For Physicians & Physician Assistants

Recommended Best Practices

Closing Practices

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

  • Try to resolve open patient cases;
  • Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);
  • Send a letter to patients that have been seen within the past year notifying them of the practice closure;
  • Notify the Rhode Island Medical Society and the Rhode Island Board of Medical Licensure and Discipline of location of medical records;
  • Create a way for patients to get their medical records for at least the next 5 years; (Though a fee can be charged for copying, the transfer of the record cannot be delayed due to lack of payment.)
  • Notify your malpractice carrier and make sure you have adequate coverage after you have stopped working.

Continuing Medical Education (CME)

Physicians are required to document to the Board of Medical Licensure and Discipline that they have earned a minimum of forty (40) hours of American Medical Association, Physician Recognition Award (AMA PRA Category) 1 Credit or American Osteo Pathic Association (AOA Category 1a) continuing medical education credits.

CMEs on Public Health Topics

At least 2 hours of continuing medical education shall be earned on topics of current concern as determined by the director of the Rhode Island Department of Health. Current topics include:

Public Health Grand Rounds

The Deparment, and the Warren Alpert Medical School, can help you meet your continuing educations requirements.

Community Health Network Programs

All programs complement the clinical care of providers. By the end of the program, patients will have learned how to set goals to improve their health and lifestyle, manage their symptoms and medication, work with their health care team, talk with family and doctors, relax, eat well and handle difficult emotions. By gaining these skills, patients will become activated and engaged in their care. Healthcare providers will receive feedback on the status of any patient referrals.

  • Healthcare providers can set up an in-person academic detailing with Community Health Network staff to learn about resources that give your patients tools to take control of their health.
  • Refer your patients to a specific Community Health Network Program

Continuity of Care

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

  • Try to resolve open patient cases;
  • Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);
  • Send a letter to patients that have been seen within the past year notifying them of the practice closure;
  • Notify the Rhode Island Medical Society and the Rhode Island Board of Medical Licensure and Discipline of location of medical records;
  • Create a way for patients to get their medical records for at least the next 5 years; (Though a fee can be charged for copying, the transfer of the record cannot be delayed due to lack of payment.)
  • Notify your malpractice carrier and make sure you have adequate coverage after you have stopped working.

Ebola

Healthcare Ethics

  • Hold as their primary responsibility the health, safety, welfare, and dignity of all human beings.
  • Uphold the tenets of patient autonomy, beneficence, and justice.
  • Hold in strict confidence information obtained through employment unless legally authorized or required by responsible performance of duty to divulge such information.
  • Actively seek to expand their knowledge and skills, keeping abreast of advances in medicine.
  • Use their knowledge and experience to contribute to an improved community.
  • Respect their professional relationship with all members of the healthcare team.
  • Respect the culture, values, beliefs, and expectations of the patient and family caregiver.
  • Not discriminate against classes or categories of patients in the delivery of needed healthcare.
  • Disclose to his or her supervisor information about errors made in the course of caring for a patient.
  • Place service to patients before personal material gain and should avoid undue influence on their judgment.
  • Not misrepresent directly or indirectly, their skills, training, professional credentials, or identity.
  • Not become sexually involved with patients or engage in, or condone, any form of sexual harassment.
  • Seek professional help if suffering from issues of addiction or substance abuse and should not engage in patient care while symptomatic or until cleared by treating professional.

Infectious Disease Reporting

Immunization

The Rhode Island State-Supplied Vaccine program provides vaccine to healthcare providers to immunize people of all ages. A table with details about these vaccines, including their age indications, is available for healthcare providers.

Additionally, a series of immunization requirements are in place in Rhode Island to ensure that healthcare providers are properly immunized.

What you should do

Enroll in the State-Supplied Vaccine Program

Healthcare providers can enroll in the program to order vaccine for both pediatric and adult patients. Enrollment must be completed online annually.

Know about requirements

Providers who participate in the State-Supplied Vaccine Program must agree to the program's terms and conditions and adhere to certain requirements for ordering, storing, and reporting on vaccines.

Before administering any vaccine, healthcare providers must give the current Vaccine Information Statement to patients (or their parents or guardians). This must be documented in the patient's medical record.

Know about patient eligibility

Influenza vaccine

  • Children: State-supplied influenza vaccine can be provided to all children (younger than 19 years of age), regardless of residence.
  • Adults: State-supplied influenza vaccine can be provided to all adult Rhode Island residents.
  • Medicare Fee-For-Service patients: Providers can use any state-supplied adult influenza vaccine for Medicare Fee-For-Service patients. (A Medicare Fee-For-Service patient is any patient whose services are billed directly to Medicare.) Providers will have to reimburse the Department of Health for doses administered to Medicare Fee-For-Service patients at the purchase price of the vaccine. Providers will be required to report weekly to the Department of Health on the products and quantities of vaccine administered to Medicare Fee-For-Service patients.

Non-influenza vaccine

Non-influenza state-supplied vaccine can be provided to all children (younger than 19 years of age). Adult, insured Rhode Island residents and adults who are non-Rhode Island residents but who are covered by a Rhode Island employer’s health plan are also eligible for non-influenza state-supplied vaccine if they are:

  • 19 to 26 years of age, or
  • At high risk, regardless of age.

Adults who are not in one of these categories can be vaccinated as follows:

Patient type Where/how to vaccinate
Uninsured but able to pay Privately-purchased vaccine, St. Joseph Center for Health and Human Services, or at a pharmacy
Uninsured and unable to pay Patient Assistance Program sites and St. Joseph Center for Health and Human Services
Insured, but not through a Rhode Island employer Privately-purchased vaccine or at a pharmacy
Covered by Medicare Fee-For-Service

SSV, but providers will have to reimburse the Department of Health for doses administered at the purchase price of the vaccine

Medical Orders for Life Sustaining Treatment (MOLST)

Medical Orders for Life Sustaining Treatment (MOLST) are instructions to follow a terminally ill patient’s wishes regarding resuscitation, feeding tubes and other life-sustaining medical treatments. The MOLST form can be used to refuse or request treatments and are completely voluntary on the part of patients. These orders can supplement Do Not Resuscitate (DNR) instructions or a COMFORT ONE bracelet. more

A physician, registered nurse practitioner, advanced practice registered nurse or physician assistant who is authorized by the patient is authorized to sign Medical Orders for Life Sustaining Treatment.

  • Treat a patient in accordance with the patient's MOLST form, even if the healthcare provider who signed the MOLST order is not on staff at a facility.
  • Ensure a patient's Medical Orders for Life Sustaining Treatment are transferred with the patient if he/she is transferred to another healthcare provider.
  • If a new terminally ill patient comes under your care, you should ask about the existence of a MOLST form from the patient and/or the facility that is transferring the patient.
  • Review the Medical Orders for Life Sustaining Treatment on admission and ensure that the orders reflect the patient’s current wishes.
  • If the terminally ill patient does not have Medical Orders for Life Sustaining Treatment, you should offer them the opportunity to complete a form on admission to a nursing home, assisted living facility, home health agency, hospice program, kidney dialysis center, or hospital.
  • Document if a terminally ill patient does not file Medical Orders for Life Sustaining Treatment and explain the consequences of making no decision to the patient or their recognized healthcare decision maker. If there are no limitations on care, except as otherwise provided by law, cardiopulmonary resuscitation will be attempted and other treatments will be given. If a choice regarding cardiopulmonary resuscitation (CPR) is not made, cardiopulmonary resuscitation will be attempted using all available treatment options.
  • Void the Medical Orders for Life Sustaining Treatment if requested by your patient. To do this draw a diagonal line through the sheet, write “VOID” in large letters across the page, and sign and date below the line. Keep the voided MOLST form in the patient’s active or archived medical record, as appropriate.
  • Follow the most recent version of the Medical Orders for Life Sustaining Treatment if more than one form is found in the medical records.

Medical Records & Meaningful use

What Medical Practices Should Do

Store patient’s medical records for at least five years after the most recent patient encounter, regardless of whether the patient is alive or dead. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. more

Provide copies when requested. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. Records should be provided within 30 days.

Make sure that records are still available if the practice is closed.

Use Electronic Health Records which provide better way to see long term medical issues and track trends among groups of people. Healthcare providers who accept medicaid or medicare must meet "meaningful use" standards. more

Physician Assistant Supervision

Physicians Assistants work as part of a healthcare team, supervised by physicians following a written and signed agreement as required by law. Sample Agreement There are four mandatory elements of the agreement:

  1. delineation of the level of supervision provided with particular reference to differing levels of supervision depending on the service being provided;
  2. requirements for communication between the Physician Assistant and the supervising physician;
  3. a job description for the Physician Assistant listing patient care responsibilities and procedures to be performed;
  4. a program of quality assurance and periodic performance review

Clinical Supervision Oversight Criteria

The level of supervision and clinical oversight must consider the:

  1. Potential for morbidity or mortality of a procedure; and
  2. Level of experience of the Physician Assistant.

For example, a new graduate PA with limited experience performing an invasive procedure (e.g. insertion of a central venous line or a closed thoracotomy) may require on-site supervision / oversight for immediate consultation whereas adequate supervision of a PA with demonstrated competency in performance and management of possible complications of the same procedure may be provided by phone. Adequate supervision of the same new graduate PA working in a clinic or office setting providing basic primary care could be safely provided by phone.

Quality Assurance

As with overall supervision, the quality assurance program should reflect the experience level of the PA. Consideration should be given to evaluating the performance of the new graduate PA weekly initially. As the PA demonstrates the ability to meet the quality expectations of the supervising physician the evaluation interval may be increased but is required to be performed at least yearly. Accepted forms of performance evaluation include:

  • medical record co-signature
  • random medical record reviews by the supervising physician
  • case presentations by the Physician Assistant

Safe Opioid Prescribing

When prescribing opioid medications for patients, it is important that both the healthcare provider and the patient be aware of their responsibilities in prescribing and using these medications. An opioid treatment agreement between patient and provider will clarify expectations.

Definitions

  • Acute Pain- expected duration less than 5 days
  • Episodic/Procedural pain (varies depending on procedure, generally less than 30 days, after 30 days treat like chronic pain)
  • Chronic pain – duration of pain more than 30 days

What Healthcare Prescribers Should Do

Take a Medical History and Physical Examination: This includes an assessment of the pain, physical and psychological function, substance abuse history, assessment of underlying or coexisting diseases or conditions, and should also include the presence of a recognized medical indication for the use of a controlled substance.

Make a Treatment Plan : The treatment plan should state objectives by which treatment success can be evaluated, such as pain relief and/or improved physical and psychosocial function, and indicate if any further diagnostic evaluations or other treatments are planned. The prescriber should tailor drug therapy to the individual medical needs of each patient. Several treatment modalities or a rehabilitation program may be necessary if the pain has differing etiologies or is associated with physical and psychosocial impairment.

Prescribe Proportionately: Only prescribe the amount of pain medicine reasonably expected to be needed. If you expect 3 days of severe pain prescribe only 3 days worth of medication. Acute Pain (< 5days) can often be managed without opioids.

Start an Opioid trial: Advise your patient to try the medication for a specified period of time and re-assess. Agree that if are not making reasonable progress, to consider stopping and trying a different approach.

Obtain Informed Consent : The prescriber should discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative. This discussion should be documented and signed by the patient, guardian or authorized representative. sample

Enter Into a Prescriber-Patient Agreement : The agreement will help you and your patient share information about medications and comply with controlled substance regulations.

Co-prescribe Naloxone : If your patient is at-risk for overdose.

Monitor your patients opioid utilization : Use the Prescription Monitoring Program before each appointment. Enroll Login Additionally, it is important to conduct random urine drug screens as well as have patients bring back pill bottles to monitor supply remaining.

Periodically Review Treatment : The prescriber should periodically review the course of opioid treatment of the patient and any new information about the etiology of the pain. Continuation or modification of opioid therapy depends on the prescriber's evaluation of progress toward treatment objectives. If the patient has not improved, the prescriber should assess the appropriateness of continued opioid treatment or trial of other modalities.

Make Consultations : The prescriber should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. In addition, prescribers should give special attention to those pain patients who are at risk for misusing their medications including those whose living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse requires extra care, monitoring, documentation and consultation with addiction medicine specialists, and may entail the use of agreements between the provider and the patient that specify the rules for medication use and consequences for misuse.

Keep Accurate Records : The prescriber should keep accurate and complete records according to items 1-5 above, including the medical history and physical examination, other evaluations and consultations, treatment plan objectives, informed consent, treatments, medications, agreements with the patient, and periodic reviews.

Be Compliant with Controlled Substances Laws & Regulations : To prescribe controlled substances, the prescriber must be licensed appropriately in Rhode Island, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions. Physicians Manual of the U.S. Drug Enforcement Administration.

Addiction is a disease, chronic and relapsing. Patients with any chronic disease deserve appropriate treatment. There are many places to find treatment for addiction and substance abuse. partial list.

Continuing Education Courses

More

Tobacco Cessation

  • Ask your patient, including teens, about their use of cigarettes, and other nicotice products at every visit;
  • Advise smokers/users to quit and assess their willingness to do so;
  • Enroll patients in QuitWorks Form;
  • Prescribe nicotine replacement therapy and/or cessaion mediation as appropriate;
  • Monitor quit status through faxed QuitWorks feedback reports
    1) Within weeks telling you that QuitWorks has spoken to your patient and if the patient consents to the counselling;
    2) Within seven months telling you the patient's quit status;
  • If a patient relapses, re-evalutate and re-refer to QuitWorks when appropriate.

Provider News

RSS
03/25/2015 13:37 EDT
This new issue brief examines unintended pregnancy among women in Rhode Island, and includes recommended actions for healthcare providers.
More

Infectious Disease News

RSS
03/16/2015 13:58 EDT
Continuing Medical Education (CME) opportunity: This CME event will provide information to healthcare providers so that they understand the latest trends in HIV and STDs, and that they can disrupt further spread of these infections by learning best practices for interacting with patients and their sexual partners. A special emphasis will be on current approaches to working with gay/bisexual men and other patients at highest risk of HIV and STDs. Participants will be provided with tools and resources to implement in their practices. This CME event will be held Thursday, April 30, 2015, from 5:15-7:30 pm at the Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI.
More

Immunization News

RSS
05/15/2015 13:26 EDT
Transition to 9-valent HPV vaccine
9-valent HPV vaccine (9vHPV) will be available for order through OSMOSSIS in July 2015. Until July 2015, continue to order 4-valent HPV vaccine (4vHPV) only as needed. (This will help prevent vaccine wastage.) Continue to vaccinate all patients using 4vHPV until 9vHPV is received. Once practices have 9vHPV, they should continue to vaccinate males with their remaining 4vHPV until their 4vHPV inventories have been depleted. Once 9vHPV is available, 4vHPV will no longer be available for order. However, practices will still be able to report doses of 4vHPV as administered in OSMOSSIS.
More