are available online for anyone at: www.acr.org/ac. The ACR, cognizant of their duty to the next generations of physicians also has resources available for instructing medical students on using the appropriateness criteria. Continued on Page 10

ACMS Bulletin / May 2022

Editorial From Page 9

Figure 1. Sample table from ACR AC® on Suspected Spine Trauma2 References 1. Taylor SL. Let’s talk about prior auth! ACMS Bulletin, November 2021, pp 319 – 321. 2. ACR Appropriateness Criteria®. American College of Radiology., Reston VA, 2021. Dr. Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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Perspective Perspective

To be, or not to be… Maria J. Sunseri, M.D. FAASM

e as scientist, as healers, have become distracted, divided and it is easy to feel conquered by the outside forces of the corporate and legal practice of medicine. These forces have their own agenda. They will not lead science the way we should be leading it. We do not need to lose our leadership role in the scientific community. There is no one better to lead than us. We have shown this in the past and we must not give up this role. No one can take it from us unless we remain silent. We have more educated people, more ways of communicating to share our thoughts and explain our ideas. More than ever, we need awaken our common sense, debate, and try a productive approach to problems facing our world today. How is it that a Chinese nonphysician scientist who trained in the USA, could go back to China and inseminate Chinese women with CRISPR genetically altered human embryos----something that is universally scientifically banned? This received some press, but not nearly what it should have, because the alteration of human evolution should outrage the medical community, especially when done in secret and against all scientific consensus. The ramifications could cause polarization for the CRISPR research going forward. There is so much promise ACMS Bulletin / May 2022

with good CRISPR research, but it is easily and very cheaply misused. We need to lead. We need to know the difference between good science and that which is detrimental. Let us not be afraid to discuss what is the essence of our humanity, what is sacred about evolution, and when life begins. As a neurologist, I have been impressed by the example of a similar dilemma in our medical profession’s history in the 1960s. With the advent of new technology and respirators, patients could be kept alive but the quality of that “life” was in question. There was also the question and need of organs for transplantation. In 1968, the Ad Hoc Committee of the Harvard Medical School convened to examine

the definition of “brain death”. They listed 2 reasons why there was a need for a definition: 1) that improvements in resuscitative and supportive measures led to increased efforts to save those who are desperately injured, and whose heart continues to beat but whose brain was irreversibly damaged: 2) obsolete criteria for the definition of death leading to controversy in obtaining organs for transplantation. The resulting Brain Death Criteria was generally accepted by the medical community. However, the concept of declaring a patient dead whose heart was still beating, even if artificially, was foreign to lay society. Therefore, in 1981 the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research was asked to consider whether death of the brain is indeed death of the person. This committee was composed of lawyers, philosophers, ethicists, religious leaders and physicians. After extensive review, the commission concluded that brain death should be endorsed as legal death and produced the Uniform Determination of Death Act (UDDA). In 1995 the American Academy of Neurology (AAN) produced guidelines on brain death determination in adults. Continued on Page 12

Perspective Perspective From Page 11

These were updated in 2010 and endorsed by the Neurocritical care Society and Child Neurological Society, the Radiological Society of North America and the American College of Radiology. The AAN reaffirmed these guidelines in 2017 and is in the process of reviewing and updating them in hopes to combine the Adult and Pediatric guidelines. The American Academy of Pediatric Neurology (AAP) also produced similar but slightly different guidelines in 1987 which were updated in 2011. Meanwhile in 2008, the President’s Council on Bioethics re-evaluated the validity of the biological and philosophical basis for brain death. Defining the essence of life and death is not easy. In 2016, the AAN Ethics, Law and Humanities Committee convened a multi-society quality improvement summit to re-evaluate aspects of brain death determination that were still contributing to lawsuits and misunderstandings. In summary, they re-affirmed the validity of the AAN

guidelines to determine brain death in adults, discussed systems to ensure that brain death determination was consistent and accurate, reviewed strategies to respond to objections to the criteria of brain death, and outlined goals to improve public trust in brain death determination. The brain death criteria have been slightly modified but essentially hold true to the tenets of the original 1968 Harvard Ad Hoc Committee. Brain death is legally accepted as death in every state in the US, but the language of states laws on determination of brain death is not uniform. In addition, brain death is accepted as criteria for death in over 80 countries. I admire my colleagues’ tenacity to address this difficult scientific and medical problem with much philosophical, ethical, legal and religious overtones, while keeping the focus on the science and the medicine. They were able to evaluate and re-evaluate this issue objectively, and welcome input from philosophers, ethicists, legal and religious leaders without losing sight of their role as the scientists in the room. It is incumbent upon us, leaders in the medical profession, to initiate and promote the same multidisciplinary approach to the burst of technology

and scientific abilities that we have available today, such as CRISPR, “embryoids”, partly human chimeras, etc, as well as the present legal emotionally charged issue of abortion. We must not be afraid to ask the scientific question: when does human life begin? What defines human life? Initially as a biochemistry/biophysics major with a minor in biomedical ethics, then a physician, then neurologist, then clinical neurophysiologist, I have revisited this question many times. Each time, the scientific logical conclusion is the same. The concept of brain death/brain life has remained the unwavering key. The guidelines for determining this may vary slightly. However, if brain death defines human death, which I believe it does, and the scientific evidence has been well vetted, then brain life should define human life. Please consider this logic of science and medical ethics. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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suppressed or was forbidden. As long as the humor, in this case name-

to us, they are still our fellow human beings.

W. Norton, 1960 (Original work published 1905).

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Perspective Perspective

Neighbors Helping Neighbors: How Communities Drive Change in Bone and Joint Health Jessica Carlson, Hannah Hamlin, and Tony DiGioia, MD There is a growing epidemic of poorly managed bone and joint health in the United States. One in four adults, nearly 58 million Americans, suffers from osteoarthritis. By 2040, this number is projected to reach 78 million. The country spends 304 billion dollars each year on arthritis care and lost earnings due to pain and disability, making it the second largest healthcare expenditure in the U.S. , and these costs are expected to increase as the population ages. Patients across American communities are presenting with deteriorating bone and joint health compounded by a growing number of related comorbidities. And the current care system is responding in a fragmented way – providing uncoordinated care and unnecessary treatments at the wrong time. Healthcare systems and providers must pivot from traditional treatment strategies to address the significant unmet needs of a nation of patients with degenerative bone and joint health conditions.

Meeting the Needs of Our Neighbors Impactful and sustainable changes to bone and joint treatment are driven by an understanding of what matters to each community. To understand what

each community needs to improve health, we must ask. Utilizing tools like “What Matters to You?” identifies the needs of patients and communities. The new Center for Bone and Joint Health at UPMC Magee-Womens Hospital emerged as a result of asking patients this simple question. When we asked, we learned that patients desire preventative approaches that build bone and joint wellness – not just curative treatments. We also identified the need to prioritize education for patients, the community, and providers. With the help of community partners, we learned that intervening early to prioritize bone and joint health requires us to meet patients where they are, in their neighborhoods, to provide the right education at the right place and the right time.

Responding to a Complex Community Supporting patients in achieving health and wellness requires attention to multiple body systems and the response of a coordinated, multidisciplinary community of care teams. This type of community promotes education and collaboration, keeps patients at the center of care, and honors the patient’s goals by enabling dialogue and the exchange of information that a siloed

healthcare system inhibits. It facilitates rapid implementation of improvements in larger health systems by distributing work across multidisciplinary champion teams. Best practices can be scaled and used to drive sustainable change as communities like the one built at the Center for Bone and Joint Health share their accomplishments. The Center for Bone and Joint Health serves complex patients with varied and unique needs. In its first cohort, the Center has provided care to patients who had an average of 10 comorbidities each. The 6 most common comorbidities are listed below.

Most Common Comorbidities Arthritis Hypertension Esophageal Reflux Bone and Joint Pain Depressive Disorder Obesity Each patient’s numerous comorbidities are a result of a siloed healthcare system that inhibits patients from achieving optimal health and function. The COVID pandemic further exacerbated chronic conditions for many patients, as they delayed care despite worsening symptoms. The complex needs of these patients www.acms.org

Perspective Perspective indicate that the only way to make long-lasting impact on the patient is through a community approach to caregiving – like the Center. When providers at the Center asked patients, “What matters to you?” they learned that bone and joint wellness begins with nutritional counseling, lifestyle management, and physical activity, and extends all the way through mental health services and social support. The Center quickly became the connector, building bridges between patients and the Midlife Health Center, the Osteoporosis Care Center, pain management services, and Western Wellness mental health services. The Center’s accomplishments, and the strengths of its community approach, are best demonstrated through the impact made on patients. Nearly half of the patients in the initial cohort were connected to services within the Center’s network of departments and providers. Most frequent referrals were to nutritional services and the Midlife Health Center. Two patients stood out as examples of how this program positively impacts patients and the community. One patient was referred to the Center by a provider familiar with the new services there. Through motivational interviewing and asking, “What Matters to You?”, this patient identified a primary goal of osteoporosis management and a secondary goal of nutrition support. With multiple comorbidities, including dental comorbidities and bone and joint pain, this patient’s complexity required a personalized, coordinated, and whole-person approach to help them achieve their goals.

Another patient was a self-referral who identified a primary goal of weight loss and a secondary goal of nutritional support. This patient reported more than a dozen comorbidities including depression. Through further screening and with the support of the care team, they expressed interest in osteoporosis screening and accessing mental health services. The Center connected this patient with the resources necessary to advance their health and meet their goals. These patients, and all patients at the Center, are further supported by a community of providers who work with and around the patient to make better health a reality. Patients identify their goals and other needs to attain health. The Center’s care teams stand ready to connect patients to the resources they need to meet those goals. This community supports the navigation of a complex healthcare system that, until now, acted as a barrier to better bone and joint health.

Building a Culture, Sharing a Mission The Center’s community is an interconnected network with members who share an identity and distinct purpose. The community builds and fosters meaningful connections through regular interactions. These connections establish rapport and build trust, develop a unique culture, and elevate the shared mission within and across teams. Relationships with providers like Dr. Helana Pietragallo flourish in patientfocused communities as the frequent interaction allows for expedited

solutions. The partnership with Dr. Pietragallo, director of the Midlife Health Center and co-medical director of the Center for Bone and Joint Health, illuminated the need for an osteoporosis screening process. Now, patients are screened for osteoporosis early, potentially identifying osteopenia or osteoporosis that can lead to dangerous fragility fractures. Patients at highest risk are referred to Dr. Pietragallo’s team which manages treatment and ensures the patients’ needs are being met. A key component to building a community like the one surrounding the Center is to build connections in and outside of standard work settings. At work, small lifts like sharing wins, both personal and professional, helps to build a positive work culture and make your team feel valued. The Center community shares wins at the start of every meeting and ends their time together with Pittsburgh bridge trivia. Crucial to the topic of bone and joint wellness? Not so much. Crucial to the mission of providing personalized, coordinated care through strong professional relationships? Absolutely. Larger lifts in building and fostering connections include events that unite patients, families, care teams, and communities. Operation Walk Pittsburgh’s annual mission trips bring experts from the Center and collaborating teams to Antigua, Guatemala to provide free hip and knee replacements. The Bone and Joint Center’s semi-annual Patient Reunion reunites patients and families with the Pittsburgh care teams that accompanied then on their journeys to better mobility. This year, the Continued on Page 16

ACMS Bulletin / May 2022

Perspective Perspective From Page 15

Driving the Change We Need in Pittsburgh The Center’s bone and joint health community effectively merges service lines and departments with UPMC Magee-Womens Hospital to meet the needs of patients. The Center provides whole-person and balanced wellness care that reaches patients from multiple approaches. It partners with community outreach champions to serve neighbors before a health crisis brings them to the hospital, further building trust and connection in the community. The community focuses on continuous education for all stakeholders – the patients, community, and providers. It serves as a replicable model for interdisciplinary teams to co-design alongside patients and community. Building a community using “What Matters to You?” and team building, the Center serves as a model of continuous care improvement that can be applied to any system.

Centers for Disease Control and Prevention. (2021). National Statistics. https://www.cdc.gov/arthritis/data_ statistics/national-statistics.html Centers for Disease Control and Prevention. (2020, February 27). Arthritis. https://www.cdc.gov/ chronicdisease/resources/publications/ factsheets/arthritis.htm Barry MJ, Edgman-Levitan S. Shared decision making–pinnacle of patient-centered care. N Engl J Med. (2012 Mar 1);366(9):7801. https://www.ncbi.nlm.nih.gov/ pubmed/?term=22375967

Ms. Hamlin is a Project Consultant at goShadow and an MHA candidate at The Ohio State University.

“

first “Block Party” will be a chance for the Center and its partners to come together outside of work, with friends and families, to celebrate their collective achievements and the new professional and friendly relationships formed. These events allow the community of multidisciplinary teams to have fun together while participating in something that contributes to the community’s mission of improving bone and joint health.

Ms. Carlson is a nurse and Sr. Improvement Specialist at the UPMC Innovation Center where she collaborates with the Center for Bone and Joint Health.

Dr. DiGioia is medical director of the Bone and Joint Center at UPMC Magee-Womens Hospital and co-medical director of the Center for Bone and Joint Health.

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Thank you for your membership in the Allegheny County Medical Society The ACMS Membership Committee appreciates your support. Your membership strengthens the society and helps protect our patients.

Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109, or email membership@acms.org.

ACMS Bulletin / May 2022

from Chef Anthony beers and fun

selected to open their own restaurant featured along with a down to earth, within the space, with 12-18 months to rustic menu. Nonalcoholic wines and win over an audience and establish their cocktails also will be showcased. Societybrand. News 25 Penn Ave., You can try a little of everything G’s On Liberty, 5104 Liberty Ave., from all four restaurants during the Bloomfield dda Coffee & Tea same meal – heaven for foodies. G’s turns former Alexander’s Italian wntown cafes. Adda Tupelo Honey, 100 West Station Bistro into a seasonal scratch kitchen ong Bengali tradition Square Drive, South Side with creative food and cocktails. ectual discourse with Craving fried green tomatoes, Coming in the fall. d coffee. Here’s your buttermilk biscuits, shrimp and grits And finally … t of Adda, with a and banana pudding – and oh yes, Chengdu Gourmet, McKnight s and coffees. fried chicken and waffles? Tupelo Road, Ross Township quare delights: Honey Café will open this fall in Station Chengdu Gourmet (the beloved quare, 6425 Penn Square to remedy that, in style. James Beard-nominated Squirrel Hill Con Alma Downtown, 613 Penn hole-in-the-wall Sichuan restaurant rito’s Alta Via pizza Ave., Downtown that regularly inspires pilgrimages from venture to Bakery The new jewel of the Downtown all over Western PA) is planning an The Pennsylvania Geriatrics Society – Western asual California style Cultural DistrictDivision featuresisinsanely good outpost McKnight Road the site of proud to announce theon 2022 recipient ofat the cousin, AVP. Enjoy Miami/Latin/Caribbean the former Oriental Market, in the plaza David C. cuisine Martinalong Award: Wendy Osei-Bonsu, a fourth-year e-forward dishes with live jazz. student at Penn State College next of to Medicine. Red Lobster. This will offer nd sandwiches for Gaucho Parrilla Argentina, 146 a much larger dining space – 6,000 Wendy’s abstract, “Diagnosing Duodenal Diverticulum, even days a week. Sixth St., Downtown square feet – and an expanded dining ”was accepted by the American Geriatrics Society quare, 6425 Penn The resident jewel of the Downtown menu. Something to look (AGS) forward to in for presentation at the AGS 2022 Annual Scientific Meeting, Cultural District dazzles with an early 2022. May 12-14, in Orlando, FL. own Richard incredible array of steaks and wood Enjoy, and be safe. a restaurant called fired meats with variety of sauces In aher award application, Wendy stated: “My current career a reservation in the and accompaniments. Takeout Paranjpewith is anan ophthalmologist goal is to pursueand residency inDr. neurology interest in ome enjoy its vast dine-in available. and medical editor of the ACMS global health, stroke, and epilepsy.” post, complete with Wild Child, 372 Butler St., Etna Bulletin. She can be reached at The award is named after David C. Martin, MD, who established the first geriatrics f space and both The brainchild of Chef Jamilka reshma_paranjpe@hotmail.com. Pittsburgh to encourage and prepare future physicians in the field of dining. fellowship in Borges, Wild Child emphasizes coastal geriatric medicine. The opinion expressed in this column is that of y Square, 6425 and island cuisine and is sure to delight. the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, iberty Mount Oliver Bodega, 225 or the Allegheny County Medical Society. Square is the Brownsville Road, Mt. Oliver

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ugust 2021 18

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Society News ELECTION 2023

The Allegheny County Medical Society is looking for motivated individuals interested in joining our leadership team to develop our Society to meet the future needs of our members and community. ACMS is now seeking candidates for the 2023 ACMS Board of Directors and ACMS Delegates to the Pennsylvania Medical Society and invite your nominations. If you want to make a difference and are interested in participating in ACMS leadership, send in your nomination. If you would like to recommend a colleague, please e mail [dhostovich@acms.org] or fax this memo back to 412-321-5323. Get involved—send in your nominations today. If you have any questions, please contact the Society at 412-321-5030; our staff is eager to assist you. Sincerely,

Mark A. Goodman, MD Mark A. Goodman, MD Secretary

NOMINATIONS FOR 2023 ELECTION [Please Print] I would like to recommend

for

Board of Directors

Delegate.

I am interested in being a candidate for the ACMS: Board of Directors

Delegate to the PAMED Society

• Represents physicians on issues impacting the practice of medicine and makes policy decisions for the Society.

• Represents the physicians of Allegheny County in creating statewide policy on issues impacting physicians, patients and the practice of medicine.

• Meets four times per year, special meetings as needed. • Three-year term: 2023-25. Eligible for reelection.

• Meets as necessary prior to attending the House of Delegates in October in Hershey, PA. • Two-year term: 2023-24. Eligible for re-election.

Name Phone Email [Please Print] Please enclose a copy of your CV. Fax the completed form to 412-321-5323 by Monday, July 15, 2022. Thank you.

ACMS Bulletin / May 2022

Materia Medica

Vericiguat (Verquvo ) ®

Lauren Sittard, PharmD and William Beathard, PharmD, BCPS Background: Verquvo (vericiguat) is a soluble guanylate cyclase (sGC) stimulator recently FDA approved indicated for use in adults with symptomatic chronic heart failure with an ejection fraction less than 45% (HFrEF) to reduce the risk of cardiovascular death and heart failure hospitalization following a hospitalization for heart failure or need for outpatient IV diuretics. By supplementing cardiac tissue with intracellular cyclic guanosine monophosphate, Verquvo contributes to both vasodilation and smooth muscle relaxation that may lead to a reduction in myocardial dysfunction thought to be associated with decreased sGC activity.1 Safety: Verquvo is contraindicated in patients who are currently taking other sGC stimulators or those who are pregnant. Due to the potential for embryo-fetal toxicity, it is recommended to obtain a pregnancy test prior to initiating treatment in women of reproductive potential. Furthermore, it is recommended for these patients to use contraception during therapy and for at least one month following the final dose of Verquvo.1While not mentioned in the prescribing information for Verquvo, it is important to note that for the medication Adempas (riociguat), another sGC stimulator, the concomitant use of nitrates, nitric oxide donors, and phosphodiesterase inhibitors are contraindicated due to the risk of hypotension.2 Tolerability: In a phase 3, randomized, double-blind, placebo-controlled trial 32.8% of patients receiving Verquvo experienced serious adverse effects as compared to 34.8% in the placebo group. Similarly, adverse effects, both serious and nonserious in nature, occurred to a lesser extent (80.5%) in the vericiguat group compared to placebo (81%). The most

common adverse events in the treatment arm consisted of hypotension (15.4%), cardiac failure (8.9%), skin and subcutaneous tissue disorders (8.7%), anemia (7.6%), dizziness (6.7%), pneumonia (6.4%), acute kidney injury (5.3%), dyspnea (5.3%), and diarrhea (5.2%). The difference between symptomatic hypotension in the vericiguat group (9.1%) was not found to be significantly different from that of the placebo group (7.9%) (95% CI: -0.3 to 2.8%, P= 0.121). Additionally, syncope was also not found to occur at a significantly different incidence in the vericiguat group compared to the placebo group (estimated percent difference: 0.6; 95% CI: -0.5 to 1.6).3 A multicenter, randomized, double-blind, placebo-controlled, dose-finding trial observed an incidence of adverse events that differed independently with dosing ranging from 70.3% to 78.9% compared to placebo with an incidence of 77.2%. Hypotension occurred at a rate of 15.4% for those on doses of 2.5 mg to 10 mg with 11% being symptomatic hypotension. Among this same group syncope occurred in 4.4% of patients and acute kidney injury in 3.3% of patients, these rates were 1.1% and 3.3% in the placebo group, respectively.4 Efficacy: The evidence put forth by the Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction (VICTORIA) trial largely contributed to the approval of vericiguat. Approximately 60% of the 5050 study participants studied with worsening heart failure were on triple therapy of a beta blocker, mineralocorticoid antagonist, and either and ACE inhibitor, ARB, or sacubitril/ valsartan. The study included 3 subgroups; patient hospitalized within 3 months prior to randomization, those hospitalized 3-6 months prior to randomization, and those who were not hospitalized but required IV diuretics within the last three months. These patients also had to have had an elevated natriuretic peptide. The researchers defined this as an

elevated natriuretic peptide was defined as a BNP ≥ 300 pg/mL or a NT-proBNP ≥ 1000 pg/ mL for patients in normal sinus rhythm and a BNP ≥ 500 pg/mL or NT-proBNP ≥ 1600 pg/ mL for patients in atrial fibrillation. This study demonstrated that in patients with HFrEF and an elevated natriuretic peptide level, over a median period of 10.8 months, vericiguat was associated with a lower incidence of a composite of death from cardiovascular causes and first hospitalization for heart failure when compared to placebo (HR: 0.90; 95% CI: 0.82 to 0.98; P= 0.02). Total hospitalizations for heart failure were found to be lower in the treatment arm when compared to placebo (HR: 0.91; 95% CI: 0.84 to 0.99; P= 0.02) as well as a composite of death from any cause and hospitalization for heart failure (HR: 0.90; 95% CI: 0.83 to 0.98; P= 0.02).3 Price: Currently, there are no generic equivalents to Verquvo on the U.S. market. The estimated retail price for a 30-day supply (30 tablets) is around $700.5 Simplicity: Vericiguat is currently available as 2.5 mg, 5 mg, and 10 mg oral tablets. The current dosing and administration recommendations per the manufacturer are a starting dose of 2.5 mg once daily with food. The recommended titration schedule increases the dose every 2 weeks, doubling the strength as tolerated until the target maintenance dose of 10 mg once daily is achieved.1 This tolerability is based on blood pressure and clinical symptoms.3 Bottom Line: Data suggests a mortality benefit with using vericiguat in select patients with worsening symptoms of HFrEF that had recently required either hospitalization or urgent treatment (IV diuretic therapy).3 Safety and tolerability data was found to be relatively similar between Verquvo and placebo, apart

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Materia Medica from hypotension.3,4 At the present time, given no generic equivalents available, the cost of this medication may limit its use.5 At the time of authorship Lauren Sittard, PharmD is a PGY-1 Pharmacy Resident at UPMC St. Margaret and can be reached at sittardl@upmc.edu. William A. Beathard, PharmD is a PGY-2 Geriatric Pharmacy Resident at UPMC St. Margaret and can be reached at beathardwa@upmc.edu. Heather Sakely, PharmD, BCPS, BCGP provided editing and mentoring for this article and can be reached at sakelyh@upmc.edu. References: 1. VERQUVO® (vericiguat) tablets, for oral use [prescribing information]. Available at: https://www.merck.com/product/usa/ pi_circulars/v/verquvo/verquvo_pi.pdf. Accessed 24 October 2021.

2022 ACMS Meeting & Activity Schedule By Committee Finance Committee Keith T. Kanel, MD, Chair August 30 November 15 Board of Directors Patricia L. Bononi, MD, Chair September 13 December 6

Delegation

Deborah Gentile, MD, Chair Bruce A. MacLeod, MD, Vice Chair

August 31

House of Delegates October 21-23

Meetings begin at 6:30PM. If you are interested in attending any of the meeting, please contact Mrs. Hostovich at 412.321.5030.

2. ADEMPAS (riociguat) tablets, for oral use [prescribing information]. Available at: https:// labeling.bayerhealthcare.com/html/products/ pi/Adempas_PI.pdf. Accessed 3 November 2021. 3. Armstrong PW, Pieske B, Anstrom KJ, et al. Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2020;382(20):1883-1893. doi:10.1056/ NEJMoa1915928 4. G heorghiade M, Greene SJ, Butler J, et al. Effect of Vericiguat, a Soluble Guanylate Cyclase Stimulator, on Natriuretic Peptide Levels in Patients With Worsening Chronic Heart Failure and Reduced Ejection Fraction: The SOCRATESREDUCED Randomized Trial. JAMA. 2015;314(21):2251-2262. 5. G oodRx. FDA Approves Verquvo for Treatment of Heart Failure. Available at: https://www.goodrx.com/blog/fda-approvesverquvo-for-heart-failure/. Accessed 3 November 2021.

ACMS Bulletin / May 2022

Legal Summary

Disclosure of Mental Health Records: Traps for Psychiatrists and Other Providers Beth Anne Jackson Dealing with subpoenas from attorneys when your patient has filed a personal injury or other lawsuit is one of the many banes of a physician’s practice. Responding incorrectly can result in a lawsuit filed against you for wrongful disclosure, a complaint to the Pennsylvania State Medical Board, or a letter from the Office of Civil Rights, a division of the federal Department of Health and Human Services that enforces HIPAA, which may result in an investigation. The stakes are even higher when you are a psychiatrist or other mental health provider and the records being requested are covered by the psychiatrist-patient privilege (codified at 42 Pa.C.S.A §5944) (hereinafter, the “Privilege”). Case Background. A recent Pennsylvania Superior Court decision, Tavella-Zirilli v. Ratner Companies, L.C. , solidified prior court holdings that a plaintiff must put her mental health directly at issue by asserting specific claims in order for certain portions of her mental health records to be subject to discovery. The Superior Court clarified what the Privilege does not protect: “records of the opinions, observations, diagnoses, or treatment alternatives of [a patient’s mental health] treatment providers.”

Rather, the Privilege protects only the “confidential communications made and information given by the client to the psychotherapist in the course of treatment” – that is, the client’s “private thoughts.” Such private thoughts are not even subject to “in camera” review by a court unless the party seeking their disclosure establishes that the plaintiff waived the Privilege by putting her mental health directly at issue. The Pennsylvania Supreme Court recognized a limited implied waiver in a personal injury case involving a man who was hit by a commercial truck because state police released a report indicating that the man was attempting to commit suicide at the time. Because the man eventually died, and the defense could not get information regarding the deceased in any other manner, the release of his mental health records was ordered. In Tavella-Zirilli, however, the Superior Court found that the plaintiff neither directly nor implicitly waived the Privilege by initiating a negligence lawsuit and seeking damages for pain and suffering resulting from chemical burns from a lengthy hair color treatment. General assertions of mental anguish, embarrassment, emotional distress or loss of consortium, if stated, do not waive the Privilege or put one’s mental health directly at issue.

Import. Attorneys can be insistent when they want records. Knowing what records you have to provide before you do and what documentation they must provide to you first is essential in protecting both patient privacy and your practice or facility. When psychotherapy notes are requested, they can only be released in very limited circumstances, when you have received: a HIPAA-compliant authorization signed by the patient that specifies disclosure of psycho-therapy notes (“all records” is not sufficient; further, the authorization may not be combined with an authorization for other records); a subpoena accompanied by a court order that specifies that psychotherapy notes be released; or a court order that specifies that psychotherapy notes be released. At all times, the release of records must be limited to what is authorized in the order or patient authorization: if “psychotherapy notes” are not specifically included, mental health treatment providers may provide only those records that pertain to diagnosis, treatment, or observation of a mental health condition, with any communications by the patient redacted. The release of this nonprivileged information can be made with a HIPAA-compliant authorization, a subpoena accompanied by a

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Legal Summary court order, or a subpoena that is accompanied by either (a) evidence that the party requesting the information has informed the individual, the time for reply has elapsed, and no objections were filed, or (b) the parties have agreed to a qualified protective order. In the Tavella-Zirilli case, the Superior Court further instructed the trial court to require that the disclosure of this information be made pursuant to a protective order that restricts the use of any information outside of the personal injury action. Conclusion. Physicians must always take care to ensure that information disclosed pursuant to a patient authorization or a court order is limited to that which is specified in the authorization or order. Moreover, a physician or other licensed professional providing mental health treatment services must take even more care to protect communications from patients because they are

ACMS Bulletin / May 2022

subject to the Privilege. State case law has made it clear that, as a general rule, a plaintiff must put their mental health directly at issue in their lawsuit in order for psychotherapy notes or similar records documenting the patient’s private thoughts to be discoverable. General assertions of mental anguish, embarrassment, emotional distress, and loss of consortium or life’s pleasures do not put the plaintiff’s mental health directly at issue and, therefore, do not result in a waiver of the psychiatrist/ psychologist-patient Privilege. DISCLAIMER: This article is for information purposes only and does not constitute legal advice. You should contact your attorney to obtain advice with respect to your specific issue or problem. Ms. Jackson is a shareholder in the Health Care Practice Group of Brown & Fortunato, P.C., which is headquartered in Amarillo, Texas, and serves healthcare providers nationally. She is licensed in both Pennsylvania and Texas and maintains an office in the greater Pittsburgh area. She may be reached locally at (724) 413-5414 or bjackson@bf-law.com. Her firm’s website is www.bf-law.com.

Improving Healthcare through Education, Service, and Physician Well-Being.

REPORTABLE DISEASES 2022: Q1 Allegheny County Health Department Selected Reportable Diseases/Conditions Selected Reportable Disease/Condition*

January to March** 2020

2021

2022

AMEBIASIS

CAMPYLOBACTERIOSIS

COVID-19

273

30516

60276

CRYPTOSPORIDIOSIS

DENGUE FEVER

GIARDIASIS

GUILLAIN-BARRE SYNDROME

HEPATITIS A

HEPATITIS B ACUTE

HEPATITIS B CHRONIC

LEGIONELLOSIS

LISTERIOSIS

MALARIA

MEASLES

MUMPS

INVASIVE MENINGOCOCCAL DISEASE

PERTUSSIS

SALMONELLOSIS

SHIGELLOSIS

SHIGATOXIN-PRODUCING E COLI

STREPTOCOCCUS PNEUMONIAE INVASIVE

TOXOPLASMOSIS

TUBERCULOSIS

TYPHOID FEVER

VARICELLA

WEST NILE VIRUS

ZIKA VIRUS

* Case classifications reflect definitions utilized by CDC Morbidity and Mortality Weekly Report. ** These counts do not reflect official case counts, as current year numbers are not yet finalized.Inaccuracies in working case counts may be due to reporting/investigation lag.

NOTE: Disease reports may be filed electronically via PA-NEDSS. To register for PA-NEDSS, go to https://www.nedss.state.pa.us/NEDSS. To report outbreaks or diseases reportable within 24 hours, please call the Health Department’s 24-hour telephone line at 412-687-2243. For more complete surveillance information, see ACHD’s 10-year summary of reportable diseases: https://www.alleghenycounty.us/Health-Department/Resources/Data-and-Reporting/Infectious-Disease-Epidemiology/Epidemiology-Reports-and-Resources.aspx.

ACMS Bulletin May 2022

Articles inside

Editorial

Perspective

Materia Medica

Editorial

Society News

Legal Summary

Specialty Report