RPM Oct 2014 | Vol 2 | No 5 by Value-Based Cancer Care

OCTOBER 2014

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VOLUME 2 • NUMBER 5

NORM 2014 Highlights

Racing to Rheumatology Excellence: NORM Members Gather for Conference

Criteria Broadened, Fines Increased for Breaches Under HIPAA By Rosemary Frei, MSc

n expert recently shared the Services (HHS) Health Insurance pitfalls of noncompliance with Portability and Accountability Act breach-reporting provisions (HIPAA) and Health Information that came into effect last year under the Technology for Economic and 1 US Department ofPHYSICIAN Health & Human Clinical Health Act.PRACTITIONERS At the National By C.J. Daniels FOR OFFICE ADMINISTRATORS, RHEUMATOLOGISTS, ASSISTANTS, AND NURSE Louisville, KY—Members of the Nat ional Organization of Rheumatology Managers (NORM) met in Louisville, KY, September 12-13, 2014, for the group’s 2014 annual conference. Approximately 150 attendees gathered for the meeting, hailing from practices throughout the United States. Attendees were treated to breakfasts and luncheons, as well as a reception and dinner Friday evening, September 12. The meeting also featured more than 40 sponsors and supporters, filling an exhibit hall with pharmaceutical companies, pharmacies, practice man agement, and patient education soft Continued on page 6

Continued on page 8

Expert Offers Tips on Navigating LCDs with ICD-10 By Ellen Martin

heumatology managers recently received an overview of Medicare local coverage determinations (LCDs) that will be used when the International Classification of Diseases, Tenth Edition (ICD-10) takes effect in 2015. At the National Organization of

Rheumatology Managers (NORM) 2014 Annual Conference, Jean Acevedo, pres ident, Acevedo Consulting Incorporated, Delray Beach, FL, discussed the ins and outs of LCDs, providing tips and practi cal solutions. Ms Acevedo’s presentation was one Continued on page 7

In partnership with

Nat ion a l O r ga n iz at ion of o R he u m atolo g y Man a gers From the publishers of

In This Issue

PUBLISHING STAFF Senior Vice President/Group Publisher Nicholas Englezos nenglezos@the-lynx-group.com Director, Client Services Zach Ceretelle zceretelle@the-lynx-group.com Editorial Directors Dalia Buffery dbuffery@the-lynx-group.com Anne M. Cooper acooper@the-lynx-group.com Associate Editor Lara J. Lorton

OCTOBER 2014

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VOLUME 2 • NUMBER 5

Copy Editor Jessica Cheng Editorial Assistant Cara Guglielmon Production Manager Marie RS Borrelli The Lynx Group President/CEO Brian Tyburski Chief Operating Officer Pam Rattananont Ferris Vice President of Finance Andrea Kelly Human Resources Jennine Leale Associate Director, Content Strategy & Development John Welz Director, Quality Control Barbara Marino Quality Control Assistant Theresa Salerno Director, Production & Manufacturing Alaina Pede

NORM 2014 Highlights

Racing to Rheumatology Excellence: NORM Members Gather for Conference............................................. 1 By C.J. Daniels

Criteria Broadened, Fines Increased for Breaches FOR OFFICE ADMINISTRATORS, RHEUMATOLOGISTS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS Under HIPAA.................................................................................................. 1 By Rosemary Frei, MSc

Expert Offers Tips on Navigating LCDs with ICD-10............................ 1 By Ellen Martin

Testing and Diagnostics

FDA to Regulate Laboratory-Developed Tests.................................. 10 By Rosemary Frei, MSc

Director, Creative & Design Robyn Jacobs

Continued on page 4

Creative & Design Assistant Lora LaRocca Director, Digital Media Anthony Romano Web Content Managers David Maldonado Anthony Trevean Digital Programmer Michael Amundsen Meeting & Events Planner Linda Sangenito Senior Project Managers Alyson Bruni Jini Gopalaswamy Project Manager Deanna Martinez Project Coordinator Mike Kodada IT Specialist Carlton Hurdle Executive Administrator Rachael Baranoski Office Coordinator Robert Sorensen Engage Healthcare Communications, LLC 1249 South River Road - Ste 202A Cranbury, NJ 08512 phone: 732-992-1880 fax: 732-992-1881

BPA Worldwide membership applied for January 2014.

MISSION STATEMENT Rheumatology healthcare requires providers to focus attention on financial concerns and strategic decisions that affect the bottom line. To continue to provide the high-quality care patients deserve, providers must master the ever-changing business of rheumatology. Rheumatology Practice Management offers process solutions for mem bers of the rheumatology care team—physicians, nurses, and auxilliary clinical staff, as well as executives, administrators, and coders/billers—to assist them in reimbursment, staffing, electronic health records, REMS, and compliance with state and federal regulations.

Rheumatology Practice Management™, ISSN 2164-4403 (print), is published 6 times a year by Engage Healthcare Communications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Copyright © 2014 by Engage Healthcare Communications, LLC. All rights reserved. Rheumatology Practice Management™ is a registered trademark of Engage Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the publisher. Printed in the United States of America. The ideas and opinions expressed in Rheumatology Practice Management™ do not necessarily reflect those of the editorial board, the editors, or the publisher. Publication of an advertisement or other product mentioned in Rheumatology Practice Management ™ should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturers about any features or limitations of products mentioned. Neither the editors nor the publisher assume any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material mentioned in this publication. POSTMASTER: Correspondence regarding subscriptions or change of address should be directed to CIRCULATION DIRECTOR, Rheumatology Practice Management™, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Fax: 732-992-1881. Yearly subscription rates: 1 year: $99.00 USD; 2 years: $149.00 USD; 3 years: $199.00 USD.

October 2014

www.RheumatologyPracticeManagement.com

In This Issue

Continued from page 3

Meaningful Use

Am I Done Clicking Yet? Mourning the Loss of the Doctor–Patient Relationship.......................... 11 By Kyle C. Harner, MD

Physician–Hospital Alignment Series

Do’s and Don’ts in Physician–Hospital Alignment, Part 3................................................................. 14 By Max Reiboldt, CPA

The Rheumatology Nurse

Clinical Research: 1 Hat or 2?….......................................................................................................... 16 By Sheree C. Carter, PhD, RN

Disaster Planning

Disaster Planning for the Medical Office............................................................................................ 18 By Mariana S-B Lamb, MS, with contributions from Richard Levine, MD

EDITORIAL ADVISORY BOARD Editor-in-Chief Iris W. Nichols

President National Organization of Rheumatology Managers Wilmington, NC Practice Administrator Arthritis & Osteoporosis Consultants of the Carolinas Charlotte, NC

Ana Reyes-Cartagena

Director of Clinical Practice Arthritis & Rheumatism Associates, P.C. Wheaton, MD

Allyson D. Eakin, RN, OCN, CCM

Clinical Research Coordinator Arthritis & Osteoporosis Consultants of the Carolinas Charlotte, NC

Kyle C. Harner, MD

Helen Hinkle

Linda McKee

Mark Post

Jay Salliotte

Practice Administrator Rheumatic Disease Associates Ltd Willow Grove, PA

Practice Administrator Premier HealthCare Associates, Inc Richmond, VA

Nancy Ellis

Practice Administrator Piedmont Arthritis Clinic Greenville, SC

Marjorie Collings

RHEUMATOLOGY PRACTICE MANAGEMENT

Carolina Arthritis Center Greenville, NC

Administrator North Texas Joint Care, P.A. Dallas, TX

I October 2014

Office Administrator Rheumatology Associates of South Texas San Antonio, TX

Business Manager Advanced Rheumatology Lansing, MI

Don’t Face the Maze of Changes in Rheumatology Alone

NORM Keeps You Informed National Organization of Rheumatology Managers

NORM’s mission is to provide rheumatology managers, administrators and managing physicians countless opportunities to network with colleagues through our listserv and annual conference. At NORM, our goals involve addressing, educating, distributing, and functioning as a conduit for rheumatologic practice management needs and expertise. “NORM, by far, surpasses the benefits of any other organization I have ever belonged to. Through the listserv, NORM members willingly assists each other by providing solutions to everyday issues that arise while managing a rheum practice. We share experiences, ideas, protocols and procedures specific to a rheumatology practice. The annual NORM conference in September is definitely the icing on the cake as we all come away with practical ideas and tools we can implement.” Mary Jo Wideman, RN, BSN, Practice Manager

Do you have questions about coding, biologics, insurance carrier denials or personnel issues? Join NORM to help find your answers. Are your questions state specific, MAC specific or national coverage issues? NORM offers rheumatology managers the opportunity to connect across the Nation. Through our listserv you receive expert advice from professionals in rheumatology! Join NORM and network with experienced managers through our listserv, gain access to our members only section which contains sample practice forms, job descriptions, and other documents that have been shared on this listserv, a list of our members, and in the future educational resources. NORM also hosts webinars throughout the year to continue supporting the education of our members. Membership is open to rheumatology professionals including physicians and those who hold a management position in a rheumatology practice.

Save the Date for our 2015 2014 Annual Conference September 12 18 & 13, 19, 2014 2015 ~ Louisville, Bellevue, WA KY

NORM ~ www.normgroup.org ~ info@normgroup.org

NORM 2014 Highlights

Racing to Rheumatology Excellence...Continued from the cover ware companies, as well as medical device companies and laboratories, among others. “Our guiding mission at NORM is to provide rheumatology managers, administrators, and managing physi cians countless opportunities to learn and grow, and to return from our

Arthritis Center, and Ana ReyesCartagena, Director of Clinical Practice, Arthritis and Rheumatism Associates. Speaker, trainer, and “undercover patient” Denise Price Thomas closed the general session on Friday with her afternoon presenta tion, “‘Would You Like to Supersize

“Our guiding mission at NORM is to provide rheumatology managers, administrators, and managing physicians countless opportunities to learn and grow, and to return from our annual conference with valuable lessons that improve their practices as well as the lives of the patients they serve.” —Iris Nichols annual conference with valuable les sons that improve their practices as well as the lives of the patients they serve,” said Iris Nichols, President of NORM. “We are so pleased with all of the presenters and participants at this year’s conference, and we thank everyone for coming together for another educational, enjoyable, and informative experience.” With the theme “Racing to Rheu matology Excellence,” the meeting opened with a presentation by Brad Nieder, MD, CSP, also known as The Healthy Humorist, who kept audi ence members laughing with his prac tical humor and advice. The after noon general session featured a Medical Necessity Panel, moderated by Kathy Rock, PT, MBA, President of Rock Consulting, and featuring panelists Kyle C. Harner, MD, Managing Physician of Carolina

That?’ An Interview to Remember.” As a new addition to the meet ing, attendees were invited to par ticipate in product theaters. These small-group gatherings featured in dustry presentations and demon strations of products related to clin ical practice and practice management. Registrants also at tended small-group morning break out sessions both Friday, September 12, and Saturday, September 13. Topics addressed Health Insurance Portability and Accountability Act breaches, Meaningful Use Stage 2, improving the quality of patient– healthcare provider interactions, updates related to Occupational Safety and Health Administration, and infection control. Other topics discussed included financial con cerns, presentations by the NORM Education Committee, and inter

RHEUMATOLOGY PRACTICE MANAGEMENT

I October 2014

personal and staff relationships. The second and final day of the meeting opened with the NORM Annual Membership Meeting, board elections, and morning announce ments. Elected board members are as follows: • Iris Nichols, President • Dave Rothhaas, Past President • Ethel Owen, Vice President • Rai McElroy, Treasurer • Cathy Evans, Secretary • Donnie Craig, Director • Karen Grace, Director • Andrea Zlatkus, Director • Nancy Ellis, Director • Lynette Byrnes, Director Audience members were then cap tivated by a presentation by Wayne Sotile, PhD, “Getting the Best Out of Medical Groups: Deepening Physician and Team Engagement and Resilience.” Dr Sotile, of the Center for Physician Resilience and the Sotile Center for Resilience, dis cussed topics such as change, motiva tion, and creating safe spaces within the work environment. Jean Acevedo, President and Senior Consultant with Acevedo Con sulting, Inc, led participants through a presentation that reviewed the im pact of the International Classification of Diseases, Tenth Edition (ICD-10), on Medicare local coverage determi nations. Together with Amiel Toyaker, MD, of Arthritis and Rheumatology Associates of Palm Beach, Ms Acevedo also presented an ICD-10 workshop with a focus on electronic health records, local cov erage determinations, cheat sheets, and checklists. “We truly hope everyone in atten dance enjoyed the meeting as much as we did,” said Ms Nichols. “We look forward to continuing to sup port rheumatology managers throughout the year, and we hope to see everyone at our next annual con ference in 2015.” l

NORM 2014 Highlights

Expert Offers Tips on Navigating...Continued from the cover of several that were delivered to a general session audience at the con ference, which was held September 12-13 in Louisville, KY. Practice managers, practice administrators, managing partners, and others at the conference gathered to learn about local coverage determinations, which serve as the framework for determination of whether treat ments and services are reasonable and necessary and will be reimbursed as a Medicare benefit under Part A or Part B.1 “Understand that because ICD10 implementation is in the future, none of the information, unless I tell you otherwise, is final,” Ms Acevedo noted. “These LCDs are all in their proposed form, assuming that we actually do go to ICD-10 in October 2015. Hopefully they won’t make any additional changes.” All LCDs have the same format, noted Ms Acevedo, and include items such as an effective date, the Current Procedural Terminology codes that are covered within it, the ICD-9 or ICD-10 codes that support medi cal necessity, and the documentation requirements. Ms Acevedo said the person in the office who is respon sible for billing should read each applicable LCD in the context of a patient’s situation and the clinical documentation. She also said it is important to read information about LCDs on the Centers for Medicare & Medicaid Services website.2 She provided a sampling of LCDs used in rheumatology and their accom panying ICD-10 codes. Among them was Cahaba Government Benefit Administrators LCD (L34257) for infliximab infusion with the ICD-10 code. The LCD includes unit equiv alents for numbers of vials: 1 vial is 10 units, 2 vials are 20 units, and so on. Ms Acevedo said Cahaba likely did this because of previous underpay ments or overpayments in cases when

not all of the contents were used from each of the vials. She noted the indications in L34257 are identical to those from the FDA, while the documentation requirements are identical to those in Cahaba’s current/active LCD for

“You need to make sure that there isn’t a repeat of anything, even the injection of Depo-Medrol, without documentation to show that the patient responded well to the previous procedure.” —Jean Acevedo

infliximab infusion, L30030. The doc umentation requirements stipulate, for example, that the medical records need to indicate the order, route of administration, amount of medica tion, and the clinical information sup porting the indication for the use and frequency of usage for each patient. “Cahaba is really pretty thorough when it comes to the actual docu mentation requirements,” said Ms Acevedo. She suggested that each physician familiarize themselves with the ICD-

October 2014

10 codes that they will use frequently with their patient population. They can focus on one specific code/diag nosis set each month, and compare their accuracy in ICD-10 coding from the beginning of that month to the end. It will take approximately a year, she estimated, for the physician to become comfortable with the most common diseases he or she sees. Ms Acevedo also delved into the details of some of the LCDs for bisphosphonate drug therapy, viscosupplementation, and intravenous bisphosphonates. She urged admin istrators to order enough ICD-10 books to allow everyone in their practices to become familiar with the rules. In addition, she said that in response to an additional develop ment request or audit, it is important to submit all of the relevant informa tion, including treatment note, the order or orders, the medical history and physical examination, and the posttreatment notes showing prog ress and response to treatment. “You need to make sure that there isn’t a repeat of anything, even the injection of Depo-Medrol, without documentation to show that the patient responded well to the previ ous procedure. And also be sure to include anything else that you can think of that will support the indi cation, the medical necessity, and the ICD-10 code. So you don’t have situations in which you say, ‘Oh no, my nurses don’t document some times, in the confusion.’ Figure out how you want to support that correct documentation going forward and educate the clinical staff according ly,” advised Ms Acevedo. l

References

1. US Centers for Medicare & Medicaid Services. Local coverage determinations. www.cms.gov/ Medicare/Coverage/DeterminationProcess/LCDs. html. Accessed September 23, 2014. 2. US Centers for Medicare & Medicaid Services. Indexes. www.cms.gov/medicare-coverage-database/ indexes/national-and-local-indexes.aspx. Accessed September 23, 2014.

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NORM 2014 Highlights

Criteria Broadened, Fines Increased...Continued from the cover Organization of Rheumatology Managers 2014 Annual Conference, Bill Fivek, president and CEO, Total Medical Compliance, discussed the strengthened provisions as well as consequences if practices are found to be noncompliant. Mr Fivek’s presentation was one of several that were delivered to small groups during breakout sessions at the conference, which was held September 12-13 in Louisville, KY. Practice managers, practice adminis trators, managing partners, and oth ers at the conference gathered to learn about current HIPAA guide lines, how to stay in compliance, and what to do should a breach occur. “One of the Health and Human Services attorneys said, ‘If you have a problem, report it. If you hinder the investigation by hiding a fact, we’ll find out. We’re pretty good. We don’t care how sorry you are, or how you’ll do things different next time,” Mr Fivek said. Mr Fivek noted the penalty for each violation that is found to be willful neglect and not corrected in a timely fashion is at least $50,000 to a maximum of $1.5 million per calendar year for the same viola tion, a ceiling that HHS wishes were higher, he said. Some fines have the potential to close practices for good. There are lower fines ($100$50,000) for violations that occur when the practice does not know of the violation and would not have known of it even if administrators were exercising reasonable diligence. The penalties are also low, although not unsubstantial ($1000-$50,000), when circumstances make it unrea sonable to comply with HIPAA. He said the best way for practices to be protected from penalties is to have careful and well-documented processes in place for the protection of patient data. “If you put preven tive processes in place after you’ve

screwed up, that’s like doing your homework after it’s due,” he said. Protected health information (PHI) today is very broadly defined to include health information that is provided orally or recorded in any medium or form, as well as e-mail addresses, license plate numbers, and any other unique identifying num ber, characteristic, or code. The final omnibus HIPAA rule that came into

The best way for practices to be protected from penalties is to have careful and welldocumented processes in place for the protection of patient data.

effect on March 26, 2013 (with com pliance required by September 23, 2013) also included expanding the compliance requirements for busi ness associates, as well as making the definition of a health information breach more stringent and clarifying when breaches must be reported to the HHS.1 According to the new rules, un authorized disclosure, acquisition, access, or use of PHI in any way that is not permitted by the Privacy Rule “is presumed to be a breach unless the covered entity [practice or business associate, as applicable] can prove otherwise,” said Mr Fivek. “Unlike your court of law where you are innocent until proven guilty, with HIPAA you’re guilty until you can prove yourself innocent. You have

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I October 2014

to demonstrate that your policies show that there couldn’t have been a breach; that the information couldn’t have gotten out to someone.” There are, however, important exclusions: when a worker who has the authority to access the informa tion accidentally accesses a record for a patient whose care they are not involved in; when a worker who has the authority to access the infor mation inadvertently shares patient information with another worker who isn’t involved in that patient’s care; or when information is shared with someone who isn’t authorized but the unauthorized person would not rea sonably have been able to retain such information, said Mr Fivek. “If I hear an individual patient’s name being discussed by someone associated with a medical practice, that’s not a breach. If I hear a patient has a certain condition but I don’t know who the person is, it’s not a breach. But if I can marry those two pieces of information, then it is a potential breach,” explained Mr Fivek. “And if it’s not a breach, it could be just a HIPAA violation that you document as an incident in your records.” Another common scenario is when someone sends a paper copy of a patient record to the wrong person. “They call up the office and say, ‘This isn’t mine. I know I’m not supposed to have this. I want to shred it.’ In situations like that, it’s perfectly acceptable to have the patient or individual who received the infor mation in error sign a confidentiality agreement,” explained Mr Fivek. The mobile electronics era has brought with it a significantly in creased potential for patient records to be seen by people who are not authorized to receive such informa tion, Mr Fivek said. Therefore it is important to have rules in place to safeguard patient information on

NORM 2014 Highlights

electronic devices, such as making sure that employees have a secure PIN to use their smartphones, that they use a personal login and pass word to access PHI, and use encryp tion or patient portals for electronic responses to patient inquiries. The practice also should have an elec tronic lockout process for when an employee leaves the practice. The effectiveness of these measures should be verified by yearly risk anal yses, which are widely available and also can be used for attestation of Meaningful Use, said Mr Fivek. In fact, every time there is a potential breach, practice admin istrators should complete a risk analysis checklist, Mr Fivek said, to document the extent and nature of the breach or potential breach and the staff members’ decision processes surrounding it. This includes doc umenting which individuals inside and outside the clinical practice the matter was discussed with, what decisions were made, and how they were made, said Mr Fivek. All patients whose information was involved in the breach must be notified by first-class mail or e-mail within 60 days of the breach’s dis covery. The written notification to the patients should include an e-mail address or phone number patients

can use for inquiries, stipulated Mr Fivek. In addition, when the breach involves data from fewer than 500 patients, the administrators must report the breach to HHS no more than 60 days after the end of the calendar year in which the breach

The mobile electronics era has brought with it a significantly increased potential for patient records to be seen by people who are not authorized to receive such information.

was discovered. When a breach involves 500 or more patients at the same time patients are notified, the practice must also notify prominent media outlets serving that geograph ic area as well as HHS.2 If an employee acted in a criminal manner by taking deliberate steps to disclose information about patients to people who are not authorized to receive that information, he or she

KEY POINTS HIPAA violations should be reported immediately and honestly in order to prevent further complications.

➤

Individual fines vary from $100 to $50,000 depending on the severity of the breach and the ability to comply with HIPAA.

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Mobile and electronic devices should be encrypted in the event of unauthorized access.

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Measures that safeguard patient information in electronic devices should be verified by yearly risk analysis.

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All affected patients should be notified of a breach within 60 days of incident; in certain circumstances, the breach should also be reported to HHS and/or media outlets.

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October 2014

can be held personally responsible, explained Mr Fivek, and the employ ee and/or the practice may be fined. Otherwise, employees are not legally responsible for breaches. If a business associate caused the breach, that person or business must provide noti fication to the covered entity within 60 days of the breachs discovery. “These folks can get you in trouble, so you need to make sure you’ve got proper documentation with them,” Mr Fivek observed. “The business associate agreement must address the timing and reporting of breaches or suspected breach situations. If you didn’t update your business associate agreements in the last year, you need to do so with your business associ ates.” He pointed to the HHS web site as a source for business associate contracts.3 He told attendees that it is impor tant to consider bringing in outside consultants if the breach is poten tially large and/or criminal in nature. “If it’s something small, you can certainly handle it yourself, but cer tainly don’t feel shy about getting some outside help…because the 60-day timer is cranking. Don’t eat up that time. You have to act with some level of expediency,” said Mr Fivek. “The one thing you want to walk away with from this presen tation is when you have a breach, act quickly. Act decisively, but act quickly. Don’t put it on the back burner, because [if you do] this is going to come bite you.” l

References

1. US Department of Health & Human Services. New rule protects, secures health information patient pri vacy. News release. January 17, 2013. www.hhs.gov/ news/press/2013pres/01/20130117b.html. Accessed September 19, 2014. 2. US Department of Health & Human Services. Instructions for providing notice of a breach to the secretary. www.hhs.gov/ocr/privacy/hipaa/admin istrative/breachnotificationrule/brinstruction.html. Accessed September 22, 2014. 3. US Department of Health & Human Services. Sample business associate agreement provisions. www.hhs.gov/ocr/privacy/hipaa/understanding/cov eredentities/contractprov.html. Accessed September 22, 2014.

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Testing and Diagnostics

FDA to Regulate Laboratory-Developed Tests By Rosemary Frei, MSc

he Food and Drug Ad min istration (FDA) recently took initial steps toward regulating laboratory-developed tests (LDTs). Used to select appropriate treatment for individual patients, LDTs are designed, made, and used within a single laboratory,1 and include genetic tests and tests used by clinicians to guide their patients’ treatment. On July 31, 2014, the FDA announced it would take “impor tant steps to ensure that certain tests used by healthcare professionals to help diagnose and treat patients provide accurate, consistent, and reliable results” by developing a framework for regulation of LDTs.2 Until now, the FDA has opted to “exercise enforcement discretion.”3 LDTs differ from tests sold to users such as hospitals and doctors’ offic es; the latter are regulated as medi cal devices. There are approximate ly 2000 laboratories that produce LDTs in the United States. The only standards that laborato ries using LDTs have had to comply with are generally accepted stan dards for good laboratory practic es under the Clinical Laboratory Improvement Amendments,3 and also state laws and accreditation requirements by relevant authorities. However, with its announcement in mid-July, the FDA indicated it will publish a proposed risk-based over sight framework for LDTs.4 The framework was written, in part, because “the agency has seri ous concerns regarding the lack of independent review of the evidence of clinical validity of LDTs. Clinical validity is the ability of a diagnos tic device to measure or detect the clinical condition for which

the device is intended. LDTs that have not been properly clinically validated for their intended use and are used to make critical clinical decisions potentially put patients at risk of missed or incorrect diagno sis, failure to administer appropri ate treatment, or administration of potentially harmful treatment with no benefit.”3 The FDA will phase in the requirements over 9 years, begin ning with high-risk tests—includ ing those used in the decisions of which therapy is best for individual patients or to screen for serious conditions such as malignant can cer3—that have the same intended use as an FDA-approved or cleared companion diagnostic test that is already on the market.3 The FDA will continue to exercise enforce ment discretion for low-risk tests; these are tests with very few or no possible deleterious consequences of inaccurate results to patients; those aimed at diagnosing rare dis eases; those that have no FDAapproved or cleared alternative; or those that are made for laboratories that are within healthcare facilities in which the patients who are being tested are also being treated.3 “Phasing in the requirements is a way not only to give the labs time to come into compliance, but [also so that] we can then adjust, based upon our resources, to provide the appropriate level of oversight,” said Jeffrey Shuren, MD, JD, director of the FDA’s Center for Devices and Radiological Health, in a media teleconference on the day of the midsummer announcement.3 A few days earlier, a group of 23 pathologists and heads of diagnostic

laboratories wrote to the head of the Office of Management and Budget.5 They urged that the FDA “refrain from issuing any draft, proposed, or final guidance document or rule that would purport to regulate LDTs as medical devices.” They expressed concern that, among other points, “FDA regulation of LDTs would stifle innovation, [and] be contrary to pub lic health” due in part to the probable slowdown of test approval “under the rigid, inflexible, and duplicative [pro posed] FDA regulatory scheme.” On July 31, the FDA also pro vided to Congress with a draft pro posal on its LDT regulation. It also intends to publish a draft version of the LDT guidance this fall,1 and then to gather public comments for 90 days.1 Meanwhile, it has also produced a final guidance on the development, review, and approval or clearance of companion diagnos tics, which are all types of tests used to identify patients who will benefit or be harmed by treatment with a particular drug.2 l

References

1. US Food and Drug Administration. Laboratory developed tests. www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/InVitroDiagnostics/ ucm407296.htm. Accessed September 11, 2014. 2. US Food and Drug Administration. FDA takes steps to help ensure the reliability of certain diag nostic tests. News release. July 31, 2014. www.fda. gov/NewsEvents/Newsroom/PressAnnouncements/ ucm407321.htm. Accessed September 11, 2014. 3. US Food and Drug Administration. Framework for regulatory oversight of laboratory developed tests (LDTs). July 31, 2014. www.fda.gov/downloads/ MedicalDevices/ProductsandMedicalProcedures/ InVitroDiagnostics/UCM407409.pdf. Accessed September 11, 2014. 4. US Food and Drug Administration. Transcript of media briefing on companion diagnostic final guid ance and proposed risk-based oversight framework for laboratory developed tests. www.fda.gov/down loads/NewsEvents/Newsroom/MediaTranscripts/ UCM408370.pdf. Accessed September 11, 2014. 5. American Clinical Laboratory Association. July 16, 2014. www.acla.com/wp-content/uploads/ 2014/07/Letter-to-OMB-from-Lab-Leaders.pdf. Accessed September 11, 2014.

Rheumatology Practice Management is now available online at: www.RheumatologyPracticeManagement.com 10

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Meaningful Use

Am I Done Clicking Yet? Mourning the Loss of the Doctor–Patient Relationship By Kyle C. Harner, MD, Managing Partner, Carolina Arthritis Center, Greenville, NC

y first experience with docu mentation outside of a hos pital was at a small internal medicine office in Richmond, VA. I was a fourth-year medical student, and the supervising internist ran a small, but very nice office near Stuart Circle. He spent a lot of time with each patient and very little time dictating a few sentences about each encounter for the patient’s medical record. When my supervising inter nist was done seeing patients for the day, he went home. I am sure he was getting paid by the prevailing insurance providers of the day. After all, he did have a nice office in a very nice part of Richmond. I often think of that month in Richmond as I spend my entire lunch hour, and up to several hours after our office closes, typing and clicking boxes. This is to make sure my notes meet all the requirements for not only a Current Procedural Terminology code 99214 office visit, but also for Meaningful Use. This is also because we would like to keep our nice office in Greenville. This begs the question, what is all this clicking about? What is all the Meaningful Use data being used for at the Centers for Medicare & Medicaid Services (CMS)? For answers, I turned to the source that everyone uses: I Googled it. Using the search “How does CMS use Meaningful Use data?”, I was rewarded with hundreds of hits about how I can meet Meaningful Use specifications, but absolutely none about what the bean counters at CMS are doing with the data we

are providing. I cannot say I was sur prised by this, but some explanation would have been nice. I did not call CMS because I did not want to hear a vague answer about quality.

I think we have come full circle on this issue, because in the end quality care takes place when a physician and patient get to spend more time together, not when a physician gets to spend more time clicking.

In our quest to meet Meaningful Use standards, our office has gone through an initial electronic med ical records transition, followed by multiple updates, the most recent

of which is to accommodate chang es stemming from Meaningful Use Stage 2. Each update brings chang es in workflow and more boxes to click. More boxes mean either less time with each patient or more time documenting after the clinic clos es. I can only hope that electronic medical records evolve into systems that no longer hinder conversation between providers and patients, but I am not going to hold my breath waiting. Is there anything that the med ical community and our patients can do about the loss of the doc tor–patient relationship, or is it too late to turn back? I certainly do not have an easy answer to this ques tion. Doctors are historically poor at advocating for themselves, but many states now have strong med ical societies and even rheumatol ogy-specific societies that lobby for the interests of their membership. Organizations like the National Organization of Rheumatology Managers (NORM) are also vital. Through NORM, managers and physicians can work together to advocate for what we consider quality care. Finally, patients likely are the most powerful lobbyists. As consumers of medical care, patients have the most to win or lose when physicians look at computer screens rather than them. I think we have come full circle on this issue, because in the end quality care takes place when a phy sician and patient get to spend more time together, not when a physician gets to spend more time clicking. l

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October 2014

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Challenges of a New Ancill Starting ary Service By Kyle

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C. Harne Arthritis Cente r, MD, Managing Partn er, Carolina r, Greenville, NC ased on group preferences and state laws, rheum atology physi- patients have limited option cians may s for pain control. Becau se of this, the cotic prescriptionor may not write narcians 3 physis for in our patients as part chronic pain of for patien practice prescribe narcotics management. ts who we feel In North Caroli need long-term na, primary care Eastern arthritis pain control. seldom write providers col FOR OFFICE such prescription to manage these We have a protoADMINISTR s, and in compl prescriptions ATORS, RHEU outside of pain that is MATOLOGISTS, management clinics iance , Medical Board with the North Carolina PHYSICIAN ASSISTANT .

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l of Rheuma

ancy Ellis’ day morning walk starts with a office to greet around the colleagues and get a feel for pressin The administrato g issues of the day. r of a busy rheum ogy practice, atolMs of the 26 people Ellis may run into any who work at Piedm ont Continued on page

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By Iris W. Nicho ls, President, Managers; National Orga Editor-in-Ch nization for ief, Rheumato Rheumatology logy Practice Manageme e are all aware nt of the many challenges and opportunities mance indicators that exami we face in tice quality rheum as well as costs, ne pracpractices. As we see from the atology evaluate our and we practices by articles, news countless them comparing blurbs, and listser to yesterday, ings, we all lookin v postg at exist encounter simila how We strive for r things. morrotoday, and preparing them they for tow. I recently (our physicians quality improvement returned from meeting where are known to a we be in this area), we have ongoin leaders together to meet discussed partnering g perfor- I these challenges. outlined my thoughts to prepar As e for

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Physician–Hospital Alignment Series

Do’s and Don’ts in Physician–Hospital Alignment, Part 3 By Max Reiboldt, CPA, President/CEO, Coker Group, Alpharetta, GA

he alignment of physicians with hospitals and health systems can be challenging in today’s healthcare climate, yet interest in alignment continues to expand. In some instances, the necessity of maintaining a strong and diverse medical staff coupled with the threat of losing critical team members and the subsequent closure of a business line may result in hospitals and health systems making decisions and promises they may not otherwise make. Considering these concerns, this series of articles on physician–hos pital alignments has explored topics relevant to those who are consider ing a relationship between practices and hospital systems. The first 2 articles in this series discussed pre transactional due diligence, struc tural design processes, governance, and compensation plans. In this third and final installment, ongoing and posttransactional relationships are explored; accountability, trans parency, partnerships, and the use of information technology are dis cussed in detail.

Ongoing Relationships Once an alignment transaction takes place, the involved parties have to continue to work together. Sometimes, with the challenges of trying to put a deal together, efforts to provide a fully transparent and accountable posttransaction struc ture can be overlooked. In order for any such affiliation structure to stand the test of time, there must be a very clear and open process in place for sharing information, data, and overall performance. Accountability is an impor

tant facet of any posttransaction relationship; both parties must be accountable to each other. For example, the employed physi

Sometimes, with the challenges of trying to put a deal together, efforts to provide a fully transparent and accountable posttransaction structure can be overlooked. cian must be accountable to his employer. This means everything from normal work performance to equipping oneself to meet the dayto-day responsibilities of the posi tion. However, accountability also applies to the employer. In this case, the employer is often the hospital, and the hospital should realize and buy into the concept that they must fulfill the things they com mitted to during the prealignment

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I October 2014

discussions. Anything less should result in some form of reconciliation between both parties. Transparency is also of great importance. Most employees (or physicians who are not fully aligned but significantly tied to a health system) seek some form of transpar ency. This may manifest as sharing of information and data (including performance) as well as openness in decision-making, not unlike the governance and leadership discus sion considered in Part 2 of this series. Thus, an attitude of sharing appropriate information and data is key to building a long-term and sustaining relationship. Partnering actions are also an important part of the behavior of both parties posttransaction. So much work, effort, and emphasis are placed on getting the deal done that this issue often is overlooked. Consequently, people start to take others for granted, which inevitably compromises trust, transparency, and accountability. Although true partnering initiatives may not be the legal structure in each arrange ment, an attitude of partnering is extremely important for the longterm sustainability of the alignment transaction. Another key to success in the ongoing relationship posttransac tion is the level and degree of infor mation technology (IT) use. This is related to transparency, but is really much greater than just shar ing information. IT in the current healthcare environment is an abso lute essential. It is imperative to be able to pull together data from a clinical standpoint that can be shared over a large number of par

Physician–Hospital Alignment Series

ticipating providers. Such forms of clinical integration are critical to the long-term success of both the hospital and the physician going forward. Education is important in this process; that is, teaching and acquainting the physicians with some level of thoroughness relative to what IT is capable of doing as well as the nuances of how best to get information into the system. When physicians are under great stress to be productive (which can largely be tied to their compensa tion), the aggravation of working with an IT system that is only partly functional does not create a longterm trusting relationship or success in the alignment strategy. Building trust and respect, there fore, is a great way to summarize these matters. Understanding roles, keeping accountability well defined, and sharing information through a transparent mechanism is a sound

formula for success as it relates to these alignment structures.

Planning for the Unwind Possibilities Although no one likes to talk about the potential for divorce, particularly prior to the marriage, these possibilities must be addressed and well documented prior to con summation of the alignment struc ture. There are ways to provide the physicians with a “soft landing” in an unwind that does not hurt the hospital, and, in the long run, could be very helpful. This should be the approach of the parties involved. Moreover, specific unwind proto cols and policies should be defined so there are no misunderstand ings as to how certain calculations will be completed or other matters resolved relevant to the unwind process. Assuming this has been done, inevitably issues will arise

KEY POINTS With the challenges of putting a deal together, efforts to provide a fully transparent and accountable post-transaction structure can be overlooked.

➤

Accountability is an important facet of any post-transaction relationship, and the physician and hospital must be accountable to each other.

that have not been specifically considered. This calls for cooler heads to prevail, with members of management of both the hospital and the physician group sitting down and doing what is best for the entire process. Often, this means reaching a compromised solution, maybe even one that is not quite as preferable to both compromising parties. Nonetheless, compromis es are essential in the spirit of working together, now and in the future, postunwind.

Summary Many do’s and don’ts apply to the entire concept of physician–hospital alignments, with variations from the very form or definition of the align ment model to the details of that model. Alignment requires a great deal of planning, expertise, and, in many instances, an independent party to help mediate the process. If these matters are addressed and appropriate agreements reached and then consistently applied, the chanc es for a most successful transaction are much enhanced for the hospital, health systems, and the physicians with whom they are aligning. l

➤

Transparency, or an attitude of sharing appropriate information and data, is key to sustaining an alignment relationship.

➤

An attitude of partnership is also extremely important to sustaining a long-term alignment relationship.

➤

Effective use of information technology is essential, as is the ability to pull together data from a clinical standpoint that can be shared over a large number of providers.

➤

Be prepared for issues that may arise from restructuring, and aim for trust, respect, and compromises.

➤

This is the final article in a 3-part series on physician–hospital alignments. To review Part 1 and Part 2 of this series, which appeared in the June 2014 and August 2014 issues of Rheumatology Practice Man agement, respectively, visit www. rheumatologypracticemanagement. com. Click on “Issues” for a dropdown selection of previous journal issues and select the appropriate issue.

Rheumatology Practice Management is now available online at: www.RheumatologyPracticeManagement.com

October 2014

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The Rheumatology Nurse

Clinical Research: 1 Hat or 2? By Sheree C. Carter, PhD, RN, Assistant Clinical Professor, The University of Alabama in Huntsville; President, Rheumatology Nurses Society

here is a growing need for dedicated healthcare pro viders from rheumatology private practice to step into the role of researcher and participate in clinical trials to evaluate treatment regimens and therapies. In addition, there is a widening gap in the rheumatology nursing literature and a great need exists for healthcare practitioners to produce and publish studies for rheumatol ogy nurses on the best practices of patient care. However, funding obstacles, finding passionate men tors, as well as the lack of scientif ically exciting and rigorous envi ronments, are frequently heralded as barriers for researchers in private practice. The pathway for practitioner/sci entist in private practice requires protected research time, passion ate mentors, and loyal advocacy. It is equally and vitally important for nurses to step into the role of researcher/investigator to develop strategies and evaluate outcomes of care, and to create, inform, and evaluate evidence-based practice in rheumatology.

Creating the Right Environment The 2010 Institute of Medicine Future of Nursing report1 and research by Benner and colleagues2 strongly advise academic nursing programs to encourage faculty to require students to follow-through on the care of their patients by examining patient outcomes. In addition, student nurses must be able to comfortably access the lit erature, be able to discern relevant research, and critically evaluate patient population-based evidence

for care of their patients before and after their clinical assignments. The passion for research and scholarly evaluation skills must be fostered in nursing school so it can nurture and grow in clinical prac tice. Nurses should be expected to acquire and consummate practice research skills, if for no other reason than to advance the art and science of nursing.

It is important that the nurse presents the duality of role concretely to the patient to eliminate therapeutic misconception.

There is benefit to private practice performing clinical research studies if properly planned, supported, and maintained. In an article published in the Journal of Medical Practice Management, Christine Pierre sug gested that private practices con sidering the clinical research arena should primarily determine if they have a sufficient patient population base to recruit from, as well as ade quate space for protocol materials, to perform any laboratory aspects of the clinical trials, and space for pharmaceutical monitors to visit, and for work related to the evalua tion of a trial.3

Points to Consider In addition, personnel responsi

RHEUMATOLOGY PRACTICE MANAGEMENT

I October 2014

ble for clinical trials should be com pletely dedicated to that service. Ideally, they should not require a dual role in maintaining an office or infusion room clinical practice along with the conduction of clin ical trials. Dedicated staff, protect ed time, and a large clinical base of patients from which to obtain potential volunteers is the very basis for success. Realizing it is not ideal in all cases to have dedicated staff for clinical trials, nurses in particu lar must be cognizant of wearing 2 hats. Nurses have the trust of the patient and must maintain a balance when working between clinical and investigator/research er responsibilities. They should be able to differentiate between the nurse-patient and researcher-par ticipant relationship. Nurse researchers must be aware of power relationships that affect the decision of patients whether to participate in a research trial.4 Nurses in researcher roles must be cognizant of the possibility that study partic ipants may have unexpressed con cerns. Think of these concerns as an exacerbation of therapeutic miscon ception. When the nurse functions in the role of a healthcare provider as well as a principal investigator, the patient may misunderstand this dual role. For example, the patient may confuse the preexisting trust ing relationship with the nurse as a healthcare provider and be fear ful of losing that relationship when approached by that same nurse in a researcher role. It is important that the nurse pre sents the duality of role concretely to the patient to eliminate thera peutic misconception. The nurse

The Rheumatology Nurse

must make clear to the patient that the right to refuse to participate in a research study is always an option at any point during the study and carries no adverse consequences or ill feelings and will not affect care in any way.

Following a Code of Practice Nursing practice is primarily ded icated to patient care and is gov erned by a distinct code of ethics by the American Nurses Association. Rheumatology nurses follow a newly designed Scope and Standards of Practice for Rheumatology Nurses.5 The US Food and Drug Admin istration Guidance on Investigator Responsibilities relates to patient protection, safety concerns, and ethical standards found in the Code of Ethics for Nurses.6 Clinical trial research also follows many dis tinct codes and documents such as the Belmont Report and Code of Federal Regulations, 21 Part 50.7 Nurses in research must critically adjust to the guidance and codes involved, and maintain the ethics and safety of the nursing profes sion when assuming a dual role in practice. In an academic setting, there has been an increase in strategies for fos tering research and evidence-based nursing practice in the clinical setting. Nurse researchers must be adequately prepared through for mal education in nursing research. Benner and colleagues2 suggest that research is a skill set that all nurses must come to realize. More rheu matology clinical nurses are needed to embrace a researcher role, not only for clinical trial research, but also for the sake of evidence-based practice. Sadly, there is little research in the literature to support evidencebased practice in rheumatology nurs

ing. Nurses in private practice can address many practical issues within nursing research with the expec tations that conclusions derived from their studies can be applied to infusion suites and other practices. Share your ideas, knowledge, and triumphs. Share equally the failures so that others do not repeat the mistakes. In rheumatology nursing today, there is a tendency for care

Share your ideas, knowledge, and triumphs. Share equally the failures so that others do not repeat the mistakes. —Sheree C. Carter, PhD, RN

and practice decisions to be based on experience, recalling outcomes from previous trial-and-effort sit uations with patients. Providing nursing research conducted in an ethical and scientific manner, spe cifically for rheumatology nursing practice, provides validation to the profession. Participation in clinical trials may add prestige to your practice. It

October 2014

can increase networking with other investigators to compare and con trast treatment modalities. The per sonal reward for an investigator is the knowledge that participation in a clinical trial can add to the body of the science of medicine. Equally important is the advancement of nursing knowledge and an impact on demonstrating how the profes sion cares specifically for rheuma tology patients. If you have the lux ury of 1 hat as a researcher, you are fortunate. If you must wear 2 hats, make sure you are very clear to your patients about which hat you are wearing in your different encoun ters. Wear only 1 hat at a time by focusing on priorities. Diligence and attention to the care of the patient comes first, and in some cases may override the research role. l Dr Carter is Assistant Clinical Pro fessor, The University of Alabama in Huntsville; and President, Rheum atology Nurses Society (RNS).

References

1. Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. www.iom.edu/Reports/2010/The-Future-ofNursing-Leading-Change-Advancing-Health.aspx. Published October 5, 2010. Accessed August 11, 2014. 2. Benner PE, Sutphen M, Leonard V, et al. Educating Nurses: A Call for Radical Transformation. 1st ed. San Francisco, CA: Jossey-Bass; 2010. 3. Pierre C. Physician to investigator: clinical practice to clinical research—ethical, operational, and financial considerations. J Med Pract Manage. 2008;24:9-12. 4. Judkins-Cohn TM, Kielwasser-Withrow K, Owen M, Ward J. Ethical principles of informed consent: exploring nurses’ dual role of care provider and researcher. J Contin Educ Nurs. 2014;45:35-42. 5. Rheumatology Nursing: Scope and Standards of Practice. American Nurses Association, Rheumatology Nurses Society. Published 2013. 6. Guidance for Industry: Investigator responsibil ities, protecting the rights, safety, and welfare of study subjects. US Department of Health & Human Services, Food and Drug Administration, Center for Drug Evaluation and Research, Center for Biologics Evaluation and Research, Center for Devices and Radiological Health. www.fda.gov/downloads/ Drugs/.../Guidances/UCM187772.pdf. Published October 2009. Accessed August 11, 2014. 7. US Department of Health, Education, and Welfare. The Belmont Report. www.hhs.gov/ohrp/humansub jects/guidance/belmont.html. Published April 18, 1979. Accessed August 11, 2014.

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Disaster Planning

Disaster Planning for the Medical Office By Mariana S-B Lamb, MS, with contributions from Richard Levine, MD

very medical practice is at risk for a natural or man-made disaster. Future events cannot be predicted, but responses to such events can be. Any medical pro fessional who has worked through a disaster can tell you either how glad they are that the practice had a disaster plan in place, or how they regret the practice was not prepared for such a risk. A serious crisis— fire, weather event, health crisis, or something else—disrupts your busi ness. It threatens income streams, company data, jobs, personal safety, and patient care. Who do you think employees and patients will turn to in an emergency? You, the practice manager. You are the one who your team members expect to have a plan. If you have a good one, then you can help guide your company through a rough spot and get the organization back on its feet. Since you never know when a crisis may strike, the best time to prepare is now. While we cannot control or pre dict the future, we can plan for it, and we are even required to do so by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Few people would argue that disaster planning is a waste of time, or that it is not important for maintain ing patient safety and continuity of care. It is clearly good business prac tice to have a plan in place to ensure the financial stability of a practice, even—and especially—in the event of a disaster. Although it is recognized as im portant, seen as a sound business practice, and even mandated by fed eral law, how many oncology practic es make disaster planning a priority? It seems to be one of those tasks that gets pushed to the back burner in favor of more immediate, more press ing needs in the office.

The most effective plan is devel oped by a team so that it does not depend solely on 1 person. It will help to designate someone as the disaster plan coordinator to lead the team. Other members to consider are the office manager, information technology manager, human resourc es manager, and accounts payable/ bookkeeper. The makeup of your team may vary depending on the size of your practice. Regardless of the titles assumed by those staff mem bers, you will want to make sure that attention is given to the specific tasks discussed below. The disaster plan coordinator will lead the team. Determine that per son’s responsibilities, including over sight, to ensure each of the other team members maintains his or her assignments. Better yet, determine responsibilities with the person to gain buy-in and ownership in devel oping the plan. Then assign a backup disaster plan coordinator so that not everything is lost if the coordinator becomes unavailable in the event of an emergency.

Before Disaster Hits Pick and choose where to start, divide them among staff and do some simultaneously, or commit to a set number of hours you will work on the plan each week. Before you know it, you will be checking tasks off your list and feeling good about it. Steps to take before disaster strikes: • Collect and organize emergency supplies. A suggested list of sup plies is available in a supplemen tary online Table at rheumatology practicemanagement.com. • Maintain hard copy and electronic lists of important contact informa tion. Keep copies in a secure place offsite. Lists may include business

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contacts such as your bank, che motherapy supplier, biohazard waste disposal agency, office sup plier, certified public accountant, or attorney. • Video and/or photograph your offices, equipment, and furniture inventory. Update it annually, and prior to any anticipated disas ter. Maintain copies both onsite and offsite. • Back up computer files on a reg ular basis. Maintain them onsite and offsite. • Prepare a script for your office telephone “on hold” message. This can be e-mailed or faxed to a ven dor that can update the script for incoming phone calls as needed. • Establish a central phone number for patients to call, as well as an alternate phone number offsite. • Identify alternate physicians and hospitals for patient referral in the event of a disaster (ie, contact county, state, and national medi cal societies for recommendations on who to include). • Determine availability and ability to administer vaccinations for dis eases such as polio, tetanus, hepa titis B, and hepatitis C. • Train staff. Once you have a writ ten plan, keep a copy of it in a spe cific place in your office, as well as an electronic copy that is accessible through your website. Then, most importantly, make the plan avail able to all staff members. Conduct training to ensure everyone knows their roles and responsibilities in the event of a disaster. Keeping team members informed will facil itate efforts should a disaster strike. The final article in this series, which provides guidance on how to engage patients and prepare for imminent disaster, will be featured in December. l

Invitation to Join the RPM Editorial Board The publishers of Rheumatology Practice Management™ (RPM) are inviting qualified rheumatology practice owners and administrators to participate as members of the RPM Editorial Board. As an Editorial Board member, you will play an active role in helping to shape the content of this exciting new publication. Rheumatology Practice Management is a niche publication focused on process solutions for rheumatology practices. RPM is designed to provide the rheumatology care team—medical, practice administrators, coders, and billers—with the knowledge and skills required to keep abreast of today’s fast-changing business environment, allowing practice professionals more time to concentrate on high-quality patient care. Each issue of RPM will focus on various areas of rheumatology practice, featuring current topics such as: • Healthcare technology • Models of care • Staffing • Reimbursement and coding • Drug updates

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nter, Gre Partner, Ca enville, NC rolina ased on gro up prefere state laws, nce rheumatology s and patients hav cians may e limited opt phy sior may not ions for cotic prescri write nar- control. Because of ptions for pat this, the 3 pain cians in chronic pain ien physimanagemen ts as part of for pat our practice prescribe North Car ients who we t. In Eastern narcotics olina, prim arth ary ritis pain con feel need long-term seldom wri te such pre care providers col trol FOR OFFIC . We hav to outside of scri E ADMINIST pain manage ptions, and in commanage these prescriptioe a protoRATORS, ment clin RHEUMATO ics, Medicapliance with the North ns that is LOGISTS, Carolina l Board. PHYSICIAN ASSISTAN From the TS, AND NU Continued on Editor RSE PR page 8 ACTITION ERS

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