After the presidency And now, dealing with some application logic with bupronorphine, we'll cover some basic ideas of emigration, then we cover knife bail immigration, and finally some ideas about political jobs and pre-comments. Well, why does it need the highest level of confidence for information that suffers from warranty activities. Very many of them characterize the law using things like heroin and cocaine. So if we don't clear the highest level of suspicion around their activity, there is a very good chance that they will not come for activity. This is the feeling back at this very important level of mindfulness that we need to secure our information. Toward which we should think is that all activities they are dominated by the tendrils of self-righteousness. Your activity with your activity or your examinee. The information has a higher level of confidence from the other activity. The psychic has a higher level of sensitivity than other experiences. Negative, negative mental probably has the highest level of self-doubt due to the negativity of information to see us when they are so necessary. The note takes care of a lot of appearance that I left to limit what we want to protect Efforts to protect information to protect information and that is what we need to protect the most we cannot really disclose that contains patient identifying information and that includes electronic medical records, it extends to patients who are the federal law that spells out the confidentiality clauses for medicine and essentially what has happened with HIPAA is that it has moved the rest of medicine to what has been already established in psychiatry and more specifically in addiction psychiatry, so it aligns the rest of medicine with something that has already been done in addiction which once again is the highest level of confidentiality that we should be offering to our patients once again it covers the electronic medical record and probably one of the trickiest parts of this confidentiality law is that you cannot even tell the family that the patient is under your care unless you have the explicit consent of the patient, so a family member comes to the hospital and says I know my son is under your care, you cannot divulge that you even have this patient under your care unless the patient has very specifically explicitly given you permission to contact the family there are exceptions to this confidentiality law internal communications these days internal communication is a little trickier than it used to be up until recently I worked at the Addiction Institute of New York which was part of Roosevelt Hospital which was part of St. Luke's and Roosevelt Hospitals which was part of Continuum Health Partners just a number of different entities that you lose a little bit of confidence as to what's internal and what's external so you have to check with your own hospital with your own health organization what is considered to be internal so you can communicate internally and what is considered to be outside of your own organization and again these days with all the mergers and the different organizations it's a little less clear to what's internal and what's external obviously the patient consents then you can break confidentiality crimes on premises or against personnel if somebody hits a staff member then you can absolutely report that to the police and you should under a lot of circumstances and you're perfectly protected in breaking confidentiality in doing so prescription data monitoring programs the state PDMPs which are quite important in our work also have access to patients and they can divulge the patient's treatment through the PDMP court orders not just court subpoenas but court orders are part of these exceptions and you should release the record medical emergencies medical emergencies obviously are situations where confidentiality may need to be broken just be careful with that not to abuse the system and call anything under the sun a medical emergency moving on to medical record keeping there are two parts that are absolute musts in having in documenting your treatment of a patient with buprenorphine and I put them up there on bold letters the first one is that you have to have a list of your patients on buprenorphine and you have to be very careful not to break the 30 patient rule in the first year or the 100 patient rule if you have been given the permission to treat 100 patients on buprenorphine or 275 limit which is the new limit for patients with buprenorphine if you have been given this permission to treat patients up to 275 patients on buprenorphine so you need to keep a list whether electronically or physically and when a patient leaves your practice you remove that patient from your list and that opens a slot for a new patient now most of us do not like to go all the way to the limit we always like to leave a few slots open if a patient who dropped out of your practice some time ago wants to come back you may want to have the ability to accept that patient back into your practice now the question often comes as to how long is a patient your patient how long does a patient stay on your list if you no longer see the patient now the clock ends in your relationship with your patient not on the day of the last time that you saw the patient but on the day that your prescription of medication for the patient expires including refills what am I saying here I see the patient today I write the prescription for a 30 day supply of buprenorphine with two refills the patient continues to be my patient from a legal perspective for the next 90 days for the first month that I gave medication plus the two refills so the patient needs to stay on your list for these 90 days and only afterwards it can open the space for a new patient good idea to have the medications prescribed in your record and inventory of controlled substances now most of us prescribe medication either electronically or physically we write a piece of paper and give it to the patient or we call it the pharmacy or electronically we prescribe medication we are also allowed to administer medication which means that the patient can bring in her or his own pills and then in our presence give the patient a medication we often do that for induction there is a third way of giving medication to a patient which is dispensing medication and that is when you as the provider has bought a number of films or pills and then you give this to your patient if you opt for the third one for dispensing medication there are lots and lots of rules and regulations that govern this activity dispensing medications you have to have labels with the patient's name on it to put on the bottles you have to have double locked cabinets you have to have extensive records of the medications that you are dispensing so unless your office really has the capability of dispensing medication the majority of us would probably just stick with prescribing and administering medications which is much more routine and pretty much done everyday in medical practices all across the country so the first rule as I said is to make sure that you absolutely do not break the 30 patient, 100 patient or 275 patient rule and have the document to support that a list of your patients on buprenorphine the second absolute requirement is that you have to record the diagnosis of an opioid use disorder in your chart electronic or physical now if you also add a few reasons why you believe that the patient suffers from opioid use disorder that's even better but the thing that absolutely needs to be there is the words opioid use disorder you can also put heroin use disorder or if you know what is the particular molecule of the opioid you can put that as well you may want to have a treatment plan and we do offer in the supplemental materials examples of treatment plans and you include the treatment goals you have documented the patient's consent with the goals you propose medications to be used and this is something that can be helpful both to you and to your patient consent is another document that you may opt to include in your package of documentation of your patient that you're treating with buprenorphine and we also have some examples of consent forms in the supplemental materials that go along with this course just remember that insurance companies do have access to the records patients have given most routinely permission for insurance companies to check medical records so this is another of those situations where the patient consents to break confidentiality to release the record to an insurance company alteration of records this is pretty much an older slide before electronic records so if you need to cross a word out make sure you don't erase it you just put a line through it and then you sign it and you enter the date when you made the change I like this line here that investigators and attorneys are trained to detect aberrations it's kind of funny but it's actually very very true and we never never alter the medical record if it is a mistake we absolutely change that but we document it and we allow people to see the original entry as well storage of records the hard rule is for two years but most of us do keep records for much longer than that most typically seven years is what most of us use for keeping the records so that we are in line in compliance with a number of other regulations state regulations and local regulations so keeping your records for at least seven years is a good idea they can be kept in a central location where not just where your practice is but it can be in let's say the hospital record but the DEA should be informed of that finally the last part of this talk office policies and procedures Andy Saxon, Dr. Saxon is going to talk more about it a little later in the course but you should on the very least know what's available in both of course in your own organization but in the community as well know about the Alcoholics Anonymous programs, the Narcotics Anonymous programs know about the psychiatric supports, the medical services that may be available just know the lay of the land both internally what is offered in your organization and externally what is available in the community partial hospitalizations intensive outpatient programs methadone clinics now called opioid treatment programs all these are resources that you should be quite familiar with in terms of coverage be realistic you cannot do 24 hour coverage so a very good idea is to partner with another physician who also has the waiver for buprenorphine so she or he can cover your practice when you go on vacation when you need to be out of the office the covering person should be knowledgeable about buprenorphine but also is a very good idea to have the waiver a point of clarification here let's say you have 28 patients on buprenorphine and you have a colleague who is also have the waiver for buprenorphine has another 26 patients on buprenorphine your colleague goes on vacation and says can you please cover my practice it doesn't mean that all 26 patients of her or his will come to your load and from a legal perspective that doesn't make, that doesn't double your practice the patients who will call you, the patients whom you will end up seeing, the patients for whom you will be prescribing medication will be added to your list so this is also a good idea to leave some space so that you can cover for colleagues of yours Finally an idea about the staff I think one of the smartest things that we have done in our place is to include the non-clinical staff into our in-services and our educational programs so the people who answer the phones the front desk people who greet the patient as they come in the drivers of the van the security guards also need to know about opioid use disorder they need to have a non-judgmental attitude towards the patients and I can tell you they tremendously appreciate being included in our educational programming Some of the financial issues you may opt to bunch all the services together and charge have one charge for the patient or you may want to break it down and let's say charge specifically for urine toxicology examinations every time you do a urine toxicology examination you charge the patient extra most of us have opted for bunching the services together under one fee Here are the codes that are used for non-psychiatrists for the treatment of buprenorphine outpatient new patient outpatient established revisit and here are the codes that we use in psychiatry for our patients as you can see here there are the usual the routine codes that we use for an outpatient new patient for medication management of course if we have to do an E&M in addition to psychotherapy then we use two codes and we do have a code for group psychotherapy that we use in outpatient practices So summarizing this part of the talk in terms of confidentiality the rest of medicine has been aligning with addiction psychiatry and we offer the highest level of confidentiality to our patients to encourage them to come to us for treatment and we only break confidentiality under very very specific situations that we outlined earlier in the talk. In terms of medical record keeping two things to keep in mind number one which are unique to buprenorphine, number one you have to have a list of your patients and make sure you don't break the 30 100 or 275 patient limit and number two you need to have you have to record the diagnosis of an opioid use disorder these are the two musts for the record. The rest of the record should also be complete but is not really all that different than the medical record that you have for any of your other patients Finally in terms of office policies and procedures, know the lay of the land both internally and externally, what's available in your organization, what's available in your community and my own plea here to include the non-clinical staff in your in-service and your education because then you really have a whole team who takes care of the patient and that is quite effective. music music

confidentiality

medical record keeping

physicians

buprenorphine

opioid use disorder