In truth, the newsletter never went away, they just stopped mailing out to save money.  It still publishes it on the Board’s website, if you know where to look.  That may soon change.

The TMB only sends out newsletter by email to a list that is kept manually.  The Board staff is looking into capturing emails during licensure process for new licensees.  It is also looking at putting a button on website in order to opt-in to the newsletter.  The Board currently asks on renewal if licensees would like to receive the newsletter.  Maybe 15% of licensees have opted not to receive emails.

During this decision, Dr. George  Williford, a member of the Board, asked staff if the individuals making these large requests could be mentioned in the newsletter and listing the cost to the agency.  He asked if this was a form of harassment.  Mari Robinson, the Executive Director, responded the Board could put together a report on requests, which it is doing it and how many requests these people have made.  This information will be presented at the November meeting.

 As we know times are tight for government due to the poor economy.  As such, the Governor asked all state agencies to cut 5% of their budgets.  For the Board that is 1.46 million dollars.  The Board was awarded by the Governor 2.5% of that money back.  In response to this new money, the Board lifted its hiring freeze.    

 Mari Robinson, the Executive Director reported the Board will post jobs in July, and actual hiring in August.  She also reported that the Licensure Division does not operate on laser fiche, they have to scan everything.  This is large efficiency loss, if they do have funds, some will be expended to bring licensure in line to laser fiche.  Also would like to get technology to allow board members to attend ISC’s remotely.  The camera they purchased did not give them the quality they had hoped for; Board members want to be able to see expressions on Respondent’s faces.  The Board is looking at spending money on a better camera to cut down on travel expenses.  Information Technology is researching the costs, and they expect to recoup the money in one to two months in travel savings.

 Ms. Robinson also reported Board staff met with chair of appropriations committee.  A big portion of the cuts were on the expert panel reviews.  They feel they are currently closing many of the cases on the front end. 

 TMB just received legislative appropriations request and fully intended not to ask for additional funding.   They are required to submit a budget and then two appendendacies with additional cuts in each.  Board staff is of the opinion that it does not have any additional monies it can cut.  If they can save on travel, they will put that in, but when you are talking about cuts of millions, it will not be a great help.  Board staff reported it will go back to letting cases sit and wait for expert reviewers, as this is a major expense.

 Board staff reported that Licensing fees have been increased, which was pointed out when they submitted the budget cuts.  This may be why they received money back.  Board staff is concerned about the budget for 2012 and 2013, which will not be finalized until the end of June 2011.  The Board believes it will need to look at brining in additional revenue.  Board staff pointed out the agency brings in triple of what is appropriated through licensure fees, renewal fees and fines.  Board staff hopes the Legislature will take this additional revenue rather than cut the Board’s base budget.  Board staff encouraged Board members communicate with legislators on how budget cuts effect the operations of the Board.

The meeting was to begin at 11:30, but due to a contentious sub-committee meeting on advertising (which I will blog about soon) the meeting started a little after 1pm. The review of applicants wrapped up at 5:45pm. My client was one of five who received an unrestricted license or permit. Three were granted a license or permit, but with a disciplinary order and six were deemed ineligible. As is normal after the Licensure Committee, there was a mix of happiness, sadness and frustration.

The Licensure process in Texas can be difficult and time consuming. If you have “issues” or lie on your application, you face a challenging time. It wise to consult with some with experience in this area and to be very organized with information that you present to the Board.

http://www.npr.org/templates/story/story.php?storyId=120346411

 I point of the story in relation to what I do is with regard to open and frank communication with patients, documenting both the education and the decisions made, and following through; with the knowledge that patients do change their minds, so the dialogue and the documentation must evolve with the patient.

 (1) The mid-level providers can obtain there own certification with the DEA and DPS.  Their individual certification number must appear on their prescription pad and they are required to have a supervisor relationship with a licensed physician.  This person is viewed as a “sponsor.”

 (2) There must be a standing protocol for the mid-level provider to prescribe using the physician’s prescription pad for the listed symptoms and only prescribe medications that are listed in the protocol for the symptoms. 

 The parties meet to discuss creating a field on the Texas Medical Board’s Physician Profile that will list all of the mid-level providers under the physician’s sponsorship who have prescriptive authority.

 The Texas Medical Board’s Standing Delegation Committee voted to create a sub-committee with the Physician Assistant Board and the Nursing Board to look into the guidelines for supervising physicians over PA’s and APN’s who have prescriptive authority under the physician’s supervision.   Their goal is to have everyone on the same page as to what the rules are and the risks involved in prescriptive delegation.

 My Take: First, physicians and mid-levels need to be sure they are in full compliance with current level and the correct paper work is in the Board denoting the supervisor relationship.  Second, look for the rules to be changed in the future.  If you have three boards get together, I can assure you the rules will change.  Given the current regulatory climate, I suspect that rules will tighten-up.  I just hope that before the Boards publish any rule changes, they talk and meet with “stake holders” in this area as any changes to mid-level prescriptive authority will have significant affect over thousands of providers.  Please continue to monitor this blog for changes.

 Based on a report by the Executive Director on Thursday, November 5^th, the Board trend on investigations appears to be a little less than last year.  In October 2009, the Board opened 50 fewer cases than it did in October 2008.  The Executive Director, Mari Robinson, attributes this change to due more careful initial review, which is now conducted by a physician and an attorney. 

 However, this does not mean that there are only a handful of cases.  There are currently 1875 open investigations with the Board.  Moreover, the Legal Division of the Board is extremely active.  There are 719 active legal cases with the Board.  Of those 101 cases are pending before SOAH.  That is a record number, and means 17.5% of all cases in Legal are at SOAH. 

 Ms. Robinson reports that the Board is experiencing a watermark situation with numbers and she does not see it going down anytime in the future. 

 Additionally, from the discussion held by the full Board on Friday, November 6^th, it appears to me that the Board members are only seeking to become more forceful with people who they deem have violation the Act.

By Andis Robeznieks
Posted: November 4, 2009 – 4:45 pm EDT

Behavior problems between doctors and nurses were reported by more than 97% of the nurses and doctors who participated in an American College of Physician Executives’ survey, which found that the most common complaints were degrading comments, yelling, cursing, inappropriate joking and refusing to work with one another.

The survey results paint a picture of “treachery and backstabbing” as doctors and nurses try to undermine each other, often right in front of bewildered patients, according to the ACPE. The organization e-mailed the survey to some 13,000 nurse and physician executives, with roughly a 67% to 33% split between the two factions, and 1,428 nurses (67.2% of respondents) and 696 doctors (32.8%) responded between July 9 and Aug. 10, 2009.

In addition to those mentioned above, other complaints included refusing to speak to each other, spreading malicious rumors, trying to get someone unjustly disciplined or fired, throwing objects and sexual harassment. Actual physical assaults, however, were reported by only 2.8% of the respondents.

When asked who most often exhibits behavior problems, 47.9% said it was an even mix; 45.4% said doctors; and 6.8% said nurses. Also, 61.2% reported having nurses terminated at their organization for behavior problems, while only 22.2% said the same of doctors.

Behavior problems arise several times a year, said 30.9% of the respondents, with 30% saying it happens weekly; 25.6% saying monthly; 9.5%, daily; 2.9%, once a year; and 1.2% saying less than once a year.

The most common complaint involved degrading comments or insults, with 85.5% (1,493) of the respondents reporting that this happened at their organization. Yelling was the next-most common, at 73.3% (1,294). A degrading comment highlighted in the survey was a physician telling a nurse: “You don’t look dumber than my dog. Why can’t you fetch what I need?”

My Take:  It is critical the professionals understand their limits and who and how they are interacting with people in the workplace.  Some may be ok with what you are saying and doing; others may take the same comment and turn you into the hospital or the boards.  Be aware of your professionalism in the workplace.

Board Chair Allen Cline, Tex. Lic. Acc.

Chung-Hwei Chernly, Tex. Lic. Acc.

Linda Wynn Drain

Raymond Graham

Terry Rascoe, M.D.

Karen Siegel, Tex. Lic. Acc.

Rachelle Webb, Tex. Lic. Acc.

Rey Ximenes, M.D.

Key Board Staff Members present:

Mari Robinson, Executive Director

Alan Moore, M.D., Medical Director

Toni Knight, Licensure Manager

Jennifer Kaufman, Assistant General Counsel

Nori Peterson

Monique Johnston

Sonja Aurellius

The Education Committee opened at approximately 9:00am.  Two organizations sought to become approved providers of Continuing Education content.  The Board granted approval for the American Association of Acupuncture and Oriental Medicine.  The Board did not approve a second group, as they have only offered one class for approval in the past.  There was discussion that the Board wanted three continuous years of courses being approved before they would consider an entity to be an approved provider. 

 The Committee continued an on-going discussion about the pros and cons of distance learning (i.e. on-line courses, self-study courses).  There was discussion on whether people actually take the necessary time to learn the material.  There was discussion about pre and post tests for such courses.  There was also discussion about embedding a timer system into on-line courses.  There was also discussion that on-line courses are the learning tool of the future.  There were no decisions made regarding this discussion. 

 The Committee did reject two courses of which they felt the CAE was not adequately related to the practice of Acupuncture and Oriental Medicine. 

 The Licensure Committee met at approximately 10:40am.  There were two applicants to be reviewed.  One applicant possessed a significant criminal history in the past, including the conviction of a felony.  The applicant presented evidence that he turned his life around and it had been nine years since his time in prison.  The Board recommended that he be granted a license under a public monitoring order.  The second applicant was a well-qualified individual who had practiced in another state since 1993, however, her education did not have the herb section; thus making her ineligible for licensure.  It was suggested that she withdraw her application. 

 The Committee discussed that it was unfortunate that such a well qualified individual could not get licensed in Texas.  The Committee directed Board staff to see if the statute allows for a limited licensure.

 The Committee recommended for licensure 43 applicants and 2 re-licensures.

 The full Board met at approximately at 11:20am.  At the full Board meeting Ms. Robinson, the Executive Director explained the new Physician’s Health Program (PHP), which will include Physicians, Physician Assistants and Acupuncturists.  Effective January 1, 2010, Confidential Orders will no longer be an option for the Board.  Instead, the Board will refer individuals addictions or physical or mental impairments to the PHP.  People who have standard of care problems or felony convictions will not be eligible for the PHP.  PHP will be run independently of the Board, but it will have to report to the Board and the Board will provide some administrative support.  The PHP allows for quick action.  There is an annual fee for the PHP of $1200 annual, which does not count towards testing or counseling.  The PHP is self-funding. 

 Under the Enforcement report, there are no current open investigations against licensees.   There are two complaints at SOAH and five cases pending in legal. 

 The Board is working on budget controls.  The biggest costs are consultant fees, which have exceeded one million dollars.  They are attempting to determine how to predict the fees in the future. 

 The Board approved one confidential order.  This person will be given the option to join the PHP once it is operational next year. 

 The Board issued two cease and desist orders against people holding themselves out as licensed Acupuncturists. 

 The Board approved the TCTCM’s acudetox training program to be taught online for non-clinical aspects of the course. 

 The Chair asked the Board members to look at the application to see if they felt the question relating to educational probation was confusing as there are several applications that claimed to have misunderstood the question.  This will be discussed at the next meeting. 

 Ms. Robinson advised that the Board’s general counsel did not find legal authority to issue non-disciplinary licensure Orders.  It is her opinion that any public order is a disciplinary action by the Board.

1.         A documented medical history and physical examination, including an assessment and consideration of the pain, physical and psychological function, any history and potential for substance abuse, coexisting diseases and conditions, and the presence of a recognized medical indication for the use of a dangerous drug or controlled substance.

In my experience included in this history and examination, the physician should review and have copies of all prior treatment records.  You need to have a documented pain scale.  In some cases, a psychological evaluation is warranted and should be a common treatment tool.  A written inquiry to local pharmacies and documenting this investigation is good protection if you are not sure.  The physician should exhaust non-controlled substance options first:  steroids, PT, OMT, and the like.  If the patient has immediately rejects this notion, you need to ask why?  What have the other physicians said and why?  What were the past treatment options for the patient, and were they followed?  If so, what were the results? If not, why not?

2.         A written treatment plan individually tailored to the patient that can objectively measure results, including but not limited to pain relief and/or improved physical and psychosocial function.  This treatment plan must consider pertinent medical history and physical examination as well as the need for further testing, consultations, referrals, or use of other treatment modalities.  This treatment plan should have both objective and subjective treatment goals. 

Part of this individualized treatment plan should be a pain contract.  Within this contact, the patient must agree that you will be the only physician to prescribe pain medications except in emergency situations, defined to mean only hospitalizations.  That the patient agrees to fill prescriptions at only one specific pharmacy of their choosing, agreed upon by the physician.  That lost medications or medications taken before the refill period will not be replaced but for emergency situations.  That if the physician makes a referral to other physician or for a diagnostic study, the patient must do so.  Failure to follow these guidelines will result in the physician firing the patient with 30 days notice a referral to three or more physicians, or refer them to insurance provider 

A normal check up schedule should be followed, with appropriate physical examinations and diagnostic studies.  All consultant reports, labs and studies must be included within the patient record.  Occasional inquiries to the designated pharmacy and to others in town should be done to ensure compliance with the contract.

 3.        The physician should discuss the risks and benefits of the use of controlled substances with the patient or guardian. 

This must be well documented in the medical record.  A statement of “patient educated” is not enough.  If the patient or family members have questions, answer the questions, and attempt to document the general tone and response to the questions.  It is even better to follow-up on such a Q &A session with a letter to the patient and/or family regarding these issues.  The letter must be included in the medical record.   At this counseling session, basic written information should also be provided.  Even if should action is basic protocol for your office, I would recommend this be also included in the medical record.

4.   The progress of the patient should be noted at reasonable (regular) intervals to evaluate the treatment objectives.  As the subjective and objective progress or regress of the patient should be evaluated and the individualized treatment pain can and could be modified, including any new information about the etiology of the pain.

As noted before, the patient should be seen a regular intervals.  I would recommend on a thirty day cycle.  This will allow you to control the prescriptions and not have to rely on refills.  It controls access to the medications all the while allowing you to see the month to month status of the patient. 

5.         Complete and accurate records of the care provided must be kept.  When controlled substances are prescribed, names, quantities prescribed, dosages, and number of authorized refills of the drugs should be recorded, keeping in mind that pain patients with a history of substance abuse or who live in an environment posing a risk for medication misuse or diversion require special consideration. 

This can become a record keeping nightmare.  A good method to comply with this provision is to photocopy the prescriptions and place it in the medical record itself.  For patients at higher risk for substance or possible diversion, document whatever safe guards utilized to continue to have the controlled substances are used for the legitimate medical purpose.  This includes counseling, charting by the patient, drug screens, and the like. Again, the key is to document.

This is merely a brief outline.  It is critical to review Board rule 170.  If you plan to work in the area of chronic pain, review the rules often, consult with an expert on your documentation, and take annual CME in this area.