MINUTES North Carolina Medical Board July 17-19, 2015 1203 Front Street Raleigh, North Carolina 1 July 17-19, 2015 General Session Minutes of the North Carolina Medical Board Meeting held July 17-19, 2015. The July 2015 meeting of the North Carolina Medical Board was held at the Board's Office, 1203 Front Street, Raleigh, NC 27609. Cheryl L. Walker-McGill, MD, President, called the meeting to order. Board members in attendance were: Pascal O. Udekwu, MD, President- Elect; Eleanor E. Greene, MD, Secretary/Treasurer; Subhash C. Gumber, MD; Mr. Michael Arnold; Ms. H. Diane Meelheim, FNP-BC; Timothy E. Lietz, MD; Mr. A. Wayne Holloman; Bryant A. Murphy, MD; Debra Bolick, MD and Ralph A. Walker. Absent: Barbara E. Walker, DO Presidential Remarks Dr. Walker-McGill commenced the meeting by reminding the Board members of their duty to avoid conflicts of interest with respect to any matters coming before the Board as required by the State Government Ethics Act. No conflicts were reported. See Appendix A for the State Ethics Commission’s findings regarding NC Medical Board Members’ conflicts of interest. Minute Approval Motion: A motion passed to approve the May13-15, 2015 Board Minutes and June 18, 2015 Board Hearing Minutes. Announcements Dr. Walker-McGill made a brief announcement recognizing that the North Carolina Medical Board was the only board that had representatives on each of the boards at a tripartite meeting held with the Federation of State Medical Boards, the National Board of Medical Examiners and the Educational Commission for Foreign Medical Graduates held in July 2015. Presentations Mr. Thom Mansfield, Chief Legal Officer, met with the Board to give an Attorney’s Report. A motion passed to close the session pursuant to Section 143-318.11(a) of the North Carolina General Statutes to prevent the disclosure of information that is confidential pursuant to Sections 90-8, 90-14, 90-16, 90-21.22 of the North Carolina General Statutes and not considered a public record within the meaning of Chapter 132 of the General Statutes and/or to preserve attorney/client privilege. The Board’s attorneys gave a report and provided legal advice regarding three non- public attorney-client privileged matters. A motion passed to return to open session. 2 July 17-19, 2015 Board Action: The Board directs the staff to continue to buy appropriate liability insurance to defend and indemnify the Board, Board members, and staff members for claims that arise from good-faith acts in the course and scope of the work of the Board. The Board also reaffirms the existing policy of reimbursing Board members and staff members for, or directly paying, reasonable uninsured expenses incurred because of claims that arise from good-faith acts in the course and scope of the work of the Board. NC PHP Reports Dr. Warren Pendergast, CEO, NC Physicians Health Program (PHP), gave the PHP Compliance Committee report. NCMB Committee Reports EXECUTIVE COMMITTEE REPORT Members present were: Cheryl L. Walker-McGill, MD, Chairperson; Pascal O. Udekwu, MD; Eleanor E. Greene, MD; Timothy E. Lietz, MD; and Mr. Michael J. Arnold. Open Session Strategic Plan a. Strategic Goals Update The Committee reviewed the updated Strategic Goals Task Tracker. Committee Recommendation: Accept as information. Board Action: Accept as information. Financial Statements a. Monthly Accounting The Committee reviewed the compiled financial statements for April 2015 and May 2015. May is the seventh month of fiscal year 2015. Committee Recommendation: Accept the financial statements as reported. Board Action: Accept Committee recommendation. Accept the financial statements as reported. 3 July 17-19, 2015 b. Investment Account Statements Mr. Matt Wedding and Mr. David Culpepper, Fifth Third Bank, Charlotte, are the Board’s investment advisors. Messrs. Wedding and Culpepper met with the Committee to discuss the financial market and the Board’s investments. Committee Recommendation: Accept as information. Board Action: Accept as information. Old Business a. KPI Overview The Committee received a review of the KPI Program and reviewed feedback from the Chiefs and others involved with the Program. Committee Recommendation: (1) Modify the target range for Legal KPI #4 (number of days to send a proposed consent order) to 33 – 41 days; (2) Add a reminder to each KPI report that the number of days reported to complete an activity includes weekends, holidays, vacation days and sick days; (3) move to a four-month reporting period (instead of a three-month reporting period); (4) continue to utilize the KPI program to identify performance improvement opportunities; and (5) work with the FSMB and other boards to publish the details of KPI programs. Board Action: Accept Committee recommendation. (1) Modify the target range for Legal KPI #4 (number of days to send a proposed consent order) to 33 – 41 days; (2) Add a reminder to each KPI report that the number of days reported to complete an activity includes weekends, holidays, vacation days and sick days; (3) move to a four-month reporting period (instead of a three-month reporting period); (4) continue to utilize the KPI program to identify performance improvement opportunities; and (5) work with the FSMB and other boards to publish the details of KPI programs. b. Indemnity and Hold Harmless Agreement for Retirement Plans Mr. Hari Gupta, Ms. April Pearce, and Mr. Patrick Balestrieri serve as trustees of the Board’s retirement plans (“the Trustees”). The Board provides fiduciary insurance to satisfy any liability and damages incurred by the Trustees acting in good faith. The Trustees have asked the Board to approve a proposed Hold Harmless and Indemnification Resolution which would satisfy liability and damages for all Trustees acting in good faith for things that the Fiduciary Policy does not cover and for monetary amounts in excess of the Fiduciary Policy limit. 4 July 17-19, 2015 Ms. Shannon Bradsher, Financial Directions, Cary, is the Senior Benefits Consultant for the retirement accounts. Ms. Bradsher met with the Committee to answer questions and provide further information regarding indemnification for Trustees. Committee Recommendation: 1) Approve the proposed Hold Harmless and Indemnification Resolution, and 2) Investigate the benefit of increasing the Board’s fiduciary liability insurance coverage. Board Action: Accept Committee recommendation. 1) Approve the proposed Hold Harmless and Indemnification Resolution, and 2) Investigate the benefit of increasing the Board’s fiduciary liability insurance coverage. c. CSRS Reports The Committee received an update regarding implementation of 21 NCAC 32Y .0101 “Controlled Substance Reporting System – Reporting Criteria.” Committee Recommendation: Accept as information. Board Action: Accept as information. d. CEO Task Tracker The Committee reviewed outstanding items on the CEO Task Tracker report. Committee Recommendation: Regarding item #5 (CCMS Concerns) - Forward CCMS concerns about Dr. Chaudhry and the Federation of State Medical Boards (“FSMB”) to the FSMB Board of Directors and request an official response. Make clear that the NCMB is submitting the CCMS comments on behalf of CCMS as a constituent of the Board, rather than on behalf of the Board itself. Regarding all other items on the tracker, accept as information. Board Action: Accept Committee recommendation. Regarding item #5 (CCMS Concerns) - Forward CCMS concerns about Dr. Chaudhry and the Federation of State Medical Boards (“FSMB”) to the FSMB Board of Directors and request an official response. Make clear that the NCMB is submitting the CCMS comments on behalf of CCMS as a constituent of the Board, rather than on behalf of the Board itself. Regarding all other items on the tracker, accept as information. 5 July 17-19, 2015 e. Legislative Update The Committee received an update on pending legislation including H543 “Amend Laws Pertaining to NC Medical Board” and H724 “Amend Composition of NC Medical Board” which would add a dedicated PA seat on the Board. Committee Recommendation: Accept as Information. Board Action: Accept as information. New Business a. Adding a CSRS Question to the Renewal Application Currently, less than half of in-state licensees with a DEA registration are registered to use the Controlled Substances Reporting System (CSRS). Increasing the number of registered CSRS users remains an important goal in addressing the serious problems associated with prescription drug abuse/diversion and avoiding mandatory registration. In an effort to encourage additional registrations, staff recommends adding a question to the license renewal form that will ask whether the licensee is registered with the CSRS and, if not, will include a link to a pre-populated registration form. Committee Recommendation: Add a question regarding CSRS registration to the license renewals for physicians and physician assistants. Board Action: Accept Committee recommendation. Add a question regarding CSRS registration to the license renewals for physicians and physician assistants. b. Nominations: Officers and Executive Committee Members The Committee nominates the following Board members as officers for 2015-2016: President-Elect – Eleanor E. Greene, MD Secretary/Treasurer – Timothy E. Lietz, MD The Committee nominates the following Board member as an at-large member of the Executive Committee for 2015-2016: Mr. Michael J. Arnold According to the NCMB Bylaws, the current President-Elect, Dr. Pascal O. Udekwu, will automatically become President on November 1 and continue as a member of the Executive Committee. In addition, the current President, Dr. Cheryl Walker-McGill, will 6 July 17-19, 2015 automatically become Immediate Past President on November 1 and continue as a member of the Executive Committee. Board Action: Accept Committee nomination of Mr. Arnold as the at-large member of the Executive Committee for 2015-2016. POLICY COMMITTEE REPORT Members Present: Mr. Arnold, Chairperson; Dr. Udekwu; Dr. B. Walker; Dr. Lietz and Ms. Meelheim New Business a. Position Statement Review i. Prescribing controlled substances for other than validated medical or therapeutic purposes, with particular reference to substance or preparations with anabolic properties (Appendix B) The Chair solicited comments from the Committee. There were no suggestions for revision of the position statement. Committee Recommendation: Accept as information. Note review of position statement. Board Action: Accept as information. ii. Physician supervision of other licensed health care providers (Appendix C) Committee members discussed their concern about the potential for boundary violations between supervising physicians and their health care supervisees. They also believe the position statement should clarify the prohibition on supervisees owning a practice and employing their supervising physician. Committee Recommendation: Ms. Meelheim and Mr. Brosius will work on proposed language to bring back to the Committee in September. Board Action: Accept Committee recommendation. Ms. Meelheim and Mr. Brosius will work on proposed language to bring back to the Committee in September. b. Contact with patients before prescribing (Appendix D) A member requested that the Policy Committee consider an additional exception to the “Contact with patients before prescribing” position statement. The member pointed out that it is a widely accepted and common practice for gastroenterologists and radiologists 7 July 17-19, 2015 to provide otherwise healthy new patients bowel prep agents, such as SUPREP Bowel Prep Kit, in anticipation of a GI procedure, such as colonoscopy, barium enema or CT colonography, prior to being seen by a physician. The member requested discussion of whether this type of practice might be included as an additional exception to this position statement. One possible general difference between this practice and the existing position statement exceptions is that this involves providing (nominally healthy) patients medication in anticipation of a diagnostic procedure rather than treatment of a specific medical condition, so that, rather than a specific exception for “bowel prep” agents, possibly the Board might consider a general exception for standard or routine diagnostic studies. Staff discussed adding an exception which would permit prescriptions preceding diagnostic tests. Some Committee members voiced concerns about whether such an exception would make a doctor immune from bad outcomes and whether such an exception was necessary if it met the standard of care. The Committee also heard from Dr. Sarah McGill who discussed the nature of the medications that are used in the gastroenterology setting and their evolution over time. Committee Recommendation: Add an exception containing the following language: “An appropriate prescription in anticipation of a diagnostic test consistent with the standard of care in that particular specialty.” NOTE: The Committee also wanted to foster a discussion, at an appropriate time, regarding whether the amount of current exceptions weighs in favor of making one general exception to the position statement. Board Action: Accept Committee recommendation. Add an exception containing the following language: “An appropriate prescription in anticipation of a diagnostic test consistent with the standard of care in that particular specialty.” NOTE: The Committee also wanted to foster a discussion, at an appropriate time, regarding whether the amount of current exceptions weighs in favor of making one general exception to the position statement. c. Electronic doctor visits a growing trend A Board Member shared an article with the committee discussing concerns regarding telemedicine and, in particular, the interruption of telemedicine into traditional face-to-face medical practice. This is, in part, a result of differing treatment of telemedicine by insurers. The Board Member cautioned that the Board should continue to monitor the access to care for patients. Committee Recommendation: None at this time. Board Action: None at this time. Old Business a. Office Based Procedures (Appendix E) 8 July 17-19, 2015 05/2015 Committee Discussion: The Committee discussed potential review of position statement to conform to current standards. The type of review was also discussed. An editorial change was noted. The Committee recognized Dr. McMullen in the audience who briefly discussed the certifying bodies for surgical centers. 05/2015 Committee Recommendation: Refer the position statement to Executive Committee for further discussion regarding potential review. Board Action: Accept Committee recommendation. Refer the position statement to Executive Committee for further discussion regarding potential review. Position Statement Review Tracking Chart The Policy Committee reviewed the Position Statement Review Tracking Chart and confirmed that all position statements are on track to be reviewed at least once every four years as required by the January 2010 Board Action. Committee Recommendation: Accept as information. Board Action: Accept as information. LICENSE COMMITTEE REPORT Members present were: Pascal O. Udekwu, MD, Chairperson, Subhash Gumber, MD, Debra Bolick and Mr. A. Wayne Holloman. Old Business a. USMLE/COMLEX/LMCC – 3 attempt limit At the May, 2015 meeting, the Licensing Committee requested additional information regarding the USMLE/COMLEX 3 attempt limit rule the Board currently has in place. Answers to the questions were provided by Staff to the Committee. Committee Recommendation: (1) Staff to contact FSMB regarding the percentage pass rate for initial and multiple attempts for USMLE steps 1, 2 and 3. (2) Staff to contact other state medical boards to determine if they have experienced more disciplinary issues with licensees who have taken multiple attempts at USMLE. Board Action: Accept Committee recommendation. (1) Staff to contact FSMB regarding the percentage pass rate for initial and multiple attempts for USMLE steps 1, 2 and 3. (2) Staff to contact other state medical boards to determine if they have experienced more disciplinary issues with licensees who have taken multiple attempts at USMLE. 9 July 17-19, 2015 b. Proposed combined medical school and residency training program at Duke Dr. Benjamin Alman, Chair, Department of Orthopaedic Surgery at Duke submitted a proposal to accept medical students into Duke’s orthopaedic residency program at the end of their third year of medical school. The license committee reviewed the proposal at the March 2015 meeting with a recommendation to table the decision pending obtaining additional information as follows: (1) Duke’s plan on when MD degrees will be conferred (2) Details of NYU 3 year program (3) Content of Duke’s 2 year curriculum. Dr. Alman submitted an email to Dr. Kirby requesting withdrawal of his proposal. Committee Recommendation: Accept as information. Board Action: Accept as information. New Business A motion passed to close the session pursuant to Section 143-318.11(a) of the North Carolina General Statutes to prevent the disclosure of information that is confidential pursuant to Sections 90-8, 90-14, 90-16, 90-21.22 of the North Carolina General Statutes and not considered a public record within the meaning of Chapter 132 of the General Statutes and/or to preserve attorney/client privilege. The License Committee reviewed two cases. A written report was presented for the Board’s review. The Board adopted the Committee’s recommendation to approve the written report. The specifics of this report are not included because these actions are not public information. A motion passed to return to open session. LICENSE INTERVIEW REPORT A motion passed to close the session pursuant to Section 143-318.11(a) of the North Carolina General Statutes to prevent the disclosure of information that is confidential pursuant to Sections 90-8, 90-14, 90-16, 90-21.22 of the North Carolina General Statutes and not considered a public record within the meaning of Chapter 132 of the General Statutes and/or to preserve attorney/client privilege. One licensure interview was conducted. A written report was presented for the Board’s review. The Board adopted the Committee’s recommendation to approve the written report. The specifics of this report are not included because these actions are not public information. 10 July 17-19, 2015